Pasien-*asien critical-ill. di perawatan icu

Pasien kritis icu

1. MNT FOR CRITICALL ILL
Rodlia, S.Gz, MKM, RD
INSTALASI GIZI RUMAH SAKIT PUSAT OTAK NASIONAL
Lantai Dasar, Jl. M.T. Haryono Kav.11 Cawang, Jakarta Timur 13630
Telp. [phone] (Hunting), Fax. [phone] ext.5004/5010
Email : [email protected]

3. Sumber : http://sunnybrook.ca/content/?page=brain-injury-critical-care

6. DEFINISI DAN KLASIFIKASI CRITICAL
ILL
Critical ill merupakan kondisi ketidakstabilan
fisiologis yang menyebabkan menyebabkan
kecacatan atau kematian dalam beberapa menit
atau jam.
Perlu diambil langkah yang yang cepat dan tepat
dalam proses asessmen, diagnosis dan intervensi
penyakit.

9. Pathophysiology of malnutrition in intensive care unit

10. Metabolic Stress
•Sepsis (infection)
•Trauma (including burns)
•Surgery
•Once the systemic response is activated, the
physiologic and metabolic changes that follow are
similar and may lead to septic shock.

11. Immediate Physiologic and Metabolic Changes
after Injury or Burn

12. Metabolic Response to Stress
•Involves most metabolic pathways
•Accelerated metabolism of Lean Body Mass
•Negative nitrogen balance
•Muscle wasting

13. Hormonal and Cell-Mediated
Response
•There is a marked increase in glucose production
and uptake secondary to gluconeogenesis, and
—Elevated hormonal levels
—Marked increase in hepatic amino acid uptake
—Protein synthesis
—Accelerated muscle breakdown

14. Respon metabolik

15. Respon metabolik

16. Ebb Phase
Syok hipovolemia, hipoksia jaringan
Penurunan curah jantung
Konsumsi oksigen menurun
Suhu tubuh menurun
Kadar insulin menurun karena glukagon
meningkat.

17. Flow Phase
Fase resusitasi cairan dan perbaikan
transportasi Oksigen
Peningkatan cardiac output
Peningkatan suhu tubuh
Peningkatan pengeluaran energi
Katabolisme protein tubuh total
Peningkatan produksi glukosa, FFA, sirkulasi
insulin / glukagon / kortisol

18. Hypermetabolic Response to Stress—
Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

19. Starvation vs. Stress
•Metabolic response to stress differs from the
responses to starvation.
•Starvation = decreased energy expenditure, use of
alternative fuels, decreased protein wasting, stored
glycogen used in 24 hours
•Late starvation = fatty acids, ketones, and glycerol
provide energy for all tissues except brain, nervous
system, and RBCs

20. Starvation vs. Stress
•Hypermetabolic state—stress causes accelerated
energy expenditure, glucose production, glucose
cycling in liver and muscle
•Hyperglycemia can occur either from insulin
resistance or excess glucose production via
gluconeogenesis and Cori cycle.
•Muscle breakdown accelerated also

21. Hormonal Stress Response
•Aldosterone—corticosteroid that causes
renal sodium retention
•Antidiuretic hormone (ADH)—stimulates
renal tubular water absorption
•These conserve water and salt to support
circulating blood volume

22. Hormonal Stress
Response
•ACTH—acts on adrenal cortex to release
cortisol (mobilizes amino acids from skeletal
muscles)
•Catecholamines—epinephrine and
norepinephrine from renal medulla to
stimulate hepatic glycogenolysis, fat
mobilization, gluconeogenesis

23. Cytokines
•Interleukin-1, interleukin-6, and tumor
necrosis factor (TNF)
•Released by phagocytes in response to tissue
damage, infection, inflammation, and some
drugs and chemicals

24. Systemic Inflammatory Response
Syndrome
•SIRS describes the inflammatory response that
occurs in infection, pancreatitis, ischemia,
burns, multiple trauma, shock, and organ injury.
•Patients with SIRS are hypermetabolic.

