ENTERAL VS PARENTERAL

Dr. dr. Luciana Sutanto, MS., SpGK.

TATALAKSANA NUTRISI
➤ Terapi Standar adalah pemberian cairan intravena, tidak
termasuk nutrisi enteral atau parenteral, serta peningkatan
asupan diet oral sesuai toleransi.
➤ Terapi Nutrisi adalah pemberian nutrisi khususnya nutrisi
enteral melalui akses enteral dan/atau nutrisi parenteral
melalui akses vena sentral.
➤ Terapi Dukungan Nutrisi adalah bagian dari Terapi Nutrisi
yang merupakan komponen perawatan medis yang meliputi
nutrisi enteral, parenteral dan oral, untuk
mempertahankan atau mengembalikan status gizi dan
kesehatan yang optimal.
TERAPI DUKUNGAN NUTRISI [ORAL-ENTERAL-PARENTERAL]
NUTRISI ENTERAL VS PARENTERAL ?
1. Kanker?
2. Malnutrisi?
3. Disfagia?
4. Gangguan kesadaran?
5. Sepsis?
6. Syok?
7. Residu lambung tinggi?
8. Diare?
ENTERAL: KELEBIHAN
➤ Mencegah atrofi mukosa usus
➤ Mempertahankan fungsi barier usus
➤ Menghambat absorpsi toksin
➤ Mencegah translokasi bakteri
➤ Mempertahankan/memperbaiki imunitas usus,
➤ Menurunkan permeabilitas mukosa usus
➤ Meningkatkan aliran darah splangnikus
➤ Lebih ekonomis dibandingkan Parenteral
➤ Risiko infeksi lebih rendah
Kudsk et all. Ann Surg 1992;215:503-11
Moore et all. J Trauma 1989;29:916-23
Moore et all. Ann Surg 1992;216:172-83
ENTERAL: INDIKASI
➤ Anoreksia
➤ Apopleksia
➤ Koma
➤ Sepsis
➤ Trauma/pembedahan
➤ Transisi dari nutrisi parenteral
ENTERAL: INDIKASI KONTRA
➤ Absolut (dapat diberikan Parenteral)
➤ Obstruksi usus
➤ Ileus dengan distensi abdomen
➤ Tidak mampu menyerap nutrien
➤ Perforasi usus
➤ Iskemia usus
➤ Abdominal compartment syndrome
ENTERAL: INDIKASI KONTRA
➤ Relatif
➤ Ileus paralitik
➤ Residu tinggi
➤ Muntah tidak terkendali
➤ Pankreatitis akut
➤ Short bowel syndrome
➤ Muntah & diare berat
➤ MODS dengan insufisiensi usus
VILI INTESTIN PIGLET

24 jam
Nutrisi Enteral
Nutrisi Parenteral Total
PARENTERAL: KELEBIHAN
➤ dapat diberikan sesegera mungkin
➤ mudah diberikan
➤ asupan kalori dapat diberikan banyak
➤ tidak dipengaruhi lambung dan fungsi saluran cerna
➤ tidak terganggu pemberian
EARLY PARENTERAL NUTRITION VS EARLY ENTERAL NUTRITION
➤ Doig G, et al. Early Parenteral Nutrition in Critically Ill Patients
With Short-term Relative Contraindications to Early Enteral
Nutrition: A Randomized Controlled Trial. JAMA 2013
➤ single-blinded MCRCT (n=1372)
➤ early parenteral nutrition (PN) in critically ill adults with
relative contraindications to early enteral nutrition (EN)
(n=686) with standard care (n=686)
➤ No difference in 60 day mortality
➤ No difference in ICU or hospital length of stay (LOS)
➤ Fewer days of mechanical ventilation, less muscle wasting
and less fat loss
ALGORITMA PEMBERIAN NUTRISI
FUNGSI SALURAN CERNA
BAIK TIDAK

ORAL ENTERAL PARENTERAL

> 6 minggu < 6 minggu < 1 minggu >

GASTRO/JEJUNO
ENTEROSTOMI NASOENTERAL
PERIFER SENTRAL

- ASPIRASI + - ASPIRASI +

PEG PEJ NGT NJT/NDT

ASPEN, JPEN 1993

➤ Pasien yang tidak dapat menerima asupan makan (protein/
energi)> 50%, direkomendasikan untuk mendapatkan nutrisi
enteral dini dalam 24 jam.
➤ Jika asupan pasien tidak dapat terpenuhi dari oral/enteral,
direkomendasikan untuk mendapatkan nutrisi parenteral
sesegera mungkin, jika memungkinkan, dalam kombinasi
dengan nutrisi enteral
ESPEN, 2019
➤ Recommendation 1
➤ Medical nutrition therapy shall be considered for all
patients staying in the ICU, mainly for more than 48 h.
➤ Grade of Recommendation: GPP - strong consensus (100%
agreement)

