Appropriate Dosing for Parenteral Nutrition:
ASPEN Recommendations
Persistent shortages of parenteral nutrition (PN) components have led to a tendency of practitioners providing less than adequate dosing,
which can lead to nutrient deficiencies and impair growth and healing. Clinicians who have entered practice within the last 10 years may have
never cared for patients receiving PN therapy without a shortage of PN components. This document provides both the appropriate PN nutrient
requirements and dosing recommendations for adult, neonatal, and pediatric patients. Please share with your colleagues.
Topline Recommendations
•
Do not ration nutrients for PN if the supply of those components is sufficient to provide the full daily dose.
•
During component shortages, follow PN management recommendations available on the ASPEN website at
nutritioncare.org/ProductShortageManagement/
•
Return to appropriate dosing as soon as the component shortage has resolved.
•
Rationing and conservation strategies are intended to be used only during shortages.
•
The lack of observed adverse events/deficiencies and the potential cost savings associated with “partial” dosing should not be the
impetus to continue less than optimal dosing.
Note:
These recommendations are general ranges and a patient’s clinical condition and organ function should be taken into account. These
recommendations do not constitute medical or other professional advice and should not be taken as such. To the extent that the information
published herein may be used to assist in the care of patients, this is the result of the sole professional judgment of the attending healthcare
professional whose judgment is the primary component of quality medical care. The information presented in here is not a substitute for
the exercise of such judgment by the healthcare professional. Circumstances in clinical settings and patient indications may require actions
different from those recommended in this document and in those cases, the judgment of the treating professional should prevail.
ASPEN Recommendations on Appropriate Parenteral Nutrition Dosing for
Adult Patients
TABLE 1. MACRONUTRIENTS
Disease/Clinical Condition
Stable
Critically ill, trauma, sepsis
Protein/Amino Acids
(g/kg/d)
0.8-1.5
1.2-2.5
Total Energy
(kcal/kg/d)
20-30
20-30
PN
Dextrose
(mg/kg/min)
4-5
<4
Component
ILE*
(g/kg/d)
1
<1
Different Amino Acid Requirements
than Above
Protein Amino Acids
(g/kg/d)
Total Energy
(kcal/kg/d)
Traumatic brain injury 1.5-2.5
Burns 1.5-2
Open abdomen Additional 15-30 g/L
exudate
Acute kidney injury 0.8-2.0
Continuous renal replacement
therapy
Additional 0.2 g/kg/d not
to exceed 2.5 g/kg/d)
Chronic kidney failure with 1.2
maintenance hemodialysis
Hepatic failure 1.2-2 (based on “dry”
weight and tolerance)
Obese 2-2.5
(based on IBW)
22-25
(based on IBW)
IBW = ideal body weight
*Soybean oil-based emulsion. For indications and dosing of other lipid injectable emulsions (ILE), see manufacturer’s product literature.
Fluid
(mL/kg/d)
30-40
Minimal to
provide adequate
macronutrients
TABLE 2. ELECTROLYTE AND MINERAL
Nutrient
Calcium*
Magnesium
Phosphorus*
Sodium
Potassium
Standard Daily Requirement
10-15 mEq
8-20 mEq
20-40 mmol
1-2 mEq/kg*
1-2 mEq/kg*
Acetate As needed to maintain acid-base balance
Chloride As needed to maintain acid-base balance
*Use caution in prescribing calcium and phosphorus related to compatibility.
GI = Gastrointestinal
Factors That Increase Needs
High protein intake
GI losses, medications, refeeding
High dextrose intake, refeeding
Diarrhea, vomiting, NG suction, GI losses
Diarrhea, vomiting, NG suction, GI losses,
medications, refeeding
Renal insufficiency, metabolic acidosis,
GI losses of bicarbonate
Metabolic alkalosis, volume depletion
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© Copyright 2019 ASPEN | American Society for Parenteral and Enteral Nutrition 1.8.19
TABLE 3. DAILY REQUIREMENTS FOR ADULT
PARENTERAL VITAMINS*
Vitamin
Standard Daily
Requirement
Thiamin (B
1
)
Riboflavin (B
2
)
Niacin (B
3
)
Folic acid
Pantothenic acid
Pyridoxine (B
6
)
Cyanocobalamin (B
12
)
Biotin
Ascorbic acid
Vitamin A
Vitamin D
Vitamin E
Vitamin K
6 mg
3.6 mg
40 mg
600 mcg
15 mg
6 mg
5 mcg
60 mcg
200 mg
990 mcg
5 mcg
10 mg
150 mcg
* Prescribe full daily dose unless patient able to ingest and/or
absorb orally/enterally. Full dose of most multivitamin products
available in the US provides the above requirements.
TABLE 4. DAILY REQUIREMENTS FOR ADULT
PARENTERAL TRACE ELEMENTS*
Trace Element
Standard Daily
Requirement
Chromium <1 mg
Copper 0.3-0.5 mg
Manganese 55 mcg
Selenium 60-100 mcg
Zinc 3-5 mg
* Prescribe full daily dose unless patient able to ingest or
absorb orally/enterally.
Note: These requirements are different than the multi-trace
element products currently available in the US.
