Total Parenteral Nutrition (TPN)

Dhadhang Wahyu Kurniawan

Laboratorium Farmasetika Unsoed

Twitter: Dhadhang_WK

Facebook: Dhadhang Wahyu Kurniawan

04/11/23 1

Cara penyiapan TPN Cara pemberian TPN Komponen TPN

04/11/23 2

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

04/11/23 3

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

04/11/23 6

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

04/11/23 7

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

04/11/23 11

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

mixing TNA, not for direct venous delivery)04/11/23 18

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

04/11/23 19

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.

04/11/23 23

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.

04/11/23 24

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

04/11/23 25

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 !!

04/11/23 30