ENTERAL NUTRITION

Yudhi Adrianto
 01 Overview of Enteral Nutrition

02 Enteral Formula Selection

OUTLINE 03 Enteral Access Device : Selection, Insertion,

Maintenance and Complication

Enteral Nutrition Diagnosis and

04 Intervention

05 Complications of Enteral Nutrition

 Jalur
Pemberian
Makan

SOURCE:
KRAUSE FOOD AND NUTRITION CARE PROCESS 14TH EDITION
 Absorption of Nutrients
(Krause Food & Nutrition Care Process 14th edition)
 Overview of Enteral Nutrition
• Makanan cair yang diberikan melalui oral/pipa selama
saluran cerna masih berfungsi baik untuk
menyerap/mencerna
• a nutritionally complete liquid formula directly into the
stomach or small intestine via a narrow tube.
• By definition, enteral nutrition means ‘within or by the
way of GI tract’.
• Consensus → gastrointestinal tract is more
physiologically and metabolically effective than the
intravenous route for nutrient utilization.
Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010
Keuntungan Enteral Nutrition
1. Lebih fisiologis daripada nutrisi parenteral
2. Fungsi saluran cerna terpelihara
3. Nutrien lengkap, mudah dalam
pengaturan cairan dan elektrolit
4. Biaya murah (cair enteral RS)
5. Aman, komplikasi sedikit dan jarang
6. Memelihara sistem imun sal cerna,
optimalisasi GALT – MALT (gut & mucosa-
associated lymphoid tissue)
Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010
Enteral VS Parenteral

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Route for Delivery Nutrition

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

 Kontraindikasi Enteral Nutrition
• Obstruksi saluran cerna
• Muntah terus menerus
• Short bowel syndrome berat (sisa 100 cm usus tersisa)
• Ileus paralytic
• Perdarahan saluran cerna
• Tidak adanya akses saluran cerna

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Optimal Timing for EN

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Optimal Timing for EN

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Enteral Formula Selection

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Enteral Formula Selection

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

 Jenis Enteral Nutrition
Formula Polimerik
• Membutuhkan kerja saluran
cerna yang baik
• Intact nutrition (utuh)
• Formula standard, fully
functional GI tract, normal
digestion, normal absorption
• Macronutrient are intact and
require digestion
Formula
Mono/Oligomerik
• Molekul nutrisi/zat gizi lebih kecil
• Absorpsi lebih mudah
• Bentuk peptida, mono/disakarida,
glukosa, MCT
• Elemental, semi elemental hydrolized
or chemically defined formula
Enteral Formula Selection
 Osmolalitas dan Osmolaritas
Osmolalitas → jumlah keseluruhan partikel larut air (i.g osmolalitas serum)

Osmolaritas → jumlah konsentrasi larutan/liter ditinjau dari jumlah

partikelnya. (meningkat TPN → pecah pembuluh darah)

Osmolalitas EN berkisar 270 – 700 mOsm.

Formula isotonik lebih mudah diserap daripada hipertonik (280 – 320

mOsm). Hipertonik formula >600 mOsm → Diare
Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010
 Enteral Formula Stability
• Influence stability : Temp, Light, Oxygen
• Rekomendasi 6 jam
• FA rantai 6:3 terjadi oksidasi bahkan disuhu
rekomendasi penyimpanan 4°C
• Kehilangan zat gizi lebih tinggi disuhu 20-30°C
• Reheating menyebabkan kehilangan zat gizi
Cara Pemberian Enteral Nutrition

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Enteral Feeding Time
Contoh Pemberian
 Contoh formula spesifik dalam Enteral Nutrisi

Kondisi critical Karakter formula EN

SIRS/Sepsis/ARDS Asam Lemak Anti Inflamasi i.g Omega 3

Bedah, Trauma, Luka Bakar Arginin, Glutamin, Asam Lemak Anti

Inflamasi i.g Omega 3

Intoleransi Sal Cerna atau Protein terhidrolisa, MCT

Malabsorpsi
 Contoh formula spesifik dalam Enteral Nutrisi
Kondisi Penyakit Karakter formula EN
Pembatasan cairan i.g Heart Densitas kalori tinggi (>1.2 kcal/cc), tinggi protein
Failure
Diabetes Mengandung bahan yang dapat menurunkan GD,
i.g serat, inulin, tempe
CKD pre-dialisis Rendah protein dan posfor
CKD on-dialisis Tinggi protein, tinggi energi, rendah posfor,
pembatasan cairan (750ml-1 L/hari)

