9/12/2021

PAIN AND NUTRITION

in Critical Care

Emil Huriani

Tujuan Pembelajaran
1. Membedakan antara nyeri akut dan kronik
2. Mengidentifikasi factor yang memperberat pengalaman nyeri pada
pasien kritis
3. Menyiapkan pasien untuk penyebab umum nyeri karena prosedur di
perawatan intensif
4. Membandingkan dan membedakan toleransi, ketergantungan fisik
(physical dependence) dan adiksi (addiction)
5. Mendiskusikan panduan praktek klinik dalam manajemen nyeri,
agitasi dan delirium pasien di perawatan intensif
6. Mengidentifikasi analgesic yang sesuai pada pasien penyakit kritis
berisiko tinggi
7. Mendeskripsikan intervensi non-farmakologis untuk mengurangi
nyeri dan kecemasan

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Definisi Nyeri
• “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.” (The International Association
for the Study of Pain)
• “pengalaman sensori dan emosional yang tidak menyenangkan yang
berhubungan dengan kerusakan jaringan actual atau potensial atau
dideskripsikan dengan istilah seperti kerusakan”
• Pain is a complex, subjective phenomenon. It is a protective
mechanism, causing one either to withdraw from or to
avoid the source of pain and seek assistance or treatment.
• Nyeri merupakan fenomena subyektif kompleks. Merupakan
mekanisme protektif, menyebabkan seseorang menolak atau menjauhi
sumber nyeri atau mencari bantuan atau pengobatan

Based • Akut
on the
duration • Kronik
Tipe
nyeri

Based
• Somatic
on the • Visceral
source
• Nerve

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Critically Ill Patient→ Acute Pain

• Respon fisiologis atas penyebab yang dapat diidentifikasi,

secara umum berakhir seiring waktu, dan memiliki ciri
berespon baik terhadap terapi opioid dan non-opioid

• Pasien di unit perawatan kritis mengalami nyeri yang

bersumber dari lebih dari 1 sumber.
• Contoh, pasien pasca operasi mengalami somatic pain yang berasal
dari tempat luka operasi, visceral pain dari organ yang
dimanipulasi, dan kemungkinan nerve pain dari serat saraf yang
terpotong atau rusak selama prosedur pembedahan

Pasien ICU juga mengalami nyeri chronic yang sering dan

saling memperberat yang harus di tangani dengan baik

Factors Contributing to Pain and Discomfort in the Critically Ill

• Symptoms of critical illness (eg, angina, ischemia, dyspnea)
• Wounds:Posttrauma, postoperative, postprocedural, or penetrating tubes and catheters
• Sleep disturbance and deprivation
• Immobility; inability to move to a comfortable position due to tubes, monitors, restraints
Physical • Temperature extremes associated with critical illness and the environment (fever,
hypothermia)

• Anxiety and depression

• Impaired communication; inability to report and describe pain
• Fear of pain, disability, or death
• Separation from family and significant others
Psychosocial • Boredom or lack of pleasant distractions
• Sleep deprivation, delirium, or altered sensorium

• Continuous noise from equipment and staff

• Continuous or unnatural patterns of light
• Awakening and physical manipulation every 1 to 2 hours for vital signs or positioning
ICU • Continuous or frequent invasive, painful procedures
Environment • Competing priorities in care (unstable vital signs, bleeding, dysrhythmias, poor
or Routine ventilation) may take precedence over pain management

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Konsekuensi Nyeri

• Berdampak negative terhadap fungsi seluruh seluruh system tubuh,

menghambat penyembuhan luka dan memperlambat penyembuhan dari
penyakit kritis.
• Respon system saraf otonom terhadap nyeri
• Vasokonstriksi dan pengingkatan denyut jantung dan kontraktilitas.
• Peningkatan nadi, tekanan darah dan curah jantung
• Peningkatan beban kerja miokard dan penggunaan oksigen
• Malas untuk bergerak, batuk dan bernafas dalam
• Gangguan pernafasan yang disebabkan oleh nyeri, termasuk penurunan upaya
nafas, dan penurunan volume dan aliran udara pernafasan.
• Komplikasi paru seperti atelectasis dan pneumonia.
• Sistem gastrointestinal : penurunan pengosongan lambung dan motilitas intestin,
• Sistem musculoskeletal : kontraksi otot, spasme, kekakuan, dan penekanan
fungsi imunitas

