Nutritional support via placement

through the nose, esophagus, stomach,

or intestines (duodenum or jejunum)
Tube feedings
Must have functioning GI tract
IF THE GUT WORKS, USE IT!
Exhaust all oral diet methods first.

Enteral
Impaired ingestion
Inability to consume adequate nutrition orally
Impaired digestion, absorption, metabolism
Severe wasting or depressed growth

Parenteral
Gastrointestinal incompetency
Hypermetabolic state with poor enteral tolerance
or accessibility

1.
2.
3.
4.
5.
6.

Applicable
Site placement
Formula selection
Nutritional/medical requirements
Rate and method of delivery
Tolerance

The suitability of a feeding formula should be evaluated

based on

Functional status of GI tract

Physical characteristics of formula (osmolality, fiber

content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte needs or

restriction

Cost effectiveness

Fungsi Sal Cerna

Ya

Tidak (1)

Enteral Nutrisi
Long-term
Gastristomy
Jejunostomi

Parenteral Nutrisi

Short-term
Nasogastric
Nasoduodenal
Nasojejunal

Fungsi sal cerna

Normal
Nutrisi
standart
Mencukupi
(2)

compromised

Short-term

TPN

PPN

Fungsi sal cerna

Farmula
khusus
Tdk Mencukupi
(3)

Longterm/retriksi
cairan

Ya
Mencukupi
(4)

TDK

1.
2.
3.
4.

Peritonitis difus, obstruksi usus, muntahmuntah, ileus, diare

Berlanjut ke makanan oral
Nutrisi parenteral sbg suplemen,
dilanjutkan ke nutrisi enteral total
Berlanjut ke diet yang lebih kompleks
dan makanan oral sesuai dgn
penerimaan

Access (medical status)

Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning

Intake easily/accurately monitored

Provides nutrition when oral is not
possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with
disease state

Preserves gut integrity

Decreases likelihood of bacterial
translocation
Preserves immunologic function of gut
Increased compliance with intake

GI, metabolic, and mechanical

complicationstube migration;
increased risk of bacterial contamination;
tube obstruction; pneumothorax
Costs more than oral diets
Labor-intensive assessment,
administration, tube patency and site
care, monitoring

Access problems (tube obstruction)

Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)

Can result from enteral feeds

High-risk patients

Poor gag reflex

Depressed mental status

Check gastric residuals if receiving

gastric feeds
Elevate head of the bed >30 degrees
during feedings
Postpyloric feeding
Nasoenteric tube placement may require
fluoroscopic visualization or endoscopic
guidance
Transgastric jejunostomy tube

Bolus300 to 400 ml rapid delivery via

syringe several times daily
Intermittent300 to 400 ml, 20 to 30 minutes,
several times/day via gravity drip or syringe
Cyclicvia pump usually at night
Continuousvia gravity drip or infusion pump

*Determined by medical status, feeding route

and volume, and nutritional goals

kcal/ml x ml given
= kcal
% protein x kcal
= kcal as protein
kcal as protein x 1 g/4 kcal
= g protein
Example: Patient drinks 200 cc of a 15.3%
protein product that has 1 kcal/ml
1 kcal/ml x 200 ml

= 200 kcal

0.153 % protein x 200 kcal = 30.6 kcal

30.6 kcal x 1g protein/4 kcal = 7.65 g protein

Healthy adult: 1 ml/kcal or 35 ml/kg

Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to
85% water
Elderly: consider 25 ml/kg with renal,
liver, or cardiac failure; or consider 35
ml/kg if history of dehydration

Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube
with water about 3 times dailyinclude
this amount in estimated needs
Example: flush with 200 cc tid

Continuous method = slow rate of 50 to

150 ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of
feeding given in 5 to 8 feedings per 24
hours
Bolus method = may give 300 to 400 ml
several time a day (push is not desired)

Diameter of feeding tube is measured in

French units
1F = 33 mm diameter
Feeding tube sizes differ for formula
types and administration techniques.

