PARENTERAL NUTRITION IN

DIABETES PATIENTS

Agung Pranoto, Panji Moeljono

Diabetes and Nutrition Center
Dr.Soetomo Teaching Hospital Airlangga University School
of Medicine
 CURRICULUM VITAE

Name : Dr. Pandji Moeljono, Sp.PD K-

EMD,FINASIM
Office Address : Rumah Sakit Angkatan Laut Dr. Ramelan
Jl. Gadung No. 1 Surabaya Indonesia
Tel 62031-8438153
Fax : 031-8437511
Home Address : Jl. Raya Dukuh Kupang 120 Surabaya
Indonesia
Tel : 62031-5683062
Mobile : 08123216601/ O317O4715O5
E-mail : pandjimulyono@yahoo.com
Date of Birth : 20th Desember 1946
Nationality : Indonesian

Educational and Professional Qualifications

University of Airlangga :1973 General Practicioner (MD)
University of Airlangga :1986 Internal Medicine Specialist
Kolegium Penyakit Dalam 2OO6 Konsultan endokrinologi
Indonesia Metabolik Diabet
Organization Membership
PERKENI Organization of Endocrinologist in Indonesia
PAPDI Organization of Indonesians Internist
IDI Organization of Medical Doctor in Indonesia

Present Position
Medical Docter at PUSKESMAS Kandangan ,
1974-1981 Pare, Kediri.
1986 - at date Internal Medicine specialist at Navy Hospital DR
Ramelan Surabaya
1990 at date Lecturer at Medical Faculty ,Hangtuah University
Surabaya
PRESENTATION POINT OF VIEW
1. Medical Nutrition Therapy in DM
2. Hospitalized Diabetes
3. Principle in Parenteral Nutrition
4. Regimen formula in DM
5. Ten guidelines P-PEN in Diabetes
Medical nutrition therapy (MNT)
MNT is an integral component of clinical care for
people with diabetes.
It includes an assessment of nutritional status
and the provision of diet modification,
counseling, or specialized nutrition therapy
TPN in Diabetes
Hyperglycemia in non-DM from TPN is based on a
age
severity of illness
the rate of dextrose infusion
77% of patients required insulin to control glycemia during
TPN needs Insulin 100 + 8 units/day.

Separate IV insulin infusion

Two-thirds of units of insulin used in 24-h period can

subsequently be added to the subsequent TPN bag(s)
TPN vs.. EN: effect on mortality, subgroup analysis in early
EN (<24 hours post ICU) and late EN.
Fiona Simpson and Gordon S Doig. Intensive Care Medicine 2004

Favor TPN Favor EN

Enteral nutrition vs. parenteral nutrition with respect to
mortality rate (RR = 1.08, p = 0.7)
Gramlich et al. Nutrition 2004

Moore 1992 is a meta-analysis and 14.5 % of this meta-analysis

PRESENTATION POINT OF VIEW
1. Medical Nutrition Therapy in DM
2. Hospitalized Diabetes
3. Principle in Parenteral Nutrition
4. Regimen formula in DM
5. Ten guidelines P-PEN in Diabetes
MNT Goals for Hospitalized
Individuals With Diabetes
Blood glucose targets for hospitalized patients:
Preprandial: < 110 mg/dl
Peak postprandial: < 180 mg/dl
Critically ill surgical patients (i.e., intensive
care unit): < 110 mg/gl
Goals of MNT for Hospitalized
Individuals with Diabetes

Optimal metabolic control of blood glucose, lipids, and blood

pressure to enhance recovery from illness and disease.
Treat the complications of diabetes
hypertension, cardiovascular disease, dyslipidemia, and nephropathy.
Provide adequate calories for illness and recovery.
Improve health through use of nutritious foods.
Address individual needs based on personal, cultural,
religious, and ethnic food preferences.
Provide a plan for continuing self-management education and
follow-up care.
Glycemic Goals in Hospital

