NUTRISI PARENTERAL Dept. Dept. Anestesiologi & Terapi Intensif Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- Medan FK-USU/RSUP H.Adam Malik- Medan 1 Modul 12B
Nov 08, 2015
NUTRISI PARENTERAL
Dept. Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- Medan*Modul 12B
DEFINITIONParenteral nutrition is partial or total nutrition administered intravenously. A peripheral or central vein is used for access
SUPPORT NUTRITION
ORAL NUTRITIONENTERAL NUTRITIONPARENTERAL NUTRITION
PARENTERAL NUTRITIONDiberikan lewat intravenaVena perifir (PPN) Vena sentral (TPN)
CONTRAINDICATIONSAbility to adequately receive and absorb necessary foods orally or by gastric or enteral tubeHemodynamic instability
CENTRAL PARENTERAL NUTRITIONSelection depends on caloric requirement,volume to be administered and patient condition, as well as final concentration of components: Amino acid > 5 %Dextrose > 20%LipidsIncludes vitamins, minerals and trace elementsOsmolality > 700 mosm / kg H20
FORMULAS : DextroseProvide 3,4 kcal /kgCan be the only source of energyDextrose infusion rate should not exceed 5mg/kg/minClosely 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 :LipidsPrevents essential fatty acid deficiency Non protein source of kacal remcommend local 1 g / kcal Available in 10%,20%, and 30% concentrationsIncluded as LCT or a mix of MCT/ LCT at 10 % and 20%Added to basic parenteral nutrition solutions or administered individualy
FORMULAS : Lipids Less hyperglicemiaLower concentration of serum insulinLess risk of hepatic damageHigh doses can interfere with immune functionsHigh infusions rates can affect respiratory functionsShould be used with care in :HyperlipidemiaSymptomatic atherosclerosisAcute pancreatitis with hypertriglyceridemia
FORMULAS:Electrolytes:Calcium, magnesium, phosporus, chloride, potassium, sodium, and acetateForms and amounts are titrated based on metabolic status and fluid / electrolyte balanceMust 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 formulasAdded daily to parenteral nutritionsAcute illnes infections preexisting malnutritions and excessive fluid loss increase vitamin requirements
FORMULAS :TRACE ELEMENTSInclude daily zinc, copper, chromium, and manganese for patients with kidney or liver failureDifferent requirement dictated by patients and pathologyPatients under extended parenteral nutritions require the addition of iron and selenium
PERIPHERAL PARENTERAL NUTRITIONSelection of peripheral access depends on clinical situation requirements, tolerance to volume and final formula concentrationOsmolality < 900 (700) mosm/kgTotal kcal limited by concentration and ratio to volume being administeredInclude of the recommend electrolytes for PN
PN : TYPES OF INFUSIONContinous total volume of formula is administered over a 24 hour periodCyclic volume is administered in one period, with infusion adjustment and a period of restSelection 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
50 ml /kg/day2500-3000 ml/dayVOLUME
ENERGY HARRIS BENEDICT INDIRECT CALORIMETRI
BEE = 25-30 k.cal/kg/dREE = [ 1.2-1.3 ] x BEERule of ThumbVO2 oxygen consumptionVCO2
SUMBER ENERGICHO & LIPID60:4050:50
OsmolarityPPN
TPN900 mOsm/L(700 mOsm/L)
OSMOLARITAS [m.Osm/L]Osmolaritas Campuran :
V1.O1 + V2.O2 + V3.O3V1 + V2 + V3=
Triofusin-E.1000(1000 ml) , Kalbamin-10% (500 ml) Ivelip-10% (500ml) Osmolaritas campuran =1400x1 + 880x0.5 + 265x0.51 + 0.5 + 0.5= 986,5 mOsm/L
Pemilihan Cairan NutrisiSumber Karbo- Hidrat, kcal/L?Sumber Lemak, kcal/L?Sumber Asam - Amino, gr/L?Vitamine, MineralOsmolaritas mOsm/L
TRIOFUSIN-500TRIOFUSIN E-1000TRIOFUSIN-1600DEXTROSE-20%IVELIP-20%INTRAFUSIN 3,5%INTRAFUSIN-10%Kalbamin-10%CLINIMIX-N9G15ECLINIMIX-N9G20E
500100016008002000
410510NPCk.cal/LAs.Aminogr/l
mOsm/L800140025001100270600880880845980351001002828
Tetes bersama 24 jamSemua substrat terbagi merataMengurangi osmolaritasProtein sparing effectCegah hypoglikemiaFluktuasi insulinCegah side effect
tetes bersamaPARENTERAL NUTRITITION
intrafusin-10%IVELIP-10%THREE WAY STOPCOCKPPN24 HOURSTriofusin-500VOLUME : 2000 mlNPC : 1000 k.calA.ACIDS : 50 grOSMOL. : 686 mOsm/L
Intrafusin10%IVELIP-10%THREE WAY STOPCOCKTPN24 HOURSTriofusinE-1000VOLUME : 2000 mlNPC : 1500 k.calA.ACIDS : 50 grOSMOL. : 986.5 mOsm/L
Teknik Pemberian,
Teknik Pemberian, All in One [AiO]R/ Clinimix
60%-70%, KH500 kcal40%-30%, lemak500 kcal1000 kcalNPCTRIOFUSIN 500Ivelip 20%1000 mL, 500 kcal, 800mOsm/L250 mL, 500 kcal, 270 mOsm/L
15 tetes/men.4 tetes/men.
Asam Amino, 35 gr1000 mL,As.amino 35 gr600 mOsm/LINTRAFUSIN3.5%
IVELIP-20%250 mL, 500 kcal, 265 mOsm/L
4 tetes/men2250 mL, 1000 kcal (NPC), 35gr as.amino ,650 mOsm/L tetes bersama 24 jam vena perifir
TRIOFUSIN 5001000 mL, 500 kcal, 800mOsm/L15 tetes/men1000 mL,As.amino 35 gr600 mOsm/L15 tetes/menitINTRAFUSIN3.5%
Triofusin E-1000IVELIP20%KALBAMIN10%Three way stop cockVOLUME : 2000 mlNPC : 2000k .calA.ACIDS : 50 grOSMOL. : 987.5 mOsm/LVena centralis
KOMPLIKASIMETABOLIK OVER DOSIS SUBSTRAT LAJU INFUSI YANG TERLALU CEPAT PEMAKAIAN LAMAMEKANIK ARTERIAL PUNCTURE PNEUMOTHORAX HEMOTHORAX THROMBOPHLEBITIS, DLL
MONITORING PATIENT OF PARENTERAL NUTRITIONMetabolicGlucoseFluid and electrolyte balanceRenal and hepatic functionTriglycerides and cholestrol
MONITORING
BALANS CAIRAN,GULA DARAH,ELEKTROLIT,ALBUMIN,KURVA SUHU,PROFIL LEMAK,BUN, SERUM CREATININ,HEMOGLOBIN, LEKOSIT,BERAT BADAN
AssesmentBody weightNitrogen balancePlasma proteinCreatinine height index
Terima kasih atas perhatian andaSemoga Tuhan selalu memberkahi kita semuaAmin
Nutrisi Parenteral Skill Menghitung kebutuhan dan menentukan pilihan jenis/komposisi nutrisi yang sesuai dengan pasien.