25. Multiple Organ Dysfunction Syndrome
•Organ dysfunction that results from direct
injury, trauma, or disease or as a response to
inflammation; the response usually is in an
organ distant from the original site of infection
or injury

26. Diagnosis of Systemic Inflammatory
Response Syndrome (SIRS)
•Site of infection established and at least two of the
following are present
—Body temperature >38° C or <36° C
—Heart rate >90 beats/minute
—Respiratory rate >20 breaths/min (tachypnea)
—PaCO2 <32 mm Hg (hyperventilation)
—WBC count >12,000/mm
3
or <4000/mm
3
—Bandemia: presence of >10% bands (immature
neutrophils) in the absence of chemotherapy-induced
neutropenia and leukopenia
•May be caused by bacterial translocation

27. Bacterial Translocation
•Changes from acute insult to the
gastrointestinal tract that may allow entry of
bacteria from the gut lumen into the body;
associated with a systemic inflammatory
response that may contribute to multiple organ
dysfunction syndrome
•Well documented in animals, may not occur to
the same extent in humans
•Early enteral feeding is thought to prevent this

28. Bacterial Translocation across Microvilli
and How It Spreads into the Bloodstream

30. Hypermetabolic Response to Stress—
Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and
Ainsley Malone, 2002.

31. PROSES ASUHAN GIZI TERSTANDAR
RODLIA, S.Gz,MKM, RD
SCREENING
DIET
NORMAL/
STANDAR
PASIEN
PULANG
STOP
TIDAK BERESIKO
MALNUTRISI
TUJUAN
TERCAPAI
BERESIKO
MALNUTRISI
PROSES ASUHAN GIZI TERSTANDAR
/PAGT
TUJUAN
TERCAPAI
TUJUAN
BELUM
TERCAPAI

32. SCREENING GIZI

33. Screening Gizi pada pasien Critical ill
•Tujuan :
1)Deteksi dini risiko malnutrisi
2)untuk memprediksi outcome dari terapi gizi

•Apabila tidak dilakukan screening gizi maka
kejadian malnutrisi tidak akan terdeksi

34. Skrining dan Asesmen
Nutrition Screening
1.Mengidentifikasi pasien berisiko malnutrisi
2.Memprediksi kemungkinan pasien berisiko malnutrisi
menjadi lebih baik atau lebih buruk
3.mengurangi jumlah dan kegawatan akibat komplikasi
(ESPEN, 2002)

Nutrition Assessment
mengidentifikasi tanda dan gejala malnutrisi dan pencegahan
malnutrisi
RODLIA, S.Gz,MKM

35. ASESMEN GIZI

36. DATA RIWAYAT PERSONAL
•Umur
•Jenis Kelamin
•Ras/suku
•Pendidikan
•pekerjaan
•Bahasa
•Disabilitas
•Mobilitas
•Riwayat merokok
•Sosial ekonomi
•Peran dalam keluarga
•Riwayat penyakit
keluarga
•Riwayat tindakan medis
: operasi, paliatif care
36

37. DATA ANTROPOMETRI
37
STATUS GIZI

38. LILA (MUAC)
•Malnutrisi ringan: <22.9 cm
•Malnutrisi sedang : <18.5 cm
•Malnutrisi Berat : < 16 cm
38

39. 39

40. Estimasi Tinggi Badan pada Pasien
Bed Rest
40
PANJANG ULNA

41. Estimasi Tinggi Badan pada Pasien
Bed Rest
41

42. TINGGI LUTUT
42

43. Konversi TL ke Estimasi TB
43
TB Pria = 6,50 + (1,38 + TL) – (0,08 x U)
TB Wanita = 89,68 + (1,53 x TL) – (0,17 x U)

44. •RUMUS MENGUKUR TINGGI LUTUT (TL)
•Jika pasien tidak memungkinkan diukur dalam keadaan berdiri (normal)
maka tinggi badan dapat diperkirakan dengan CARA MENGUKUR TINGGI
LUTUT
•TB berdasarkan Tinggi Lutut (TL)
•TB Pria = 64,19 - (0.40 + U) + (2,02 x TL)
•TB Wanita = 84,88 - (0.24 x U) +(1,83 x TL)
•Keterangan : U = Umur
Contoh kasus:
Wanita Umur 40 tahun Hasil pengukuran Tinggi Lututnya 60 cm
Hitung berapa Tinggi Badannya
TB Wanita = 84,88 - (0.24 x 40) + (1,83 x 60)
TB Wanita = 89.68 - (9.6) + (109.8)
= 189.88 cm atau 1.89 m

Referensi: Chumlea W.Cet al.Estimating Stature from Knee Height for Person
60-90 Years of Age. J.Am Geriatri.Soc. 33 : 116-120 (1985)

45. standar:
Laki-laki : 29,3 cm, Perempuan : 28,5 cm
Interpretasi status gizi berdasarkan % LILA:
•Obesitas: >120%
•Overweight : 110-120%
•Normal : 90-110%
•Underweight : < 90%

