Parenteral Nutrition Calculation: Custom 2-in-1 + Lipid Piggyback

Learn how to calculate a custom 2-in-1 parenteral nutrition recommendation with a lipid piggyback for an individual sedated with propofol. This video is a great starting place for individuals new to parenteral nutrition calculations, or to those looking to refresh on their skills!
EDIT: Intravenous lipid emulsions
Thanks to the emailer who pointed out that not all lipids are the same for kcals/g!
When considering lipids, different %'s will contribute different kcals/gram. The correct values are as follows:
10% emulsions are 11 kcal/gram or 1.1 kcal/mL
20% emulsions (most commonly used) are 10 kcal/gram or 2 kcal/mL
30% emulsions (used for bulk compounding) are 10 kcals/gram
Note: while these values are common for most lipid products, not all products contain the same lipid and glycerol content. Information for specific lipid products can be found within the product's prescribing information.
Closed Captions provided by Sara Kerr, RDN.

[@annabusenburg2094]

Yes to more videos on electrolyte and fluid calculations and would love some NICU case studies. Thank you!

[@meganusher2635]

Would love a video on estimating fluid needs outside of baseline needs!

[@chelseynelson8619]

Would love to see some videos on electrolyte calculations!

[@israkhattab1890]

Yes please

[@wildkindom101]

Thank you so much for this explanation! Things were not clicking in my mind but after watching this video I feel like Einstein! :)

[@demigatewood5440]

I would love to see some videos on calculating electrolytes!

[@onismochipato2980]

Educative and comprehensive video. If you you could as well provide a video on management of electrolytes by a dietician

[@jillm5702]

Such an amazing review, thank you!

[@ndukanwankwo8393]

Thank you very much, this was a great help

[@Andrea-ky9lh]

This is so helpful. Thanks so much!

[@peach2324]

Amazing thank you so much !

[@kristinarozenblit3626]

Thank you! Very useful ;)

[@ahmadabdelrehim1157]

Awesome!!

[@mohammedshahalam5354]

A useful video for those who are interested in calculating TPN. Can we expect some more videos on case studies.

[@DietitiansinNutritionSupport]

Thanks for the thoughts, we have some TPN cases in our upcoming plans!

[@nancyliu7714]

Hello! Any calculations on 3 in 1?

[@aracelieckert2613]

Please, I would like to see an example where electrolytes can be customized, and also calculation for a TPN high protein for dialysis patients. Thank you

[@erikagrant3762]

Looking forward to electrolyte calculation, do you have an update on release?

[@DietitiansinNutritionSupport]

Thanks for asking! Electrolytes are next in the cue. Hoping to start releasing in July :)

[@camilleyue1637]

Your video is helpful! Would you consider to add lipid in a daily basic if the patient’s triglyceride is normal?

[@DietitiansinNutritionSupport]

Hello! For a "healthy" patient requiring parenteral nutrition, lipids can be provided daily or can be provided every other/every third day depending on their current triglyceride levels. If the individual is struggling with high triglyceride labs that may be a sign they are unable to tolerate the quantity or frequency of lipid provisions. On the other hand, if the individual is struggling with hyperglycemia but not hypertriglyceridemia, that might be an instance in which you could increase the quantity or frequency of lipids and decrease dextrose provisions. So depending on the clinical condition of the patient and the lab value trends, you could consider daily lipids for a patient able to maintain appropriate triglycerides. Hope this helps!

[@Ana-ut3ru]

Very helpful video!! I am confused in the lipid portion. Why did you use 10kcal/g? and what equation did you use to convert 13g to 130 kcal?

[@DietitiansinNutritionSupport]

Hello, thanks for your question! The 10kcal/gram of lipids is a standard quantity of calories/gram for 20% or 30% lipid emulsions (they are higher than the 9kcal/g we use to calculate oral intake or pure fat due to the glycerol within the PN lipid emulsion). 10% lipid emulsions are slightly different and have 11 kcals/gram. For the 13 grams of lipid (we rounded up our 12.6 grams to have a whole number), we are looking to get the total value of kcals provided if we give a solution that has 10 kcal/1 g lipid, so we used stoichiometry (in this case multiplication with unit cancelation): 13 g lipid. * 10 kcal ----- = 1 g lipid 130 g lipid * kcal -------- = 1 g lipid Cancel out the lipid units (130g lipid/1 g lipid) = 130 kcal Hopefully that math makes sense, it’s a little challenging to write out like this. If not, please let us know and we are happy to try and clarify further!

[@Ana-ut3ru]

@@DietitiansinNutritionSupport Thank you so much for the explanation! Make sense now :)

[@adamdaly79]

I see that with the enteral calculations, energy is used as the main factor and then protein is just checked against total energy. But here, the protein (or aa) comes first and then lipid and carbohydrate are calculated after. Is there a reason for this? Could one calculate an enteral regimen in this parenteral format and vice versa?

