‫ن‬

‫ه‬ ‫م‬‫َ‬ ‫ْ‬

‫ح‬ ‫َّ‬
‫ر‬ ‫ال‬ ‫ه‬
‫للا‬ ‫بسم‬
‫يم‬
‫ح ه‬ ‫ال َّر ه‬
Total
Parenteral
Nutrition
Sebuah metode pemberian
makanan melalui infusi campuran
seluruh nutrisi yang diperlukan
pasien ke dalam sistem sirkulasi.
Usus merupakan jalur terbaik untuk
pemerian nutrisi
Nutrisi Parenteral diindikasi bila
terdapat disfungsi gastrointestinal
yang parah (Pasien tidak dapat
memperoleh makanan yang
memadai )
 INDICATIONS

 In well-nourished adults, 7 - 10 days of starvation with conventional

intravenous support (using 5% dextrose solutions) is generally accepted.
 If the period of starvation is to extend beyond this time, or the patient is not
well-nourished, Total Parenteral Nutrition (TPN) is necessary to prevent the
potential complications of malnutrition.
 Indications for TPN
Short-term use
Bowel injury, surgery, major trauma or burns
Bowel disease (e.g. obstructions, fistulas)
Severe malnutrition
Nutritional preparation prior to surgery.
Malabsorption - bowel cancer
Severe pancreatitis
 Malnourished patients who have high risk of aspiration
Long-term use (HOME PN)
Prolonged Intestinal Failure
Crohn’s Disease
Bowel resection
 Kebutuhan Nutrisi

 Energy: Glucose
Lipid
 Amino acids (Nitrogen)
 Water and electrolytes
 Vitamins
 Trace elements
 Requirements:
Energy
 Individual : BB, Umur, Jenis Kelamin, Aktivitas dan proses penyakit.
 Estimasi kebutuhan energi
 Orang dewasa + 25-30 kcal/ kgBW/day.
 Kebutuhan mungkin meningkat pada pasien injury or infection.
 Energy Requirements
Patient condition Basal Approximate energy
metabolic Requirement
rate (kcal/kg/day)
No postoperative Normal 25-30
complications, GIT
fistula without infection
Mild peritonitis, long-bone 25% above 30-35
fracture, mild to moderate normal
injury, malnourished
Severe injury or infection 50% above 35-45
normal
Burn 40-100% of total body Up to 100% 45-80
surface above normal
 Requirements:
 Sumber Energy : Glucose

Kebanyakan diperoleh dari glucose, karena :

 Mudah dimetabolisme kebanyakan pasien
 Menurunkan gluconeogenesis.
 1 gm of glucose gives 4 Kcals.

Pasien dapat mentoleransi 4-5 mg.kg-1.Min-1, utk

resistensi insulin mungkin dapat terjadi
hiperglikemia.
Larutan Glucose 5% aman diberikan melalui
vena perifer , Tetapi pada konsentrasi lebih tinggi
melalui vena sentral.
Larutan 20, 25, or even 50 % diperlukan untuk
mendapatkan energi yang mamadai.
 Requirements:
 Sumber Energy : Lipid

Mobilisasi lemak akibat dari stress and infeksi.

Trigliserida sumber pembakaran pending
pada kondisi ini, apabila dari glukose tidak
memenuhi
 Diperlukan pembatasan pd Px hypertriglyceridemia.

Lipid adalah sumber asam lemak esensial

Idealnya energi dari lemak <40% (20-30%).
Emulsi lemak dapat diberikan melalui vena
perifer
Nilai kalori lemak 9Kcal/g, Nilai emulsi lemak
10Kcal/g tergantung kandungan glycerol and
phospholipids.
 Requirements:
 Nitrogen
 Protein (asam amino)
 Kebutuhan protein 0.8 g/kg/day.
 Penyakit, intake makanan buruk & inaktivitas, kehilangan protein tubuh 
kelelahan kehilangan masssa otot.
 Critically ill patients : 1.5-2.5 g protein/kg/day tergantung stadiumnya
(major trauma or burn > infection or after surgery
> standard)
 Penurunan kebutuhan pada penyakit hepar dan renal.
 Requirements:
 Nitrogen
Daily Protein requirements

Condition Example requirement

Basic requirements Normal person 0.5-1g/Kg
Slightly increased Post-operative, cancer, 1.5g/Kg
requirements inflammatory
Moderately increased Sepsis, polytrauma 2g/Kg
requirements
Highly increased Peritonitis, burns, 2.5g/Kg
requirements
Reduced requirements Renal failure, hepatic 0.6g/Kg
encephalopathy
 Requirements:
 Nitrogen

Laut as.amino menyediakan semua

as.am.esential
 Sediaan 3.5 - 15 %
 1gm of protein = 0.16 gm of N2.
 Requirements:
 Fluids and electrolytes
 Dws muda : 20–40 mL/kg/hari
 Dws tua : 30 mL/kg/hari
 Na, K, Cl, Ca, Mg, P. Tergantung status Px
 Keseimbangan asam basa merupakan prioritas
 Kebanyakan elektrolit dpt ditambahkan pd lart as.amino/glukosa
 Sodium bicarbonate konst tinggi dapat meningkatkan pH campuran
as.amino/glukosa
 Requirements:
 Fluids and electrolytes

Nutrient Requirements (/Kg/day)

Water 20-40 mL
Sodium 0.5-1.0 mmol
Potassium 0.5-1.0 mmol
Magnesium 0.1-0.2 mmol
Calcium 0.05-0.15mmol
Phosphate 0.2-0.5mmol
Chloride/Acetate So a to maintain acid-base balance
(normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)
 Requirements:
Vitamins
Px dng penyakit parah ada peningkatan
kebutuhan vitamin
Vitamin larut lemak (A,D,E,K) or larut air (B,C).
Formula Multivitamin parenteral biasanya
mengandung12 vitamin
 Penambahan dapat diberikan secara
terpisah
 Requirements:
 Trace minerals

Larutan multi elemen tersedia secara komersial

Zat besi biasanya dipisahkan (stabilitas) diberikan
secara terpisah

Mineral Recommended dietary Suggested daily

allowance (RDA) for daily intravenous intake
oral intake (mg) (mg)
Zinc 15 2.5-5
Copper 2-3 0.5-1.5
Manganese 2.5-5 0.15-0.8
Chromium 0.05-0.2 0.01-0.015
Iron 10 (males)-18 (females) 3
Osmolarity:

PPN: Maximum of 900 milliosmoles / liter

TPN: >900 - 3000 m.osmol /liter
Amino acids (10 m.osmol/gm), dextrose
(5 m.osmol/gm) and electrolytes (2
m.osmol /mEq) contribute most to the
osmolarity, while lipids give 1.5
m.osmol/gm.
 Application:
 The Solution

 Manually mixed in hospital pharmacy or nutrition-mixing service,

 premixed solutions,

 Separate administration for every element alone in a separate line.

 Application:
 Venous access
PPN: (<900 m.osmol/L): a peripheral line can be
enough.
TPN: Central venous access is fundamental,
Complications of TPN

 Sepsis
 Pneumothorax
 Air embolism
 Clotted catheter line
 Catheter displacement
 Fluid overload
 Hyperglycemia
 Rebound Hypoglycemia
 ‫َ‬ ‫َ‬
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