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NUTRISI PARENTERAL
DEFINITION
Parenteral nutrition is partial or total
nutrition administered intravenously. A
peripheral or central vein is used for
access
SUPPORT NUTRITION
ORAL NUTRITION
ENTERAL NUTRITION
PARENTERAL NUTRITION
PARENTERAL NUTRITION
Diberikan lewat intravena
Vena perifir (PPN)
Vena sentral (TPN)
INDICATIONS
Non-functional GI-tract
Impossible to use the GI-tract
Intestinal obstruction
Peritonitis
Intractable vomiting
Severe diarrhea
High output enterocutaneus fistula
Short bowel syndrome (<70 cm)
Severe malabsorption
CONTRAINDICATIONS
Ability to adequately receive and absorb
necessary foods orally or by gastric or
enteral tube
Hemodynamic instability
CENTRAL PARENTERAL
NUTRITION
Selection depends on caloric
requirement,volume to be administered and
patient condition, as well as final concentration
of components:
Amino acid > 5 %
Dextrose > 20%
Lipids
Includes vitamins, minerals and trace elements
Osmolality > 700 mosm / kg H20
FORMULAS :
Dextrose
Provide 3,4 kcal /kg
Can be the only source of energy
Dextrose infusion rate should not exceed
5mg/kg/min
Closely 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 :
Lipids
Prevents essential fatty acid deficiency
Non protein source of kacal remcommend
local 1 g / kcal
Available in 10%,20%, and 30%
concentrations
Included as LCT or a mix of MCT/ LCT at 10
% and 20%
Added to basic parenteral nutrition solutions or
administered individualy
FORMULAS :
Lipids
Less hyperglicemia
Lower concentration of serum insulin
Less risk of hepatic damage
High doses can interfere with immune functions
High infusions rates can affect respiratory functions
Should be used with care in :
Hyperlipidemia
Symptomatic atherosclerosis
Acute pancreatitis with hypertriglyceridemia
FORMULAS:
Electrolytes:
Calcium, magnesium, phosporus, chloride,
potassium, sodium, and acetate
Forms and amounts are titrated based on
metabolic status and fluid / electrolyte balance
Must 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 formulas
- Added daily to parenteral nutritions
- Acute illnes infections preexisting
malnutritions and excessive fluid loss
increase vitamin requirements
FORMULAS :
TRACE ELEMENTS
Include daily zinc, copper, chromium,
and manganese for patients with kidney
or liver failure
Different requirement dictated by patients
and pathology
Patients under extended parenteral
nutritions require the addition of iron
and selenium
PERIPHERAL PARENTERAL
NUTRITION
Selection of peripheral access depends on
clinical situation requirements, tolerance to
volume and final formula concentration
Osmolality < 900 (700) mosm/kg
Total kcal limited by concentration and ratio to
volume being administered
Include of the recommend electrolytes for
PN
PN : TYPES OF INFUSION
Continous total volume of formula is
administered over a 24 hour period
Cyclic volume is administered in one
period, with infusion adjustment and a
period of rest
Selection of infusion type depends on
patients condition
Use a parenteral infusion pump
HAEMODYNAMIC
(DO2)
VOLUME
50 ml /kg/day
2500-3000 ml/day
VCO2
HARRIS BENEDICT
INDIRECT CALORIMETRI
Rule of Thumb
BEE = 25-30 k.cal/kg/d
REE = [ 1.2-1.3 ] x BEE
SUMBER ENERGI
CHO & LIPID
60:40
50:50
Osmolarity
PPN
TPN
900 mOsm/L
(700 mOsm/L)
OSMOLARITAS [m.Osm/L]
Osmolaritas Campuran :
=
Osmolaritas campuran =
1400x1 + 880x0.5 + 265x0.5
1 + 0.5 + 0.5
= 986,5 mOsm/L
Sumber Lemak,
kcal/L?
Osmolaritas
mOsm/L
Vitamine,
Mineral
Sumber Asam
- Amino, gr/L?
NPC
k.cal/L
TRIOFUSIN-500
500
As.Amin
o
mOsm/L
gr/l
800
TRIOFUSIN E-1000
1000
1400
TRIOFUSIN-1600
1600
2500
800
1100
2000
270
DEXTROSE-20%
IVELIP-20%
INTRAFUSIN 3,5%
35
600
INTRAFUSIN-10%
100
880
Kalbamin-10%
100
880
CLINIMIX-N9G15E
410
28
845
CLINIMIX-N9G20E
510
28
980
PARENTERAL
NUTRITITION
tetes bersama
Triofusin
-500
intrafu
sin10%
IVELI
P10%
VOLUME
NPC
A.ACIDS
OSMOL.
THREE WAY
STOPCOCK
: 2000 ml
: 1000 k.cal
: 50 gr
: 686 mOsm/L
PPN
24 HOURS
Triofusin
E-1000
Intrafu IVELI
sin10%
P10%
VOLUME
NPC
A.ACIDS
OSMOL.
THREE WAY
STOPCOCK
: 2000 ml
: 1500 k.cal
: 50 gr
: 986.5 mOsm/L
TPN
24 HOURS
Teknik
Pemberian,
Teknik
Pemberian, All
in One [AiO]
R/ Clinimix
1000 kcal
NPC
60%-70%, KH
40%-30%, lemak
500 kcal
500 kcal
TRIOFUSI
N
Ivelip 20%
500
250 mL,
1000 mL,
500 kcal,
800mOsm/L
15 tetes/men.
500 kcal,
270 mOsm/L
4 tetes/men.
Asam Amino,
35 gr
INTRAFUSIN
3.5%
1000 mL,
As.amino 35 gr
600 mOsm/L
TRIOFUSIN
IVELIP-20%
500
INTRAFUSIN
3.5%
250 mL,
1000 mL,
500 kcal,
800mOsm/L
15 tetes/men
500 kcal,
1000 mL,
265 mOsm/L
As.amino 35 gr
4 tetes/men
600 mOsm/L
15 tetes/menit
Triofusin E1000
IVELIP
KALBAMIN
20%
10%
Three way
stop cock
VOLUME
NPC
A.ACIDS
OSMOL.
: 2000 ml
: 2000k .cal
: 50 gr
: 987.5 mOsm/L
Vena
centralis
KOMPLIKASI
METABOLIK
OVER DOSIS SUBSTRAT
LAJU INFUSI YANG TERLALU CEPAT
PEMAKAIAN LAMA
MEKANIK
ARTERIAL PUNCTURE
PNEUMOTHORAX
HEMOTHORAX
THROMBOPHLEBITIS,
DLL
MONITORING PATIENT OF
PARENTERAL NUTRITION
Metabolic
Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholestrol
MONITORIN
G
BALANS CAIRAN,
GULA DARAH,
ELEKTROLIT,
ALBUMIN,
KURVA SUHU,
PROFIL LEMAK,
BUN, SERUM CREATININ,
HEMOGLOBIN, LEKOSIT,
BERAT BADAN
Assesment
Body weight
Nitrogen balance
Plasma protein
Creatinine height index