Optimizing

Nutrition
Therapy
dr. PAUL A DWIYANU PULMONOLOGIST,
CONSULTANT
 Prevalence of Malnutrition
Malnutrition occurs frequently in hospitalized patients it is associated with

01 Increased complication

Prolonged length of stay 02

03 Increased mortality
 Biochemical
parameter

Anthropometric
Assessment evaluated measurement
nutritional status

Subjective Global
Assessment
 Subjective Global Assessment

over the last 6 months

during the past 2 weeks Nausea, Vomiting, diarrhea,A
norexia
Weight changes
Gastrointestinal
symptom Illness and Nutritional
Requiremen
Dietary Intake
Fungtional
capacity
•No changes . Physical Exam
•Changes – Duration Dysfungtion – Duration
-Type - Type ( ambulatory/be
- Inadequed conventional diet
( glosisitis, angular stomatitis,
-Total liquid diet
dridden) loss subcutan etc)
- Clear liquid diet (hypocaloric)
- Fasting
Nutrional Requirement Composition

20%
Lipid

68%
12 Carbohydrates
%
Protein
 Nutrional Requirement

Stable patients Stressed patients

0,8 – 1,0 g/kgBW Protein 1,2 – 2.0 g/kgBW

25%-30% of calories Lipids 20%-35% of calories

50%-65% of calories Carbohydrates

Energy
Harris Benedict Equation x Stress factor

“ Rule of Thumb” : 25 – 30 kcal/kgBW

Indirect calorimetry
 Hyperglycemia,COPD,hypercapnia may
benefit from

LOW carbohydrate High lipids about 50%

about 30% calories calories
 Calculating
Harris-Benedict Basal Variables
Equatio Energy Expenditure

gender, weight (kg), height (cm), age (years)

Men:
66.47 + (13.75 x weight) + (5 x height) - (6.76 x age
Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

“Rule of Tumb”

Calorie requirement = 25 to 30 kcal/kg/day

 Variables : Calorie requirement = BEE
gender, weight (kg), height x activity factor x stress
(cm), age (years) factor

Harris-Benedict
Equation

Men: Women:
66.47 + (13.75 x weight) + 655.1 + (9.56 x weight) +
(5 x height) - (6.76 x age) (1.85 x height) – (4.67 x age)
 “Rule of Tumb”

Calorie requirement = 25 to 30 kcal/kg/day

Nutrients kcal

01 Protein (4 kcal / g)

Carbohydrates
02 Enteral 4 kcal / g
Parental 3.4 kcal / g

03 Lipids (9 kcal / g)

Water
04
05 Vitamins (Water and fat soluble)

Minerals (Electrolytes , trace elements and ultra trace minerals)

06
 COOH
Chemical Structure of an Amino Acid
R

NH3

Nitrogen Balance

NB = IN – (UN + RNL)

NB : Nitrogen Balance
IN : Ingested Nitrogen
UN : 24-Hour Urine Nitrogen
RNL : Remaining Nitrogen Loss (3.1 g/l)
 Respiratory Quotient (RQ)

RQ = Vco2 - Glucose oxidation RQ

Vo2 1 glucose = 6 O2 = 6 CO2 + 6 H2O 6/6 = 1.0

- Fat oxidation
RQ : Respiratory Quotient 1 palmitate + 23 O2 = 16 CO2 + 16 H2O 16/23 = 0.7
Vco2 : Co2 Produced
Vo2 : Oxygen Consumed - Protein Oxidation
1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O 4.1/5.1 = 0.8

- Lipogenesis > 1.0 – 8.0

 ALGORITMA NUTRITIONS ROUTE

GIT
FUNCTION

GOOD POOR

ORAL ENTERAL PARENTERAL

> 7 days < 7 days

> 6 weeks < 6 weeks
Gastro/jejuno
NASOENTERAL CENTRAL PERIFER
Enterostomi

- aspiration + - aspiration +

PEG PEJ NGT NJT/NDT

 Enteral Nutritional

Oral Tube feeding

supplement

“ if the gut works use it”

 Enteral Formula: Selection
• Metabolic requirements

• Patient condition or status

• Pre-existing conditions

• Gl function

• The physician should know the formula’s nutrient profile

• to meet specific patient needs

• Understand the clinical evidence supporting specific

• formula use

• Data obtained exclusive from animal models may or may not apply to the clinical setting
 Resembles normal feeding
and digestion patterns

