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 (PEG) or G-tube (button) Enteral Nutrition Oesophagostomy Gastronomy* Radiological Inserted gastronomy (RIG)* Surgical gastronomy Nasoduodenal* Tube Feeding Duodenal Extended gastronomy* Naso jejunal Jejunal Extended gastronomy* Direct access Surgical jejunostomy Fine needle catheter

Enteral Nutrition Products KALBE NUTRITIONAL PRODUCTS NUTRISI ENTERAL NUTRISI PARENTERAL ANAK TINGGI PROTEIN GANGGUAN HATI GANGGUAN GINJAL ENTRAKID PEPTISOL HEPATOSOL/ HEPATOSOL LOLA NEPHRISOL/ NEPHRISOL-D KANKER NUTRICAN SEIMBANG ENTRAMIX NEUROLOGI PEPTIBREN SISTEM IMUN PEPTIMUNE

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 pneumothorax chylothorax hematothorax air embolus arterial puncture nerve injury Mechanical poor catheter placement phlebitis thrombosis catheter occlusion rupture embolus Infection catheter insertion site subcutaneous tunnel colonization bacterimia sepsis

Complications PN Metabolic Hyperglycemia Electrolyte imbalance Prerenal azotemia Abnormal acid-basa balance Overfeeding Hepatic steatosis Increased CO2 production Respiratory distress syndrome Gastrointestinal Liver function disorder Gastrointestinal atropy

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 KALBAMIN DISEASE SPECIFIC AMINOFUSIN HEPAR COMAFUSIN HEPAR RENXAMIN CLINOLEIC CLINIMIX

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

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