Manfaat pengurangan nyeri yang efektif

• Cardiovascular → Penurunan denyut jantung, tekanan darah dan beban

miokard
• Respiratory → peningkatan pernafasan, oksigenasi, kemampuan untuk
melakukan nafas dalam dan latihan batuk, dan penurunan kejadian
komplikasi pernafasan
• Neurologic → penurunan kecemasan dan bingung, meningkatkan tidur
• Gastrointestinal/Nutritional → meningkatkan pengosongan lambung,
meningkatkan keseimbangan positif nitrogen, meningkatkan selera
makan
• Musculoskeletal → ambulasi lebih cepat, menurunkan komplikasi
imobilitas
• Economic → menurunkan lama perawatan, menurunkan biaya,
meningkatkan kepuasan pasien terhadap perawatan

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Pengkajian Nyeri
Behavioral Pain Scale (BPS) Critical care Pain Observation
Tools (CPOT)
Item Deskripsi

Ekspresi Rileks 1
Wajah
Sedikit tegang 2
Sangat tegang 3
Meringis 4
Pergerakan Tidak ada Gerakan 1
ekstremitas
Sedikit fleksi 2
atas
Fleksi dengan jari fleksi 3
Selalu meregang 4
Kepatuhan Dapat mentoleransi 1
dengan
Batuk namun hampir selalu 2
ventilator
dapat mentoleransi ventilator
Melawan ventilator 3
Tidak mampu mengontrol 4
ventilasi

Intervensi farmakologi nyeri: non-opioid

Obat Dosis dewasa Dosis anak Keterangan
Acetaminophen 325–650 mg every 4–6 10–15 mg/kg Tersedia dalam bentuk cair
h every 4–6 h Tidak memiliki efek anti-inflamasi
Dosis melebihi 4.000 mg/hari
meningkatkan risiko toksisitas hati.
Aspirin 325–650 mg every 4–6 10–15 mg/kg Dapat menyebabkan perdarahan
h every 4–6 h gastrointestinal atau pascaoperasi
Celecoxib 100–400 mg twice a day Lebih sedikit efek samping daripada
(Celebrex) obat antiinflamasi nonsteroid lainnya
Jauh lebih mahal
Ibuprofen 200–400 mg every 4–6 4–10 mg/kg Tersedia dalam bentuk cair
(Motrin) h every 6–8 h
Indomethacin 25–50 mg every 8–12 h Tersedia dalam bentuk rektal dan IV
(Indocin) Tingginya insiden efek samping
Ketorolac 30–60 mg IM initially, Tersedia dalam bentuk parenteral
(Toradol) then: Batasi penggunaan hingga 5 hari
30 mg IV every 6 h or 30 Kontraindikasi dengan insufisiensi ginjal
mg IM every 6 h 10 mg
PO every 4–6 h
Naproxen 500 mg initially then 5 mg/kg every Tersedia dalam bentuk cair
(Naprosyn) 250 mg 12 h
every 6–8 h

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Intervensi Farmakologi Nyeri: Opioid

Obat Dosis (mg) Waktu kerja Keterangan
Oral IM/IV
Morfin 30 20 5–10 menit, IV Standar emas dibandingkan opioid lain
30 menit, oral Tidak direkomendasikan dengan ketidakstabilan
Diberikan setiap hemodinamik atau insufisiensi hati/ginjal
3-4 jam
Fentanyl 0.1 Onset 1-2 mnt, Obat pilihan untuk analgesia onset cepat
IV Lebih disukai pada pasien dengan insufisiensi hati atau
ginjal
Dengan bentuk transdermal, penundaan 12-24 jam ke
efek puncak
Hydromorfon 7.5 1.5 5-10 menit, IV Durasi yang lebih kuat dan sedikit lebih pendek
(Dilaudid) daripada morfin
Bentuk rektal tersedia
Methadone 2.5- 2.5-10 10-15 mnt, oral Waktu paruh yang panjang, kondisi mapan yang tidak
(Dolophine) 10 dapat diprediksi
Akumulasi dengan dosis berulang, menyebabkan sedasi
berlebihan
Konsultasikan dengan spesialis nyeri atau paliatif
karena metabolisme yang sangat bervariasi dan
kompleks pada masing-masing pasien
Oxycodone 20 30 mnt, oral Dosis harus individual karena variabilitas yang tinggi
(OxyContin) dalam farmakokinetik.