250-500 mL of formula
INTERMITTENT
Administered over 30-60
minutes

5-8 times daily

TUBE
FEEDING Infusion Pump Indication
ENTERAL 24 hours / day - Small intestine
NUTRITION - Fluid restrictions
ORAL During part of the day or at - Risk of aspiration
night - Need for precise flow rate
- Nocturnal Feeding
Plan : day 1 : 1000 mL over - Infants and small children
CONTINOUS 24 hours

day 2 : 1500 mL over 24

hours Gravity Infusion
- Suitable for intermittent feeding
day 3 : final volume - Ambulatory patients
according to needs - Gastric feeding
Enteral Nutrition Category

Polymeric Olygomeric Disease

Formula Formula Specific
•commercial formula
•blenderized
formula

01 02 03
 Polymeric Formula
Patients must have Contain intact macronutrients
( Ensure, Pedyasure)

Intact protein
Functional GI tract
• Normal digestion Disaccharides
• Normal Absorption
polysaccharides

Polyunsaturated fatty acid (PUFA)

Medium chain triglycerides (MCT)

Oligomeric Formula Categories
Hydrolyzed macronutrients facilitate digestion and absorption component

Amino Acid Glucose polymers

( Glutamin, Argini )

Peptides
08 01 Polyunsaturated fatty acid
07 02 (PUFA)

Monosaccharides Medium chain

06 03 triglycerides

Disaccharides 05 04 Vitamins and minerals

Indication for use:

Inflammatory bowel disease

Early enteral feeding Malabsorption

intolerance to
Pancreatic Short bowel
polymer
insufficiency syndrome
formula
Disease Specific Formula

• Pulmonary disease
• Critical care
• HIV -/ AIDS
• Cancer induced weight loss
• Glucose intolerance
• Hepatic insufficiency & Renal
Failure
 Non-Functional Hemodynamic
01 01

Contraindications
gastrointestinal tract instability
Indications

Impossible to use the Ability to adequately rec

02 gastrointestinal tract eive and absorb 02
necessary foods orally
or by gastric or enteral
Need for intestinal
03 rest
tube

Palliative use in terminal

04 patient is controversial
Central Parenteral Nutrition

Selection depends on caloric requirements, volume to be administered and

patient condition, as well as final concentration or components:

Amino Dextrose Lipids Includes vit Osmolality

Acids > 20% amins, min > 700 mOs
> 5% erals, and m/kg H2O
trace elem
ents
Peripheral Parenteral Nutrition

Selection of peripheral access depends on clinical situation requirements, tolerance

to volume, and final formula concentration

Osmolality Total kcal limited by Incude ½ of the

< 700 mOsm/kg concentration and ratio recommended e
to volume being admin lectrolytes for P
istered N
Parenteral Nutrition
Dextrose

Provides 3.4 kcal/kg Closely related to

solution osmolality

can be the only source of dextrose infusion rate should not

energy exceed 5 mg/kg/min
 Formulas : Parenteral Nutrition
Amino Acids

Standard concentratio Energy value of amino Nitrogen (g)

n can vary between acids (4 kcal/kg) = protein (g) / 6.25
5% and15%
Formulas: Parenteral Nutrition
Lipids

Added to basic parenteral

Prevent essential fatty nutrition solitions or
acid deficiency administered individually

Non-protein source of Includes as LCT or

kcal. Recommended dose a mix of MCT/LCT
1 g/kg/day at 10% and 20%
Available in 10%
20% and 30% co
ncentrations
Formulas: Parenteral Nutrition
• Lipids
Should be used
Less hyperglycemia
with care in:

Lower concentrations
- Hyperlipidemia
of serum insulin
- Symtomatic ath
erosclerosis
- Acute pancreatit
Less risk of hepatic is with hypertriglyc
damage eridemia

High doses can

interfere with immune
functions

High infusion rates

can affect respiratory
functions

ALLPPT.com _ Free Powerpoint Templates, Diagrams and Charts

Electrolytes

01 02 03
Calcium, magnesium, Forms and amounts Must consider calcium-
phosphorus, chloride, are titrated based on phosphate solubility
potassium, metabolic
sodium, and acetate status and fluid/ele
ctrolyte balance

