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)

INDICATIONSNon-functional GI-tractImpossible to use the GI-tractIntestinal obstructionPeritonitisIntractable vomitingSevere diarrheaHigh output enterocutaneus fistulaShort bowel syndrome (

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.