kuliah nutrisi parenteral.ppt
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Transcript of kuliah nutrisi parenteral.ppt
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NUTRISI PARENTERALNUTRISI PARENTERALNUTRISI PARENTERALNUTRISI PARENTERAL
Hasanul Arifin
BAGIAN ANESTESIOLOGI DAN REANIMASIBAGIAN ANESTESIOLOGI DAN REANIMASIFAKULTAS KEDOKTERAN USUFAKULTAS KEDOKTERAN USU
MEDANMEDAN
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• Short periods of food deprivation well tolerated– in previously well nourished
– if illness not too severe or prolonged
• Nutrition requirements in ICU altered• Malnutrition before admission increases morbidity
and brings death sooner• Malnutrition develops within ICU• Need to show that nutrition can reduce morbidity
and mortality
What we have to know about nutrition in the ICU
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Normal starvation vs hypercatabolic response to critical illness
S t a r v a t i o n
Reduced basal metabolic rate,reduced caloric requirements
Fat becomes the principal non-carbohydrate energy source as lipolysis is stimularted by a fall in insulin and rise in glucagon
Protein and lean body mass is preserved until late into the starvation period
The restoration of adequate nutritional support leads to rapid resumption of an anabolic state
Hypercatabolic response to critical illness
Increased basal metabolic rate, calorie requirements. Increased secrection of "stress" hormones [catecholamines, cortisol, etc.] and cytokines
Impaired capacity to use carbohydrate and fat as energy source, resulting in an increased protein breakdown as alternative energy source
Massive nitrogen losses from the breakdown of muscle protein [nitrogen loss can approach 30 g/day, equivalent to 800 g muscle]
Catabolic state not reversed by resumption of adequate nutrition. hyperalimentation may precipitate its own problems [lipaemia, liver dysfunction, metabolic acidosis]
Keith Bresland; Nutritional support, in Hand Book of Critical Care,192:1998.
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Characteristic Nutritional support Metabolic support
Setting
Basis
Focus
Fuel
NPC/gr N
Amino acids[g/kg/d]
% NPCas fat
Malnutrition
Starvation
Restore visceral protein synthesis and lean body mass metaboism
Glucose
>150/1
1-1.5
0-60
Hypermetabolism/organ failureMetabolic stress response
Preserve organ functionPreserve organ structurePrevent subtrate limited
Mixed
<100/1
1.5-2.5
30-40
Table 124-2. Shoemaker; Textbook of critical care 1119:1989
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SUPPORT NUTRITION
AB
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Nutritional support should be a routine part of the care of our
patients, especially of the critically ill .
The main goal of nutritional support is to The main goal of nutritional support is to minimise the loss of protein and energy.minimise the loss of protein and energy.
NUTRITION is a BASIC of SURVIVAL RECOVERY
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NaCl 0.9%
D5W RL
1500 ml fluid, 100 k.cal energy, 0 gr Amino Acids, 140 1500 ml fluid, 100 k.cal energy, 0 gr Amino Acids, 140 mEq NamEq Na+, +, 2 mEq K 2 mEq K++, ,
20 drips/min. change continue
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Recommendation for Clinical Recommendation for Clinical PracticePractice
• STABLE HAEMODYNAMIC (DO2)
• START LOW GO SLOW END SLOW
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50 ml /kg/day50 ml /kg/day
2500-3000 ml/day2500-3000 ml/day
VOLUME,VOLUME,
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ENERGYENERGY
• HARRIS BENEDICT
• INDIRECT CALORIMETRI
BEE = 25-30 k.cal/kg/dBEE = 25-30 k.cal/kg/dREE = [ 1.2-1.3 ] x BEEREE = [ 1.2-1.3 ] x BEE
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SUMBER ENERGI,
• KARBOHIDRAT RQ = 1 PaCO2 ventilasi
R/ Karbohidrat + Lipid minimal glukose 150-200 gr . jangan > 5-6 gr/kg/hari makin tinggi kandungan kalori makin
tinggi osmolaritas cairan
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Lipid,• RQ = 0.7 PaCO2
• sumber EFA, pada parenteral nutrition minimal 2 x/minggu,
• 265-270 mOsm/L
• LCT, LCT/MCT (50:50)
• tetes 24 jam.