46. BED Scale

47. Asesmen gizi pasien Critical Ill
Medical / Social History Diagnosis Medis. Riwayat Pengobatan,
Riwayat pembedahan dsb
Food-/Nutrition-Related History 1)Asupan enteral, parenteral
2)Konstipasi, diare, aspirasi
3)Gejala lain yang berhubungan
dengan kemampuan penyerapan
makanan dengan normal (residu)
Antropometri BB
TB
Riwayat Kehilangan BB
IMT
LILA
Biokimia Albumin, pre albumin, CRP, Hb, Hct,
Trombosit, Elektrolit, GDA, GDP,
GD2JPP, dsb

49. DATA BIOKIMIA TERKAIT GIZI
49

50. 50
Academy of Nutrition and Dietetics, Evidence
Analysis Library (2009):
No correlation between serum albumin and
prealbumin in prolonged protein-energy restriction
No research available to correlate serum albumin or
prealbumin with nitrogen balance
Indicators of inflammation, NOT indicators of
nutritional status
Do not respond to feeding interventions in the setting
of inflammation!!

51. DATA BIOKIMIA TERKAIT GIZI
51

52. DATA FISIK-KLINIS FOKUS GIZI
•Keadaan Umum : sadar, pelo dll
•Sistem kardio : Bradikardi, Takikardi,
Dyspnea
•Sistem Digestive, mulut dll : Asites,
kembung, nyeri abdomen, konstipasi,
diare, mual, muntah, penurunan nafsu
makan, kesulitan menelan, saliva
berlebihan, dll
•Edema
•Kulit kering
•Tanda-tanda Vital : Tekanan darah, nadi,
Rr, suhu
52

53. DATA RIWAYAT MAKAN
•Asupan energy dan zat gizi
•Riwayat Diet : enteral, parenteral,
puasa dll
•Riwayat Obat-obatan terkait gizi
•Pengetahuan, keyakinan
•Aktifitas Fisik dan fungsional :
aktifitas fisik (durasi, frekuensi),
kemampuan makan sendiri
dll
53
Zat gizi
makro, mikro,
termasuk
cairan

54. Sosialisasi Persiapan Akreditasi
4
KARS RS PON
10/12/19

5

55. 10/12/19 55

56. KEMUNGKINAN PROBLEM
1)Malnutrition
2)Dysphagia
3)Inadequate protein-energy intake
4)Inadequate enteral intake
5)Altered GI function
6)Increased nutrient needs
7)Increased energy expenditure
8)Impaired nutrition utilization
9)Excessive fluid intake
10)Excessive energy intake
11)Inadequate oral food/beverage intake, dsb
56

57. INTERVENSI GIZI

59. PRINSIP

61. Konsep pemberian makanan
enteral

62. Indikasi pemberian
enteral

63. Kapan Enteral tidak boleh
diberikan??
•GRV (volume residu gastrik) > 500 ml dan atau
adanya perdarahan saluran cerna
•Distensi abdomen
•Hemodinamik belum stabil
•Muntah yang tidak terkontrol / terus menerus
•Aspirasi
•Diare kronik
•Shock hipovolemik
•Kejang

64. Enteral feeding
“If the gut works – use it”
Nasogastric (NG)
Nasojejunal (NJ)
Percutaneous Endoscopic
Gastrostomy (PEG)
Percutaneous Endoscopic
Jejunostomy (PEJ)

65. http://www.baxternutritionacademy.com/ie/images/NutriAc-
Mod-2.3-Fig1_big.jpg

66. 66

67. Protokol Pemberian Makanan Enteral
Parenteral
Pasien
Masuk
Asesmen Gizi
GI Track
berfungsi ?
Ya Tidak
Obstruksi,
Peritonitis
Pankreatitis
Akut,
muntah
berlebihan,
short-bowel
Syndrom,
Ileus
Parenteral
Jangka
Panjang
Jangka Pendek
Gastrostomi
Jejunostomi
Nasogastric
Nasodoudenal
Nasojejunal
Jangka Panjang ,
restriksi cairan
Jangka
Pendek
Central PN
Perifer PN
Evaluasi Fungsi GI
Track ?
Asupan Cukup
=> Oral Nutrisi
Asupan
Kurang
Fungsi GI Track
kembali ?
Ya Tidak
HEMODINAMIK
HARUS STABIL

68. Conditions That Often Require
Nutritional Support

69. Conditions That Often Require
Nutritional Support –cont’d

70. Manfaat enteral
Mencegah atrofi mukosa usus
Mempertahankan fungsi barrier usus
Mencegah translokasi bakteri
Mempertahankan/memperbaiki imunitas usus
Mengurangi infeksi
Menurunkan permeabilitas mukosa usus
Mencegah terjadinya katabolisme
memperbaiki nitrogen balance negative
mempertahankan fungsi GIT

