ASUHAN GIZI PADA PASIEN CRITICALL ILL

Rodlia, S.Gz, MKM, RD

Sumber : http://sunnybrook.ca/content/?page=brain-injury-critical-care
 DEFINISI CRITICAL ILL
 Critical ill merupakan kondisi ketidakstabilan
fisiologis yang menyebabkan kecacatan atau
kematian dalam beberapa menit atau jam.
 Perlu diambil langkah yang yang cepat dan
tepat dalam proses asessmen, diagnosis dan
intervensi penyakit.
Pathophysiology of malnutrition in intensive care
unit
 MALNUTRISI PADA CRITICAL ILL

 Malnutrisi merupakan kondisi ketidakseimbangan

gizi (imbalance in nutrition) baik gizi kurang maupun
gizi lebih
 Malnutrisi dapat berkembang sebagai konsekuensi
dari kekurangan asupan makanan, peningkatan
kebutuhan berhubungan dengan kondisi penyakit,
gangguan penyerapan zat gizi, atau kombinasi dari
faktor-faktor tersebut
 Malnutrisi berhubungan dengan infeksi, hilangnya
masa otot, gangguan penyembuhan luka, LOS tinggi
dan biaya tinggi serta peningkatan risiko kematian
 Definition of malnutrition

 BMI <18.5kg/m2

 Unintentional weight loss >10% in 3 – 6 months

 A BMI <20kg/m and unintentional weight loss >5% in

3 – 6 months
Respon metabolik
Respon metabolik
 Ebb Phase
 Immediate—hypovolemia, shock, tissue hypoxia
 Decreased cardiac output
 Decreased oxygen consumption
 Lowered body temperature
 Insulin levels drop because glucagon is elevated.
 Flow Phase
 Follows fluid resuscitation and O2 transport
 Increased cardiac output begins
 Increased body temperature
 Increased energy expenditure
 Total body protein catabolism begins
 Marked increase in glucose production, FFAs,
circulating insulin/glucagon/cortisol
 Hypermetabolic Response to Stress—
Pathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
 PROSES ASUHAN GIZI TERSTANDAR
TIDAK BERESIKO TUJUAN
MALNUTRISI
TERCAPAI
DIET STOP PASIEN
SCREENING NORMAL/ PULANG
STANDAR

BERESIKO
MALNUTRISI

PROSES ASUHAN GIZI

TUJUAN
TERSTANDAR /PAGT TERCAPAI

TUJUAN
BELUM
RODLIA, S.Gz,MKM, RD TERCAPAI
 Screening Gizi pada pasien Critical ill
• Tujuan :
1) Deteksi dini risiko malnutrisi
2) untuk memprediksi outcome dari terapi gizi

• Apabila tidak dilakukan screening gizi maka

kejadian malnutrisi tidak akan terdeksi
 Skrining dan Asesmen
Nutrition Screening
1.Mengidentifikasi pasien berisiko malnutrisi
2.Memprediksi kemungkinan pasien berisiko malnutrisi menjadi
lebih baik atau lebih buruk
3.mengurangi jumlah dan kegawatan akibat komplikasi (ESPEN,
2002)

Nutrition Assessment
mengidentifikasi tanda dan gejala malnutrisi dan pencegahan
malnutrisi

RODLIA, S.Gz,MKM
 Asesmen gizi pasien Critical Ill
Medical / Social History Diagnosis Medis. Riwayat Pengobatan,
Riwayat pembedahan dsb

Food-/Nutrition-Related History 1) Asupan enteral, parenteral

2) Konstipasi, diare, aspirasi
3) Gejala lain yang berhubungan dengan
kemampuan penyerapan makanan
dengan normal (residu)

Antropometri BB
TB
Riwayat Kehilangan BB
IMT
LILA

Biokimia Albumin, pre albumin, CRP, Hb, Hct,

Trombosit, Elektrolit, GDA, GDP, GD2JPP,
dsb
 Penentuan Diagnosis Gizi Pasien
Critical ill
• Diagnosis gizi yang dimungkinkan untuk pasien critical ill
1) Malnutrition
2) Inadequate protein-energy intake
3) Inadequate enteral intake
4) Altered GI function
5) Increased nutrient needs
6) Increased energy expenditure
7) Impaired nutrition utilization
8) Excessive fluid intake
9) Excessive energy intake
10) Inadequate oral food/beverage intake, dsb
Intervensi gizi pasien Critical ill
Intervensi gizi pasien Critical ill
ENTERAL
 Enteral
• makanan enteral adalah makanan yang
diberikan pada pasien yang tidak dapat
memenuhi kebutuhan gizinya melalui rute
oral, sehingga diberikan melalui tube ke dalam
lambung (gastric tube), nasogastric tube
(NGT), atau jejunum, dapat secara manual
maupun dengan bantuan pompa mesin
 Enteral feeding
“If the gut works – use it”

