Total Parenteral Nutrition (TPN) Nuryanti, M.Sc, Apt Laboratorium Farmasetika Jurusan Farmasi FKIK UNSOED 4/16/2017

Cara penyiapan TPN Cara pemberian TPN Komponen TPN 4/16/2017

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 4/16/2017

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 4/16/2017

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 4/16/2017

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

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 4/16/2017

Parenteral Nutrition Vitamin Guidelines 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 B12 mg 5.0 Biotin mcg 60 B5 dexpanthenol mg 15 *Federal Register 66(77): April 20, 2000

Calculating Calories Carbohydrate:   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 2-4 2-3 K 1-3 1-2 Ca 0.5-1 0.25-0.5 Mg Phos (mMol) 1-1.5 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) 4/16/2017

Other requirements Fluid—30 to 50 ml/kg (1.5 to 3 L/day) Electrolytes 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 4/16/2017

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,Th a% 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. 4/16/2017

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. 4/16/2017

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 4/16/2017

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 !! 4/16/2017