72. Komplikasi makanan enteral
Berhubungan dengan Gizi
•Aspirasi
•Dehidrasi/Overhidrasi
•infeksi saluran nafas
•Infesksi nosokomial
•Refeeding syndrome

73. ASPRASI
73

74. Syarat makanan enteral
•Osmolaritas : 300-500mOsm/Kg
•Memiliki kepadatan kalori yang tinggi. minimal
1 kkal/ml cairan, untuk formula standar : 1,2-
2,0 kkal/ml
•Kandungan gizi yang seimbang
•Memiliki osmolaritas yang sama dengan
osmolaritas cairan tubuh
•Mudah serap

75. Tipe makanan enteral
Produk Blenderized Products
Polymeric / Standard Products
Calorically Dense Products
Elemental and Semi-Elemental Products
Specialized / Disease-Specific Products
Modular/ Incomplete Products
Metabolic Products

76. Blenderized Products
Blenderized formulas were developed
for individuals with intolerance to semi-
synthetic formulas.
These formulas are made from liquefying
actual foods such as chicken, peas,
carrots, tomatoes and cranberry juice.
Similar formulas can been made in the
home but “homemade” formulations
carry a risk of bacterial contamination.

77. Polymeric / Standard
Products
Polymeric or standard formulas are nutritionally
complete. They are made with intact protein,
carbohydrates, long chain triglycerides, vitamins
and minerals.
They may also include fiber and are administered
through an enteral feeding tube.
Examples: Fibersoure HN, Jevity 1 Cal, Jevity 1.2
Cal, Isosource HN, Nutren 1.0, Nutren 1.0 Fiber,
Osmolite 1 Cal, Osmolite 1.2 Cal, Promote,
Promote with Fiber, Nutren Replete, Nutren
Replete with fiber

78. Calorically Dense Products
Calorically dense formulas are nutritionally complete
and provide more calories than standard enteral
products.
They may provide equal to or greater than 1.5 kcal
/cc.
They contain vitamins, minerals protein,
carbohydrates, and mainly long chain triglycerides.
These formulas may also include fiber.
Examples: Ensure Plus, Boost Plus, Jevity 1.5, Nutren
1.5, Nutren 2.0, Osmolite 1.5 Cal, Two Cal HN,
Resource 2.0 and Resurgex Select

79. Elemental and Semi-Elemental Products
Elemental and semi-elemental enteral formulas are
nutritionally complete but their building blocks are broken
down into smaller components.
Elemental formulas contain individual amino acids, glucose
polymers, and are low fat with only about 2% to 3% of
calories derived from long chain triglycerides (LCT).
Medium chain triglycerides (MCT) are the predominant fat
source, and can be absorbed directly across the small
intestinal mucosa into the portal vein in the absence of lipase
or bile salts.
Semielemental formulas contain peptides of varying chain
length, simple sugars, glucose polymers and fat, primarily as
MCT.
Examples: Crucial, Optimental, Peptamen, Peptamen 1.5,
Vital HN, Vital 1.0Cal, Vital 1.5 Cal, Vivonex Plus, Vivonex RTF,
Vivonex TEN and Tolerex

80. Specialized / Disease-Specific
Products
Specialized / disease-specific products are nutritionally
complete and are designed to meet the needs of
individuals with specific disease states, such as diabetes,
renal dysfunction, liver dysfunction, respiratory
dysfunction, acute illness or wound healing.
Specialized formulas may contain biologically active
substances or nutrients such as glutamine, arginine,
nucleotides or essential fatty acids
Examples: Diabetasol, Glucerna, Nutren Glytrol, Nepro
with Carb Steady, Novasource Renal, Nutrihep, Perative,
Pulmocare, Nutren Pulmonary, Impact, Impact 1.5, and
Oxepa

81. Modular/ Incomplete Products
Modular/ Incomplete products are used to deliver
an additional source of a specific nutrient.
They are not designed to meet 100% of estimated
nutritional needs, but can provide additional
calories, or protein or fat.
They may be taken alone or in combination with
other products.
Examples: Duocal, Polycose, Benecalorie, Promod,
Beneprotein, MCT oil, Microlipid, Juven, and other
glutamine containing products