 Nasogastric (NG)
 Nasojejunal (NJ)
 Percutaneous Endoscopic Gastrostomy (PEG)
 Percutaneous Endoscopic Jejunostomy (PEJ)
http://www.baxternutritionacademy.com/ie/images/NutriAc-Mod-2.3-Fig1_big.jpg
 Indikasi pemberian enteral

 Impaired ingestion
 Inability to consume adequate nutrition orally
 Impaired digestion, absorption, metabolism
 Severe wasting or depressed growth
Conditions That Often Require Nutritional
Support
Conditions That Often Require Nutritional
Support –cont’d
 Manfaat enteral
 Mencegah atrofi mukosa usus
 Mempertahankan fungsi barrier usus
 Mencegah translokasi bakteri
 Mempertahankan/memperbaiki imunitas usus
 Mengurangi infeksi
 Menurunkan permeabilitas mukosa usus
 Mencegah terjadinya katabolisme
 memperbaiki nitrogen balance negative
 mempertahankan fungsi GIT
 Komplikasi makanan enteral
• Aspirasi
• Dehidrasi/Overhidrasi
• infeksi saluran nafas
• Infesksi nosokomial
• Refeeding syndrome
 Syarat makanan enteral
• Osmolaritas : 300-500mOsm/Kg
• Memiliki kepadatan kalori yang tinggi. minimal
1 kkal/ml cairan, untuk formula standar : 1,2-
2,0 kkal/ml
• Kandungan gizi yang seimbang
• Memiliki osmolaritas yang sama dengan
osmolaritas cairan tubuh
• Mudah serap
 Tipe makanan enteral
Produk Blenderized Products
Polymeric / Standard Products
Calorically Dense Products
Elemental and Semi-Elemental Products
Specialized / Disease-Specific Products
Modular/ Incomplete Products
Metabolic Products
 Blenderized Products
 Blenderized formulas were developed for
individuals with intolerance to semi-
synthetic formulas.
 These formulas are made from liquefying
actual foods such as chicken, peas,
carrots, tomatoes and cranberry juice.
 Similar formulas can been made in the
home but “homemade” formulations
carry a risk of bacterial contamination.
 Polymeric / Standard Products
 Polymeric or standard formulas are nutritionally
complete. They are made with intact protein,
carbohydrates, long chain triglycerides, vitamins
and minerals.
 They may also include fiber and are administered
through an enteral feeding tube.
 Examples: Fibersoure HN, Jevity 1 Cal, Jevity 1.2
Cal, Isosource HN, Nutren 1.0, Nutren 1.0 Fiber,
Osmolite 1 Cal, Osmolite 1.2 Cal, Promote,
Promote with Fiber, Nutren Replete, Nutren
Replete with fiber
 Calorically Dense Products
 Calorically dense formulas are nutritionally complete
and provide more calories than standard enteral
products.
 They may provide equal to or greater than 1.5 kcal /cc.
 They contain vitamins, minerals protein, carbohydrates,
and mainly long chain triglycerides.
 These formulas may also include fiber.
 Examples: Ensure Plus, Boost Plus, Jevity 1.5, Nutren
1.5, Nutren 2.0, Osmolite 1.5 Cal, Two Cal HN,
Resource 2.0 and Resurgex Select
 Elemental and Semi-Elemental Products
 Elemental and semi-elemental enteral formulas are nutritionally
complete but their building blocks are broken down into smaller
components.
 Elemental formulas contain individual amino acids, glucose polymers,
and are low fat with only about 2% to 3% of calories derived from
long chain triglycerides (LCT).
 Medium chain triglycerides (MCT) are the predominant fat source,
and can be absorbed directly across the small intestinal mucosa into
the portal vein in the absence of lipase or bile salts.
 Semielemental formulas contain peptides of varying chain length,
simple sugars, glucose polymers and fat, primarily as MCT.
 Examples: Crucial, Optimental, Peptamen, Peptamen 1.5, Vital HN,
Vital 1.0Cal, Vital 1.5 Cal, Vivonex Plus, Vivonex RTF, Vivonex TEN and
Tolerex
Specialized / Disease-Specific Products
 Specialized / disease-specific products are nutritionally
complete and are designed to meet the needs of individuals
with specific disease states, such as diabetes, renal
dysfunction, liver dysfunction, respiratory dysfunction, acute
illness or wound healing.
 Specialized formulas may contain biologically active
substances or nutrients such as glutamine, arginine,
nucleotides or essential fatty acids
 Examples: Diabetasol, Glucerna, Nutren Glytrol, Nepro with
Carb Steady, Novasource Renal, Nutrihep, Perative,
Pulmocare, Nutren Pulmonary, Impact, Impact 1.5, and Oxepa
Modular/ Incomplete Products
 Modular/ Incomplete products are used to deliver an
additional source of a specific nutrient.
 They are not designed to meet 100% of estimated
nutritional needs, but can provide additional calories, or
protein or fat.
 They may be taken alone or in combination with other
products.
 Examples: Duocal, Polycose, Benecalorie, Promod,
Beneprotein, MCT oil, Microlipid, Juven, and other
glutamine containing products
 Metabolic Products
 Metabolic products are used to in the
dietary management of inborn errors
metabolism such as phenylketonuria, maple
syrup urine disease and tyrosinemia.
 Examples: Milupa MSUD2, MSUD Aid,
Periflex Advance and Ketonex 2
 CARA PEMBERIAN ENTERAL
1. Bolus
250-400 mL of formula every 4-6 hours
Bolus feeding risk : aspiration
2. Intermittent feeding
300-400mL every 3-6 hours, 30-60 min infusion using
gravity drip or feeding pump infusion and feeding bag
3. Continuous infusion
slow rate infusion pump over 16-24 hours
4. Cyclic feedings
infused over 8-16 hours, night time feeding
preferred for ambulatory patients
CONTOH
 Pasien menerima 1800 kcal 6 x
 Diberikan Bolus  1800/6 = 300 ml setiap
pemberian
 Lebih toleran jika diberikan continuous–
1800/24 jam jadi setiap jam 75 ml/jam
CONTOH
KEBUTUHAN ENERGI DAN ZAT
GIZI
 PREDICTIVE EQUATIONS FOR
ESTIMATION OF ENERGY
NEEDS IN CRITICAL CARE

