Dukungan Nutrisi pada Pasien

Sakit Kritis

Ike Sri Redjeki

SMF Anestesiologi & Reanimasi Rumah

Sakit Hasan Sadikin /FK UNPAD
Bandung
 Objektif
• Definisi dan kategori pasien yang termasuk
sakit kritis
• Perubahan metabolisme pada pasien-pasien
sakit kritis
• Dukungan nutrisi pada pasien-pasien sakit
kritis secara umum
• Dukungan Nutrisi pada keadaan khusus
• Contoh kasus
 FASTHUG
• Feeding
• Analgesia
• Sedation
• Thrombolytic Therapy
• Head elevation
• Ulcer prophylactic
• Glucose Control
Pasien sakit kritis
Patofisiologi pasien sakit kritis : respon stres yang berat
 Pro Anti
inflammatory Initial insult inflammatory
response response

Systemic spill over Systemic spill

of pro Systemic over of anti
inflammatory
mediators
reaction inflammatory
mediator

SIRS
Suppression of
Cardiovascular CARS immune system
compromised
CARS
predominate

Homeostasis Apoptosis Organ

CARS and death with
SIRS balance minimal Dysfunction
inflammation SIRS
predominate
 Stress Response ( neuroendocrine response )
A. Afferent stimuli
(Hypovolemia, trauma, hypoxemia,pain, anesthesia, MODS, sepsis,toxins &bacteria )

B. Transmitters
( Blood and lymphatics, peripheral nerves, CNS)

C. Effector site
Sympathetic nerv syst Hypothalamus Kidney Pancr
Adrenal medula Ant pituitary Post pituitary
islets Renin,
Adr cortex angiotens
Epinephrn ADH Glukagon
norepinephr Cortison, aldostr, Insulin
Aldostrn
G.H
 Pengaruh Sitokin yang dilepaskan pada
respons stres

Sitokin yang dikeluarkan Akibat pelepasan sitokin

karena proses lokal - Mobilisasi dari asam
- Penyembuhan luka amino, stimulasi sintesa
dari acute phase protein
- Stimulasi angiogenesis
- Jumlah lekosit
- Migrasi lekosit
- Febris, timbul rasa tidak
- Perubahan fibroblast
nyaman
- Lokalisasi luka dan
- Timbul tanda-tanda sepsis
infeksi yang lain
 Respons metabolisme pada pasien-pasien sakit kritis
( kondisi katabolik)
Maladaptive SIRS dan
CARS
Adaptive response
• Inflamasi yang hebat
• Anabolic phase
• Katabolisme protein • Cytokines reduction
• Supresi sistim imun • Hormonal response gradually
diminishes
• Disfungsi organ
  gluconeogenesis
• Gagal Organ   catecolamines
  aldosterone and ADH
• Salt and water loss
  insulin and  glucagon
• protein anabolism
 Physiologic Changes Associated with Stress Response
Response Physiologic benefit
Protein catabolism Ensure adequate substrate
for acute phase response,
gluconeogenesis, wound
healing, immune function
Hyperglycemia Ensure substrate availabiility
Sodium & water Maintain iv volume
retention
Increase HR, CO Maintain organ perfusion
Hypercoagulability Hemostasis
Increase Sympathetic Increase CO, substrate
tone avalability
Potential Physiologic Risk
Functional tissue loss,
hypoalbuminemia
Hypoalbuminemia,
hyperglycemia, osmotic diuresis,
immune dysfunction
Hyponatremia, hypervolemia,
pulmonary edema, CHF,
Hypokalemia, Hypo Mgemia
Cardiac work, myocardial
ischemia, arrhythmia
Microvasc thrombosis, DVT,
Pulmonary embolus
Increase cardiac irritability,
Hyperglycemia, inhibit insulin,
shunting blood from gut
 Perjalanan penyakit pada pasien-pasien dengan stres
respons
Burns, trauma, Sepsis, Pancreatitis, Peritonotis
Respons
Surgery, Stres
Radiation Th/
Ebb phase

Syok, hipoksi, dll

Resusitasi
Kondisi katabolisme / Respons akut
hiperkatabolisme
Flow phase Respons
Maladaptif
Recovery Adaptive response
(anabolic phase)
 Dampak klinis dari respons maladaptif yang
tidak terkendali

• Malnutrisi
• Penurunan fungsi
imunologis • Lama perawatan di ICU
• Disfungsi organ/ gagal & RS
organ
• Morbiditas
• Mortalitas
• Biaya alat dan obat2an
• Biaya perawatan
Pasien Sakit Kritis  hipermelabolik, katabolik, imun respons
bifasik ( meningkat/menurun)