Intervensi farmakologi: sedasi

Obat Rekomendasi penggunaan Waktu Efek samping
kerja IV
Diazepam Untuk sedasi cepat pada pasien 2-5 mnt Depresi pernafasan
(Valium) dengan agitasi akut Hipotensi, Plebitis
Lorazepam Untuk sedasi jangka panjang 15-20 Depresi pernafasan
(Ativan) pada sebagian besar pasien mnt Hipotensi
melalui infus intermiten atau Asidosis/dosis tinggi menyebabkan
kontinu gagal ginjal
Midazolam Untuk sedasi sadar dan sedasi 2-5 mnt Depresi pernafasan, Hipotensi
(Versed) cepat pada pasien agitasi akut Perlambatan bangun dan
Hanya untuk penggunaan perlambatan penyapihan jika
jangka pendek digunakan jangka panjang
Propofol Obat penenang yang disukai 1-2 mnt Nyeri saat diinjeksikan
ketika kebangkitan cepat itu Peningkatan trigliserida
penting Depresi pernafasan
Lebih disukai untuk pasien Hipotensi, Pankreatitis
dengan ventilasi mekanis Reaksi alergi
Dexmedetomid Sedasi jangka pendek 5-10 Bradikardi
ine Lebih disukai untuk pasien mnt Hipotensi
dengan risiko delirium dan Kehilangan refleks jaman nafas
ventilasi mekanis

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Intervensi non farmakologi

• Modifikasi lingkungan
• Sleep Hygiene
• Mobilisasi dini
• Terapi alternatif dan komplementer
• music therapy, pet therapy, art therapy, healing touch or massage,
aromatherapy
• Teknik relaksasi

Nursing diagnosis
• Nyeri akut

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Nutrition in Critical care

Nutritional Support

Improves wound healing

Improves outcome

Decreases complications
Decreases the hypermetabolic
response to tissue injury
(DO2/VO2)

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Pengkajian nutrisi
Tinggi dan berat badan pasien saat ini, dan jika baru saja
terjadi perubahan yang signifikan

Informasi tentang alergi makanan, terutama alergi kerang

untuk pasien yang memerlukan media kontras

Konsumsi suplemen nutrisi karena beberapa suplemen dapat

mengubah keseimbangan elektrolit dan metabolisme pasien

Kesulitan menelan, mual atau muntah, atau konstipasi atau

diare

Jumlah alkohol yang dikonsumsi

Semua jenis diet yang mungkin dilakukan pasien, baik yang

diresepkan secara medis atau ditentukan sendiri

Pengkajian nutrisi
Setiap shift atau sesuai kebutuhan.

Skrining malnutrisi menggunakan alat skrining yang diakui seperti

Malnutrition Universal Screening Tool (MUST) atau NUTRItion Risk in
the Critically ill score (NUTRIC).

Pertimbangkan sindrom refeeding (pola makan yang buruk sebelum

masuk rumah sakit).

Periksa posisi selang nasogastrik dan volume residu lambung (jika

menggunakan makanan enteral).

Periksa indikasi, rute, risiko, manfaat, dan tujuan dukungan nutrisi

(20–30 kkal/kg/hari)

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NUTRIC
Score
Variable

Nursing diagnosis

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Intervention

Periksa penilaian
menelan (ini
Periksa berat badan mungkin termasuk
pasien setiap
dalam kewenangan
minggu.
terapis bicara dan
bahasa).

Dokumentasikan Periksa tekanan

asupan nutrisi (oral, darah dan denyut
enteral, dan jantung, dan output
parenteral) urin 0,5mL/kg/jam.

Nutrition: Critical care implications

• oral,
Methods
• enteral,
of delivery
• parenteral

• level of consciousness
• the presence of an endotracheal tube or
Influencing tracheostomy
Factors • the patient’s ability to swallow
• the level of function of the
gastrointestinal tract.

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Daily nutrient requirements
Nutrient Amount per day
Protein 0.7–1.0 g/kg/day
(nitrogen)
Carbohydrate Amount needed will depend on the
patient’s energy requirements, two-thirds
of which are usually provided by
carbohydrate, and one-third
by fat
A useful quick estimate of requirements is:
Male: 25–30 kcal/kg/day
Female: 20–25 kcal/kg/day
Fat Only necessary in very small amounts to
prevent fatty acid deficiency. Usually the
amount delivered contributes to
providing energy. It represents between
one-third and one-half of the total
number of calories required
A useful quick estimate of requirements is
0.8–1.0 g/kg/day
Electrolyte daily requirement
9/12/2021
Influencing factors
Hypermetabolism can increase
protein requirements to 1.5–2.0
g/kg/day (0.15–0.3 g/kg/day)
Patients with respiratory
insufficiency or weaning
after long-term ventilation
may not handle the amount
of carbon dioxide produced
when intake exceeds
requirement. Ratios of fat
to carbohydrate should be
changed to 50:50
Tolerance of intravenous
fat can be limited,
and the amount delivered
may need to be adjusted if
this is the case
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Strategi pemberian kalori dan protein pada

pasien kritis

Enteral nutrition

• Preserves the intestinal mucosal integrity :

❖Maintains mucosal immunity.

❖Prevents of increased mucosal permeability.
❖Decreases bacterial translocation.

