NUTRISI PARENTERAL

Hasanul Arifin
BAGIAN ANESTESIOLOGI DAN REANIMASI FAKULTAS KEDOKTERAN USU MEDAN

Hospital Malnutrition: Critical Evidence

The skeleton in the Hospital Closet
Height not recorded in 56% of cases Body weight not recorded in 23% of cases 61% of those whose weight was recorded lost >6kg 37% had albumin < 3.0 g/dl
Butterwoth CE, Nutr. Today 1974

Hospital Malnutrition : Prevalence

Numerous studies on hospital malnutrition have been published. Prevalence malnutrition in US Hospitals today ranges from 30% to 50% Patients nutritional status declines with extended hospital stay
Coats KG et al. J Am Diet Assc. 1993

Malnutrition Among Hospitalized Patients : A problem of Physician Awareness

Up to 50% of hospitalized patients may be malnourished on admission Before nutritional assessment training :
Only 12.5% of malnourished patients are identified

After 4 hours of training :

100% of patients are identified
Roubenoff et al, Arch Intern Med. 1987

Prevalence of Malnutrition in Hospitalized Patients

10%
severely malnutrition moderately malnutrition adequate nutritional state

21% 69%

Detsky et al, JPEN 1987

Prevalence of Malnutrition in Hospitalized Patients

In a published Brithis Study :
46% of general medicine patients 45% of patients with respiratoy problems 27% of surgical patients 43% of elderly patients
Percentage of malnourished patients at time of admission.
McWhirter et al. Br Med J 1994

Prevalence of Malnutrition in Hospitalized Patients

Jakarta 20% - 60%

Majalah Gizi Indonesia

Malnutrition and its consequences

Changes in intestinal barier Reduction in glomerular filtration Alteration in cardiac function Altered drug pharmacokinetics

Roediger 1994; Green 1999; Zarowitz 1990

Malnutrition and its consequences

Loss of weight Slow wound healing Impaired immunity Increase in length of hospital stays Increase treatment costs Increase in mortality

Roediger 1994; Green 1999; Zarowitz 1990

Malnutrition and Slow Wound Healing

Foot Amputation, 86% of well nourished patients healed without problems Only 20% of malnourished patients healed successfully
Dickhaut SC et al. J Bone Joint Surg Am 1984

Malnutrition and Increased Complications

42% of severely malnourished patients suffer major complications 9% of moderately malnourished patients suffer major complications Severely malnourished patients are four times more likely to suffer postoperative complications than well nourished patients.
Detsky et al. JAMA 1994

Hospital Stay :
Malnutrition increase time and costs
severe

Nutritional status

mild

days

normal

days

10

15

20

Robinson et al JPEN 1987

Nutrition Therapy Affects Outcomes: Early Nutrition

Length of stay (days)
80 70 60 50 40 30 20 10 0 Fed at 3 days at 7 days
Garrel et al, J Burn Rehabil. 1991

Fed at 3 days at 7 days

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.

SUPPORT NUTRITION
ORAL NUTRITION ENTERAL NUTRITION PARENTERAL NUTRITION

PARENTERAL NUTRITION
Diberikan lewat intravena Vena perifir (PPN) Vena sentral (TPN)

PARENTERAL NUTRITION
Semua substrat nutrisi (nutrient) diberikan melalui intravena dalam bentuk cairan nutrisi Semakin tinggi kandungan nutrient dalam suatu cairan nutrisi, semakin tinggi osmolaritas cairan tersebut.

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+,

INDICATIONS
Non-functional GI-tract Impossible to use the GI-tract
Intestinal obstruction Peritonitis Intractable vomiting Severe diarrhea High output enterocutaneus fistula Short bowel syndrome (<70 cm) Severe malabsorption

Need for intestinal rest Palliative use in terminal patients is controversial

CONTRAINDICATIONS
Ability to adequately receive and absorb necessary foods orally or by gastric or enteral tube Hemodynamic instability

Recommendation for Clinical Practice

STABLE

HAEMODYNAMIC (DO2)

START LOW GO SLOW END SLOW

VOLUME,
50 ml /kg/day

2500-3000 ml/day

VO2 oxygen consumption ENERGY VCO2

HARRIS BENEDICT INDIRECT CALORIMETRI

Rule of Thumb
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

Bagaimana perbandingan KH dan Lipid sebagai NPC?

60-40
KH Lipid

Protein,
balans nitrogen balans positif pada critically ill, mengurangi laju kehilangan protein BCAA R/ Amiparen-10%, Aminofusin-10% dosis : 0.8-2.0 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

Pemilihan Cairan Nutrisi

Sumber Karbo- Hidrat, kcal/L? Osmolaritas mOsm/L

Sumber Lemak, kcal/L?

Vitamine, Mineral
Sumber Asam - Amino, gr/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

720 kcal + 360 kcal

30 gr +

gr as.amino

Trifluid

1080 kcal, gr 420 as.amino

750 kcal

NPC
60%-70%, KH
450 kcal

40%-30%, lemak
300 kcal

T R I F L U I D LIPID INTRAVENA 10%

300 mL, 300 kcal, 265 mOsm/L 5 tetes/men.

1000 mL, 420 kcal, 800mOsm/L 15 tetes/men.

Asam Amino, 30 gr
P A N

A
M I N G

1000 mL,
As.amino 27gr 507mOsm/L

T R I F L U I D

LIPID INTRAVENA 10%

P A N A M I N G

300 mL, 300 kcal,

1000 mL, 420 kcal, 800mOsm/L 15tetes/men

265 mOsm/L
5 tetes/men.

1000 mL,As.amino 27gr, 507 mOsm/L, 15 tetes/men

2300 mL, 720 kcal, 27gr as.amino ,603 mOsm/L tetes bersama 24 jam vena perifir

TRIPAREN No-1

LIPID-iv 10%

AMIPAREN

VOLUME NPC A.ACIDS OSMOL.

: 2000 ml : 1430 k.cal : 50 gr : 992.5 mOsm/L

Three way stop cock

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