The proportion of carbohydrate, amino acid, and fat is dictated by a few basic principles. Dextrose provided at a rate of 7 mg/kg/min, once glycogen stores have been repleted, engenders a lipogenic response. This is evidenced by a respiratory quotient of greater than 1, development of fatty liver, and excess carbon dioxide production. An infusion rate of 4 mg/kg/min appears to be optimal and is less likely to lead to hyperglycemia. Hyperglycemia has an untoward effect on phagocytosis apart from any other metabolic sequelae incumbent on high insulin levels, such as diminished fluid excretion. In practice, this level is achieved only when glucose control is attained on about day 2 or 3.
Nitrogen requirement ranges from 250 to 400 mg/kg/day depending on the amount of stress (1 g N is equivalent to 6.25 g protein). Again, no advantage is gained by administering surplus nitrogen.
The remaining calories can be administered as fat. The use of fat as a calorie source obviates the problems of high-dose dextrose infusions while providing the essential fatty acids and the immunomodulating functions alluded to earlier.
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