kuliah nutrisi parenteral.ppt

NUTRISI PARENTERALNUTRISI PARENTERALNUTRISI PARENTERALNUTRISI PARENTERAL

Hasanul Arifin

BAGIAN ANESTESIOLOGI DAN REANIMASIBAGIAN ANESTESIOLOGI DAN REANIMASIFAKULTAS KEDOKTERAN USUFAKULTAS KEDOKTERAN USU

MEDANMEDAN

• Short periods of food deprivation well tolerated– in previously well nourished

– if illness not too severe or prolonged

• Nutrition requirements in ICU altered• Malnutrition before admission increases morbidity

and brings death sooner• Malnutrition develops within ICU• Need to show that nutrition can reduce morbidity

and mortality

What we have to know about nutrition in the ICU

Normal starvation vs hypercatabolic response to critical illness

S t a r v a t i o n

Reduced basal metabolic rate,reduced caloric requirements

Fat becomes the principal non-carbohydrate energy source as lipolysis is stimularted by a fall in insulin and rise in glucagon

Protein and lean body mass is preserved until late into the starvation period

The restoration of adequate nutritional support leads to rapid resumption of an anabolic state

Hypercatabolic response to critical illness

Increased basal metabolic rate, calorie requirements. Increased secrection of "stress" hormones [catecholamines, cortisol, etc.] and cytokines

Impaired capacity to use carbohydrate and fat as energy source, resulting in an increased protein breakdown as alternative energy source

Massive nitrogen losses from the breakdown of muscle protein [nitrogen loss can approach 30 g/day, equivalent to 800 g muscle]

Catabolic state not reversed by resumption of adequate nutrition. hyperalimentation may precipitate its own problems [lipaemia, liver dysfunction, metabolic acidosis]

Keith Bresland; Nutritional support, in Hand Book of Critical Care,192:1998.

Characteristic Nutritional support Metabolic support

Setting

Basis

Focus

Fuel

NPC/gr N

Amino acids[g/kg/d]

% NPCas fat

Malnutrition

Starvation

Restore visceral protein synthesis and lean body mass metaboism

Glucose

>150/1

1-1.5

0-60

Hypermetabolism/organ failureMetabolic stress response

Preserve organ functionPreserve organ structurePrevent subtrate limited

Mixed

<100/1

1.5-2.5

30-40

Table 124-2. Shoemaker; Textbook of critical care 1119:1989

SUPPORT NUTRITION

AB

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 The main goal of nutritional support is to minimise the loss of protein and energy.minimise the loss of protein and energy.

NUTRITION is a BASIC of SURVIVAL RECOVERY

NaCl 0.9%

D5W RL

1500 ml fluid, 100 k.cal energy, 0 gr Amino Acids, 140 1500 ml fluid, 100 k.cal energy, 0 gr Amino Acids, 140 mEq NamEq Na+, +, 2 mEq K 2 mEq K++, ,

20 drips/min. change continue

Recommendation for Clinical Recommendation for Clinical PracticePractice

• STABLE HAEMODYNAMIC (DO2)

• START LOW GO SLOW END SLOW

50 ml /kg/day50 ml /kg/day

2500-3000 ml/day2500-3000 ml/day

VOLUME,VOLUME,

ENERGYENERGY

• HARRIS BENEDICT

• INDIRECT CALORIMETRI

BEE = 25-30 k.cal/kg/dBEE = 25-30 k.cal/kg/dREE = [ 1.2-1.3 ] x BEEREE = [ 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

Protein,• balans nitrogen positifbalans nitrogen positif

• pada critically ill, pada critically ill, laju kehilangan protein laju kehilangan protein

• BCAA BCAA drive ventilasi, drive ventilasi, R/ Amiparen-10%,R/ Amiparen-10%,

R/ Aminofusin 10%R/ Aminofusin 10%

• dosis : 0.8-1.5 gr/kg/haridosis : 0.8-1.5 gr/kg/hari

• Protein sparing effect (1gr protein dilindungi Protein sparing effect (1gr protein dilindungi 25 k.cal KH/Lipid)25 k.cal KH/Lipid)

• TPN- glutamine enrichedTPN- glutamine enriched

Stimulates hepatic glycogen synthesis

Metabolic fuel for rapidly proliferating tissues

(enterocyte, immune (enterocyte, immune cells,)cells,)