Tujuan dukungan nutrisi :

• Menyesuaikan asupan dengan perubahan metabolisme yang
terjadi
• Mempertahankan masa sel tubuh (otot, usus. mukosa dan
organ2 lain)
• Mencegah dan mengatasi kekurangan zat2 nutrisi yang spesifik
• Mempertahankan fungsi sistim imun untuk mengatasi infeksi
• Mencegah komplikasi yang dapat timbul sehubungan dg
tehnik pemberian nutrisi
 Prosedur pemberian dukungan nutrisi

1. Penilaian Status Nutrisi

dan kebutuhan dukungan
nutrisi
 Tentukan kebutuhan energi 2. Tentukan jenis
 Ada/ tidaknya ggn substrat nutrisi yang
keseimbangan nutrisi diperlukan
 Tentukan kemungkinan adanya  Evaluasi kebutuhan sec
defisiensi substrt 2 yg spesifik kuantitaif
 Evaluasi kebutuhan
kualitatif

3. MONITOR
 Penilaian Status Nutrisi pada Pasien2 Sakit
Kritis

• Metoda tradisional : sulit untuk dipenuhi

– Riwayat kebiasaan makan :
– BB: setelah resusitasi ?
– Anthropometric: tidak sensitif untuk perubahan2 yang
akut
– Plasma protein: dipengaruhi oleh respons stres
• Penilaian klinis
– Memperkirakan berat ringannya penyakit, respons stres,
dan tingkat perubahan metabolisme
– Memperkirakan jumlah substrat nutrisi yang dibutuhkan
 Substrat nutrisi Jumlah

Kebutuhan energi, Air cc/kgBB/hari 25 – 30 (kritis)

cairan dan elektrolit 30 – 50

Energi 25 – 30 (kritis)
Kcal/kgBB/hari 30 – 50

As.Amino/prot 1,2 – 1,5

Gr/kgBB/hari

Na meq/kgBB/hari 1 -2

K meq/kgBB/hari 1

Glukosa : lemak 3:1 - 1;1

 40
Critically ill patients

30
PERCENT
OF
20 Third
BODY Space
WEIGHT
10

0
Intra- Inter- Plasma
Cellular Stitial Volume
Adolph H. Giesecke, Fluid Fluid
Lawrence D. Egbert
 Cairan dan Elektrolit

• Setelah resusitasi • Pada pasien dari

cairan tubuh ber+ katabolik  anabolik
• Expansi ECF ( cairan akan terjadi perubahan
ekstra sel)  15-20% keseimbangan cairan
• Kadar plasma tubuh
elektrolit yang adekuat • Kebutuhan
diperlukan untuk micronutrient
sintesa protein meningkat pada
respons stres
 Normal Adult Water and Electrolyte
Requirement
(electrolyte meq/kgBW/day and water cc/m2)

Component Minimal needs Usual needs

Na 0,3 0,7-3,6
K 0,3 - 0,5 0,7 - 2,1
Ca 0,2 0,4 - 1,1
Mg 0,2 - 0,4 0,3 - 0,7
Cl 0,3 0,7 - 3,6
Water 870 1500
 Kebutuhan Kalori

• Perubahan fisiologi pada katabolisme/

hipermetabolisme
  Produksi panas
  Energy expenditure ( 25 – 50%)
  laju nafas
  laju nadi
• Kebutuhan kalori (kcal/kg method)
– 25 – 30 kcal/kg (ASPEN Board of Directors, 1993)
– Glukose merupakan substrat yg utama
– Lemak digunakan utk memenuhi 20-30%
 Resting Energy Expenditure
+110
+100 Burns gr. III
+90 > 20% BSA
+80
+70
+60
+50
+40 Severe infection
+30
+20 Multiple fracture
Basal Resting +10

10%
Normal
-10 Starvation (parsial)
-20
-30
-40

Kinney
 Metabolisme KH
• Dibutuhkan minimal 100g/hari • Kecepatan pemberian
untuk mempertahankan fungsi <5 mg/kg/menit
CNS, sum2 tulang, sel darah
merah, jaringan yang
mengalami injuri • Jumlah tsb kira2 50-60%
total kebutuhan energi
• Pada respon stres : kecepatan pada psn sakit kritis
max oxidasi glukosa
4-6mg/kgBB/hr

