How to

monitoring
Emmy Pranggono
Internal Medicine Department
Pulmonary and Critical Care Division
Universitas Padjajaran/RS dr Hasan Sadikin
 Introduction
• After nutritional administration  do a next step
– is not less important
– called monitoring and evaluasi
• can not be apart
• The doctor give more attention to another “Urgent”
planning
– Near of the day when the patient will discharging from hospital
we just alert that the nutrition administration is un controlled
– The patient postponed to dicharge because of another problem
caused by nutrition administration such as
• refeeding syndroma which is can be fatal
Our patient is not as simple
as patient in the ward
NUTRITIONAL PROGRAMME
NUTRITIONAL PROGRAMME
 FLUID and NUTRITION FLOW CHART

• PROBLEM
hemodynamic/CNS/GIT/Respiration/Renal/Me
tabolic/ Others

• Fluids requirement/day :
• Fluids for drugs :
• Fluid for nutrition :
• Fluids balance :
 Calori: …………..kcal/kgBW = …...........kcal/24h
Compotion :
Protein : .….gr/kgBW = …….gr/24h
= kcal/24h
Calori non protein (CH anf Fat) =
Total calori – protein calori = ..... kcal
CH : fat ratio
80 % : 20 %
70 % : 30 %
60 % : 40 %
50 % : 50 %
·       
Route Formula Fluid Calori CH Fat Protein Others
(cc) (kcal) (kcal) (kkal) (gr)

Enteral

1.

2.

Parenteral

1.

2.

3.

Total
 MONITORING AND EVALUATION
MONITORING AND EVALUATION
PROGRAMME
PROGRAME
• The purpose is how we monitor and evaluation
the nutrition program until the patient leaving
hospital and continuiting at home
• Kind of Monitoring
– regular monitoring
– optional monitoring
• gut retention
• hemodynamic instability
– tight monitoring for some cases
• gut bleeding
• Timely
– every hour
– every day
– every week/every 2 weeks
 Reguler monitoring
• In patient with hemodinamicc instability by
means patient recieving varopressor/inotropic
– Every hour vital sign monitoring
– Evaluation for
• Urine production due to fluids administration
• PF ratio (PaO2 /FiO2) due to oxygen needs for substrat
metabolisme
• Ajust the fluids and calorie intake
Optional monitoring for gut retention and hemodynamic instability

• Feed the Gut programme : 20cc/hour

• Check retention every 4 hour
– If more than 250 cc in 4 hours decrease the administration
– If less than 250 cc in 4 hourscc continue the administration
• Rationale
– Estimation of gastric content in 24 hour as much as 2400cc, means
100cc/hour  400cc/4 hours.
– If we give formula via NGT 20cc/hour  80cc/4 hours
– So in 4 hours the gastric volume approximately 480 cc
• That means
– there is retention/no absorption if the gastric residu is more than 50% or
250 cc
– Always evaluation every 4 hour
REABSORBSI CAIRAN Dan ELEKTROLIT melalui TRAKTUS G

MINUM 1.5-2 liter

Saliva 1.5 Gastric juice 1.5

Pancreatic juice 2 Bile 1

Duodenum 8

Jejunum - ileum 3

Ileo-caecal 1.5

STOOL 0.15 liter

Optional monitoring for gut retention and hemodynamic instability

• In patient with hemodynamic instability

• Remember :
• The needs of oxygen when starting metabolisme
is different from substrat to substrat
– Choose the substrat with less oxygen needs using Respiratory
Quotient (RQ)
– Decrease the amount of calories if the condition become
worsening
• Always noted : Start low, go slow, stop slow
 Respiratory Quotient (RQ)
Respiratory disorder
To make an energy (ATP) always needs some energy

Respiratory Quotient (RQ) = Liters CO2 produced

Liters O2 consumed

RQ
Glucose oxidation
1glucose + 6 O₂= 6 CO₂ + 6 H₂O 6/6 = 1

Fat oxidation
1 palmitat + 23 O₂= 16 CO₂+ 16 H₂O 16/23 = 0.7

Protein oxidation
1 amino acid + 5.1 O₂= 4.1 CO₂+ 2.8 H₂O 4.1/5.1 = 0.8
 Example Formulation

• Combination between enteral dan parenteral feeding

• Administration - day 2 : 75% (1050kcal)
• Protein 0.8 gr/kgBW= 75% x 40gr = 30gr
• Carbohidrat : Fat = 70% : 30%
• Enteral :
– 20cc/hour enteral formula 500cc = 500kcal
– Check gut retention every 4 hour
• Parenteral
• Amout of calories is 1050-500 kcal = 550 kcal, consist of
– Protein
– Carbohidrat 70%
– Fat 30%
Tight monitoring for some cases
(gut bleeding)
• Look at the enterocyte which is lining as a
barrier of lumen to microcirculation
• If there are some disruption of the enterocyte
integrity caused by
– any of citokine
– perfusion disorders (micro emboli)
• The microrganime will enter to the circulation
as its called Bacterial Translocation
• Most appropiate route
– No gut limitation  early enteral feeding
• Better gut perfusion
• Inhibit hyperglycemia (GLP1)
• Feed the Gut to promote entorocyte healing
because nutrient from lumen can enter the
entrocyte by osmosis proscess
• 20 cc/hour (ignore the calorie)
• Check retension : if below 250cc/4 hour continue
• Increase slowly
• Always check retention every 4 hour
 Nutrition problem in critical ill

GLP-1 release
 Timely Monitoring and evaluation

• Check
– Hemodynamic and Urine out put every hours
– Blood glucose and BUN /creatinin, electrolite
every 3 days
– Cholesterol profile and transaminase every week
– Protein and albumin every 2 weeks
Best monitoring and Evaluation the Route of
nutrient Administration

• Enteral
– Check the placement of NGT, use appropiate size
– Mantain tube patency
• Routine irrigation with water or normal saline
• Always use tube more than 30cc
– Alert of nasal pressure necrosis
– Prevent pulmonary aspiration
• Elevate the head 30 0r 45 º
• Use continuouse rather than intermittent feeding
• Parenteral
– Check the IV placement (Central or peripherally)
• Pneumothorax
– Blood glucose monitoring
– Avoid site infection
• Potentially lethal outcomes
 Prevent Refeeding Syndrome
• Caused by rapidly advancing feeding in malnourished
patient
• Characterized by
– Hypo phosphatemia
– Hipokalemia
– Hipomagnesia
– Fluid overload
• Anticipate it and correct fluid and electrolyte
deficiencies before strating feeding
• Slowly advance feeding rate
 Conclusion
• Monitoring and evaluation is
– an important protocol beside the nutrition
programme
– It is should be as apart from nutrition programme
– can prevent of complication of nutrition
programme
• Hopely giving better care for patient during
and after hospitalization
TERIMAKASI
H