Maintain skeletal muscle

Stimulates protein synthesis

Inhibits protein degradation

L-glutamine

Nitrogen and carbon transport

Carrier of nitrogen (as ammonia) and carbon (as glutamate) between tissues

Acid-Base balance

Biosynthesis

Precursor of amino acids, peptide, protein,nucleic acids

Substrate for gluconeogenesis

Potential source of glutamate for glutathione synthesismetabolic functions

LUNGSLUNGS

SKELETAL MUSCLESKELETAL MUSCLE

BRAINBRAIN

PLASMA PLASMA GLUTAMINE GLUTAMINE

POOLPOOLLIVERLIVER

IMMUNE IMMUNE CELLSCELLS

GUTGUT

KIDNEYKIDNEY

Normal glutamine flux between tissues in the basal stateNormal glutamine flux between tissues in the basal state

LUNGSLUNGS

SKELETAL MUSCLESKELETAL MUSCLE

BRAINBRAIN

PLASMA PLASMA GLUTAMINE GLUTAMINE

POOLPOOL

LIVERLIVER

IMMUNE IMMUNE CELLSCELLS

GUTGUT

KIDNEYKIDNEY

Trauma induces conciderable changes in glutamine fluxTrauma induces conciderable changes in glutamine flux

Glutamine in TPN

Increases protein synthesis andnitrogen balance

Improves gutfunction

Improves immunefunction

Reduced hospital stay

Improvedmood

Reduced waterretention

clinical benefits of glutamine in TPN

Osmolarity

PPN

TPN900 mOsm/L

OSMOLARITAS [m.Osm/L]OSMOLARITAS [m.Osm/L]

Osmolaritas Campuran :Osmolaritas Campuran :

V1.O1 + V2.O2 + V3.O3V1.O1 + V2.O2 + V3.O3

V1 + V2 + V3V1 + V2 + V3==

Triparen No-1(1000 ml) , Amiparen-10% Triparen No-1(1000 ml) , Amiparen-10% (500 ml), Ivelip-10% (500 ml)(500 ml), Ivelip-10% (500 ml)

Osmolaritas campuran =

1400x1 + 880x0.5 + 265x0.51 + 0.5 + 0.5

= 986,5 mOsm/L

TRIOFUSIN-500TRIOFUSIN-500

TRIOFUSIN E-1000TRIOFUSIN E-1000

TRIOFUSIN-1600TRIOFUSIN-1600

DEXTROSE-20%DEXTROSE-20%

IVELIP-10%IVELIP-10%

IVELIP-20%IVELIP-20%

INTRAFUSIN 3,5%INTRAFUSIN 3,5%

INTRAFUSIN-10%INTRAFUSIN-10%

500500

10001000

16001600

800800

10001000

20002000

NPC

k.cal/L

As.Amino

gr/l

mOsm/L

800800

14001400

25002500

11001100

265265

270270

600600

880880

3535

100100

Tetes bersama 24 jam• Semua substrat terbagi merataSemua substrat terbagi merata

• Mengurangi osmolaritasMengurangi osmolaritas

• Protein sparing effectProtein sparing effect

• Cegah hypoglikemiaCegah hypoglikemia

• Fluktuasi insulinFluktuasi insulin

• Cegah side effectCegah side effect

tetes bersamatetes bersama

PARENTERAL PARENTERAL NUTRITITIONNUTRITITION

intrafusin-10%

IVELIP-

10%

THREE WAY STOPCOCK

PPN24 HOURS

Triofusin-500

VOLUME : 2000 mlNPC : 1000 k.calA.ACIDS : 50 grOSMOL. : 686 mOsm/L

Intrafusin10%

IVELIP-

10%

THREE WAY STOPCOCK

TPN24 HOURS

Triofusin

E-1000VOLUME : 2000 mlNPC : 1500 k.calA.ACIDS : 50 grOSMOL. : 986.5 mOsm/L

Teknik Teknik Pemberian, Pemberian,

Teknik Teknik Pemberian, All Pemberian, All in One [AiO]in One [AiO]

R/R/ ClinimixClinimix

KOMPLIKASI,METABOLIK,

• OVER DOSIS SUBSTRAT

• LAJU INFUSI YANG TERLALU CEPAT

• PEMAKAIAN LAMA

MEKANIK• ARTERIAL PUNCTUREARTERIAL PUNCTURE

• PNEUMOTHORAXPNEUMOTHORAX

• HEMOTHORAXHEMOTHORAX

• THROMBOPHLEBITIS, THROMBOPHLEBITIS,

• DLLDLL

MONITORING,

BALANS CAIRAN,

GULA DARAH,

ELEKTROLIT,

ALBUMIN,

KURVA SUHU,

PROFIL LEMAK,

BUN, SERUM CREATININ,

HEMOGLOBIN, LEKOSIT,

BERAT BADAN

Thank youThank you