Schmeltz , 2011
PRESENTATION POINT OF VIEW
1. Medical Nutrition Therapy in DM
2. Hospitalized Diabetes
3. Principle in Parenteral Nutrition
4. Regimen formula in DM
5. Ten guidelines P-PEN in Diabetes
 First Step to be Considered
A well-nourished: can tolerate 7 days of starvation with SRI
Malnourished: wound healing, immune function, or ventilatory
function are impaired
PCM: Weight loss >20% of usual , Severe < 80% of standar
standardd
> 10 % during the previus 6 mnh or weiht/heigh <
90 % of standard (mild PCM)
SRI (systemic response to inflammation)
inflammation, injury, and infection increase the rate of lean tissue loss.
Consequence of SRI:
fluid retention and hyperglycemia
impairment of anabolic responses to nutritional support.
 IDENTIFIED OF SRI
CLINICAL SIGN ;TACHYCARDIA,TACHYPNEA,AND/OR t
elevation/depresion
LEKOCYTOSIS
Severity of systemic response to
inflammation (SRI)
Severe SRI:
sepsis or other inflammatory conditions like
pancreatitis requiring ICU care, multiple trauma with
an Injury Severity Score > 2025 or APACHE II > 25,
closed head injury with a Glasgow Coma Scale < 8, or
major third-degree burns of >40% of body surface
area.
Moderate SRI
less severe infections, injuries, or inflammatory
conditions like pneumonia, major surgery, acute
hepatic or renal insufficiency, and exacerbations of
ulcerative colitis or regional enteritis requiring
hospitalization.
Time to Feed
Severe SRI requires early feeding
Moderate SRI benefits from adequate feeding by
day 57 if the patient was initially well
nourished.
Severely malnourished, candidates for elective
major surgery benefit from preoperative
nutritional repletion for 57 days.
Moderate SRI and Moderate PCM: benefit from
earlier feeding within the first several days.
 THE TIMING OF NUTRITIONAL
SUPPORT

Preexisting Nutritional Status

The Presence and Extent of SRI

The Anticipated Clinical Course

Algorithm for implementation of SNS
Specialized Nutritional Support

Continued in the following page

INDICATION & CONTRA
INDICATION CONTRA INDICATION
Non-functional Ability to adequately
gastrointestinal tract receive and adsorb
Impossible to use the necessary foods orally or
gastrointestinal tract by gastric or enteral tube
Need for intestinal rest Hemodinamic instability

Palliative use in terminal

patients is controversial
Benefits of nutritional support
Gramlich et al. 2004, Silk DB and Menzies Gow N 2001, Jeejeebhoy KN 2001

Improved wound healing

Decreased catabolic response to injury
Improved clinical outcomes
complications
rehabilitation
length of stay
costs
Adverse effects and risks
Jeejeebhoy KN 2001, OBoyle et al. 1998, Gramlich et al. 2004

Parenteral nutrition Early enteral nutrition

Overfeeding Procedure-related
Hyperglycemia complications Lipman 1998,
Woodcock 2000
Infectious complications
Gut mucosal atrophy? High gastric residuals
Jiang X-H et al. 2003 Bacterial colonization of the
(n=40), method: urine stomach
excretion ratios of Aspiration pneumonia
lactulose and mannitol
Bacterial translocation?
Animal studies
 Parenteral Nutrition
Central Parenteral Nutrition
Selection depends on caloric
requirements, volume to be
administered and patient
condition, asa well as final
concentration of components
Amino acids > 5%
Dextrose > 20%
Lipids
Vitamins, minerals, trace
elements
Osmolality > 700 mOsm/kg H2O
Peripheral Parenteral
Nutrition
Selection depends on clinical
situation, requirements,
tolerance to volume, and
final formula concentration
Osmolality < 700 mOsm/kg
H2O
Total kcal limited by
concentration and ratioo to
volume being administered
Amino Acids
Essential Conditionally Essential
Leucine Glutamine
Lysine Arginine
Valine
Threonine
Isoleicine
Non essentiale
Phenylalanin Alanine
Methionine Tyrosine
Histidine Aspartic Acid
Tryptophan Glutamic acid
Cysteine
Glycine
Serine
Proline
 Effects of glutamine
Local and systemic insults provision:
1. Maintenance of gut
integrity
Gut 1 Brain 2. Support of the
immune system
Damage of the Stimulation of
3. Inhibition of muscle
gut mucosa the sympathicus degradation
4 4. Inhibition of
Translocation of Stress
glatamine depletion
bacteria and hormones
Glutamine depletion of
endotoxins
the organism
Insulin
Glutamine flux in
catabolic situations

