1 DIPENSING PARENTERAL NUTRISI - iKnow

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)5

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 HoodsVertical 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

5

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/L2. Multiply the grams of protein per liter by 10 Example: 30 g of protein x 10 = 300

mOsm/L3. 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 = 1605. Total osmolarity = 500 + 300 + 60 + 160 =

1020 mOsm/LSource: K&M and PN Nutrition in ADA, Nutrition in Clinical Practice. P 626

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 washingq Glovingq Perform aseptic

technique

The Final Product

After work, see (check)q Leaking containerq 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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