Prof. dr. Nova Kapantow, DAN., MSc., SpGK
TUNJANGAN NUTRISITERHADAP
BENCANA PERUT
MODUL BENCANA PERUT
TUNJANGAN NUTRISI
BENCANA PERUT
GI TIDAK BERFUNGSI
NUTRISI PARENTERAL
GI BERFUNGSI
NUTRISI ENTERAL
metode pemberian mkn melalui jalur IV.=intravenous feeding ok lgs dimasukkan ke
sirkulasi sistemik tanpa melalui sirkulasi portal dan sistim limfatik.
Zat gizi yg diberikan: btk terdigesti dan steril
Parenteral Nutrition
Parenteral Nutrition
1. Indications, Contraindications and Routes of Administration
2. Macronutrient and Micronutrient Use in TPN
Common Indications for PN
Inability to absorb adequate nutrients via the GI tract : Massive small-bowel resection / short
bowel syndrome Severe, untreatable steatorrhea /
diarrhoea / malabsorption Complete bowel obstruction, or intestinal
pseudo-obstruction Prolonged acute abdomen or ileus
Common Indications for PN
Severe catabolism & GI tract unusable within 5–7 days
Enteral access not feasible, not adequate or not tolerated
Pancreatitis with intolerance (eg pain) of jejunal nutrition
High output EC fistula (>500 mL) & no distal enteral access
Potential Indications for PN
Enterocutaneous fistula IBD unresponsive to medical therapyPartial small bowel obstruction Intensive chemotherapy / severe
mucositis Intractable vomiting if jejunal feeding
not possible
Contra-indications to PN Functioning gastrointestinal tract
Treatment anticipated for < 5 days in patients without severe malnutrition
Inability to obtain venous access
Poor prognosis that does not warrant aggressive nutrition support
When the risks of PN are judged to exceed the potential benefits
How Do We Give PN?
Administration of PN
PN solutions are hypertonicInfusion, therefore, via:
Central venous catheter, or Peripheral venous catheter with
*reduced* osmolarity
Rute pembuluh darah sentral
Central sites: Internal jugular vein
Subclavian veinFemoral vein
Percutaneous CentralVenous Access
Peripherally inserted central catheters: PICC Placed at bedside or radiologically
Subclavian vein – used to be most common Can be placed & removed at bedside, but Generally, placed radiologically Confirm placement with chest x-ray Can change over a wire to replace
Peripherally Inserted Central Catheter (P.I.C.C.) Line
Tip in SVC
O
• More expensive than peripheral lines
• More difficult to place• Last up to 6 - 12 months• Restrict arm movement• Allow higher osmolarity
“Central” TPN solutions
Implanted Central Venous Catheters (e.g. Hickman, Groshong, Port-A-Cath)
For prolonged TPN: Also for fluids, chemotherapy, blood draws
Catheter inserted ‘operatively’Placed with fluoroscopic guidance Implanted into a subcutaneous tunnel
Tunnelled (“Hickman”) Line
Implanted Venous Access Device
Central IV: PICCPROS Can infuse solutions
> 900 mOsmol/l May be placed by RN Decreased CRI vs
other central lines: HPN Can be multi-lumen Usable for CT contrast
CONS Shorter life than other
central lines (< 12 m) More difficult self care Blood sampling not
always possible More frequent flushing
and maintenance More painful
Central IV: Hickman / BrovacPROS Can infuse solutions
> 900 mOsmol/l Allow full IV nutritional
support Can be multi-lumen Longevity: 1 -3 years Easier self-care (than
PICC &, possibly, port)
CONS Surgical / Radiological
procedure More complex More difficult to remove
Tube protruding from chest may affect body image
More restrictive than a port
Central IV: Implantable PortPROS Can infuse solutions
> 900 mOsmol/l Allow full IV nutritional
support Greatest longevity Easier self-care (only
needed if accessed) Improved body image &
activity
CONS Surgical / Radiological
procedure More complex More difficult to remove
Access requires placement of a Huber needle
Infection risk during access
Rute pembuluh darah perifer
Peripheral IV: short-linePROS Least expensive Easily placed and
removed Lowest risk for CRI Beneficial for short-
term support (< 1 week)
CONS Need to change often
Every 48-72h
Phlebitis and vein injury Only one lumen Limits energy delivery
Volume Osmolality (600-900
mOsm/l) pH restriction (pH 5-9)
Peripheral IV: mid-linePROS May be used for a
longer duration than peripheral
Ease of placement compared to central lines
Allows access to larger vessel
CONS Not a central line Must follow guidelines
for peripheral lines for concentration, pH and infusion rates
Metabolik Komplikasi dini:
Vol. berlebihan, hiperglikemia, refeeding syndrome, dll
Komplikasi lanjut: Def. A. lemak esensial, def. trace mineral, def. vit,
penyakit tulang metabolik, steatosis hepatik, dan kolestasis hepatik.