 Harris-Benedict x 1.3-1.5 for stress

 ASPEN Guidelines:
25 – 30 calories per kg per day*
 Ireton-Jones Equations**
 Penn State equations
 Swinamer equation

*ASPEN Board of Directors. JPEN 26;1S, 2002

** Ireton-Jones CS, Jones JD. Why use predictive equations for energy expenditure assessment? JADA
97(suppl):A44, 1997.
**Wall J, Ireton-Jones CS, et al. JADA 95(suppl):A24, 1995.
MURSYID BUSTAMI DALAM PELTIHAN PAGT STROKE RSPON
 1,2 - 2 g/kgBB/hari (BMI < 30 kg/m2)
2 g /kg BBI (BMI 30-40 kg/m2)
2,5 g / kg BBI (BMI >40 kg/m2)
(Aspen, 2009)
MURSYID BUSTAMI DALAM PELTIHAN PAGT STROKE RSPON
KEBUTUHAN LEMAK 0,7- 1,5 g/kgBB/hari
(Aspen, 2009)

• 20-35% dari kebutuhan energi

• Perhatikan kondisi pasien, misal : hyperlipidemia
• Lemak sedang < 30 %, lemak jenuh :
a. Dislipidemia I : < 10% kebutuhan energi total
b. Dislipidemia II : < 7% kebutuhan energi total
• Lemak tak jenuh tunggal maupun ganda :
Dislipidemia I dan II : 10-15% kebutuhan energi total
• Kolesterol : DM < 200 mg/hari, non DM : < 300 mg/hari
KEBUTUHAN CAIRAN
• Dewasa : 30-40 ml/kg BB
• Perhatikan balance cairan tubuh
• Perhatikan fungsi ginjal
 REFEEDING
SYNDROME
“Severe fluid and electrolyte shifts and related metabolic
complications in malnourished patients undergoing
refeeding.”