• dosis: maximal 50% (60%) dari NPC
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Protein,• balans nitrogen positifbalans nitrogen positif
• pada critically ill, pada critically ill, laju kehilangan protein laju kehilangan protein
• BCAA BCAA drive ventilasi, drive ventilasi, R/ Amiparen-10%,R/ Amiparen-10%,
R/ Aminofusin 10%R/ Aminofusin 10%
• dosis : 0.8-1.5 gr/kg/haridosis : 0.8-1.5 gr/kg/hari
• Protein sparing effect (1gr protein dilindungi Protein sparing effect (1gr protein dilindungi 25 k.cal KH/Lipid)25 k.cal KH/Lipid)
• TPN- glutamine enrichedTPN- glutamine enriched
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Stimulates hepatic glycogen synthesis
Metabolic fuel for rapidly proliferating tissues
(enterocyte, immune (enterocyte, immune cells,)cells,)
Maintain skeletal muscle
Stimulates protein synthesis
Inhibits protein degradation
L-glutamine
Nitrogen and carbon transport
Carrier of nitrogen (as ammonia) and carbon (as glutamate) between tissues
Acid-Base balance
Biosynthesis
Precursor of amino acids, peptide, protein,nucleic acids
Substrate for gluconeogenesis
Potential source of glutamate for glutathione synthesismetabolic functions
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LUNGSLUNGS
SKELETAL MUSCLESKELETAL MUSCLE
BRAINBRAIN
PLASMA PLASMA GLUTAMINE GLUTAMINE
POOLPOOLLIVERLIVER
IMMUNE IMMUNE CELLSCELLS
GUTGUT
KIDNEYKIDNEY
Normal glutamine flux between tissues in the basal stateNormal glutamine flux between tissues in the basal state
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LUNGSLUNGS
SKELETAL MUSCLESKELETAL MUSCLE
BRAINBRAIN
PLASMA PLASMA GLUTAMINE GLUTAMINE
POOLPOOL
LIVERLIVER
IMMUNE IMMUNE CELLSCELLS
GUTGUT
KIDNEYKIDNEY
Trauma induces conciderable changes in glutamine fluxTrauma induces conciderable changes in glutamine flux
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Glutamine in TPN
Increases protein synthesis andnitrogen balance
Improves gutfunction
Improves immunefunction
Reduced hospital stay
Improvedmood
Reduced waterretention
clinical benefits of glutamine in TPN
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Osmolarity
PPN
TPN900 mOsm/L
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OSMOLARITAS [m.Osm/L]OSMOLARITAS [m.Osm/L]
Osmolaritas Campuran :Osmolaritas Campuran :
V1.O1 + V2.O2 + V3.O3V1.O1 + V2.O2 + V3.O3
V1 + V2 + V3V1 + V2 + V3==
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Triparen No-1(1000 ml) , Amiparen-10% Triparen No-1(1000 ml) , Amiparen-10% (500 ml), Ivelip-10% (500 ml)(500 ml), Ivelip-10% (500 ml)
Osmolaritas campuran =
1400x1 + 880x0.5 + 265x0.51 + 0.5 + 0.5
= 986,5 mOsm/L
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TRIOFUSIN-500TRIOFUSIN-500
TRIOFUSIN E-1000TRIOFUSIN E-1000
TRIOFUSIN-1600TRIOFUSIN-1600
DEXTROSE-20%DEXTROSE-20%
IVELIP-10%IVELIP-10%
IVELIP-20%IVELIP-20%
INTRAFUSIN 3,5%INTRAFUSIN 3,5%
INTRAFUSIN-10%INTRAFUSIN-10%
500500
10001000
16001600
800800
10001000
20002000
NPC
k.cal/L
As.Amino
gr/l
mOsm/L
800800
14001400
25002500
11001100
265265
270270
600600
880880
3535
100100
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Tetes bersama 24 jam• Semua substrat terbagi merataSemua substrat terbagi merata
• Mengurangi osmolaritasMengurangi osmolaritas
• Protein sparing effectProtein sparing effect
• Cegah hypoglikemiaCegah hypoglikemia
• Fluktuasi insulinFluktuasi insulin
• Cegah side effectCegah side effect
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tetes bersamatetes bersama
PARENTERAL PARENTERAL NUTRITITIONNUTRITITION
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intrafusin-10%
IVELIP-
10%
THREE WAY STOPCOCK
PPN24 HOURS
Triofusin-500
VOLUME : 2000 mlNPC : 1000 k.calA.ACIDS : 50 grOSMOL. : 686 mOsm/L
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Intrafusin10%
IVELIP-
10%
THREE WAY STOPCOCK
TPN24 HOURS
Triofusin
E-1000VOLUME : 2000 mlNPC : 1500 k.calA.ACIDS : 50 grOSMOL. : 986.5 mOsm/L
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Teknik Teknik Pemberian, Pemberian,
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Teknik Teknik Pemberian, All Pemberian, All in One [AiO]in One [AiO]
R/R/ ClinimixClinimix
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KOMPLIKASI,METABOLIK,
• OVER DOSIS SUBSTRAT
• LAJU INFUSI YANG TERLALU CEPAT
• PEMAKAIAN LAMA
MEKANIK• ARTERIAL PUNCTUREARTERIAL PUNCTURE
• PNEUMOTHORAXPNEUMOTHORAX
• HEMOTHORAXHEMOTHORAX
• THROMBOPHLEBITIS, THROMBOPHLEBITIS,
• DLLDLL
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MONITORING,
BALANS CAIRAN,
GULA DARAH,
ELEKTROLIT,
ALBUMIN,
KURVA SUHU,
PROFIL LEMAK,
BUN, SERUM CREATININ,
HEMOGLOBIN, LEKOSIT,
BERAT BADAN
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Thank youThank you