➤ Recommendation 3
➤ Oral diet shall be preferred over EN or PN in critically
ill patients who are able to eat.
➤ Grade of recommendation: GPP - strong consensus (100%
agreement)
ESPEN, 2019
➤ Recommendation 4
➤ If oral intake is not possible, early EN (within 48 h) in
critically ill adult patients should be performed/initiated
rather than delaying EN.
➤ Grade of recommendation: B - strong consensus (100%
agreement)

➤ Recommendation 5
➤ If oral intake is not possible, early EN (within 48 h) shall
be performed/initiated in critically ill adult patients rather
than early PN.
➤ Grade of recommendation: A - strong consensus (100%
agreement)
ESPEN, 2019
➤ Recommendation 6
➤ In case of contraindications to oral and EN, PN should
be implemented within three to seven days
➤ Grade of recommendation: B - consensus (89% agreement)

➤ Recommendation 7
➤ Early and progressive PN can be provided instead of no
nutrition in case of contraindications for EN in
severely malnourished patients.
➤ Grade of Recommendation: 0 - strong consensus (95%
agreement).
ESPEN, 2019
➤ Recommendation 8
➤ To avoid overfeeding, early full EN and PN shall not be
used in critically ill patients but shall be prescribed
within three to seven days.
➤ Grade of recommendation: A - strong consensus (100%
agreement).
➤ Commentary to recommendations 3 - 8.

➤ Recommendation 9
➤ Continuous rather than bolus EN should be used.
➤ Grade of recommendation: B - strong consensus (95%
agreement)
ESPEN, 2019
➤ Recommendation 10
➤ Gastric access should be used as the standard approach to initiate
EN.
➤ Grade of recommendation: GPP - strong consensus (100% agreement)
➤ Recommendation 11
➤ In patients with gastric feeding intolerance not solved with
prokinetic agents, postpyloric feeding should be used.
➤ Grade of recommendation: B - strong consensus (100% agreement)
➤ Recommendation 12
➤ In patients deemed to be at high risk for aspiration, postpyloric,
mainly jejunal feeding can be performed.
➤ Grade of recommendation: GPP - strong consensus (95% agreement).
ESPEN, 2019
➤ Recommendation 10
➤ Gastric access should be used as the standard approach to initiate
EN.
➤ Grade of recommendation: GPP - strong consensus (100% agreement)
➤ Recommendation 11
➤ In patients with gastric feeding intolerance not solved with
prokinetic agents, postpyloric feeding should be used.
➤ Grade of recommendation: B - strong consensus (100% agreement)
➤ Recommendation 12
➤ In patients deemed to be at high risk for aspiration, postpyloric,
mainly jejunal feeding can be performed.
➤ Grade of recommendation: GPP - strong consensus (95% agreement).
ESPEN, 2019
➤ Recommendation 13
➤ In critically ill patients with gastric feeding intolerance,
intravenous erythromycin should be used as a first line
prokinetic therapy.
➤ Grade of recommendation: B e strong consensus (100%
agreement)

➤ Recommendation 14
➤ Alternatively, intravenous metoclopramide or a
combination of metoclopramide and erythromycin can
be used as a prokinetic therapy.
➤ Grade of recommendation: 0 e strong consensus (100%
agreement)
ESPEN, 2019
➤ The measurement of gastric residual volume (GRV) for the
assessment of gastrointestinal dysfunction is common and
may help to identify intolerance to EN during initiation and
progression of EN. However, monitoring of established EN
with continued measurements of GRV may not be
necessary. We suggest that enteral feeding should be
delayed when GRV is >500 mL/6 h. In this situation, and if
examination of the abdomen does not suggest an acute
abdominal complication, application of prokinetics should be
considered. ASPEN/SCCM.
GASTRIC VOLUME AFTER DRINKING 200 ML SPECIFIC ONS
SUTANTO, DKK. PHILSPEN ONLINE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION, 2012.

VOLUME
(mL)
400"

350"
Serie
300" Serie

Serie
250"
Serie
200"
Serie

150" Serie

Serie
100"
Serie
50" Serie

0"
EMPTY
1" DRINK
2" 30’ 3" 60’
4" 5"90’ 6"120’
200 ML
 VOLUME RESIDU LAMBUNG

Volume
mL 250 -

200 -

150 -X

100 -

50 -X

0 -l l l l l l
Jam 6 10 14 18 22 2
KESIMPULAN
➤ Pada pasien sakit kritis, jika asupan oral tidak terpenuhi,
pilihan pemberian nutrisi adalah enteral (dalam 48 jam),
bukan parenteral.

➤ Pada keadaan kontra indikasi pemberian oral dan enteral,

nutrisi parenteral dierikan pada hari ke 3 - 7.
 TERIMA
KASIH
The 6th Indinesian SEPSIS Forum
Solo, 2019