• Jumlah = 400-600 g/hr pada

psn dg BB 70 Kg
 Metabolisme Lemak
• Terjadi peningkatan • Kecepatan pemberian
oksidasi asam lemak 0.1 gr/kgBB/jam
• Sumber asam lemak • Harus diberikan
esensial perlahan dalam waktu
• Protein sparing 18-24 jam
• Kalori tinggi dengan
volume rendah
• Preparat lemak : 3-5%
asam lemak esensial
 Classification of LIPID as source of
nutrition
Fatty acid are classified according to
structural characteristic :
•The length of carbon chain
– Short chain ( < 8 carbon)
– Medium chain ( 8 – 14 carbon)
– Long chain ( > 16 carbon)
•The presence and position of double bond in
the chain
– saturated
– unsaturated ( omega 3,6,9)
 LCT/MCT  in combination

• The tolerance of mixed LCT/MCT can be

administered safely at a rate of 0,7 – 1,5 g/kg
over 12 – 24 h
• MCT  Metabolized  more rapid from the
circulation
• Less pro-inflammatory agents ( Less precursor of
protaglandin formation )

Grade B
 Metabolisme protein

• Kebutuhan  pada hipermetabolisme , stres, pasien2 sakit kritis

• Urinary urea excretion ≈ 85% pemecahan protein tubuh
• Asupan protein :
– Mengurangi jumlah yang hilang karena katabolisme
– Mempertahankan lean body mass
– Menyediakan jml protein yang cukup untuk memperbaiki sel2
tubuh dan penyembuhan
– rata2 diperlukan 1.2 – 2 gr/ kgBB/ hari
(75 – 100 g protein/ hari )
– (1 g nitrogen = 6.25 g protein = 30 g lean tissue)
– NPC:P ratio = 100 : 1
Intake protein

Katabolisme
protein

Keseimbangan metabolisme
protein pada pasien2 sakit
kritis
 Jenis2 Protein
per NGT( enteral feeding )
• Poli – peptida
• Di – peptida
• Oligo – peptida ] > Mudah
dicerna

Enzimatic system  protein 

kondisi pada katabolik  terganggu
Fungsi Saluran Cerna adalah kunci ketika akan
memberikan dukungan Nutrisi
Saluran Cerna Saluran Cerna
Tidak berfungsi Compromised

TPN
Saluran Cerna
Normal
1-10 tahun
 Monitoring
• Tanda2 vital
• Akses: iv lines perifer, CVP, pipa
Nasogastrik ( posisi, sumbatan, dll)
• Efek Metabolisme : GDS dan elektrolit
setiap hari, ureum kreatinin 1-2 hari sekali
atau sesuai kebutuhan lain2 bisa 1 minggu
sekali
Penyakit2 kritis
Nutrient Requirements in Pulmonary
Failure
• Calories: don’t overfeed when weaning to prevent
increased CO2 production
– Provide 25-30 kcal/kg or resting energy expenditure
• Protein: 1.5-2 g/kg
– Amino acids may increase ventilation, increase O2
consumption and ventilatory response to hypoxia and
hypercapnea
• Carbohydrate: <5 ,g/kg/min
– Overall calories more important than percent CHO
• Fat: N3 FA may be anti-inflammatory and alter immune
status in sepsis/ARDS
 Respiratory Quotient (RQ)
• RQ is the ratio of carbon dioxide produced
to oxygen consumed; is an indicator of fuel
utilization
• Normal (physiologic) range is 0.5 to 1.5
• High RQ in a ventilator patient may make it
difficult to wean the patient from the
respirator
 Respiratory Quotient Values for Various Fuel
Substrates
Fat 0.7
Protein 0.8
Carbohydrate 1.0
Mixed Diet ~0.85
Alcohol 0.67

Underfed <0.8
Adequately fed 0.8-1.0
Overfed >1.0
 Trauma

Severe SIRS
Early MOF
Moderate SIRS
Insult
Moderate
GUT immunosuppression
Severe
immunosuppression CARS
Ischemic/reperfusion
laparotomy, ICU th/,
Disuse(TPN)

Infections Late MOF

Ileus, colonization,
permeability , GALT
 Nutrient Requirements for Liver
Failure
• Calories: caloric requirements affected by acuteness of
disease, seriousness of injury, absorption, other organ
failure, sepsis; 25-35 kcals/kg or REE
• Protein: well nourished/low stress: 0.8 g/kg;
malnourished/with metabolic stress: up to 1.5 g/kg
• CHO: ~70% non-protein calories; in acute failure, may
need continuous glucose infusion
– Chronic: may have diabetes/hypoglycemia requiring
controlled CHO and insulin; in septic pts hypoglycemia
occurs in 50% of cirrhotics
• FAT: 30% non-protein calories; MCT may be helpful
with LCT malabsorption
 Nutrient Requirements in ARF