Solomon &Kirby (1990)

 REFEEDING
SYNDROME
During starvation
•Insulin concentrations decrease and glucagon
levels rise
•Glycogen stores rapidly converted to glucose
•Gluconeogenesis activated – glucose synthesis
from protein and lipid breakdown
•Catabolism of fat and muscle  loss of lean body
mass, water and minerals
 REFEEDING
SYNDROME
During refeeding

Switch from fat to carbohydrate metabolism

Insulin release stimulated by glucose load
 cellular glucose, phosphorus, potassium and
water uptake
Extracellular depletion of phosphate, potassium,
magnesium
Clinical symptoms
 CLINICAL SYMPTOMS
Electrolytes Cardiac Respiratory Hepatic Renal

Low Altered Acute Liver dysfunction

phosphorus myocardial ventilatory
function drive
Arrhythmia
CHF

Low Arrhythmia Respiratory Exacerbation of Polyuria

potassium Cardiac arrest depression hepatic Polydipsia
encephalopathy Decreased
GFR

Low Arrhythmia Respiratory

magnesium Tachycardia depression
 CLINICAL SYMPTOMS
Electrolytes GI Neuromuscular Haematologic
Low phosphorus Lethargy, Haemolytic
weakness, anaemia, WBC
seizures, coma, dysfunction,
confusion, thrombocytopenia
paralysis,
rhabdomyolysis

Low potassium Constipation Paralysis,

Ileus rhabdomyolysis
Low magnesium Abdo pain Ataxia
Anorexia Confusion
Diarrhoea Muscle tremors
Constipation Weakness
Tetany
 WHO IS AT RISK?
NICE guidelines (2006)

Some risk:
People who have eaten little or nothing for more
than 5 days
Patients at risk are malnourished, particularly
marasmic patients
Can occur with enteral or parenteral nutrition
Results from intracellular electrolyte shift
REFEEDING
SYNDROME
Patients at risk are malnourished, particularly marasmic
patients
Can occur with enteral or parenteral nutrition
Results from intracellular electrolyte shift
 REFEEDING SYNDROME
SYMPTOMS

 Reduced serum levels of magnesium,

potassium, and phosphorus
 Hyperglycemia and hyperinsulinemia
 Interstitial fluid retention
 Cardiac decompensation and arrest
REFEEDING SYNDROME
PREVENTION/TREATMENT
• Monitor and supplement electrolytes, vitamins
and minerals prior to and during infusion of PN
until levels remain stable
• Initiate feedings with 15-20 kcal/kg or 1000
kcals/day and 1.2-1.5 g protein/kg/day
• Limit fluid to 800 ml + insensible losses (adjust
per patient fluid tolerance and status)

Fuhrman MP. Defensive strategies for avoiding and managing parenteral nutrition
complications. P. 102. In Sharpening your skills as a nutrition support dietitian. DNS,
2003.
 WHO IS AT RISK?
High risk:
One or more of the following:
BMI < 16kg/m
unintentional weight loss > 15% in last 3 – 6 months
Little or no nutritional intake for >10days
Low levels of potassium, phosphate or magnesium prior to
feeding
Little or no nutritional intake for more than 5 days
History of alcohol abuse or drugs: insulin, chemotherapy,
antacids or diuretics
 MANAGING REFEEDING
SYNDROME
 Consider Pabrinex (high dose thiamine) and
balanced multivitamin/mineral supplement

 Feed cautiously – 10kcal/kg for first 2 days, 5kcal/kg

in extreme cases (dietitian will advise). Increase
slowly (over 4 -7 days)

 Monitor biochemistry regularly including phosphate,

magnesium and potassium correcting low levels as
necessary
PARENTERAL NUTRITION
http://media.oncologynurseadvisor.com/images/2011/08/04/feature_0811_art_185457.jpg
Conditions That Often Require Nutritional Support –
cont’d
 Indications for Parenteral Nutrition

Short term: Long term:

Severe pancreatitis Inflammatory bowel disease

Mucositis post-chemo with Radiation enteritis
intolerance of enteral nutrition Motility disorders
Gut failure
Extreme short bowel syndrome
Prolonged nil by mouth (NBM)
Chronic malabsorption
post major excisional surgery
High output or enterocutaneous
fistula
Intractable vomiting
Malnourished patient unable to
establish enteral nutrition
parenteral lipids and carbohydrates recommended by ESPEN for adult
ICU patients

http://www.baxternutritionacademy.com/ie/parenteral_nutrition/pn_guidelines.html
http://www.baxternutritionacademy.com/ie/parenteral_nutrition/pn_guidelines.html
Formula-formula Parenteral
nutrition
Formula-formula Parenteral nutrition
Formula-formula Parenteral nutrition
 Menghitung tetes infus
• tetesan infus per menit (TPM) secara
sederhana ini di rumuskan oleh Puruhito.
• Infus set makro (1 ml = 20 tetes) biasanya
digunakan untuk pasien dewasa. Sedangkan
mikro (1 ml = 60 tetes) biasanya digunakan
untuk pasien anak-anak.
Rumus dasar

