PARENTERAL - ENTERAL NUTRITION

pada PASIEN dengan MALNUTRISI

Fitri Vidyastuti dr, Sp.GK

 Definition of Malnutrition

Malnutrition can be defined as “a state resulting from lack of intake or

uptake of nutrition that leads to altered body composition (decreased fat
free mass) and body cell mass leading to diminished physical and mental
function and impaired clinical outcome from disease”

Cederholm T, et al., ESPEN guidelines on definitions and terminology of clinical nutrition, Clinical Nutrition (2016)
 Etiology of Malnutrition

The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition Consensus
Malnutrition Characteristics: Application in Practice; Nutr Clin Pract. 2013;28:639-650
 Route of
Nutritional
Intervention

ASPEN; 1998
 Indication EN
• If “under nutrition” already exist  nutritionally
problems
• Unintentional weight loss
• Insufficient to meet requirement to metabolic
demand
• If it is anticipated that the patient will be unable to
eat more than requirement
• If an inadequate food intake ( < 80 % of estimated
energy expenditure) is anticipated for more than
requirement
 Route of Enteral Nutrition
Protein and energy enriched

Oral

Sip feeding

Naso gastric*

Pharyngostomy
Gastric Percutaneous endoscopic gastromy
Oesophagostomy (PEG) or G-tube (button)
Enteral
Nutrition
Gastronomy* Radiological Inserted gastronomy
(RIG)*

Nasoduodenal* Surgical gastronomy

Tube
Feeding Duodenal

Extended gastronomy*

Naso jejunal

Jejunal Extended gastronomy*

Direct access
Surgical jejunostomy
Fine needle catheter
 Enteral Nutrition Products
KALBE
NUTRITIONAL
PRODUCTS

NUTRISI NUTRISI
PARENTERAL ENTERAL

GANGGUAN GANGGUAN TINGGI NEUROLOGI SISTEM IMUN

SEIMBANG KANKER ANAK
GINJAL HATI PROTEIN

HEPATOSOL/
NEPHRISOL/ PEPTIBREN PEPTIMUNE
ENTRAMIX NUTRICAN HEPATOSOL PEPTISOL ENTRAKID
NEPHRISOL-D
LOLA
 Indication PN
• If early EN is not feasible or available over the first 7
days after admission.
• More than 10% involuntary weight loss over a 2-3
months period.
• Less than 75% of ideal or usual body weight
• Serum prealbumin less than 10 mg/dl serum
transferrin less than 100 mg/dl
• History of inadequate oral intake for more than 7
days .
 Route of PN
> 900 mOsm/L
Amino acid > 5 %
Dextrose > 20 %
Lipids
Includes vitamins, minerals, and trace
elements
PN for > 7 – 14 days

600 – 900 mOsm/L

PN for short-term < 7 – 14 days
 Complications PN (Catheter-Related)

Insertion Mechanical Infection

• pneumothorax • poor catheter • catheter
• chylothorax placement insertion site
• hematothorax • phlebitis • subcutaneous
• air embolus • thrombosis tunnel
• arterial • catheter • colonization
puncture occlusion • bacterimia
• nerve injury • rupture • sepsis
• embolus
 Complications PN
Metabolic Overfeeding Gastrointestinal
• Hyperglycemia • Hepatic • Liver function
• Electrolyte steatosis disorder
imbalance • Hyperglycemia • Gastrointestinal
• Prerenal • Prerenal atropy
azotemia azotemia
• Abnormal acid- • Increased CO2
basa balance production
• Respiratory
distress
syndrome
 Monitoring PN
• Glucose
• Fluid and electrolyte balance
• Renal and hepatic function
• Triglycerides and cholesterol
• Body weight
• Nitrogen balance
• Plasma protein
• Creatinine/height index
Guidelines for Nutritional Monitoring
Test Initial Stable Hospitalized Patient Home Patient

Body weight daily daily twice weekly

Output : urin every 8 hours daily twice weekly
stool daily twice weekly
Urine glucose every 6 hours every 6 hours twice weekly
Blood :
Glucose daily every other day weekly
Electrolytes daily every other day monthly
BUN, creatinine daily weekly monthly
Total protein, weekly weekly monthly
Albumin
transferrin
Calcium, weekly weekly monthly
phoshorus
LDH, AST, Bilirubin weekly weekly monthly
Alkaline phosphatase
TIBC,iron Weekly weekly monthly
CBC, differential, weekly weekly monthly
prothrombin time
Anthropometrics monthly monthly
Nitrogen balance twice weekly weekly monthly
 Parenteral Nutrition Products
KALBE NUTRITIONAL
PRODUCTS

NUTRISI PARENTERAL NUTRISI ENTERAL

KARBOHIDRAT LARUTAN ASAM AMINO EMULSI LEMAK MULTICHAMBER BAG

TRIOFUSIN AMINOFUSIN L-600 CLINOLEIC CLINIMIX

KALBAMIN

DISEASE SPECIFIC

AMINOFUSIN HEPAR

COMAFUSIN HEPAR

RENXAMIN
 PRODUK KARBOHIDRAT PROTEIN LEMAK VITAMIN &
MINERAL

Triofusin 500,
√ - - -
1000, 1600

Triofusin E1000 √ - - √

Aminofusin L-600 √ √ - √

Kalbamin 10% - √ - -

Aminofusin
√ √ - √
Hepar

Comafusin Hepar √ √ - √

Renxamin 9% - √ - -

Clinoleic 20% - - √ -

Clinimix N9G15E
√ √ - √
Clinimix N9G20E
Terima Kasih