82. Metabolic Products
Metabolic products are used to in the
dietary management of inborn errors
metabolism such as phenylketonuria,
maple syrup urine disease and
tyrosinemia.
Examples: Milupa MSUD2, MSUD Aid,
Periflex Advance, Ketonex 2, KETOCAL

84. Cara pemberian ENTERAL
1. Bolus
•250-400 mL of formula every 4-6 hours
•Bolus feeding risk : aspiration
2. Intermittent feeding
300-400mL every 3-6 hours, 30-60 min
infusion using gravity drip or feeding
pump infusion and feeding bag
3. Continuous infusion
•slow rate infusion pump over 16-24 hours
4. Cyclic feedings
•infused over 8-16 hours, night time feeding
preferred for ambulatory patients

86. Contoh
Pasien menerima 1800 kcal 6 x
Diberikan Bolus  1800/6 = 300 ml setiap
pemberian
Lebih toleran jika diberikan contionous– 1800/24
jam jadi setiap jam 75 ml/jam
06,00 10,00 14,00 18,00 20,00 22,00
EN = 4:1 Bagaimana strateginya???

87. KEBUTUHAN ENERGI DAN
ZAT GIZI

88. Predictive Equations for Estimation
of Energy Needs in Critical Care
Harris-Benedict x 1.3-1.5 for stress
ASPEN Guidelines:
25 – 30 calories per kg per day*
Ireton-Jones Equations**
Penn State equations
Swinamer equation
*ASPEN Board of Directors. JPEN 26;1S, 2002
** Ireton-Jones CS, Jones JD. Why use predictive equations for energy expenditure
assessment? JADA 97(suppl):A44, 1997.
**Wall J, Ireton-Jones CS, et al. JADA 95(suppl):A24, 1995.

89. Mursyid Bustami dalam peltihan PAGT STROKE RSPON

92. MURSYID BUSTAMI DALAM PELTIHANPAGTSTROKERSPON
1,2 - 2 g/kgBB/hari (BMI < 30
kg/m2)
2 g /kg BBI (BMI 30-40 kg/m2)
2,5 g / kg BBI (BMI >40 kg/m2)
(Aspen, 2009)

93. RINGKASAN KEBUTUHAN ENERGI DAN PROTEIN
Low Nutrition Risk High Nutrition Risk
a. Timing of EN Initiation 24−48 hours
Energy provision during
1st week
1/3−2/3 of energy
requirement
80−100% of energy
requirement within 3 days
while monitoring for
refeeding syndrome
Protein provision during
1st week
1.2−2 g/kg BW
b. Timing and Dose of PN After 7 days if EN is not
feasible
Within 3 days if EN is not
feasible. Provide 80% of
energy requirement or
≤20kcal/kg with adequate
protein (≥1.2g/kg)
Energy & protein provision
after 1st week
Full feeding
c. Timing of SPN Initiation After 7−10 days if EN alone is unable to meet >60% of
energy and protein requirement

94. Kebutuhan lemak
•20-35% dari kebutuhan energi
•Perhatikan kondisi pasien, misal : hyperlipidemia
•Lemak sedang < 30 %, lemak jenuh :
a.Dislipidemia I : < 10% kebutuhan energi total
b.Dislipidemia II : < 7% kebutuhan energi total
• Lemak tak jenuh tunggal maupun ganda :
Dislipidemia I dan II : 10-15% kebutuhan energi total
•Kolesterol : DM < 200 mg/hari, non DM : < 300
mg/hari
0,7- 1,5
g/kgBB/hari (Aspen,
2009)

95. Kebutuhan cairan
•Dewasa : 30-40 ml/kg BB
•Perhatikan balance cairan tubuh
•Perhatikan fungsi ginjal

96. CONTOH MAKANAN ENTERAL

97. Masalah yang biasa terjadi pada
pemberian Nutrisi enteral
Kasus Tindakan
Alergi Lactosa - Pilih Formula Enteral Low Lactose
atau free lactose
Alergi Protein Hewani - Pilih formula dg bahan dasar kedelai
atau kacang hijau
Refluks, Muntah -Lihat Posisi pasien saat pemberian
enteral
-Jangan diberikan Bolus
-Start : 20 ml/ jam sampai 24 jam
Diare Telusuri penyebab
Konstipasi Berikan ekstrak fiber

98. PARENTERAL

99. DEFINISI
•Nutrisi parenteral (PN) adalah pemberian
makanan melalui intravena, yang meliputi
protein, karbohidrat, Lemak, mineral dan
elektrolit, vitamin dan unsur lainnya untuk
pasien yang tidak bisa makan melalui Saluran
Gastrointestinal atau pasien tidak dapat
menerima serta tidak dapat menyerap
makanan dengan baik sehingga dapat berisiko
malnutrisi.

