DIPENSING PARENTERAL NUTRISI
Drs. Muhammad Yahya., Sp.FRS, Apt
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Disampaikan Pada Acara
In House Training RS PHC
Surabaya, 13-14 November 2018
Parenteral Nutrisi
Amino Acid + Dextrose +
Electrolyte + Mineral + race elements
Lipid Emulsion + Vitamins
Separate infusion
All the macro-
and micro-nutrients in one single
infusion bag
Two-in-one All-in-one
TPN Definition
T: Total means that all the daily nutritional needs
for a child or adolescent are in the TPN bag.
P: Parenteral means that the daily feedings are
given to the child or adolescent through a vein.
N: Nutrition means all the proteins, fats, carbohydrates, vit and minerals that
are needed
for growth and activity. (1)
INDIKASI UTAMA PEMBERIAN TPN
Px Kurang gizi yang kehilangan berat badan > 10% dari berat badan terakhir
Saluran pencernaan tidak berfungsi sama sekali
Tidak ada asupan makanan oral selama 3-5 hari dengan status gizi buruk
Components of TPN Formulations
Macro:
Calorie: Dextrose
Lipid Protein: Aminoacid Fluid
Micro:
Electrolytes (Na, K) Minerals (Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
Vit (A, E, C, B, Folic acid)
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must always be prepared in a pharmacy aseptic unit.
Aseptic Technique
Manipulating sterile products without compromising their sterility
proper use of LAFW
strict aseptic technique
Conscientious work habits
Aseptic Technique requere
ü Skills needed to properly use laminar airflow workbench (LAFW) or laminar airflow hood
ü Personnel who prepare & administer sterile products
ü Sterile compounding area, complete with sterilized equipment & supplies
Laminar Airflow Workbenches
Principle of LAFWs
twice-filtered laminar layers of aseptic air
continuously sweep work area inside hood
prevents entry of contaminated room air
2 common types of LAFWs
horizontal flow
vertical flow
IV Hoods
Vertical Hoods used for preparing hazardous
medications
Designed to protect
preparer from exposure to hazardous medications
Horizontal Hoods most common for sterile
preparation of IV solutions
LAFW
Must run for 15 -3o minutes if turned off & back on
Clean sides of hoods using up & down direction
start at HEPA
work toward outer edge of hood
Order of cleaning
walls 1st
floor of hood 2nd
Frequency
beginning of each shift
before each batch
after spills
when surface contamination is known or suspected
Do not use spray bottles of alcohol in hood
Personnel who administer sterile products
Personnel who administer sterile products
Assasing RPO Parenteral Nutrisi
Mathematical calculations should be done before aseptic technique work
Do Data entry
Preparing medical device and medicines
Prepare containers and etiquette before, during and after work
Etiquette
Patient identify (name, No. Reg. / date of birth, room)
Name of drug and intravenous fluids mixed
Dosage of medication amd volume of intravenous fluids
Mixing date
Expire date (Beyoun Use Dated / BUD)
Final volume
Speed of giving / drip.
TPN Container
Container made of Ethyl Vinyl Acetate (EVA)
Glass bottle
Container made of Polypropylene (PP)
Route of Administration Parenteral Nutrisi
Used for the sort term (max 2 weeks)
Osmolarity of
solution < 900 mOsm/L
subclavian veins
internal and external jugular vein
cephalic and basilic veins
Peripheraly Inserted Central Catheters (PICC)
Umbilical vein
Used for the long tine
Osmolarity of solution
> 900 mOsm/L
Peripheral Vein Central Vein
RPO Nutrisi Parenteral
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D 12,5 40
27,5
7,5
27,5 35
35 35 7,5
x 140 = 110
x 140 = 30
Perhitungan
q Untuk memperoleh D 12,5 %
q KCl 7,46 % @ 25 ml 1 ml = 1 mEq
RPO Nutrisi Parenteral
250,7
Calculating the Osmolarity of a Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5 Example: 100 g of dextrose x 5 = 500
mOsm/L
2. Multiply the grams of protein per liter by 10 Example: 30 g of protein x 10 = 300
mOsm/L
3. Multiply the grams of lipid per liter by 1.5 Example: 40 g lipid x 1.5 = 60.
4. Multiply the mEq per L [sodium + potassium + calcium + magnesium] X 2
Example: 80 X 2 = 160
5. Total osmolarity = 500 + 300 + 60 + 160 = 1020 Source: K&M and PN Nutrition in ADA, Nutrition in Clinical Practice. P 626mOsm/L
Osmolarity Quick Calculation
To calculate solution osmolarity:
• multiply grams of dextrose per liter by 5
• multiply grams of protein per liter by 10
• add a & b
• add 300 to 400 to the answer from "c".
(Vitamins and minerals contribute about 300 to 400 mOsm/L.)
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
OSMOLARITAS ( mOsm / l )
Vol total larutan 250,7 ml
Dextrosa
140 ml D 12,5 % = 17,5 g
g Dexrosa /L = 17,5 x 1000/250,7 = 69,8 g/L
mOsm/L Dextrosa = 69,8 x 5 = 349 mOsmo/L
Protein
77 ml AA 6 % = 4,62 g
4,62 x 1000/250,7 = 18,4 g/L
mOsm/L Protein = 19,2 x 10 = 184 mOsm/L
Dari Mineral dan Vitamin 300-400 mOsm/L
Total mOsm/L = 349 + 184 + (300-400) = 833-933
Formula TPN MY Rev 1
Which Need to be consideration in the work of aseptic
techniques
All the jewelry on the wrist and finger should be removed (through inside the glove
Meal, dringking and smoking activities are prohibitted
Talk / cough / sneeze direced away
Non-essential material (Calculator, pencil, notebooks) should not be place on the
praparation table)
Personnel who prepare TPN
Personnel Who Prepare TPN
Personil using
Personal Protective Equipment (PPE)
q
Hands washing
q
Gloving
q
Perform aseptic
technique
The Final Product
After work, see (check)
q Leaking container
q Particles in solution
q The existence of physical change (color and sediment)
Storage
Temperature 2-8 0C
Do not storage in room T more than 24 hours
Take 4-6 hours
from the refrigrator before giving TPN and leave it at
room T
Instability of Emulsion
Ditjen Binfar & Alkes, Depkes RI, 2009, Pedoman Dasar Dispensing Sediaan Steril
ESPEN Guidelines on Parenteral Nutrition: Intensive care, Clinical Nutrition 28
(2009) 387–400.
Essentials of Aseptic Dispensing, Version 2 - 2014 asia4safehadling
Pharmacy Practice for
Technicians.Preparing Sterile Intravenous Product.
USP, 797, Sterile compounding of pharmaceutics
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