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Modul 12B

NUTRISI PARENTERAL

Dept. Anestesiologi & Terapi Intensif


FK-USU/RSUP H.Adam Malik- Medan

DEFINITION
Parenteral nutrition is partial or total
nutrition administered intravenously. A
peripheral or central vein is used for
access

SUPPORT NUTRITION
ORAL NUTRITION
ENTERAL NUTRITION
PARENTERAL NUTRITION

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

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

CENTRAL PARENTERAL
NUTRITION
Selection depends on caloric
requirement,volume to be administered and
patient condition, as well as final concentration
of components:
Amino acid > 5 %
Dextrose > 20%
Lipids
Includes vitamins, minerals and trace elements
Osmolality > 700 mosm / kg H20

FORMULAS :
Dextrose
Provide 3,4 kcal /kg
Can be the only source of energy
Dextrose infusion rate should not exceed
5mg/kg/min
Closely related to solution osmolality

FORMULAS :
Amino acids
Standart concentrations can vary between 5
% and 15 %
Energy value of amino acids ( 4 kcal /g )
Nitrogen ( g ) = protein ( g )/ 6.25

FORMULAS :
Lipids
Prevents essential fatty acid deficiency
Non protein source of kacal remcommend
local 1 g / kcal
Available in 10%,20%, and 30%
concentrations
Included as LCT or a mix of MCT/ LCT at 10
% and 20%
Added to basic parenteral nutrition solutions or
administered individualy

FORMULAS :
Lipids

Less hyperglicemia
Lower concentration of serum insulin
Less risk of hepatic damage
High doses can interfere with immune functions
High infusions rates can affect respiratory functions
Should be used with care in :
Hyperlipidemia
Symptomatic atherosclerosis
Acute pancreatitis with hypertriglyceridemia

FORMULAS:
Electrolytes:
Calcium, magnesium, phosporus, chloride,
potassium, sodium, and acetate
Forms and amounts are titrated based on
metabolic status and fluid / electrolyte balance
Must consider calcium phospate solubility

FORMULAS:
Vitamins and minerals
- In general, amounts below daily recommend
intake for healty people but nonetheless
sufficeint to cover requirements are added to
oral or enteral formulas
- Added daily to parenteral nutritions
- Acute illnes infections preexisting
malnutritions and excessive fluid loss
increase vitamin requirements

FORMULAS :
TRACE ELEMENTS
Include daily zinc, copper, chromium,
and manganese for patients with kidney
or liver failure
Different requirement dictated by patients
and pathology
Patients under extended parenteral
nutritions require the addition of iron
and selenium

PERIPHERAL PARENTERAL
NUTRITION
Selection of peripheral access depends on
clinical situation requirements, tolerance to
volume and final formula concentration
Osmolality < 900 (700) mosm/kg
Total kcal limited by concentration and ratio to
volume being administered
Include of the recommend electrolytes for
PN

PN : TYPES OF INFUSION
Continous total volume of formula is
administered over a 24 hour period
Cyclic volume is administered in one
period, with infusion adjustment and a
period of rest
Selection of infusion type depends on
patients condition
Use a parenteral infusion pump

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
CHO & LIPID

60:40
50:50

Osmolarity
PPN
TPN

900 mOsm/L
(700 mOsm/L)

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

V1.O1 + V2.O2 + V3.O3


V1 + V2 + V3

Triofusin-E.1000(1000 ml) , Kalbamin-10%


(500 ml) Ivelip-10% (500ml)

Osmolaritas campuran =
1400x1 + 880x0.5 + 265x0.5
1 + 0.5 + 0.5
= 986,5 mOsm/L

Pemilihan Cairan Nutrisi


Sumber
Karbo- Hidrat,
kcal/L?

Sumber Lemak,
kcal/L?

Osmolaritas
mOsm/L

Vitamine,
Mineral
Sumber Asam
- Amino, gr/L?

NPC
k.cal/L
TRIOFUSIN-500

500

As.Amin
o

mOsm/L

gr/l

800

TRIOFUSIN E-1000

1000

1400

TRIOFUSIN-1600

1600

2500

800

1100

2000

270

DEXTROSE-20%
IVELIP-20%
INTRAFUSIN 3,5%

35

600

INTRAFUSIN-10%

100

880

Kalbamin-10%

100

880

CLINIMIX-N9G15E

410

28

845

CLINIMIX-N9G20E

510

28

980

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
-500

intrafu
sin10%

IVELI
P10%

VOLUME
NPC
A.ACIDS
OSMOL.

THREE WAY
STOPCOCK

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

PPN
24 HOURS

Triofusin
E-1000

Intrafu IVELI
sin10%
P10%

VOLUME
NPC
A.ACIDS
OSMOL.

THREE WAY
STOPCOCK

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

TPN
24 HOURS

Teknik
Pemberian,

Teknik
Pemberian, All
in One [AiO]

R/ Clinimix

1000 kcal
NPC
60%-70%, KH

40%-30%, lemak

500 kcal

500 kcal

TRIOFUSI
N

Ivelip 20%

500

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

500 kcal,
270 mOsm/L
4 tetes/men.

Asam Amino,
35 gr

INTRAFUSIN
3.5%

1000 mL,
As.amino 35 gr
600 mOsm/L

TRIOFUSIN

IVELIP-20%

500

INTRAFUSIN
3.5%

250 mL,
1000 mL,
500 kcal,
800mOsm/L
15 tetes/men

500 kcal,

1000 mL,

265 mOsm/L

As.amino 35 gr

4 tetes/men

600 mOsm/L
15 tetes/menit

2250 mL, 1000 kcal (NPC), 35gr as.amino ,650 mOsm/L


tetes bersama 24 jam vena perifir

Triofusin E1000

IVELIP

KALBAMIN

20%

10%

Three way
stop cock
VOLUME
NPC
A.ACIDS
OSMOL.

: 2000 ml
: 2000k .cal
: 50 gr
: 987.5 mOsm/L

Vena
centralis

KOMPLIKASI
METABOLIK
OVER DOSIS SUBSTRAT
LAJU INFUSI YANG TERLALU CEPAT
PEMAKAIAN LAMA

MEKANIK
ARTERIAL PUNCTURE
PNEUMOTHORAX
HEMOTHORAX
THROMBOPHLEBITIS,
DLL

MONITORING PATIENT OF
PARENTERAL NUTRITION
Metabolic

Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholestrol

MONITORIN
G
BALANS CAIRAN,
GULA DARAH,
ELEKTROLIT,
ALBUMIN,
KURVA SUHU,
PROFIL LEMAK,
BUN, SERUM CREATININ,
HEMOGLOBIN, LEKOSIT,
BERAT BADAN

Assesment

Body weight
Nitrogen balance
Plasma protein
Creatinine height index

Terima kasih atas perhatian anda


Semoga Tuhan selalu memberkahi kita semua
Amin

Nutrisi Parenteral Skill


Menghitung kebutuhan dan
menentukan pilihan
jenis/komposisi nutrisi yang
sesuai dengan pasien.