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Agust W.

Harimawan
Kamis, 25 Agustus 2015
OUTLINES

1. KONDISI KRITIS
2. DUKUNGAN NUTRISI : Jenis Nutrisi, Cara
Pemberian, Metode Pemberian, Kebutuhan
Energi, Waktu Pemberian, dan Komposisi
3. OPTIMALISASI NE
Definition Of Critical Illness
Critical illness is any disease process which causes
physiological instability leading to disability or death
within minutes or hours.

Stress Response
The bodys Attempt to promote healing and resolve
inflammation when homeostasis is disrupted

Dr Paul Frost is Consultant in Intensive Care Medicine. British Journal of Hospital Medicine, October 2007, Vol 68, No 10
PENYAKIT

CEDERA INFEKSI

KRITIS

RESPONS METABOLIK
Metabolic Response to Critical Illness
CADANGAN
ENERGI

INTERNATIONAL ANESTHESIOLOGY CLINICS. Volume 47, Number 1, 121138 @ 2009, Lippincott Williams & Wilkins
Metabolic Response to Critical Illness Cont.
MEDICAL NUTRITION THERAPY

SUCCESS
THERAPY
Radiotherapy
Antibiotic

Operation
Drugs

NUTRITION

Dikutip dari Presentasi Prof. DR. Dr. Eddy Rahardjo, SpAn KIC. 7
ICU : NUTRITION SUPPORT

Current nutrition guidelines UNIFORMLY recommend


using Enteral Nutrition (EN) as first-line nutrition
therapy, starting early within 24-48 hours after ICU
admission.

Carmona Monge FJ, Martinez Lareo M, Garcia Gomez S, et al. effectiveness and safety of goal directed nurse-led blood glucose
control in an intensive care unit: a prospective observational study. Enferm Intensiva. 2012;23;11-16.
ICU : NUTRITION
NUTRITION SUPPORT
SUPPORT ---

Rationale :

Early EN has several non-nutritional benefits such as


supporting the immune and metabolic responses as
well as preserving gut integrity

Carmona Monge FJ, Martinez Lareo M, Garcia Gomez S, et al. effectiveness and safety of goal directed nurse-led blood glucose
control in an intensive care unit: a prospective observational study. Enferm Intensiva. 2012;23;11-16.
KONTRAINDIKASI PEMBERIAN NE

1. Acute Abdomen
2. Acute Gastrointestinal Bleediing
3. Mechanical Illeus
4. Intestinal Perforation
5. Persistent Attacks of Diarrhoea
6. Intestinal Obstruction
1. JENIS NUTRISI
NUTRISI ENTERAL
NO TIPE KETERANGAN
1 Intact/ Mengandung protein, bebas laktosa, dan kalori normal
Polymeric GIT berfungsi normal
2 Monomeric/ Protein bentuk dipeptida, tripeptida, dan/atau asam amino bebas,
Oligomeric/ Lemak, dan karbohidrat yang dicernakan sebelumnya; MCTs yang
Hydrolyzed/ tinggi dan rendah PUFAs
Elemental Gangguan saluran pencernaan yang berat
3 Diperkaya Mengandung tambahan serat dan/atau fructooligosaccharides
serat (FOS) untuk memperbaiki fungsi saluran cerna dan untuk
mengembalikan Integritas koloni
4 Modular Mengandung satu jenis zat gizi
Pelengkap
5 Khusus Dirancang untuk kondisi penyakit yang spesifik seperti ACKD,
PPOK, DM, dan Immunodefisiensi
NUTRISI PARENTERAL

NP adalah metode pemberian nutrisi yang mengandung makro dan mikronutrien,


bisa juga obat obatan, diberikan melalui pembuluh darah (Howell, 2008)
Kalori < 80% BEE atau 1/3 BEE
2. CARA PEMBERIAN NUTRISI

1. ORAL
2. ENTERAL : Gastric,
Postpyloric
3. PARENTERAL :
Central, Perifer
4. KOMBINASI
3. Metode Pemberian Nutrisi
Enteral
I. CONTINOUS TUBE FEEDINGS:
Pemberian tetesan dengan pompa yang menyalurkan volume konstan
Pasien dgn gula darah tidak terkontrol, sindroma refeeding, jejunostomi,
penggunaan intubasi
II. CYCLIC TUBE FEEDINGS :
Pemberian melalui pompa dalam periode waktu tertentu
Direkomendasikan untuk pasien dengan pipa jejunal
III. INTERMITTENT GRAVITY DRIP :
Pemberian 240-270 ml selama 20-60 mnt
Digunakan pada pasien dengan pengosongan lambung lambat Aspirasi
IV. BOLUS TUBE FEEDINGS :
Pemberian 240-480 ml selama 10-20 mnt
Pasien dengan dukungan nutrisi yang lama dan regimen formula tetap
NP :
VENA PERIFER