Systemic reaction Glutamine release Immune cells 2 Insufficient glutamine

Proteolysis supply
Proliferation

Local insults: radiation,

Catabolism chemotheraphy,
inflammation, severe
3 diarrhea.
Muscle
Systemic insults:
malnutrition, shock,
Multiple organ failure sepsis, severe trauma,
advanced carcinoma

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 297
Uses of Amino Acids
Nonprotein kcal : N ratio
the most severely stressed patients : 80 : 1
severely stressed patients : 100 : 1
Unstressed patients: 150 : 1
 Dextrose Solution Concentrations
Percent Dextrose
Notation
Solution
Dextrose solutions are (g/100mL)
available in the following concentrations:

5% 5 D5W
10% 10 D10W
20% 20 D20W
30% 30 D30W
40% 40 D40W
50% 50 D50W
60% 60 D60W
70% 70 D70W

D50W is most commonly used for TPN.

Infusion Rate of Dextrose
60 kg patient:
Dextrose infusion should not be greater than
.36g/kg/hr
0.36 x 60 kg x 24 hr = 518 grams per day

Excess glucose:
fatty liver.
excess CO2 production, which is undesirable for
patients with respiratory problems.
DEXTROSE IN PARENTERAL NUTRITION

Monohydric glucose (dextrose): 3.4 kcal/gram.

Concentrated dextrose solution (50% to 70%)
Dextrose:
can be used as the sole source of energy
or in different combinations with lipid emulsions

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 294
 ADVERSE EFFECTS OF DEXTROSE
As the only source of energy
Hyperglycemia or hypoglycemia
hyperosmolar dehydration
Hypophosphatemia
essential fatty acid deficiency
fatty infiltration of the liver
increased CO2 production
increased excretion of catecholamine
Contraindicated as Glucose as the sole source:
essential fatty acid deficiencies, fluid overload, difficult-to-manage
diabetes, or respiratory insufficiency with hypercapnia.

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 294
Lipid Emulsions
Lipids in parenteral nutrition are used as a source
of essential fatty acids (EFA) and energy. Lipid
emulsions are composed of soybean and/or
safflower oil, glycerol, and egg phospholipid.
4% of total kcaloric intake should be EFAs to
prevent EFA deficiency.
Since IV lipids are isotonic and calorically dense,
they are a good source of kcalories for hypermetabolic patients
volume or carbohydrate restrictions: Lipids can provide up to 60% of
non-protein calories.
Lipid Emulsion Administration
Example calculation of maximum daily lipids
60 kg patient: 2.5g/kg x 60 kg = 150g per day max

To prevent hyperlipidemia, lipid emulsions are

not provided continuously.
2-3 times per week, but can be provided daily.
Infusion times of 4-6 hours for 10% lipids and 8-12
hours for 20% lipids are recommended,
although 12-24 hour infusions may be better tolerated
by some patients.
Max dose: 2.5g/kg per day
Contraindications for Lipid Emulsions
Abnormal lipid metabolism
Lipid nephrosis
Acute pancreatitis (if concomitant with or caused by
hyperlipidemia)
Severe egg allergies

With caution if the patient has:

A blood coagulation disorder
Moderate to severe liver disease
Compromised pulmonary function
 The Structure of Lipids

Medium chain triglycerides do not require carnitine for

oxidation and therefore may be more easily used for
energy in the stressed patient. MCTs produce greater
numbers of ketones than LCTs, and ketones can be a
secondary source of energy for peripheral tissues.

