Nicole Mize 3-6 lab

10-29-2014/10:00 AM
S. Pt is recovering from GI surgery to remove colon polyps. After surgery, pt was unable to consume PO
and has not had any BS. TPN has been recommended due to severe wt loss that has occurred in the last
8 days. Pt was well nourished PTA.
O. 58 YOM
Dx: Colon polyps, removal surgery 8 days ago
BS absent
abd distended no BM x 2 d
Ht 510 (177.8 cm)
Wt 156.2# (71 kg)
IBW: 166 # %IBW: 94 % (nl)
UBW: 165# %UBW: 95% (mild deficit)
%wt loss: 5.3% in 8 d (severe)

BMI: 22.5 kg/m2 (nl)

EER (AF 1.4): 2300 kcal/d (32.4 kcal/kg)

Est Pro: 106 gm pro (424 kcal, 18.4% kcal, 1.5 gm/kg, kcal: g N: 135.6)
Est Fat: 77gm fat (69 gm lipid soln) (690 kcal, 30% kcal, .97 gm/kg)
Est Dextrose: 349gm (1186 kcal, 51.6% kcal)
Fluid: 2300 ml (32 ml/kg)
MD TPN Day 1 Diet Order: 500 gm dextrose (1700 kcal, 71% kcals, GIR 4.9mg/kg/min)
75 gm AA (300 kcal, 13%kcals, 200 kcal:gm N, 1.06gm/kg)
200ml 20% lipids (400kcal 17%kcals, .56g/kg)
Total: 2400kcal
A. Less than optimal parenteral nutrition infusion related to inappropriate dextrose, fat, and protein
delivery for patients needs as evidenced by high GIR (4.9mg/kg/min), low fat kcals (13%kcals), and high
kcal:gm N ratio (200 kcal:gm N)
Pt has clinical signs of GI impairment (no BS, no BM x 2 days, abd distended). Although pt BMI is
normal, pts rapid weight loss and increased nutrient requirements for healing/recovery place him at
increased nutrition risk for complications and infection after GI surgery. Because pt was well nourished
PTA, meeting above estimated nutrient requirements via TPN will provide adequate energy and protein
to spare muscle and stabilize weight.
After assessing Day 1 TPN doctor order, reevaluation of order recommended due to risk of
complications. Reduce 500 g dextrose, as GIR is above recommended 2ml/kg/min for first day. Above
this range puts pt at risk for hyperglycemia, electrolyte imbalances and refeeding syndrome. Increase 75
gm AA to meet protein recommendations for recovery state and proper immune function (1.5 gm/kg).
Increase 200 ml 20% lipids to meet requirements for adequate 30% of total calories. MD diet order does
provide adequate calories for a 1.4 IF, as pt has undergone major surgery and lost weight. Adjustments
to TPN will slightly lower kcals (2400 to 2300).
Due to severe weight loss, pt likely to be motivated to consent to TPN adjustments.
P. Bowel rest with complete nutrient support via TPN:
Goal: 2300 ml (96 ml/hr continuous infusion) TPN containing AA 4.6% (106gm), D 15.2% (349 gm)
with 345ml IL 20% (69gm lipid; .97gm/kg/day) at a rate of 29ml/hr q 12 hrs continuous infusion
GIR 3.4 mg/kg/min
kcal: 2300
kcal: g N: 135.6

Nicole Mize 3-6 lab

Total provides Pro: 18.4% kcal, 1.5 gm/kg; Fat: 69 gm lipid soln, 30% kcal, .97 gm/kg; Dextrose: 51.6%
kcal and meets 2300 ml fluid requirements. This fluid requirement was chosen to meet both the
30ml/kg recommendation and the kcal=ml recommendation.
Start with Day 1 recommendations. As tolerated and after monitoring for hyperglycemia, possible return
of BM, electrolyte, fluid adequacy, TGs and serum alb, proceed towards Day 3 goal.
Day 1: 2300ml (96 ml/hr continuous infusion) TPN containing AA 4.6% (106gm), D 7.6% (174.5 gm)
with 345ml IL 20% (69gm lipid; .97gm/kg/day) at a rate of 29ml/hr q 12 hrs continuous infusion
GIR 1.7 mg/kg/min
kcal: 1707
Day 2: 2300 ml (96 ml/hr continuous infusion) TPN containing AA 4.6% (106gm), D 11.4% (261.8 gm)
with 345ml IL 20% (69gm lipid; .97gm/kg/day) at a rate of 29ml/hr q 12 hrs continuous infusion
GIR 2.6 mg/kg/min
kcal: 2004
Day 3: 2300 ml (96 ml/hr continuous infusion) TPN containing AA 4.6% (106gm), D 15.2% (349 gm)
with 345ml IL 20% (69gm lipid; .97gm/kg/day) at a rate of 29ml/hr q 12 hrs continuous infusion
GIR 3.4 mg/kg/min
kcal: 2300
F/U in 4 days to re-assess TPN requirements with daily wt, I&Os, and lab results (alb, Chem 7).

Nicole S. Mize, RD in-training