•ASPEN, 2012

100. INDIKASI
Indikasi penggunaan PN adalah ketika kondisi Saluran
gastrointestinal :
•Tidak berfungsi atau kerusakan secara anatomy (misalnya
penyumbatan, ileus, fistula, dismotilitas)
•Tidak dapat diakses (misalnya muntah yang sulit diatasi
disertai kesulitan pemberian makan via jejunum dan rute lain)
•Asupan oral atau enteral tidak adekuat (mis.Pada keadaan
malabsorpsi seperti short bowel syndrome, enteritis atau
Ketidakmampuan untuk menerima makanan enteral secara
penuh)

101. Indikasi
Gastrointestinal
Incompetency
•Severe acut pancreatitis
•Severe inflamatory bowel
disease
•Small bowel ischemia
•Intestinal atresia
•Severe liver failure
•Mayor gastrointestinal
surgery
Critical Illness w/poor
tolerance accessibility
•Multiorgan System Failure
•Major trauma or burns
•Bone marrow transplantation
•Acute respiratory failure with
ventilator dependency aand
gastrointestinal malfunction
•Severe wasting in renal failure
with dialysis
•Small bowel transplantation,
immediate postoperatively

103. http://media.oncologynurseadvisor.com/images/2011/08/04/feature_0811_art_18
5457.jpg

105. PROTOKOL PEMBERIAN MAKANAN
PARENTERAL
GI Track
berfungsi ?
Ya Tidak
Apakah pasien malnutrisi/
berisiko tinggi malnutrisi
(ex.critical ill)

Ya Tidak
Mulai parenteral
dalam 24-48 jam
Mengembalikan
peristaltik usus
Central PN lebih
direkomendasikan
Apakah dimungkinkan
parenteral selama 5 hari
atau lebih
Ya Tidak

PN bisa diberikan dalam durasi
tertentu, tetap memperhatikan
fungsi GI track, apabila kembali
segera gunakan.
Dapatkah kebutuhan gizi
terpenuhi (oral/enteral) dalam
5 hari ?
Ya Tidak
Makanan Enteral /
oral sesegera mungkin
diberikan, parenteral
hanya sebagai
tambahan dan TPN
tidak
direkomendasikan

106. Komplikasi Parenteral
Parenteral Nutrisi harganya mahal,kompleks dan dapat
menyebabkan komplikasi-2 berikut :
•Komplikasi teknis : berkaitan dengan pemasangan kateter
seperti pneumotoraks, emboli udara
•Komplikasi infeksi : ditandai oleh demam, seperti pada
flebitis, infeksi pada tempat pemasangan
•Komplikasi metabolik: berkaitan dengan gangguan
keseimbangan glukosa (hiper/hipo), elektrolit (hipokalemia,
hiperkalemia)

107. PRESKRIPSI DIET

109. Parenteral lipids and carbohydrates
recommended by ESPEN
for adult ICU patients

111. Formula-formula
Parenteral nutrition

112. DASAR

113. Formula-formula Parenteral nutrition

114. Formula-formula Parenteral
nutrition

117. PENGHITUNGAN BALANCE CAIRAN UNTUK DEWASA
Balance Cairan = CM – CK – IWL
CM : Cairan Masuk
CK : Cairan Keluar
*Rumus IWL IWL = (15 x BB )
24 jam
Rumus IWL Kenaikan Suhu
[(10% x CM)x jumlah kenaikan suhu] + IWL
normal
24 jam

118. PENGHITUNGAN BALANCE CAIRAN
UNTUK DEWASA
•Input cairan: Air (makan+Minum) = ......cc
Cairan Infus
Therapi injeksi
Air Metabolisme
= ......cc
= ......cc
= ......cc
(Hitung AM=
5 cc/kgBB/hari)
•Output cairan: Urine
Feses
= ......cc
= .....cc
(kondisi normal 1 BAB
feses = 100 cc)
Muntah/perdarahan
cairan drainage luka = .....cc
IWL = .....cc
(hitung IWL= 15 cc/kgBB/hari)

IWL = Insensible Water Loss

120. PERHATIKAN …..

123. Specialized Nutrients in Critical Care
•Include supplemental branched chain amino acids,
glutamine, arginine, omega-3 fatty acids, RNA, others
•Most studies used more than one nutrient, making
assessment of efficacy of specific supplements
impossible
•Immune-enhancing formulas may reduce infectious
complications in critically ill pts but not alter
mortality
•Mortality may actually be increased in some
subgroups (septic patients)
ASPEN BOD. JPEN 26;91SA, 1992

