Kuliah Parenteral Nutrition

8/10/2019 Kuliah Parenteral Nutrition

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PARENTERALNUTRITION

Parenteral nutrition (PN) is feeding a personintravenously, bypassing the usual process of eating

and digestion. The person receives nutritional

formulas containing salts, glucose, amino acids, lipids

and added vitamins.

It is called total parenteral nutrition (TPN) when no

food is given by other routes.

http://en.wikipedia.org/wiki/Intravenous

http://en.wikipedia.org/wiki/Eating

http://en.wikipedia.org/wiki/Digestion


http://en.wikipedia.org/wiki/Salt


http://en.wikipedia.org/wiki/Glucose


http://en.wikipedia.org/wiki/Amino_acid


http://en.wikipedia.org/wiki/Lipid



http://en.wikipedia.org/wiki/Vitamin









http://en.wikipedia.org/wiki/Eating

http://en.wikipedia.org/wiki/Intravenous



Home TPN formula IV bags on a pole connected to IV lines.

Total Parenteral Nutrition (TPN) = Total NutritionAdmixture (TNA)

1. IV therapy that provides nutrition to patients

who cannot take nourishment by mouth.

2.

The aim of TPN is to replace and maintain byIV infusion essential nutrients when (and only

when) oral or tube feedings are contraindicated

or inadequate.

http://en.wikipedia.org/wiki/File:Infuuszakjes.jpg

http://en.wikipedia.org/wiki/File:Tpn_3bag.jpg

http://en.wikipedia.org/wiki/File:Infuuszakjes.jpg

http://en.wikipedia.org/wiki/File:Tpn_3bag.jpg



3.

Typical situations when TPN is used include:

a. Severely undernourished patients without

oral intake > 1 week

b.

Severe pancreatitisc.

Severe inflammatory bowel disease

(Crohn’s disease and ulcerative colitis)

d.

Extensive bowel surgery (i.e., short bowel

syndrome)

e. Small bowel obstruction (SBO)

f. Pregnancy (in cases of severe nausea and

vomiting)

g. Head-injury patients

TPN or TNA formulations are TPNs containing IV fat

emulsion in the same container with traditional amino

acids, dextrose, and electrolytes formulations

Short-term PN may be used if :

1. a person's digestive system has shut down (for

instance by peritonitis), and

2.

they are at a low enough weight to cause concerns

about nutrition during an extended hospital stay.

Long-term PN is:

http://en.wikipedia.org/wiki/Peritonitis





Chronic PN is performed through a central

intravenous catheter, usually through the subclavian or jugular vein with the tip of the catheter at the

superior vena cava without entering the right atrium.

Another common practice is to use a PICC line, which

originates in the arm, and extends to one of the central

veins, such as the subclavian with the tip in thesuperior vena cava.

In infants, sometimes the umbilical vein is used.

In most US hospitals, clinical pharmacists evaluate the

patient's individual data and decide what PN formula

to use.

Basic Nutrients and Fluid:

a.

Dextrose – the major source of calories; each gram

of dextrose provides 3.4 kcal.

http://en.wikipedia.org/wiki/Subclavian_vein



http://en.wikipedia.org/wiki/Jugular_vein



http://en.wikipedia.org/wiki/PICC_line



http://en.wikipedia.org/wiki/Umbilical_vein



http://en.wikipedia.org/wiki/Clinical_pharmacist









b.

Amino acids – for the protein synthesis required

for tissue growth and repair; each gram of protein

provides 4 kcal.

c.

Fat – for required essential fatty acids and as a

source of calories; each gram of fat provides 9

kcal.

d. Basic electrolytes – Na, K, Mg, Ca, phosphate.

e.

Vitamins

f.

Trace elements – Cu, Cr, Zn, Mn, Se

Histamine H2-receptor antagonists

To prevent and treat upper gastrointestinal,stress-related ulceration and are often

included in TPN formulations

Intravenous Fat Emulsion



Fat emulsions are used to supply in a small volume of

isotonic liquid a large amount of energy; they supply

the body with essential fatty acids and triglycerides.

Fat emulsions for IV nutrition contain vegetable oil

and a phospholipids emulsifier.

In Intralipid, purified egg-yolk phospholipids are used

as the emulsifier.

Isotonicity with blood is obtained by the addition of

sorbitol, xylitol, or glycerol.

Intralipid has been used as the basis of an IV drug

carrier, for example for diazepam.

To avoid adverse effects on injection it is importantthat the particle size of the emulsions is small and

remains so on storage.

After storage of Intralipid for two years at 4oC, more

than 99% of the particles visible by light microscopy

had a diameter of less than 1 µm; that is, there was

practically no change in mean diameter.

The addition of electrolyte or drugs to IV fat

emulsions is contraindicated because of the risk of

destabilizing the emulsion.



Addition of cationic local anaesthetics reduces the

electrophoretic mobility of the dispersed fat globules,

and this is undoubtedly one contribution to instability.

One study found both minimum stability and

minimum zeta potential on addition to Intralipid of 3 x

10-3

Mol dm-3

CaCl2 and 2.5 x 10-1

Mol dm-3

NaCl.