• Calories: 25-45 kcals/kg dry weight or REE

• Protein: about 10-16 g amino acids lost per day with CRRT
– ARF w/o HD (expected to resolve within a few days): 0.6-
1 g pro/kg
– Acute HD: 1.2-1.4 g/kg; acute PD: 1.2-1.5 g/kg; CRRT:
1.5-2.5 g/kg
• CHO: ~60% total calories; limit to 5 mg/kg/min; peripheral
insulin resistance may limit CHO
– In CWHD(F) watch for CHO in dialysate or replacement
fluids
• Fat: 20-35% of total calories; lipid clearance may be impaired
 Multiple Organ Failure: SIRS
• Site of infection established and at least two of
the following are present
—Body temperature >38° C or <36° C
—Heart rate >90 beats/minute
—Respiratory rate >20 breaths/min (tachypnea)
—PaCO2 <32 mm Hg (hyperventilation)
—WBC count >12,000/mm3 or <4000/mm3
—Bandemia: presence of >10% bands
(immature neutrophils) in the absence of
chemotherapy-induced neutropenia and
leukopenia
 Nutrition/Metabolism
Considerations
• Determine priorities for medical and
nutrition therapy
– 3-5 times higher catabolism
– Increased skeletal muscle proteolysis
– Shift of amino acids from periphery to viscera
for gluconeogenesis
 Nutrient Needs in MODS

• Calories: 25 kcal/kg or REE  acute phase

• Protein: up to 1.5-2.0 g/kg
• Fat: 30% nonprotein calories; ↑ MCT if bile
salt deficient; Omega3 vs Omega 6
• Micronutrients: evaluate individually
• Fluid: based on fluid status

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening

Your Skills as a Nutrition Support Dietitian, 2003
 Feeding Route

• EN usually preferred over PN; PN may

worsen liver function
• Intubation does not preclude aspiration
• EN not contraindicated with varices
• Patients with CRF often may have
gastroparesis; may need motility agent

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening

Your Skills as a Nutrition Support Dietitian, 2003
 Formula Selection
• Concentrated formulas may be helpful with
fluid restriction
• Formulas restricted in phos and potassium
may be helpful in pts with high phos and
K+
• Immune-enhancing formulas (controversial)

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening

Your Skills as a Nutrition Support Dietitian, 2003
 Conclusion
• Critically ill patients with organ failure
present special challenges to the nutrition
care professional and medical team
• Medical and nutritional goals must be
prioritized in these complex patients
Kasus :
Laki2 40 thn mangalami kecelakaan lalulintas. Tiba di
UGD dengan keadaan tidak sadar,
Tekanan darah : 90/60, nadi : 120x/mnt, Hb 8 gr%, 
mendapat therapi cairan 3000 cc Ringer Asetat ( Asering)

Tensi naik 110/80, nadi 100x/mnt, Hb 5 gr%  akut

abdoomen  dilakukan pembedahan  robekan hepar
dan perdarahan 2000 cc hematoma retroperitoneal yang
luas, selama operasi diberikan HES 1000 cc dan
transfuusi 1000 cc.
Usus intak, tidak ada kerusakan, pascabedah pasien
dirawat di ICU dengan respirator
A. Penaggulangan resusitasi
B. Mulai nutrisi?
C. Perjalanan penyakit  pasien sempat
mengalami gagal ginjal dan pembedahan ulang
D. Pasien termasuk  pasien sakit kritis
- kriteria
- enteral/parenteral/kombinasi?
- jumlahnya?
- jenis substrat?
- Monitor?
 Perbedaan perubahan metabolisme pada
pasien starvasi dan sakit kritis
Psn starvasi Psn sakit kritis

REE Decreased Increased

Respiratory quotient (RQ) (0.6 - 0.7) (0.8 - 0.9)
Primary fuels Fat Mixed
Mediator activation ---- +++
Proteolysis + +++
BCAA’s + +++
Hepatic protein synthesis + +++
Urea genesis + +++
Urinary nitrogen loss + +++
Insulin   (Resistant)
Gluconeogenesis + +++
Ketone body production ++++ +