< 600-900
mOsm/liter
KH dan
protein Tidak restriksi
konsentrasi cairan
kecil

5 -7 hari.
VENA Tersedia vena
PERIFER yang adekuat

Bahaya Osmolaritas tinggi : tromphlebitis, bahkan tromboemboli


NP :
VENA SENTRAL
Vena femoralis,
V. Jugularis, v. subclavia.
Osmolaritas tinggi > 900
mOsm/L
PICC (peripherally inserted
central catheter), v
subklavia dengan ujung di v
sentral.
4. KEBUTUHAN ENERGI
CONSEQUENCES OF OVER & UNDER FEEDING
RULE OF THUMB

Rule of Thumb
Calorie Requirement = 25 to 30 kcal/kg/day

Quick Method.. Simply multiply the patients weight by


25 to 30 kcal.
When using this method, Do Not make further
adjustments for activity and stress of disease.
KEBUTUHAN ENERGI PADA PASIEN ICU

ESPEN : ICU Nutrition 2014


BERAT BADAN IDEAL

BB IDEAL (Brocca modifikasi)


BBI = 90% (TB 100)
UNTUK TB < 160 cm & TB < 150 CM
ESTIMASI TINGGI BADAN

Demispan (half-arm span) is


the distance from the midline
at the Sternal Notch to the
web between the middle and
ring fingers along outstretched
arm. Height is then calculated
from a standard formula

Females
Height in cm = (1.35 x demispan in cm) + 60.1
Males HIckson M, Frost G. A comparison of three
methods for estimating height in the acutely ill
Height in cm = (1.40 x demispan in cm) + 57.8 elderly population. J Hum Nutr Diet. 2003;6:1-3
5. TIMING PEMBERIAN NUTRISI
STRESS RESPONSES

START

OPTIMAL

Nutrition in Critical Illness


Gail A. Cresci and Robert G. Martindale
EARLY VS. DELAYED NUTRIENT INTAKE
Canadian Clinical Practice Guidelines. March 2013
Conclusions:
1. Early Enteral Nutrition, when compared to delayed nutrient intake is
associated with a trend towards a reduction in mortality in critically ill
patients.
2. Early Enteral Nutrition, when compared to delayed nutrient intake is
associated with a significant reduction in infectious complications.
3. Early Enteral Nutrition, when compared to delayed nutrient intake has
no effect on ICU or hospital length of stay.
4. Early Enteral Nutrition, when compared to delayed nutrient intake
improves nutritional intake.

Enteral nutrition in the intervention group was started within 24-48 hours of admission/resuscitation.
Early vs. Delayed Supplemental Parenteral Nutrition
Canadian Clinical Practice Guidelines. March 2013
Conclusions:
1. Early vs late PN to supplement EN has no effect on mortality in critically
ill patients.
2. Early supplemental PN is associated with an increase in infectious
complications in critically ill patients compared to late supplemental PN.
3. Early supplemental PN is associated with significantly longer ICU and
hospital length of stay in critically ill patients compared to late
supplemental PN.
4. Early supplemental PN is associated with an increase in duration of
ventilation in critically ill patients compared to late supplemental PN.
Conclusions
Late-initiation of PN was associated with Faster Recovery
and Fewer Complications, when compared with early
initiation.
Intentional Underfeeding: TROPHIC FEEDS VS FULL FEEDS
Canadian Clinical Practice Guidelines. March 2013
Conclusions:
1. The use of trophic vs full feeds has no effect on mortality in
critically ill patients
2. The use of trophic vs full feeds has no effect on VAP in critically ill
patients
3. The use of trophic vs full feeds may be associated with significant
underfeeding but better gastrointestinal tolerance in critically ill
patients.
6. KOMPOSISI
KEBUTUHAN ZAT GIZI MAKRO
Strategies To Minimize
Interruptions In Enteral Nutrition

Fowler

CriticalCareNurse Vol 34, No. 4, AUGUST 2014


TAKE HOME MESSAGE
1. Terjadi perubahan metabolisme nutrisi pada
pasien kritis.
2. Nutrisi merupakan bagian integral dari
pengobatan pasien sehingga harus memperhatikan
jumlah kalori, jenis nutrisi, rute pemberian, cara
pemberian, waktu dan lama pemberian.
3. Monev terhadap toleransi pasien agar tercapai
pemberian nutrisi yang optimal.