Vitamin and Minerals

01 02 03
In general, amounts below Added daily to paren Acute illness, infection, pre
daily recommended teral nutrition existing malnutrition, and
intake for healthy people, excessive fluid loss increa
but nonetheless sufficient se vitamin requirements
to cover requirements, are
added to oral or enteral
formulas
 Include daily zinc,
copper, chromium,
and manganese for
patients with
kidney or liver
failure

Trace
Elements

Patients under extended

parenteral nutrition require the
addition of iron and selenium Different requirements
dictated by patient and
pathology
Disease Specific Formula Selection
Pulmonary disease with CO2 retention

1 Decreased carbohydrate content↓

2 Increased fat content↑

3 High caloric density↑

4 Intact proteins

5 Fiber supplement
Excess Glucose Metabolism

CO2
Cytoplasma

lipogenesis
Glucose Mithocondria

Glucose
Piruvat Siklus kreb
Cori Cycle
Piruvat Asetil COoA

ATP

Lactate Lactate
Cancer induced weight loss

Complex metabolite syndr

ome ( anorexia, fatigue,
significant weight loss & early satiety )
muscle wasting
Cannot correct by
additional calories
etiology are pro
inflammatory cytokines,
acute phase response,
abnormal metabolism,
proteolysis inducing factor
 Cancer- Induced weight loss Recommendation :

High proteins and Zn to build Eicosapentaenoic acid

muscle↑ (EPA)

Low fat to avoid early Antioxidants (vitamins A C

satiety ↓ E & Se)

Low in sucrose for better Folate and iron for anemia

patient acceptance ↓

High in fermentable fiber ↑

Excess Fatty Acid Supply

Free Fatty Acid

Cytoplasma

Fatty acid
Mitochondria
Carnitin

Acetyl C
Fatty acid
oA
G-6-Oxidation

Low insulin

High insulin
Trigliserida
Ketone
 Disease-Specific Formula Selection:
Critical Care (Mechanical Ventilation)
Lung Injury / SIRS / ARDS

Eicosapentaenoic Gamma-linolenic
acid (EPA) Acid (GLA)
01 02

No arginine 05 03
supplementation
04

High caloric Antioxidants

density ↑
Inflamasi Respond

Cytoplasma

glucose Asetil CoA

Mitochondria
Glucose
piruvat Siklus kreb

piruvat ATP
Cori cycle

lactate

lactate
Blockage TNF α,
IL, Leucotrien
Fatty Acid Metabolism

Blockage TNF α, IL
Pembuluh darah
Cytoplasma

Fatty ac
id Mitochondria
Trigliserida
Carnitin

Fatty a
cid ATP
Fatty acid
G-6-Oxidation

trigliserida
Glicerol
Desease-Specific Formula Selection:
Critical Care

Arginine (a double-edged sword)

• Conditionally essential nutrient that enhances wound healing

• Support immune system and is associated with reduced infectious
complications

“Giving Arginine to a specific patient is like putting

gasoline on an already Burning fire”
 Disease-Specific Formula Selection
Critical Care
Nutrient Choices

Eicosapentaen
Hydrolyzed oic acid (EPA),
or intact Arginine Gamma-
proteins linolenic Acid
(GLA)

Taurine,
Glutamine Antioxidants
Carnitine
 Disease-Specific Formula Selection:
Advanced AIDS (with weight loss)

Weight loss > 5% below normal

CD4 < 400

Serum albumin < 3.0 g/dL

Diarrhea

Impaired immune function

Opportunistic infection
Disease-Specific Formula Selection :
Advanced AIDS (with weight loss)
Recommendations

Increased Low fat for Added fiber EPA to down Increased

protein ↑ improved regulate levels of anti
tolerance ↓ metabolic oxidants (beta
changes -carotene, vita
associated min E, C) and
with cachexia B vitamin (B6,
B12) ↑
 Summary
Defined nutritional screening and assessment

Caloric
Energy distribution and Select
requirements protein intake appropriate
vary according vary according route, method
to patients patient of
clinical administration,
condition metabolic formula
status
thank’s
BEE dikalikan 1,2 pada kondisi :

