NUTRISI PARENTERAL

Hasanul Arifin
BAGIAN ANESTESIOLOGI DAN REANIMASI FAKULTAS KEDOKTERAN USU MEDAN

What we have to know about nutrition in the ICU

Short periods of food deprivation well tolerated
in previously well nourished if illness not too severe or prolonged

Nutrition requirements in ICU altered Malnutrition before admission increases morbidity and brings death sooner Malnutrition develops within ICU Need to show that nutrition can reduce morbidity and mortality

Normal starvation vs hypercatabolic response to critical illness

St a r va t ion
Reduced basal metabolic rate, reduced caloric requirements

Hypercatabolic response to critical illness

Increased basal metabolic rate, calorie requirements. Increased secrection of "stress" hormones [catecholamines, cortisol, etc.] and cy tokines

Fat becomes the principal Impaired capacity to use carbohy drate and f at as energy non-carbohy drate energy source as source, resulting in an increased protein breakdown as lipoly sis is stimularted by a f all in insulin alternativ e energy source and rise in glucagon Protein and lean body mass is preserv ed until late into the starv ation period Massiv e nitrogen losses f rom the breakdown of muscle protein [nitrogen loss can approach 30 g/day , equiv alent to 800 g muscle]

The restoration of adequate nutritional support leads to rapid resumption of an anabolic state

Catabolic state not rev ersed by resumption of adequate nutrition. hy peralimentation may precipitate its own problems [lipaemia, liv er dy sf unction, metabolic acidosis]

Keith Bresland; Nutritional support, in Hand Book of Critical Care,192:1998.

Characteristic Setting Basis Focus

Nutritional support Malnutrition Starvation

Metabolic support Hypermetabolism/organ failure Metabolic stress response

Restore visceral protein Preserve organ function synthesis and lean body Preserve organ structure Prevent subtrate limited mass metaboism Glucose >150/1 1-1.5 0-60 Mixed <100/1 1.5-2.5 30-40

Fuel NPC/gr N Amino acids [g/kg/d] % NPCas fat

Table 124-2. Shoemaker; Textbook of critical care 1119:1989

A B
SUPPORT NUTRITION

NUTRITION is a BASIC of SURVIVAL RECOVERY

Nutritional support should be a routine part of the care of our patients, especially of the critically ill .

The main goal of nutritional support is to minimise the loss of protein and energy.

NaCl
0.9%

D5W

RL

20 drips/min. change continue

1500 ml fluid, 100 k.cal energy, 0 gr Amino Acids, 140 mEq Na+, 2 mEq K+,

Recommendation for Clinical Practice

STABLE

HAEMODYNAMIC (DO2)

START LOW GO SLOW END SLOW

VOLUME,
50 ml /kg/day

2500-3000 ml/day

ENERGY
HARRIS BENEDICT INDIRECT CALORIMETRI

BEE = 25-30 k.cal/kg/d REE = [ 1.2-1.3 ] x BEE

SUMBER ENERGI,
KARBOHIDRAT
RQ = 1 PaCO2 ventilasi

R/ Karbohidrat + Lipid

minimal glukose 150-200 gr . jangan > 5-6 gr/kg/hari makin tinggi kandungan kalori makin tinggi osmolaritas cairan

Lipid,
RQ = 0.7 PaCO2 sumber EFA, pada parenteral nutrition minimal 2 x/minggu, 265-270 mOsm/L LCT, LCT/MCT (50:50) tetes 24 jam. dosis: maximal 50% (60%) dari NPC

Protein,
balans nitrogen positif pada critically ill, laju kehilangan protein BCAA drive ventilasi, R/ Amiparen-10%, R/ Aminofusin 10% dosis : 0.8-1.5 gr/kg/hari Protein sparing effect (1gr protein dilindungi 25 k.cal KH/Lipid) TPN- glutamine enriched

Metabolic fuel for rapidly proliferating tissues (enterocyte, immune cells,)

Nitrogen and carbon transport

Carrier of nitrogen (as ammonia) and carbon (as glutamate) between tissues

Maintain skeletal muscle

Stimulates protein synthesis Inhibits protein degradation

L-glutamine

Acid-Base balance

Stimulates hepatic glycogen synthesis

Biosynthesis
Precursor of amino acids, peptide, protein,nucleic acids Substrate for gluconeogenesis

metabolic functions

Potential source of glutamate for glutathione synthesis

LUNGS

SKELETAL MUSCLE

BRAIN

PLASMA GLUTAMINE POOL

IMMUNE CELLS

LIVER

KIDNEY

GUT

Normal glutamine flux between tissues in the basal state

LUNGS

SKELETAL MUSCLE

BRAIN

PLASMA GLUTAMINE POOL

IMMUNE CELLS

LIVER

KIDNEY GUT

Trauma induces conciderable changes in glutamine flux

Increases protein synthesis and nitrogen balance

Reduced hospital stay

Improves gut function

Glutamine in TPN

Improved mood

Improves immune function

Reduced water retention

clinical benefits of glutamine in TPN

Osmolarity
PPN TPN
900 mOsm/L

OSMOLARITAS [m.Osm/L] Osmolaritas Campuran : =

V1.O1 + V2.O2 + V3.O3

V1 + V2 + V3

Triparen No-1(1000 ml) , Amiparen-10% (500 ml), Ivelip-10% (500 ml)

Osmolaritas campuran =
1400x1 + 880x0.5 + 265x0.5 1 + 0.5 + 0.5

= 986,5 mOsm/L

NPC
k.cal/L TRIOFUSIN-500 TRIOFUSIN E-1000 TRIOFUSIN-1600 DEXTROSE-20% IVELIP-10% IVELIP-20% INTRAFUSIN 3,5% INTRAFUSIN-10% 500 1000 1600 800 1000 2000

As.Amino gr/l

mOsm/L 800 1400 2500 1100 265 270

35 100

600 880

Tetes bersama 24 jam

Semua substrat terbagi merata Mengurangi osmolaritas Protein sparing effect Cegah hypoglikemia Fluktuasi insulin Cegah side effect

PARENTERAL NUTRITITION

tetes bersama

Triofusin- intrafusin IVELIP10% 500 -10%

VOLUME NPC A.ACIDS OSMOL.

: 2000 ml : 1000 k.cal : 50 gr : 686 mOsm/L

THREE WAY STOPCOCK

PPN
24 HOURS

Triofusin Intrafusin IVELIP10% 10% E-1000

VOLUME NPC A.ACIDS OSMOL.

: 2000 ml : 1500 k.cal : 50 gr : 986.5 mOsm/L

THREE WAY STOPCOCK

TPN
24 HOURS

Teknik Pemberian,

Teknik Pemberian, All in One [AiO]

R/ Clinimix

KOMPLIKASI,
METABOLIK,
OVER DOSIS SUBSTRAT

LAJU INFUSI YANG TERLALU CEPAT

PEMAKAIAN LAMA

MEKANIK

ARTERIAL PUNCTURE
PNEUMOTHORAX HEMOTHORAX THROMBOPHLEBITIS, DLL

MONITORING,
BALANS CAIRAN, GULA DARAH, ELEKTROLIT,

ALBUMIN,
KURVA SUHU, PROFIL LEMAK,

BUN, SERUM CREATININ,

HEMOGLOBIN, LEKOSIT, BERAT BADAN

Thank you