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Total Parenteral Nutrition (TPN)

Total Parenteral Nutrition (TPN). Nuryanti, M.Sc, Apt Laboratorium Farmasetika Jurusan Farmasi FKIK UNSOED. Cara penyiapan TPN Cara pemberian TPN Komponen TPN. Definisi. Penyediaan semua nutrisi melalui selain saluran pencernaan

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Total Parenteral Nutrition (TPN)

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  1. Total Parenteral Nutrition (TPN) Nuryanti, M.Sc, Apt Laboratorium Farmasetika Jurusan Farmasi FKIK UNSOED

  2. Cara penyiapan TPN • Cara pemberian TPN • Komponen TPN

  3. 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 kedalam suatu vena perifer atau yang lebih kecil

  4. Nutrien, dibutuhkan untuk: • pertumbuhan sel • fungsi seluler • sintesis karbohidrat-lemak-protein • kontraksi otot • penyembuhan luka • daya tahan tubuh/kekebalan • integritas percernaan

  5. 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

  6. 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

  7. 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

  8. 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.

  9. 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

  10. 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.

  11. 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

  12. Parenteral Nutrition Vitamin Guidelines *Federal Register 66(77): April 20, 2000

  13. 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

  14. Balance of Calories • Dextrose: 40% - 60% • Amino Acids: 10%- 12% • Lipids: 25 – 50% • This is the ideal balance at the completion of the advance

  15. Electrolytes (mEq/kg/day)

  16. 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

  17. 3:1 • AA % must be at least 2% • Must be standard AA • Ca + Mg must be < 20 mEq/L • Cracks the fat emulsion

  18. 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)

  19. 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

  20. PN Solution Componentsa

  21. 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

  22. 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

  23. 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.

  24. 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.

  25. 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

  26. Two-in-One PN

  27. PN Compounding Machines: Automix

  28. PN Compounding Machines: Micromix

  29. 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

  30. Thanks !!

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