124. Monitoring dan Evaluasi Gizi
•Commonly Used Nutrition Monitoring & Evaluation Domains
1)Enteral or parenteral nutrition intake
2)Energy intake
3)Digestive system
4)Vitamin profile
5)Weight or weight change
6)Electrolyte and renal profile
7)Food intake

126. Obat-obatan yang sering digunakan

127. Kolaboratif Tim Kesehatan
126

128. KOMPLIKASI DIARE PADA PASIEN
CRITICAL ILL

129. Diarrhoea or abdominal
bloating/pain complicating enteral
nutrition
Confirm diarrhoea. Check stool
chart, discuss with nursing staff
No diarrhoea,
continue current
management
Yes diarrhoea
evident
Medication involvement?
Antibiotics, sorbitol-
containing medications,
laxatives
Positive for C difficile? Potential sites of contamination
(HACCP)?
Yes improve
handling of formula and
equipment
Yes, treat
No
Does formula contain
FODMAPs?
Is osmolality of formula or feeding
regimen high?
Yes switch to a
FODMAPs-free formula
Yes, trial
continuous
or low energy
density formula
No
Does modifying fiber content
improve symptoms?

Trial fiber or fiber-
free formula
Consider elemental formula or
parenteral nutrition if
unsuccessful
Figure 1. A suggested flow chart for the management of patients with diarrhoea or other abdominal symptoms
complicating enteral nutrition. FODMAPs, Fermentable, Oliogo-, Di-, Mono-saccharides, And Polols; HACCP, Hazard
Analysis and Critical Control Point guideline

130. WORKSHOP KASUS

131. KASUS
Tuan H, laki-laki berusia 64 tahun dirawat di ruang NCCU (Neuro
Critical Care Unit) dengan diagnosis medis Cerebral infarction, tinggi
badan 170 cm, Berat Badan 73 Kg. Pasien mempunyai riwayat
Diabetes Mellitus sejak 10 tahun yang lalu dan penyakit jantung
koroner 3 tahun yang lalu.
Tingkat kesadaran pasien : GCS E2M5Vett, hemodinamik unstable
dengan support Dobutamin 20 mcg/kgbb/menit, vascon 0,25
mcg/kgbb/menit, drip Cedocard 1 mg/jam, drip morphin 1 mg/jam,
pasien streess ulcer dengan residu kecoklatan dan diberikan terapi
Omeprazol 80 mg/8 jam, saat ini terpasang CVC (+20) IVFD : Nacl
0,9% 1000 cc/24 jam. Pasien juga terpasang DC (Dower cathether)
dengan produksi urine kemerahan (Hematuria). Balance cairan
selama 24 jam : +575,68 cc, diuresis/24 jam : 0,62 cc/kg bb/ jam.
Terpasang NGT 16.
Suhu tubuh : 36,5 °C, Tekanan Darah : 126/86 mmHg, Respiration
Rate : 16 x/menit, Heart Rate : 121 x/ menit.

132. KASUS
Pemeriksaan CT scan kepala tanpa kontras : Infark akut lanjut lobus
frontoparietotemporal kanan hingga basal ganglia kanan disertai
transformasi perdarahan. Herniasi subfalcine dan hidrosefalus
obstruktif. Impending herniasi transtentorial

Radiografi thorax proyeksi AP posisi supine: Jantung kesan tidak
membesar. Aorta dan mediastinum superior tidak melebar. Trakea
di tengah. Kedua hilus baik. Corakan vaskuler kedua paru
meningkat. Diafragma licin. Kedua sinus kostofrenikus lancip.
Tulang-tulang dan jaringan lunak dinding dada baik. Kesan : Sugestif
bendungan paru.

133. KASUS
Pemeriksaan Nilai Normal Hasil
Analisa Gas Darah
pH
PCO2
PO2
Bikarbonat (HCO3)
Total CO2
Saturasi O2
Kelebihan Basa

7.35 - 7.45
35 - 45 mmHg
83 – 108 mmHg
21 – 28 mmol/L
23 – 27 mmol/L
95 – 98 %
-2 s/d +3 mEq/L

7,4
24
43
15
16
80,9
-7,3
Leukosit 5 – 10 x 10
3
/uL 12
Trombosit 150 – 400 ribu/uL 503
Ureum Darah 16,6 – 48,5 mg/dL 49,9
Kreatinin Darah 0,67 – 1,17mg/dL 1,39
eGFR >=90 : Normal 60-89; Mildly decreased 45-59 ; Mildly to
moderately decreased 30-44; Moderately to severely
decreased 15-29; Severely decreased <15 : Kidney
failure KDIGO 2012
53,2