A mixture of LCT and MCT may be beneficial for some

patients.
Conditions that can alter mineral needs:

Mineral Increase Needs Decrease Needs

Potassium wasting meds Potassium sparing meds
Diuresis Renal failure
Potassium
Anabolism Massive tissue
GI losses (vomiting, diarrhea) destruction
Diuretic use Hepatic failure
Sodium GI losses (above) Congestive heart failure

Calcium Pregnancy, Pancreatitis Hypercalcemia

Phosphorus Anabolism Renal failure
Metabolic alkalosis Metabolic acidosis
Chloride
Nasogastric suction
Anabolism Renal failure
Mg wasting meds
Hypokalemia
Magnesium
Alcoholism
GI losses (short bowel
syndrome, diarrhea, )
From: American Dietetic Association Diet Manual, Chicago: ADA, 1993
DAILY VITAMIN SUPPLEMENTS FOR PN FORMULAS

Vitamin Alowance

Thiamin (B1) 3 mg
Riboflavin (B2) 3.6 mg
Niacin (B3) 40 mg
Folic acid 400 mcg
Pantothenic acid 15 mg
Pyridoxin (B6) 4 mg
Cyanovcobalamin (B12) 5 mcg
Biotin 60 mcg
Ascorbic acid (c) 100 mg
Vitamin A 3,300 IU
Vitamin D 200 IU
Vitamin E 10 IU
Vitamin K is supplied at 2 4 mg/week in patients not receiving anticoagulant therapy

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 303
 RECOMMENDED AMOUNTS OF
PARENTERAL MINERALS

Mineral Quantity
Zinc 2.5 4 mg
Copper 0.5 1.5 mg
Chromium 10.0 15.0 mcg
Manganese 0.15 0.8 mg

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 305
 CALCULATING SUPPLEMENTARY IRON
DOSAGE

mg of iron = 0.66 x BW [100 Hgb (100)]

14.8

BW = Body weight in kg
Hgb = % hemoglobin in grams/dL

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 305
PRESENTATION POINT OF VIEW
1. Medical Nutrition Therapy in DM
2. Hospitalized Diabetes
3. Principle in Parenteral Nutrition
4. Regimen formula in DM
5. Ten guidelines P-PEN in Diabetes
 MACRONUTRIENT FORMULA DESIGNED FOR PARENTERAL
NUTRITION OF SPECIFIC PATIENTS
Criteria
Determine total energy needs
Multiply kcal by the desired substrate
(carbohydrates, protein, lipids) distribution
To determine total grams in the final solution,
divide by kcal/gram
Determine the volume of stock solutions of dextrose,
amino
acids, and lipids to achieve grams of nutrients needed
Desired grams + % stock solution =
required volume of solution
Add the total volume of macronutrients and evaluate
based
on fluid requirements. If necessary, total volume can be
increased with sterilized water
Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 308
Examples
1,600 kcal
1,600 x 55% carbohydrates = 880 kcal
1,600 x 20% proteins = 320 kcal
1,600 x 25% lipids = 400 kcal
880 + 3.4 = 259 grams of dextrose
320 + 4.0 = 80 grams of amino acids
400 + 2.0 = 200 mL of lipids at 20%
D70: 259 + 0.70 = 370 mL
15% Amino acids: 80 + 0.15 = 533 mL
400 kcal of lipids + 2 kcal/mL of lipids at 20% =
200
mL (if lipids are used, indicate whether the
desired infusion is a three-in-one, daily, weekly,
twice weekly, or more times per week)
370 + 533 + 200 = 1,103 mL
 SAMPLE PERIPHERAL PARENTERAL NUTRITION
FORMULAS WITH OR WITHOUT LIPIDS