Kanker Tinggi protein, antioksidan dan anti inflamasi

Enteral Access Device : Selection,
Insertion, Maintenance and
Complication
Enteral Nutrition Need

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

 Karakter dan Letak Tube
Monitoring Polyurethane Silicone
Comfort Lower Higher
Stiffness Higher Lower
Wall Width Thinner Thicker
Fungal Degradation More Resistant Less Resistant
Common Use NGT NGT

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Enteral Nutrition Diagnosis and
Intervention
 OPSI Diagnosis Gizi Pasien

1) Malnutrition
2) Inadequate protein-energy intake
3) Inadequate enteral intake
4) Altered GI function
5) Increased nutrient needs
6) Increased energy expenditure
7) Impaired nutrition utilization
8) Excessive fluid intake
9) Excessive energy intake
10) Inadequate oral food/beverage intake, dsb
Diagnosis Gizi terkait EN
 Intervensi Nutrisi Enteral (ND 2.1)
• Modify composition of enteral nutrition (e.g., formula name or description,
special additives including supplemental fat, carbohydrate, or protein, fiber)
• Modify concentration of enteral nutrition (e.g., calories/kcal/kJ per mL)
• Modify rate of enteral nutrition (e.g., mL/hour)
• Modify volume of enteral nutrition (e.g., mL/day, mL/feeding)
• Modify schedule of enteral nutrition (e.g., number of hours per 24 hours,
continuous, intermittent, bolus)
• Modify route of enteral nutrition (e.g., nasoentric, oroenteric, percutaneous, or
surgical access with gastric, duodenal or jejunal placement)
• Enteral nutrition site care (e.g., change dressings and provide enteral feeding tube
site care)
• Feeding tube flush (e.g., type, volume mL/flush, frequency) (IDNT, Page 122)
 Monitoring Makanan Enteral

• Assessment fisik dan klinis

• Tanda tanda vital
• Intake cairan
• Output cairan
• Trend berat badan
• Data laboratorium terkait gizi

Sumber:
Sumber: A.S.P.E.N
A.S.P.E.N “Enteral
“Enteral Nutrition
Nutrition Handbook”
Handbook” 2010
2010
Complications of Enteral Nutrition
 EN Related Complications

GASTROIN METABOLIC MECHANICAL Other

TESTINAL

• Nausea Vomiting • Fluid imbalance - Tube - Peristomal

• Gastroesophageal • Electrolyte misplacement Infection
Reflux • Acid – Base - Tube occlusion
• Aspiration Disturbance - Tube migtation
• Diarrhea • Refeeding
• Constipation Syndrome
• Malabsorption • Glucose
Intolerance

Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010

Common Allergies of EN
Aspiration of EN
Nausea or Vomiting
Gastric Residual Volume (GRV)
 Nutrition Requirements
• Suggest indirect calorimetry (IC)
• Use a published predictive equation (25–30 kcal/kg/d) to
determine caloric requirements for BMI < 30. ) protein should be
provided in the range of 1.2–2.0g/kg ABW*/day in the patient with
BMI less than 30
• If IC unavailable, suggest 11–14 kcal/kg ABW*/day for BMI 30–50,
and 22–25 kcal/kg IBW**/day for BMI > 50. Protein is suggested at
≥ 2.0 gm/kg IBW**/day for BMI 30–40, and up to 2.5 gm/kg
IBW**/day for BMI ≥ 40.
Sumber: A.S.P.E.N “Enteral Nutrition Handbook” 2010
Kesimpulan
• EN memiliki banyak kegunaan sesuai jenis
formulannya
• Monitoring komplikasi dan adekuasi perlu
dilakukan setiap hari
• Diagnosis gizi yang tepat diperlukan pada
pasien dengan EN
• Terapi yang tepat meminimalisir
komplikasi pasien dan meningkatkan QoL
Reference
TERIMA KASIH