Pediatrics
Low residue
High protein
Volume restriction
Diabetic
Pulmonary/COPD

1.

Blender

2.

Polimer

3.

Monomer

digunakan untuk pasien normal atau dgn ggn

sal cerna minimal; masih diperlukan absorbsi;
mengandung karbohidrat-lemak-protein utuh
dgn kekentalan penuh, viskositas rendah,
osmolaritas 300-500mOsm/kg, 1-1,2 kcal/cc
- susu
- bebas laktosa
untuk pasien dgn ggn sal.cerna yg
membutuhkan nutrisi yg sdh dihidrolisis,
osmolaritas ~ proses hidrolisis, 1-1,2 kcal/cc,

Nama dagang
Diabetasol
Ensure
Entraso
Falkamin
Isocal
Neprishol
Nutrison
Peptisol
Pepti 2000 variant
Sustacal

Indikasi
DM
Diit TKTP dengan rendah residu
Cachesia dan pasien dg diit TKTP
Isufisiensi hati yang memerlukan
asupan protein yang rendah
terutama BCAA
malnutrisi
Isufisiensi ginjal bersama diit rendah
protein
Pasien yang tidak bisa, tidak boleh,
dan tidak mau makan dan minum
Cachesia atau pasien yang
memerlukan diit protein
Gangguan pencernaan dan absorbsi
dg kebutuhan TKTP
Cachesia dan malnutrisi

Central access
TPN both long- and short-term placement

Peripheral or PPN
New catheters allow longer support via
this method limited to 800 to 900 mOsm/kg
due to thrombophlebitis

<2000 kcal required or <10 days

Central sites:
Internal jugular
Subclavian vein
Femoral vein

15- 30

Kcal required
(10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated

Provides nutrients when less than

2 to 3 feet of small intestine remains
Allows nutrition support when GI intolerance
prevents oral or enteral support

GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight
loss
Nutritional needs not met; patient refuses
food

GI tract works
Terminally ill
Only needed briefly (<14 days)

Avoid excess kcal (> 40 kcal/kg)

Adults
kcal/kg BW
Obeseuse desired BMI range or an
adjusted factor

Adjusted IBW for obesity

Female:
([actual weight IBW] x 0.32) +
IBW
Male:
([actual weight IBW] x 0.38) +
IBW

Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml

1.2 to 1.5 g protein/kg IBW

mild or moderate stress
2.5 g protein/kg IBW
burns or severe trauma

Max. 0.36 g/kg BW/hr

Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems

4% to 10% kcals given as lipid meets EFA

requirements; or 2% to 4% kcals given as
lineoleic acid
Usual range 25% to 35% max. 60% of kcal
or 2.5 g fat/kg

Fluid30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements

Nama Dagang
Aminofusin
Aminofusin PAED
Aminofusin TPN
Aminoleban

Aminovel 600/1000

Amiparen
EAS primer

Indikasi
Keadaan katabolik, seperti infeksi berat, luka
bakar, cidera berat dengan balance nitrogen
negatif
Neonatus prematur dan bayi yang menderita
defisiensi protein atau penyakit dengan
peningkatan kebutuhan protein
Keadaan katabolik dengan balance nitrogen
negatif
Keadaan ensefalopati pada penderita penyakit
hati yang akut/kronis. Aminoleban tidak boleh
diberikan pada keletihan ginjal yang berat dan
gangguan metabolisme asamamino lainnya
Status gizi yang tidak memadai dan memerlukan
nutrisi parenteral seperti short bowel syndrome,
anoreksia dan gangguan gastrointestinal yang
berat
Hiponatremia, malnutrisi, pra/pasca bedah
Keadaan azotemia, GGA, dan isufisiensi renalyang
kronik. AES jugadapat diberikan pada penderita
pasca dialisis untuk menggantikan asam amino
yang hilang. Keadaan yang memerlukan nutrisi