• Faktor tetes : 1 ml = 20 tetes (makro)

• Faktor tetes : 1 ml = 60 tetes (mikro)
Seorang pasien laki-laki usia 55 tahun dengan berat 50 kg
datang ke IGD dan membutuhkan 1500 ml cairan RL.
Berapa tetes infus yang dibutuhkan jika kebutuhan cairan
pasien mesti dicapai dalam waktu 12 jam?
= 1500 x 20 / (12 x 60)
= 20000 / 720
= 27,77 ~ 28 tetes / menit
 PENGHITUNGAN BALANCE CAIRAN UNTUK DEWASA 

Balance Cairan = CM – CK – IWL

CM : Cairan Masuk
CK : Cairan Keluar

*Rumus IWL   IWL = (15 x BB )

                     24 jam
Rumus IWL Kenaikan Suhu
 [(10% x CM)x jumlah kenaikan suhu]  + IWL normal
                           24 jam
 PENGHITUNGAN BALANCE CAIRAN
UNTUK DEWASA 
• Input cairan:     Air (makan+Minum)  = ......cc
                               Cairan Infus               = ......cc
                               Therapi injeksi           = ......cc
                               Air Metabolisme        = ......cc   
(Hitung AM= 5 cc/kgBB/hari)
• Output cairan:   Urine                          = ......cc
                              Feses                          = .....cc
(kondisi normal 1 BAB feses = 100 cc)
                              Muntah/perdarahan
                              cairan drainage luka   = .....cc
                              IWL                           = .....cc
(hitung IWL= 15 cc/kgBB/hari)
                           
IWL = Insensible Water Loss
 Macronutrient Concentrations in PN
Solutions
• Macronutrient concentrations (%) = the grams
of solute/100 ml of fluid
• D70 has 70 grams of dextrose per 100 ml.
• 10% amino acid solution has 10 grams amino
acids/100 ml of solution
• 20% lipids has 20 grams of lipid/100 ml of
solution
 Protein Content Calculations
• To calculate the grams Example Protein
of protein supplied by a Calculation
TPN solution, multiply • 1000 ml of 8% amino
the total volume of acids:
amino acid solution (in • 1000 ml x 8 g/100 ml =
ml*) supplied in a day 80g
by the amino acid
• Or 1000 x .08 = 80 g
concentration.
 Sample Dextrose Calculation
• 1000 ml of D10W (10% dextrose)
– 1000 ml x 10g / 100 ml = 100 g dextrose

• 100g dextrose x 4 kcal/g = 400 kcal

PERHATIKAN …..
 Monitoring dan Evaluasi Gizi
• Commonly Used Nutrition Monitoring & Evaluation Domains
1) Enteral or parenteral nutrition intake
2) Energy intake
3) Digestive system
4) Vitamin profile
5) Weight or weight change
6) Electrolyte and renal profile
7) Food intake
Potensial Evaluations of Nutrition
Diagnosis Progress
Kolaboratif Tim Kesehatan

98
Terima Kasih
 Daftar Pustaka
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors.
Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric
Patients, 2009. JPEN J Parenter Enteral Nutr 2009;33:255–259.
Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines:
Nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr 2009;33:260–276.
August D, Teitelbaum D, Albina J, et al. Guidelines for the use of parenteral and enteral
nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26(1
Suppl.):1SA–138SA.Erratum in JPEN J Parenter Enteral Nutr 2002;26:144.
Arsenault D, Brenn M, Kim S, et al. A.S.P.E.N. Clinical Guidelines: hyperglycemia and
hypoglycemia in the neonate receiving parenteral nutrition. JPEN J Parenter Enteral Nutr
2012;36:81–95.
http://pen.sagepub.com/content/33/2/122.full.pdf+html
http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Guidelines/
http://www.baxternutritionacademy.com/ie/parenteral_nutrition/
parenteral_nutrition.html