Total Parenteral Nutrition (TPN)
Dhadhang Wahyu Kurniawan
Laboratorium Farmasetika Unsoed
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Cara penyiapan TPN Cara pemberian TPN Komponen TPN
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Definisi Penyediaan semua nutrisi melalui
selain saluran pencernaan Penghantaran nutrisi secara
intravena, misalnya melalui aliran darah. Nutrisi parenteral Tengah: sering disebut total
parenteral nutrition (TPN); dihantarkan ke vena pusat
Nutrisi parenteral perifer (PPN): dihantarkan ke dalam suatu vena perifer atau yang lebih kecil
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Nutrien, dibutuhkan untuk: pertumbuhan sel fungsi seluler sintesis karbohidrat-lemak-protein kontraksi otot penyembuhan luka daya tahan tubuh/kekebalan integritas percernaan
BATASAN
Ke dalam TPN (volume besar) tidak boleh ditambahkan pengawet karena dapat menyebabkan terjadinya toksisitas akibat pemberian pengawet dalam jumlah besar.
Syarat untuk semua TPN: Steril Bebas pirogen Bebas partikel partikulat Dikemas dalam kemasan dosis tunggal Bebas pengawet
Indikasi Mereka yang tidak makan: anorexia
nervosa Mereka yang tidak bisa makan:
stenosis esofagus, prolong ileus, Mereka yang tidak diizinkan untuk
makan: gastrointestinal fistula, inflamasi penyakit usus, radiasi enteritis, chemotoxicity GI, pankreatitis
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Indikasi Mereka yang tidak cukup makan:
sindrom usus pendek, burn, sepsis Mereka yang dapat mengatur apa
yang mereka makan: kegagalan hati
Lain-lain: gagal ginjal, operasi
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Components of TPN
TPN may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elements.
A TPN solution may contain all or some of these substances, depending on client’s condition.
Komponen TPN Nutritional content: TPN
requires water (30 to 40 mL/kg/day), energy (30 to 60 kcal/kg/day, depending on energy expenditure), amino acids (1 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals
Fluid. Fluid is an essential component of parenteral nutrition.
Calories. Carbohydrate. Glucose is the main source Protein. This is delivered as a synthetic
crystalline amino acid solution. Adverse effects of excess protein include a rise in urea and ammonia
Intralipid. An oil-in-water emulsion derived from egg phospholipid, soyabean and glycerol.
Komponen TPN
Komponen TPN
Minerals. Sodium, potassium, chloride, calcium, magnesium and phosphorus levels need to be closely monitored
Trace Elements. Zinc, copper, manganese, selenium, fluorine and iodine are provided in a number of commercial TPN preparations.
Vitamins. The daily requirements for both water and fat soluble vitamins can be provided in TPN
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Parenteral Nutrition Vitamin Guidelines
Vitamin FDA Guidelines*
A IU 3300 IU
D IU 200 IU
E IU 10 IU
K mcg 150 mcg
C mg 200
Folate mcg 600
Niacin mg 40
Vitamin FDA Guidelines*
B2 mg 3.6
B1 mg 6
B6 mg 6
B12 mg 5.0
Biotin mcg 60
B5 dexpanthenol
mg
15
*Federal Register 66(77): April 20, 2000
Calculating Calories
Carbohydrate:ml/24h TPN x % Dextrose x 3.4 kcal/g = kcal/kg
100 x wt (kg) Fat: ml/24h 20% intralipid x 2 kcal/ml =
kcal/kgwt (kg)
Protein: g/kg protein x 4 kcal/g = kcal/kg
Balance of Calories Dextrose: 40% - 60% Amino Acids: 10%- 12% Lipids: 25 – 50% This is the ideal balance at the
completion of the advance
Electrolytes (mEq/kg/day)
Infant and Toddler
Children Adolescents
Na 2-4 2-4 2-3
K 1-3 1-3 1-2
Ca 1-2 0.5-1 0.25-0.5
Mg 0.25-0.5 0.25-0.5 0.25-0.5
Phos(mMol)
1-1.5 0.5-1 0.5-0.75
3:1
Means all 3 main ingredients are in one bag Amino acids Fat emulsion Dextrose
Will not do in neonatal AA’s Decreases Ca/phos compatability Cannot see if the Ca/Phos precipitates
3:1 AA % must be at least 2% Must be standard AA Ca + Mg must be < 20 mEq/L
Cracks the fat emulsion
Parenteral base solutions Karbohidrat
Tersedia dalam konsentrasi 5 – 70% D30, D50 and D70 used for manual mixing
Asam amino Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20%
solutions 8.5% and 10% generally used for manual
mixing Lemak
10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in
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Other requirements
Fluid—30 to 50 ml/kg (1.5 to 3 L/day)
Sterile water is added to PN admixture to meet fluid requirements
Electrolytes Use acetate or chloride forms to
manage metabolic acidosis or alkalosis
Vitamins: multivitamin formulations Trace elements
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PN Solution Componentsa
Central Peripheral ---Solutions--- Solutions
Lipid- Dextrose- based based
Dextrose 14.5% 35.0% <10.0%
Amino Acids 5.5% 5.0% <4.25%
Fat 5.0% 250 ml/ 3.0 - 8.0% 20% fat q M,Tha% Final Concentration Courtesy of Marian, MJ.
Initiation of PN: Formulation
Generally energy and protein needs can be met in adults by day 2 or 3
In neonates and peds, time to reach full support relates inversely to age, may be 3-5 days
Initiation of PN: formulation
As protein associated with few metabolic side effects, maximum amount of protein can be given on the first day, up to 60-70 grams/liter
Maximum carbohydrate given first day 150-200 g/day or a 15-20% final dextrose concentration
In patients with glucose intolerance, 100-150 g dextrose or 10-15% glucose concentration may be given initially
ASPEN Nutrition Support Practice Manual 2005; p. 98-99
Ketika akan menggunakan TPN, konfirmasikan label tas TPN dengan bentuk order yang asli
Larutan dapat dimodifikasi berdasarkan hasil laboratorium, gangguan yang dialami, hypermetabolism, atau faktor lain.
Lipid: emulsi lipid yang tersedia secara komersial sering ditambahkan untuk memasok asam lemak esensial dan trigliserida; 20 sampai 30% dari total kalori biasanya diberikan sebagai lipid.
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Pemberian TPN
Sebelum TPN diberikan, lihat larutan yang masih tertutup.
Ini harus jelas dan bebas dari bahan mengambang. Remas tas dengan lembut atau amati wadah larutan untuk memastikan tidak ada kebocoran.
Jangan menggunakan solusi jika sudah berubah warna, jika mengandung partikel, atau jika kantong atau wadah bocor.
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Pemberian TPN Karena larutan TPN kebanyakan
terkonsentrasi dan dapat menyebabkan trombosis vena perifer, maka biasanya diperlukan kateter vena sentral.
Larutannya dimulai perlahan-lahan pada 50% dihitung dari kebutuhan biasanya untuk 24 jam pertama
Insulin: Jumlah insulin reguler yang diberikan (ditambahkan secara langsung ke larutan TPN) tergantung pada tingkat glukosa darah
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Two-in-One PN
PN Compounding Machines: Automix
PN Compounding Machines: Micromix
Document in Chart Type of feeding formula and
tube Method (bolus, drip, pump) Rate and water flush Intake energy and protein Tolerance, complications, and
corrective actions Patient education
Thanks !!
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