MODUL BENCANA PERUT

TUNJANGAN NUTRISI TERHADAP BENCANA PERUT

Prof. dr. Nova Kapantow, DAN., MSc., SpGK

TUNJANGAN NUTRISI
BENCANA PERUT
GI BERFUNGSI

GI TIDAK BERFUNGSI

NUTRISI ENTERAL

NUTRISI PARENTERAL

Parenteral Nutrition

metode pemberian mkn melalui jalur IV.

=intravenous feeding ok lgs dimasukkan ke sirkulasi sistemik tanpa melalui sirkulasi portal dan sistim limfatik. Zat gizi yg diberikan: btk terdigesti dan steril

Parenteral Nutrition
1. Indications, Contraindications and Routes of Administration
2. Macronutrient and Micronutrient Use in TPN

Common Indications for PN

Inability to absorb adequate nutrients via the GI tract :

Massive small-bowel resection / short bowel syndrome Severe, untreatable steatorrhea / diarrhoea / malabsorption Complete bowel obstruction, or intestinal pseudo-obstruction Prolonged acute abdomen or ileus

Common Indications for PN

Severe catabolism & GI tract unusable within 57 days Enteral access not feasible, not adequate or not tolerated Pancreatitis with intolerance (eg pain) of jejunal nutrition

High output EC fistula (>500 mL) & no distal enteral access

Potential Indications for PN

Enterocutaneous fistula

IBD unresponsive to medical therapy

Partial small bowel obstruction Intensive chemotherapy / severe mucositis Intractable vomiting if jejunal feeding not possible

Contra-indications to PN

Functioning gastrointestinal tract

Treatment anticipated for < 5 days in patients without severe malnutrition

Inability to obtain venous access Poor prognosis that does not warrant aggressive nutrition support

When the risks of PN are judged to exceed the potential benefits

How Do We Give PN?

Administration of PN

PN solutions are hypertonic

Infusion, therefore, via:

Central venous catheter, or

Peripheral venous catheter with *reduced* osmolarity

Rute pembuluh darah sentral

Central sites: Internal jugular vein Subclavian vein Femoral vein

Percutaneous Central Venous Access

Peripherally inserted central catheters: PICC

Placed at bedside or radiologically

Subclavian vein used to be most common

Can be placed & removed at bedside, but

Generally, placed radiologically

Confirm placement with chest x-ray Can change over a wire to replace

Peripherally Inserted Central Catheter (P.I.C.C.) Line

More expensive than peripheral lines

More difficult to place

Last up to 6 - 12 months Restrict arm movement Allow higher osmolarity Central TPN solutions

Tip in SVC

Implanted Central Venous Catheters

(e.g. Hickman, Groshong, Port-A-Cath)

For prolonged TPN:

Also for fluids, chemotherapy, blood draws

Catheter inserted operatively

Placed with fluoroscopic guidance

Implanted into a subcutaneous tunnel

Tunnelled (Hickman) Line

Implanted Venous Access Device

Central IV: PICC

PROS

CONS

Can infuse solutions > 900 mOsmol/l May be placed by RN

Shorter life than other central lines (< 12 m) More difficult self care

Decreased CRI vs other central lines: HPN

Can be multi-lumen Usable for CT contrast

Blood sampling not always possible

More frequent flushing and maintenance More painful

Central IV: Hickman / Brovac

PROS

CONS

Can infuse solutions > 900 mOsmol/l Allow full IV nutritional support Can be multi-lumen Longevity: 1 -3 years Easier self-care (than PICC &, possibly, port)

Surgical / Radiological procedure

More complex

More difficult to remove

Tube protruding from chest may affect body image More restrictive than a port

Central IV: Implantable Port

PROS

CONS

Can infuse solutions > 900 mOsmol/l Allow full IV nutritional support Greatest longevity Easier self-care (only needed if accessed) Improved body image & activity

Surgical / Radiological procedure

More complex More difficult to remove

Access requires placement of a Huber needle

Infection risk during access

Rute pembuluh darah perifer

Peripheral IV: short-line

PROS

CONS

Least expensive Easily placed and removed Lowest risk for CRI Beneficial for shortterm support (< 1 week)

Need to change often

Every 48-72h

Phlebitis and vein injury

Only one lumen Limits energy delivery

Volume Osmolality (600-900 mOsm/l) pH restriction (pH 5-9)

Peripheral IV: mid-line

PROS

CONS

May be used for a longer duration than peripheral Ease of placement compared to central lines Allows access to larger vessel

Not a central line Must follow guidelines for peripheral lines for concentration, pH and infusion rates

Complications of PN

Metabolik

Komplikasi dini:

Vol. berlebihan, hiperglikemia, refeeding syndrome, dll Def. A. lemak esensial, def. trace mineral, def. vit, penyakit tulang metabolik, steatosis hepatik, dan kolestasis hepatik.