Ketidakseimbangan cairan dan elektrolit
Complications of PN
Complications of PN Catheters
Catheter infectionsCatheter occlusionCatheter injury/leakageCatheter migrationVenous thrombosis
Risk Factors for Infection
Site - Subclavian < Int. jugular < Femoral Material - Silastic / Polyurethane < PVC Type - Subclavian (0.9) < PICC (1.4 / 1000d)
- Single lumen < Multi-lumen Care - 2% chlorhexidine (5.9 % catheter colonisation)
70% isopropyl alcohol (15.6%) 10% povidone iodine (19.5%)
Patient - young, poor technique, smoking, Crohn’s, jejunostomy, thrombosis, narcotics
Macronutrient and Micronutrient Use in TPN
Formula
Larutan utk NP sentral diformulasi bdsrkn perhitungan kebutuhan protein dan energi
Pada beb. keadaan (mis. ketidak-seimbangan elektrolit atau tdpt disfungsi organ, maka komposisi disesuaikan dg kondisi p/.
Designing Parenteral Regimens Assess nutritional status and set goals. Evaluate constraints on nutrient delivery. Assess fluid, electrolyte, vitamin, trace element
requirements Order nutrients (protein, CHO, fat), fluids/
electrolytes/ trace elements Determine administration (rate and duration). Avoid metabolic complications.
Parenteral NutritionCarbohydrate (10 - 25% Dextrose)Amino Acids (0.8 to 1.2 g /kg)Lipid Emulsion, incl E.F.A. (10 - 30%)Vitamins / Minerals / Trace ElementsElectrolytesFluid (2 - 3 litres /day)
How Much Should We Give?
Estimate of Requirements
Most hospitalized patients will require 30 kcals/kg/dCHO – can utilise dextrose up to 5
mg/kg/min
Protein – The average patient requires 0.8 – 2.0 g protein/kg usual body weight
Constraints on Nutrient Delivery
Do not overload body’s disposal systems
renal, hepatic, respiratory
Nutritional regimen should make sense clinically
Composition of Standard Parenteral Dextrose Solutions
5% - 70% solution dextrose in water
3.4 kcal/gm
500 ml of a 50% solution contains
50 gm/100 ml x 500 ml = 250 gm dextrose
250 gm x 3.4 kcal/gm = 850 kcal
Composition of Standard Parenteral Amino Acid Solutions
Synthetic crystalline amino acidsContain essential and non-essential AAVariable amounts of electrolytesConcentrations depend on final volumeHypertonic solutions
Characteristics ofIntravenous Lipid Emulsions
Concentrations 10% and 20%
Parent oil Soybean or Safflower
Osmolarity 280 - 340 mOsm/l
Caloric content 10% = 1.1 kcal/ml20% = 2.0 kcal/ml
Electrolytes in Parenteral Nutrition Solutions
Appropriate prescription requires regular monitoring
For maintenance provision Add directly to the PN solution
Tailor to individual patient needs Additional replacement for abnormal losses Deletions for patients with certain diseases
Vitamins/Trace Elements in Parenteral Nutrition Solutions
Meet established guidelines for PN Water and fat-soluble vitamins provided Required for zinc, copper, manganese,
chromium & selenium Added daily to the solution Requirements may be increased for patients
with abnormal losses
Prosedur Standar Pemberian
Hari 1 : mulai dg 50 ml/jam Hari 2 : 75 ml/jam Hari 3 dst : 125 ml/jam
Pemberhentian: bertahap (dari 50% kmd 70% dlm 30-60 menit sebelum berhenti).
Ok dekstrosa menstimulasi sekresi insulin, dan level insulin akan tetap ↑ saat infus dextrosa dihentikan hipoglikemia.
Oki ↓ dosis bertahap cegah hipoglikemia.
15- 30
Monitoring Patients on Parenteral Nutrition
Clinical status
Metabolic and biochemical aspects
Delivery
Catheter care, pump, % volume infused
Nutritional status/reassessment
Thank You!
PN – Summary Guidelines1. Determine if PN is truly indicated2. Assess the patient (medical history, medication profile,
anthropometric data & lab values)3. Determine need for long-term vs. short term
<7–10 days
4. Confirm or establish adequate IV access Peripheral or central?
5. Determine estimated kcal, protein and lipid needs 20–30 kcal/kg Protein 0.8–1.5 gm/kg
Higher levels may be needed in severe catabolic states Lipid to provide ≤30% of kcals
PN – Summary Guidelines6. Determine initial electrolyte, vitamin and trace element
requirements; consider ongoing losses7. Consider any additional additives to PN formulation
including insulin and H2-receptor antagonists
8. Monitor for: Risk of refeeding syndrome Glucose intolerance
Start low & advance slowly if labs stable over 24-48 hours Fluid, electrolyte, metabolic, macro- and micro-nutrient changes Complications – sepsis, thrombosis, abuse
9. Initiate trophic feedings or convert patient to PO or enteral feeding when feasible