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Enteral nutrition

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Intermittent and Bolus Methods of

Feeding in Critical Care
Ichimaru S., Amagai T. (2014) Intermittent and Bolus Methods of Feeding in Critical Care. In: Rajendram R., Preedy V.,
Patel V. (eds) Diet and Nutrition in Critical Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8503-2_139-1

• Four modalities of delivering enteral tube feeding

have been developed: continuous, cyclic,
intermittent, and bolus.
• Many factors are taken into consideration when
selecting a delivery method, such as the medical
condition of the patient, expected tolerance to
tube feeding, location of the feeding tube tip, type
of formula used, nutritional requirement, mobility
of patient, availability of electric feeding pump, and
cost.
• At present, no evidence suggests that any one
feeding method is superior to the others.
• In critical care settings, it is generally acceptable for
pump-assisted continuous feeding to be initiated at
a rate of 10-20 ml/h and then gradually increased
to the target rate.
• For medically stable patients, intermittent and
bolus feeding methods are preferred due to
practical issues, such as patient mobility,
convenience, and cost.
• Recent guidelines have not recommended any
specific feeding method for either critically ill or
stable patients

Continuous tube feeding

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Small Bowel Tube

Advantages of Small Bowel Feed

• Improved absorptive capacity.

• Less impairment of motility.
• Better respiratory function as it prevents gastric distension.
• Greater distance between the delivery site and the pharynx &
respiratory tree.

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Parenteral nutrition
Intravenous administration of nutrition, which may
include protein, carbohydrate, fat, minerals and
electrolytes, vitamins and other trace elements for
patients who cannot eat or absorb enough food through
tube feeding formula or by mouth to maintain
good nutrition status.

• Parenteral nutrition is indicated within 24–48 h if the

following conditions are present:
• oral nutrition is not expected to be given within the next 3
days
• enteral nutrition is contraindicated or not tolerated.

Advantages of parenteral nutrition

• It ensures that essential nutrients are delivered.
• It allows the gastrointestinal tract to rest.
Disadvantages of parenteral nutrition
• Potential risks from central venous access insertion (e.g.
pneumothorax, arterial puncture, catheter misplacement).
• Potential risks from ongoing use of central venous access (e.g.
infection, thrombus, air embolus).
• Increased risk of metabolic abnormalities.
• Increased risk of overfeeding.
• Gut mucosal atrophy.
• Increased financial cost and mortality compared with enteral
feeding.

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Issues associated with parenteral feedings

Access: Parenteral nutrition is delivered through a catheter with its tip in the
superior vena cava or the right atrium.
• To aid in the prevention of catheter-related sepsis, full barrier precautions
should be utilized during insertion of the catheter, and the site should be
prepped with chlorhexidine.
• The subclavian vein is the recommended access, so a chest x-ray to rule out
pneumothorax and to ensure catheter placement is required following catheter
insertion and before the IV is utilized.
• A dedicated line is required for infusion of parenteral nutrition. No other IV
infusions or boluses should be administered through the line and no blood
should be drawn from it.
• Policies vary from institution to institution but most require changing the
parenteral nutrition solution bag and tubing aseptically every 24 hours.
Overfeeding due to the high concentration of glucose and lipids. Patients who are
receiving propofol for sedation should not receive lipids in their parenteral
nutrition.

Hyperglycemia: Critically ill patients who are receiving parenteral nutrition should
be started on intensive glucose management and insulin therapy.
Hypoglycemia: A sudden decrease in the rate of infusion of parenteral nutrition
can cause the patient’s blood sugar to plummet. Therefore, parenteral nutrition is
rarely stopped abruptly, and it is always infused using an infusion pump.
Risk of infection:
• Ensuring that the central line has been inserted utilizing full barrier precautions
is the first step in decreasing the risk of infection.
• Maintaining a dedicated line is the second step. The dressing on the access site
should be aseptically applied, securely attached, and changed in accordance
with agency policy.
• Removing lipids from the parenteral nutrition is also helpful in preventing
infection because lipids support the growth of many microorganisms.
• The patient should be monitored for signs of sepsis, including fever, chills,
elevated white blood count, and positive blood cultures.
• If the catheter site is thought to be the source of infection, the catheter is
discontinued and the tip is usually sent for culture and sensitivity.

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Evaluation
• Determining the patient’s weight daily (expect
weight stabilization or 1/4 to 1/2 pound weight
gain per day with adequate nutrition)
• Examining the following lab studies:
• Albumin or prealbumin
• Hemoglobin and hematocrit
• Electrolytes, including potassium
• Magnesium
• Phosphorus
• Assessing the patient’s wounds for granulating
tissue

THANK

YOU

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