ASPEN Recommendations on Appropriate Parenteral Nutrition Dosing for
Neonatal and Pediatric Patients
TABLE 5. DOSING FOR INITIATION AND ADVANCEMENT OF PN MACRONUTRIENTS
Initiation Advance By Goals
Infants (<1 y)
Preterm
Protein (g/kg/d)* 1-3
(3–4 max)
Dextrose (mg/kg/min) 6–8
Term
2.5–3
6–8
ILE (g/kg/d)** 0.5–1 0.5–1
Preterm
—
1–2
0.5–1
Term
—
Preterm
3–4
Term
2.5–3
1–2
0.5–1
10–14
(max
14–18)
10–14
(max
14–18)
3 2.5–3
(max 0.15 (max 0.15
g/kg/h) g/kg/h)
Children (1–10 y)
Protein (g/kg/d) 1.5–2.5 — 1.5–2.5
Dextrose (mg/kg/min) 3–6 1–2 8–10
ILE (g/kg/d)** 1–2 0.5–1 2–2.5
Adolescents
Protein (g/kg/d) 0.8–2 ­— 0.8–2
Dextrose (mg/kg/min) 2.5–3 1–2 5–6
ILE (g/kg/d)** 1 1 1–2
*Protein does not need to be titrated; protein needs are increased with critical illness.
** ILE dosing based on soybean oil-based emulsion. See manufacturer's product information for dosing of other
ILE products.
ILE= Lipid injectable emulsion
GIR = glucose infusion rate; GIR calculation (mg/kg/m) = [dextrose (g/d) x 1000] / [24 (h/d) x 60 (m/hr) x weight (kg)]
TABLE 7. PN DAILY MULTIPLE VITAMIN PRODUCT DOSING
Manufacturer Recommendations† NAG-AMA Recommendations◊
Weight (kg) Dose (mL) Weight (kg) Dose (mL)
Less than 1
1 to less than 3
1.5
3.25
Less than 2.5
Greater than or
equal to 2.5
2 mL/kg
5 mL
Greater than 3 5
† Infuvite Pediatric (Baxter) and M.V.I. Pediatric (Hospira)
◊ Nutrition Advisory Group-American Medical Association
TABLE 8. PN TRACE ELEMENT DAILY DOSING*
Trace Element
Zinc
Preterm Neonates
400 mcg/kg
Term Neonates
3-10 kg
250 mcg/kg
Copper 20 mcg/kg 20 mcg/kg
Manganese 1 mcg/kg 1 mcg/kg
Children 10-40 kg
50 mcg/kg
(max 5000
mcg/d)
20 mcg/kg
(max 500
mcg/d)
1 mcg/kg
(max 55 mcg/d)
Adolescents
Greater
than 40 kg
2-5 mg
200-500 mcg
40-100 mcg
Chromium 0.05-0.3 mcg/kg 0.2 mcg/kg 0.2 mcg/kg
(max 5 mcg/d)
5-15 mcg
TABLE 6. PN ELECTROLYTE AND MINERAL DAILY DOSING*
Preterm Neonates Infants/Children
Adolescents & Children
Greater than 50 kg
Sodium 2-5 mEq/kg 2-5 mEq/kg 1-2 mEq/kg
Potassium 2-4 mEq/kg 2-4 mEq/kg 1-2 mEq/kg
Calcium 2-4 mEq/kg 0.5-4 mEq/kg 10-20 mEq
Phosphorus 1-2 mmol/kg 0.5-2 mmol/kg 10-40 mmol
Magnesium 0.3-0.5 mEq/kg 0.3-0.5 mEq/kg 10-30 mEq
Acetate As needed to maintain acid base-balance
Chloride As needed to maintain acid base-balance
*Use caution in prescribing calcium and phosphorus related to compatibility.
Selenium 2 mcg/kg 2 mcg/kg 2 mcg/kg
(max 100
mcg/d)
40-60 mcg
*Note: These requirements are different than the multi-trace element products currently available in the US.
Per Heather Kistler, RD, CSP, LDN
Inpatient
References
Pediatric & Neonatal Dietitian:
Corkins MR, ed.
The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2nd Ed.
Silver Spring, MD: ASPEN; 2015.
In
McClave SM, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill
regards to the GIR it’s recommended to not start with more than 10% dextrose and if peripheral
not
patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
to exceed 12.5% dextrose concentration; for central lines not to exceed 25% dextrose
concentration.
JPEN J Parenter Enteral Nutr.
2016; 40(2):159–211.
I do
Mirtallo JM, et al. A.S.P.E.N. Safe Practices for Parenteral Nutrition
feel that the dosing guidelines for adolescents may
JPEN J Parenter Enteral Nutr.
end up giving a bit
2004;28(6):S39-S70.
much for a starter TPN.
For
Mueller CM, ed.
adolescents
The ASPEN Adult Nutrition Support Core Curriculum, 3rd Ed.
I usually start around 150 gm dextrose (even
Silver Spring, MD: ASPEN;
if this is lower than 10%
2017.
dextrose) and
between 1-1.5 g/kg amino acid and around 40gm Lipid (template only lets you dose in gm/kg for
Vanek VW, et al. A call to action to bring safer parenteral micronutrient products to the U.S. market.
Nutr Clin Pract.
Lipid
2015;30(4):559–569.
so I typically figure out what the g/kg would be to hit around 40gm Lipid).
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© Copyright 2019 ASPEN | American Society for Parenteral and Enteral Nutrition 1.8.19
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