1. Demam. BEE x 1,1 untuk setiap kenaikan 1 derjad C diatas s

uhu normal tubuh
2. Stress ringan. BEE x 1,2
3. Stress sedang . BEE x 1,4
4. Stress berat. BEE x 1,6
Persaman haris Benedict dapat pula menghitung BEE

PRIA — BEE = 66.47 + (13.75 x weight) + (5 x height)

– (6.76 x Age)
WANITA— BEE = 655.1 + (9.56 x weight) + (1.8 x
height) – (4.68 x Age)
• KH diperkirakan 70% dari total kalori yang di
perlukan
• Protein. Diperlukan protein yang lebih besar
dari normal dikarenakan proses hiperkatabo
lisme pada pasien penyakit kritis
• Lemak. Diperlukan 30% dari total energy ha
rian yang diperlukan
• Cairan. Kebutuhan cairan diperkirakan men
capai 30 ml/KgBB
• Vitamin
 Intake total harus mencukupi untuk

Energi, protein, aktivitas dan Toleransi GIT,

mineral, kondisi yang ketidakstabila
mikronutrien,s mendasari n metabolik
erat, cairan penyakit
dan elektrolit
Cara pemberian
nutrisi
Parenteral
Enteral
Nutrisi enteral Indikasi Kontraindikasi

Inadekuat
intake oral Syok
selama 1-3 hari

Obstruksi usus

Diare berat

Fistula
enterocutaneus
Komposisi pemberian enteral

Berat jenis kalori

Osmolalitas

Protein

Lemak

serat
Pemberian makanan

• Pemberian melalui selang infus

diberikan 12-16 jam dalam sehari.
Harus dimonitor adanya retensi
pada lambung.
• Posisi elevasi antara 40-45 derajad
melindungi resiko aspirasi
Komplikasi pemberian nutrisi enteral

Sumbatan
aspirasi
pada selang

Intoleransi
Diare
makanan

Sindrom
refeeding
 Nutrisi parenteral

Indikasi pemberian

Jangka pendek Jangka panjang

(<14 hari) (>30 hari)
Jenis yang Cairan Dextrose
digunakan

Cairan asam amino elektrolit

Emulsi lemak
Komplikasi pemberian nutrisi parenteral

Oksidasi yang
Infeksi akibat selang
menyebabkan
pemberian
kerusakan sel

Hiperglikemia,
Atropi mukosa
hiperfosfatemia
Monitoring pada pasien yang diberikan nutrisi
parenteral
 Farmakonutrien

Suplemen arginin Glutamin

Prebiotik dan Hormon seperti

probiotik kolesistokinin dan
peptide YY
 Pemeriksaan fisik
You can simply impress your audience and add a
unique zing and appeal to your Presentations.

Penentuan
status
nutrisi
dilakukan Tes biokimia
melalui You can simply impress your audience and add a
unique zing and appeal to your Presentations.
Tujuan pemberian nutrisi pada pasien ICU

Mencegah
komplikasi
Menjaga metabolik
fungsi
imunitas
Memelihara
massa
tubuh
Nutritional Requirement
Pengeluaran energy diukur dari volume konsumsi o2 (VO2) dan
volume produksi CO2 (VCO2)

REE (kcal/day) = [(3.9 x VO2) + (1.1 x VCO2) - 61] x 1440

Pengeluaran energy harian disebut dengan BEE. Didefinisikan

sebagai panas yang diproduksi dari metabolisme basal

BEE (kcal/day) = 25 x body weight in

kilograms.
Fatty Acid Metabolism

Blockage TN
F α, IL
Pembuluh darah

Cytoplasma

Fatty ac
id Mitochondria
Trigliserida Carnitin

Fatty a
cid ATP
Fatty acid
G-6-Oxidation

trigliserida
glicerol
 Ideal weight

Actual weight

In malnutrition, energy expenditure must be calculated based on actual body weight

Early Detection of Malnutrition

Elderly

Alcoholism

Hipermetabolik

History of chronic disease

Gastrointestinal disease
Chronic renal insufficiency
BMI <18,5 Cancer
COPD
Alat uji untuk mengukur nutrisi

MUST MNA NRS-2002

SGA MST NRI