[@DietitiansinNutritionSupport]

Great question! With enteral formulas, these are mixtures that are already formulated by a company and are not "custom" made for patients. When enteral products are developed, they are formulated to include each macronutrient in a generally appropriate quantity to try and meet the needs of the target patient for each formula. Because we cannot select how much of each macronutrient goes in the enteral formula due to them being pre-made mixtures, we thus guide off of energy and then verify if the formula/quantity selected will suit a patient's needs. For this reason, we are not really able to use the reverse approach of selecting exactly how many grams of each macronutrient may be needed for an enteral solution as we will be confined to the content of the premade formulas. Notably, some institutions do use additives to enteral formulas like powdered protein/amino acids that can alter macronutrient composition as needed.

[@adamdaly79]

@@DietitiansinNutritionSupport Ah thank you, so it's not so much a difference between enteral and parenteral, but between non-custom and custom. Great.

[@scarredwarrior3614]

Are there any videos on calculating needs for anorexic patients?

[@ljoye123]

Hi I’m a dietitian new to these calculations. Is there a way for me to get personal help with this? Can I call you?

[@DietitiansinNutritionSupport]

Please feel free to contact us at studentcoordinator at dnsdpg.org

[@melissagrove7617]

Will you being doing a PPN example?

[@DietitiansinNutritionSupport]

Hello! We are working on some PPN examples for the near future :)

[@melissagrove7617]

Great! Your videos are very helpful!

[@ronniejv1510]

Hello can you help me to solve this case: A 7yr.old patient who weighs 16 kg and 110cm in height was diagnosed with small bowel obstruction. After surgical resection, a 40cm post duodenal small bowel was left. He was maintained initially on TPN. A.) Calculate the needed component of its parenteral nutrition for the first 3 days. 1. Source of protein nitrogen 2. Glucose 3 . Lipid 4. Fluid replacement B.) What are the micronutrients that must be added

[@ronniejv1510]

Given: Gram/ kg Nitrogen: DAY1:0.15, DAY2:0.2, DAY3: 0.3 GLUCOSE: DAY1: 4, DAY2: 6, DAY3: 8 LIPID: DAY1: 1.5, DAY2: 2, DAY3: 2

[@DietitiansinNutritionSupport]

Thanks for your question. We recommend you look up calculations for macronutrient needs for pediatric patients, then you can continue on the the process of determining calories from protein, and divide the remaining calories for dextrose and lipid. Note that micronutrient needs also vary slightly between adult and pediatric patients, so take that into consideration.

[@melissagrove7617]

What is the best practice for tapering TPN?

[@DietitiansinNutritionSupport]

Hello! Tapering of TPN is dependent on the circumstances and your facility. For cyclic PN to prevent rebound hypoglycemia/hyperglycemia you may do something like half rate PN for an hour at the beginning and end of the cycle. Or if it’s for weaning purposes, a common approach is weaning or discontinuing PN when oral/EN intake is at least 50% goals. Thanks for your question!

[@carmelitalatinanutritionis4226]

It's interesting how you subtracted the kcal from protein to determine carb and fat needs. In our MNT class they are instructing us to calculate the fluids needed and using that number to determine protein and carbs. I'm not sure why they are teaching us a different way... I'm more confused now :(

[@DietitiansinNutritionSupport]

Thanks for your comment, and sorry for the feelings of confusion! There are multiple different ways to appropriately determine nutrition support provisions and our approach is just one way. If your MNT course is using fluid needs as a starting point that can be particularly helpful for patients with a fluid restriction for example. You may also learn other approaches from different preceptors and clinicians as you continue in your education and career. From a grading perspective it's likely that your instructors are looking for calculations using their methods, so that approach is probably best for you to use. Good luck to you in the rest of your training!

[@filipeferrari8024]

what percent of calories from dextrose should diabetics receive?

[@DietitiansinNutritionSupport]

Great question! As with any patient, we want our recommendation to be individualized for the patient’s specific needs, meaning this answer sort of depends on the person and the place. This would include looking glucose control, general clinical status, considering protein and lipid needs, and utilizing the products that are available to you. For example, an individual with diabetes with well controlled blood glucose levels may do well with a similar regimen to an individual without diabetes. If you HAD to pick a range of total calories from carbohydrates to provide for an individual with diabetes, it would likely fall within the 45-60% range. Note that there are also a variety of approaches to determining a PN prescription, that can differ from what we present in this video, such as calculating a specific number of grams/kg for all macros instead of guiding off of energy needs, which could be an appropriate option for an individual with or without diabetes. Hope this helps!

[@mayawehbi3315]

Why we choose 70% in dextrose

[@DietitiansinNutritionSupport]

After we’ve established our protein needs, we want to select our other macronutrient needs. Carbohydrates have a higher acceptable macronutrient distribution range (AMDR) than lipids, so the 70% split helps us to contribute more of the remaining calories to carbohydrates than lipid. Hope that helps!

[@happyandhealthy888]

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