Intrafusin 10%

Intrafusin 3,5% SX-E

Intralipid 105/20%
(ivelip)
PE 90

Pan Amin G
Triofusin 500

Keadaan yangmemerlukan TPN jangka pendek dan

parsial jangka panjang. Larutan ini dapat
menstimulus sintesis albumin. Larutan intrafusin 10%
dapat diberikan bersamaan dengan larutan yang
mengandung kalori dan elektrolit
Cachesia dan malnutrisi yang memerlukan suplemen
kalori dalam waktu lama seperti malnutrisi yang
menyertai cedera otak berat. Intralipid tidak boleh
diberikan pada pasien sislipidemia, insufisiensi hati
yang berat dan syok mendadak
Keadan yang memerlukan nutrisi parentaral perifer
total atau parsial jangka pendek, pre/post operasi,
sepsis, luka bakar, gagalginjal, neonatus
Malnutrisi atau hipoproteinemia yang memerlukan
pasokan asam amino, tidak boleh diberikan pada
koma hepatikum, kelainan ginjal yang berat dan
gangguan metabolisme asam amino dan intoleransi
fruktosa yangherediter
Keadaan yang memerlukan kalori lewat nutrisi
parenteral total atau parsial khususnya selama
metabolisme post agresi
Keadaan yangmemerlukan kalori dan elektrolit lewat

1. Multiply the grams of dextrose per liter by

5. Example: 50 g of dextrose x 5 = 250
mOsm/L
2. Multiply the grams of protein per liter by
10. Example: 30 g of protein x 10 = 300
mOsm/L
3. Fat is isotonic and does not contribute to
osmolarity.
4. Electrolytes further add to osmolarity.
Total osmolarity = 250 + 300 = 500
mOsm/L

Total nutrient admixture of amino acids,

glucose, additives
3-in-1 solution of lipid, amino acids, glucose,
additives

Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs
or switch to dextrose IV)
Cyclic give 12 to 18 hours per day

Infection
Hemodynamic stability
Catheter care
Refeeding syndrome

Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest

Weight
(daily)

Blood
Daily
Electrolytes (Na+, K+, Cl-)
Glucose
Acid-base status
3 times/week
BUN
Ca+, P
Plasma transaminases

Blood
Twice/week
Ammonia
Mg
Plasma transaminases
Weekly
Hgb
Prothrombin time
Zn
Cu
Triglycerides

Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)

Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration
(daily)
WBC and differential (as needed)
Cultures (as needed)

PPN
Site irritation

TPN
1. Catheter sepsis
2. Placement problems
3. Metabolic

Energy
Infant
50 to 60 kcal/kg/day maintenance
70 to 120 kcal/kg/day growth

Child >1yr
BEE
1to 8 yrs 70 to 100 kcal/kg/day
8 to 12 yrs 60 to 75 kcal/kg/day
12 to 18 yrs 45 to 60 kcal/kg/day
Injury factors
1.25 mild stress
1.50 nutritional depletion
2.00 high stress

Protein:
Infant
2.4 to 4 g/kg/day <1500 g
weight
2.0 to 2.5 g/kg/day 0 to 12
months
normal weight

Child >1 year

1 to 8 years 1.5 to 2.0 g/kg/day
8 to 15 years 1.0 to 1.5 g/kg/day

Carbohydrate
Infant preterm:
4 to 6 mg/kg/minute begin rate
Term infants:
8 to 9 mg/kg/minute begin rate

Fat
Infants:
0.5 to 1.0 g/kg/day min for EFA
needs
2 to 3 g/kg/day max

Vitamins and minerals:

See tables in textbook

Fluid and electrolytes

Infant:
LBW 125 to 150 ml/kg/day
2 to 4 mmol/kg/day for
electrolytes

Other infants and children

Type of feeding formula and tube

Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and
corrective actions
Patient education

Plan any tubefeedings or parenteral

nutrition around diet restrictions.
IF the nutrient would be restricted on the
oral diet, then it needs to be considered
when planning any kind of nutrition support.