1 a patient with chronic kidney disease stage iv

Question

1. A patient with Chronic Kidney Disease (Stage IV), who makes very little urine, presents to the hospital with severe nutritional deficiencies.  You are starting her on TPN for nutritional support. Her Non-protein calorie requirement is 1600 kcals.  Which lipid product would you choose and why?

1. 10% 250mL
2. 10% 500mL
3. 20% 250mL

2. What is the formula or recipe (%) of the following PN bag containing the following ingredients: Dextrose 425g, Protein 84g, total volume 2000mL?

1. Dextrose
2. Protein
3. How many mL of 70% dextrose solution are needed to make this PN?

3. A 38 yo female is initiated on a PPN for nutritional support. On the second day of administration, she develops swelling around the peripheral IV site accompanied by erythema and pain.  The current bag contains: Dextrose 387g, Protein 90g, total volume 1600mL

1. What is her current formula? (Dextrose% and Protein%)
2. Why do you think she has developed pain, swelling, and erythema?
3. How would you change the dextrose and protein concentrations above if the medicine team wanted to continue administering parenteral nutrition peripherally (PPN) using the same volume? How many kcals would this provide?

4. AJ 37 yo female is admitted to the burn ICU for burn injuries sustained during a house fire. She has 30% total body burns and is in critical condition. Prior to the house fire, she was in her usual state of health.

NKDA                                               Current Meds:           Zosyn 4.5g q8h
PMH: HTN                                                                 Vancomycin 1g q12h
SocH: (+) tobacco                                                    Furosemide 40mg IV q12h
                                                                             Famotidine 40mg IV daily
            Wt: 64 kg        Ht: 170 cm                                 Morphine PCA

1. Calculate AJ's basal energy expenditure using the Harris-Benedict Equation:
2. What does this represent?
3. Determine her TOTAL caloric requirement using stress and activity factors. Stress Factor 1.8 (Burn); Activity factor 1.2 (confined to bed)
4. Determine her volume requirement (round to the nearest 100 mL). (use the formula: 1500mL + 20mL x (# kg over 20kg))
5. Do you think she has an increased or decreased fluid requirement?
6. Calculate her daily protein need in grams and kcals. Use the maximum g/kg/day for patients under severe stress.
7. Calculate AJ's non-protein calories
8. Calculate her lipid requirement (in kcals) if the goal formula contains lipids at 35% of non-protein calories
9. You have 20% lipids available at the hospital. How many milliliters of the 20% lipids are needed to achieve the kcals calculated above? (hint:: 20% lipids contain 2 kcal/ml)
10. Calculate her dextrose requirement if the goal formula contains dextrose at 65% of non-protein calories. Calculate kcals and grams of dextrose.
11. Is this less than the maximum mg/kg/min for dextrose (assume it is run over 24 hours)?
12. Regardless of your answer for (j), write the final recipe for AJ's TPN using your calculations above:

  i.    Protein

  ii.    Dextrose

  iii.    Lipids (20% lipids  ______ mL)

5. AJ develops chronic renal failure after 6 months of hospitalizations and rehabs (CrCl= 22 ml/m).  She is not undergoing dialysis or CRRT. How does this change your TPN formula (say in words, do not re calculate)?