These concentrations are recommended to be the

maximum levels of these additives.

TPN & ADMIXTURES

THE PHARMACEUTICAL

ISSUES

PN admixtures contain over 50 chemical entities

stability issues

PHYSICAL STABILITY



Physical stability of TPN takes in forms of:

Precipitation of solids

Cracking of the lipid emulsion

Precipitation has two risks:

1.

the potential to infuse solid particles fatal

emboli

2. the nutrients may not be infused

Precipitation of calcium phosphate:

Ca (H2PO4)2 relatively soluble (solubility ~18 g/L)

CaHPO4(2H2O) precipitation is time limited

(solubility ~300 mg/L)

Ca3(PO4)2 precipitation is relatively immediate

Trace elements:

Iron PO4 and Cu PO4 are precipitated

LIPID DESTABILIZATION



TPN the oil-in-water lipid emulsion

destabilized by positively charge ions and

heat

the large lipid globules could occlude the

lung microvasculature and cause

respiratory and circulatory compromise

and lead to death.

positively ions and especially divalent and

trivalent ions, such as Ca2+

and Mg2+

,

have more significant effect.

low concentrations of amino acids and

glucose reduce the stability and increase

the tendency for creaming.

identify the destabilization by using

optical microscope and particle size

counters.

CHEMICAL STABILITY

Chemical stability takes many forms



Chemical stability of the vitamins and

amino acids.

Vitamin stability:Will define the shelf-life of the formulation

Vitamin C oxidation is accelerated by heat,

oxygen, trace elements (Cu)

Vitamin A photolysis and vitamin E photo-

oxidation

Prevention: minimize O2 presence and light

protection.

Amino acid stability:

The amino acid profile should be maintained

for the shelf-life of the formulation.

MICROBIAL STABILITY

PN is highly nutritious but hypertonic medium

Limit microbial growth.

Growth in lipid alone is greater

Manipulation should only be performedusing validated aseptic techniques



SHELF-LIFE AND TEMPERATURE

CONTROL

PN formulation usually has a shelf-life up to 90days at 2 – 8oC followed by 24 hours at room

temperature for infusion.

The compounding should strictly be aseptic

The temperature during the infusion period

should be known

Formulations used at higher temperature must

have been validated.

DRUG STABILITY

The addition of drugs to PN admixtures or Y-site

co-administration:

Is actively discouraged unless the compatibility

has been formally confirmed

Extreme competition for IV access

prompt consideration of drug and PN

combinations.



Many factors need to be considered for addition of

drugs to PN admixtures:1.

the physical and chemical stability of the PN

2.

the physical and chemical stability of the drug

3.

the bioavailability of the drug

4. The effect of stopping and starting Y-site

infusions on the actual administration rate.

The extrapolate data of stability should be used

with caution.

In practice, drugs should only be infused with PN

when all other possibilities have been exhausted,such as gaining further IV access and changing

the drug(s) to clinically acceptable non-IV

alternatives.

The relative risks of stopping and starting the

PN infusion in most cases the risks outweigh the

benefits

If the option is adopted, the line must be

flushed before and after with an



appropriate volume of solution known to

be stable with both the PN and the drug.

FILTRATION

All IV fluids pass through the lung

microvasculature with its capillary diameter of 8 – 12

m.

The presence of particulate matters:

to cause direct embolization,

direct damage to the endothelia,

formation of granulomata,

formation of foreign body giant cells, and

To have thrombogenic effect.

The presence of microbial and fungal matter:

can cause a serious infection, or

Inflammatory response.

The precautions to minimize the particulate load

or the compounded regimen must include:



use of in-lead filters (25 m) and filter needles

or straws (5 m) during compounding to

catch larger particles such as cored rubber

from bottles and glass shards from ampoules

air particle levels kept within defined limits in

aseptic rooms by the use of air filters and non-

shedding clothing and wipes

use of quality of raw materials with minimal

particulate presence, including empty bags and

leads

Confirmation of physical and chemical

stability of the formulation prior to aseptic

compounding applying approved mixing

order (stability for the required shelf-life timeand conditions).

The filters have been endorsed to be used for

patients requiring intensive or prolonged

parenteral therapy, including home patients, the

immunocompromised, neonates, and children.

The filters should be placed as close to the patient

as possible and validated for the PN to be used.



For 2-in-1 formulations --> use the 0.2 m filters

For 3-in-1 formulations --> use 1.2 m filters

LIGHT PROTECTION

Vitamin A and E are degraded by phototherapy

light and sunlight.

It is recommended that all regimens should be

protected from light both during storage and

during infusion, since:

lipid does not totally protect againstvitamin photo-degradation

Maillard reaction (a complex pathway of

chemical reactions that starts with a

condensation of the carbonyl group of the

glucose and the amino group of the amino

acid) is influenced by light exposure

Lipid per-oxidation is accelerated by a

range of factors including exposure to

certain wavelengths of light



In order to minimize confusion.

Validated bag covers should always be used.

THIS IS THE END OF THE LECTURE OF

TPN

Kuliah Parenteral Nutrition

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