Without Lipids With Lipids

Dextrose 500 mL of 10% solution 500 mL of 10% solution

Amino acids 500 mL of 3.5% solution 500 mL of 3.5% solution
Lipids - 100 mL of 20% solution
Total volume 1,000 mL 1,100 mL
Protein 17.5 g/L 16 g/L
Nonprotein kcal 170 kcal/mL 336 kcal/L
Approx. osmolality 512 mOsm/L 496 mOsm/L

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 306
 SUGGESTED MONITORING PLAN FOR TOTAL
PARENTERAL NUTRITION

Parameter Frequency*

Blood glucose Every six hours

Vital signs Every eight hours
Blood electrolytes Daily
Blood urea nitrogen (BUN), creatine Daily
Blood calcium and phosphorus Daily
Magnesium, hepatic enzymes, and blood bilirubin Every two days
Blood triglycerides, cholesterol, and albumin One time weekly
Urinary urea nitrogen for 24 hours One time weekly*
Estimated nutrient intake Daily
Monitoring of liquids ingested and eliminated Daily
Body weight Daily
* Frequency can decrease once the patient is stable

Total Nutritional Therapy version 2.0, Program Manual, Chapter 17: Parenteral Nutrition, pp. 311
 DOSIS INSULIN DALAM BOTOL PADA NPE
Rumus 2.5-1 , 5-1
(Tjokroprawiro, 1995)

ASK-DNC
1 Glukosa : Setiap 2.5 gram - 1 Unit Insulin Dalam Botol

2 Fruktosa, Xylitol
Sorbitol, Maltosa Setiap 5 gram - 1 Unit Insulin Dalam Botol
PRESENTATION POINT OF VIEW
1. Medical Nutrition Therapy in DM
2. Hospitalized Diabetes
3. Principle in Parenteral Nutrition
4. Regimen formula in DM
5. Ten guidelines P-PEN in Diabetes
Ten guidelines P-PEN in Diabetes
(Tjokroprawiro, 2006)

1. Check Osmol < 600 1000 mOsm

2. Fluid 30 ml/kgBW and 30 kCal/kgBW
3. Normal hemodynamic & rapid blood glucose < 250 mg/dl
4. P-PEN if blood glucose < 250 mg/dl
5. Day 1 3: Start Slow Go Slow (400-800 kCal/day)
6. Glucose/Maltose: 100-150 g/day
7. AA-Infusion : Continuous Infusion; Day 2-3; Backed up: 25
kcal/1g AA
8. Fat Emulsion : 20-40 % NPC; 20% Solution is
Recommended
9. Fat Emulsion : 10 Advantages, Continuous Infusion for 24
hrs
10. P-PEN : Do Perfectly !!
 AMINOFLUID
Electrolytes, 7.5% Glucose, 3% Amino Acids
Practical and Complete Maintenance Solution for Better Clinical Outcome

Komposisi AMINOFLUID1000 ML
Ingredients Composition Ingredients Composition
L-Isoleucine 2.4 Sodium 35
L-Leucine 4.2 Potassium 20
L-Lysine 3.15 Magnesium 5
Essential amino acid L-Methionine 1.17 Calcium 5
(g/1000 mL) L-Phenylalanine 2.1 Chloride 35
L-Threonine 1.71 Electrolytes Sulfate 5
L-Tryptophan 0.6 (mEq/L) Acetate 13
L-Valine 2.4 Gluconate 5
L-Alanine 2.4 Lactate 20
L-Arginine 3.15 Citrate 6
L-Histidine 1.5 Phosphorus (mmol/L) 10
L-Proline 1.5 Zinc (mol/L) 5
Nonessential amino acid L-Serine 0.9 Total amino acids 30 gr
(g/1000 mL) L-Tyrosine 1.5 BCAA (% in Total amino acids) 9 gr
Glycine 1.77 Dextrose 75 gr
L-Cysteine 0.3 Total energy in 1,000 mL 420 kcal
L-Glutamic acid 0.3 Osmolarity (mOsm/Lt) 817
L-Aspartic acid 0.3 pH ~6.7