Total Parenteral Nutrition (TPN)

Dhadhang Wahyu Kurniawan Laboratorium Farmasetika Unsoed Twitter: Dhadhang_WK Facebook: Dhadhang Wahyu Kurniawan

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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 clients 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

Komponen TPN

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

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 A IU D IU E IU K mcg C mg Folate mcg Niacin mg FDA Guidelines* 3300 IU 200 IU 10 IU 150 mcg 200 600 40 Vitamin B2 mg B1 mg B6 mg B12 mg Biotin mcg
B5 dexpanthenol
mg

FDA Guidelines* 3.6 6 6 5.0 60 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/kg wt (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 K Ca Mg Phos
(mMol)

2-4 1-3 1-2 0.25-0.5 1-1.5

2-4 1-3 0.5-1 0.25-0.5 0.5-1

2-3 1-2 0.25-0.5 0.25-0.5 0.5-0.75

3:1

Means all 3 main ingredients are in one bag

Amino acids Fat emulsion Dextrose Decreases Ca/phos compatability Cannot see if the Ca/Phos precipitates

Will not do in neonatal AAs

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 Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions 8.5% and 10% generally used for manual mixing 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA, not for direct venous delivery)
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Asam amino

Lemak

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Other requirements

Fluid30 to 50 ml/kg (1.5 to 3 L/day)

Sterile water is added to PN admixture to meet fluid requirements Use acetate or chloride forms to manage metabolic acidosis or alkalosis

Electrolytes

Vitamins: multivitamin formulations Trace elements

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PN Solution Componentsa
Central ---Solutions--Lipidbased Dextrose Amino Acids Fat
a% Final Concentration

Peripheral Solutions

Dextrosebased 35.0% 5.0% 250 ml/ 20% fat q M,Th <10.0% <4.25% 3.0 - 8.0%

14.5% 5.5% 5.0%

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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