Komplikasi lanjut:

Ketidakseimbangan cairan dan elektrolit

Complications of PN Catheters
Catheter infections Catheter occlusion Catheter injury/leakage Catheter migration Venous thrombosis

Risk Factors for Infection

Site - Subclavian < Int. jugular < Femoral

Material - Silastic / Polyurethane < PVC Type - Subclavian (0.9) < PICC (1.4 / 1000d) - Single lumen < Multi-lumen Care - 2% chlorhexidine (5.9 % catheter colonisation) 70% isopropyl alcohol (15.6%) 10% povidone iodine (19.5%) Patient - young, poor technique, smoking, Crohns, jejunostomy, thrombosis, narcotics

Macronutrient and Micronutrient Use in TPN

Formula

Larutan utk NP sentral diformulasi bdsrkn perhitungan kebutuhan protein dan energi
Pada beb. keadaan (mis. ketidakseimbangan elektrolit atau tdpt disfungsi organ, maka komposisi disesuaikan dg kondisi p/.

Designing Parenteral Regimens

Assess nutritional status and set goals. Evaluate constraints on nutrient delivery. Assess fluid, electrolyte, vitamin, trace element requirements Order nutrients (protein, CHO, fat), fluids/ electrolytes/ trace elements Determine administration (rate and duration). Avoid metabolic complications.

Parenteral Nutrition

Carbohydrate (10 - 25% Dextrose) Amino Acids (0.8 to 1.2 g /kg)

Lipid Emulsion, incl E.F.A. (10 - 30%)

Vitamins / Minerals / Trace Elements

Electrolytes
Fluid (2 - 3 litres /day)

How Much Should We Give?

Estimate of Requirements
Most

hospitalized patients will require 30 kcals/kg/d

CHO

can utilise dextrose up to 5 mg/kg/min

Protein

The average patient requires 0.8 2.0 g protein/kg usual body weight

Constraints on Nutrient Delivery

Do not overload bodys disposal systems

renal, hepatic, respiratory

Nutritional regimen should make sense clinically

Composition of Standard Parenteral Dextrose Solutions

5% - 70% solution dextrose in water 3.4 kcal/gm 500 ml of a 50% solution contains

50 gm/100 ml x 500 ml = 250 gm dextrose

250 gm x 3.4 kcal/gm = 850 kcal

Composition of Standard Parenteral Amino Acid Solutions

Synthetic crystalline amino acids

Contain essential and non-essential AA

Variable amounts of electrolytes

Concentrations depend on final volume

Hypertonic solutions

Characteristics of Intravenous Lipid Emulsions

Concentrations

10% and 20%

Parent oil
Osmolarity Caloric content

Soybean or Safflower
280 - 340 mOsm/l 10% = 1.1 kcal/ml 20% = 2.0 kcal/ml

Electrolytes in Parenteral Nutrition Solutions

Appropriate prescription requires regular monitoring

For maintenance provision

Add directly to the PN solution

Tailor to individual patient needs

Additional replacement for abnormal losses Deletions for patients with certain diseases

Vitamins/Trace Elements in Parenteral Nutrition Solutions

Meet established guidelines for PN Water and fat-soluble vitamins provided

Required for zinc, copper, manganese, chromium & selenium

Added daily to the solution

Requirements may be increased for patients with abnormal losses

Prosedur Standar Pemberian

Hari 1
Hari 2

: mulai dg 50 ml/jam
: 75 ml/jam

Hari 3 dst : 125 ml/jam

Pemberhentian: bertahap (dari 50% kmd 70% dlm 3060 menit sebelum berhenti). Ok dekstrosa menstimulasi sekresi insulin, dan level insulin akan tetap saat infus dextrosa dihentikan hipoglikemia. Oki dosis bertahap cegah hipoglikemia.

15- 30

Monitoring Patients on Parenteral Nutrition

Clinical status Metabolic and biochemical aspects Delivery

Catheter care, pump, % volume infused

Nutritional status/reassessment

PN Summary Guidelines
1. Determine if PN is truly indicated 2. Assess the patient (medical history, medication profile, anthropometric data & lab values) 3. Determine need for long-term vs. short term
<710 days

4. Confirm or establish adequate IV access

Peripheral or central?

5. Determine estimated kcal, protein and lipid needs

2030 kcal/kg Protein 0.81.5 gm/kg Higher levels may be needed in severe catabolic states Lipid to provide 30% of kcals

PN Summary Guidelines
6. Determine initial electrolyte, vitamin and trace element requirements; consider ongoing losses 7. Consider any additional additives to PN formulation including insulin and H2-receptor antagonists 8. Monitor for:
Risk of refeeding syndrome Glucose intolerance Start low & advance slowly if labs stable over 24-48 hours Fluid, electrolyte, metabolic, macro- and micro-nutrient changes Complications sepsis, thrombosis, abuse

9. Initiate trophic feedings or convert patient to PO or enteral feeding when feasible