134. Pemeriksaan Nilai Normal Hasil
Kolesterol Total < 200 mg/dL : Tidak Berisiko 200-239: Risiko Sedang
>= 240 : Risiko Tinggi
97
Kolesterol LDL direk < 100 mg/dL : Optimal 100-129: Mendekati Optimal
130-159: Batas Tinggi 160-189: Tinggi
55
Kolesterol HDL < 40 : Risiko Lebih Besar >= 60: Tidak Berisiko 35
Glukosa Rapid 60-180 mg/dL 475
GD2JPP < 140 mg/dL 201
Asam Urat 3,4 – 7 mg/dL 7,7
Hemoglobin 13 – 16 mg/dL 14,4
Natrium Darah 136 – 146 mmol/L 130
Kalium Darah 3,5 – 5 mmol/L 5,7
Klorida Darah 98 – 106 mmol/L 97
Albumin 3,5 – 5,2 g/dL 3
HbA1C 4 – 5,6 % 12,1

135. Asupan enteral saat ini 10 % dari kebutuhan
basal 1200 kkal dengan densitas kalori (1 kkal :
1 cc) via NGT serta infus Nacl 500 ml/24 jam
0,9%.
Obat-obatan yang diberikan : Clopidogrel
Tablet 75 mg, Gliquidon Tablet 30 mg, Apidra
Solostar 3 ml Solution, Injection 100 IU/1ml,
Ondansetron Solution, Injection 4 mg/2ml.
KASUS

136. Kunci kasus
•Asesmen
1)Riwayat Personal
2)Antropometri
3)Biokimia terkait Gizi
4)Fisik/Klinis terkait Gizi
5)Riwayat Gizi dan Makanan

137. Riwayat Personal
•Jenis Kelamin : laki2 (Tn H)
•usia 64 tahun
•Diagnosis Medis : Cerebral infarction
•Pasien mempunyai riwayat Diabetes Mellitus sejak
10 tahun yang lalu dan penyakit jantung koroner 3
tahun yang lalu.
•Riwayat Obat-obatan : Clopidogrel => obat yang
berfungsi untuk mencegah trombosit (platelet)
saling menempel yang berisiko membentuk
gumpalan darah

138. Antropometri
•BB 73 kg
•TB 170 cm
•BBI = 63 kg
•IMT : 25,26 kg/m2 (Status Gizi Obesitas
Derajad I)

139. Biokimia terkait Gizi
PCO2 : rendah
PO2 : rendah
Bikarbonat (HCO3) : rendah
Total CO2 : rendah
Saturasi O2 : rendah
Kelebihan Basa : rendah
Leukosit : tinggi
Trombosit : tinggi
Ureum darah : tinggi
Kreatinin darah : tinggi

eGFR : penurunan ringan
Kolesterol HDL : berisiko tinggi
Glukosa Rapid : tinggi
GD2JPP : tinggi
Asam Urat : tinggi
Natrium Darah : rendah
Kalium Darah : tinggi
Albumin : rendah
HbA1C : tinggi

140. Fisik/Klinis terkait Gizi
•Pasien terpasang NGT
•residu coklat
•stress ulcer
•terpasang CVC
•GCS : E2M5Vett
•Terpasang endotracheal tube (ett)
•Terpasang DC (Dower cathether)
Suhu tubuh : 36,5 °C,
Tekanan Darah : 126/86
mmHg,
Respiration Rate : 16 x/menit,
Heart Rate : 121 x/ menit.
Pemeriksaan CT scan kepala tanpa
kontras : Infark akut
Radiografi thorax proyeksi AP posisi
supine : Sugestif bendungan paru
Hemodinamik unstable
Produksi urine kemerahan
(Hematuria).

141. Riwayat Gizi dan Makanan
•Asupan enteral saat ini 120 kkal
•Asupan Parenteral : infus Nacl 500 ml/24 jam 0,9%.
•Intake Enteral : 10 %
•Intake Parenteral : -
•Obat-obatan yang diberikan : Gliquidon Tablet 30 mg, Apidra
Solostar 3 ml Solution, Injection 100 IU/1ml, Ondansetron
Solution, Injection 4 mg/2ml.

142. OBAT-OBATAN
OBAT INDIKASI EFEK SAMPING
Gliquidon obat antidiabetik oral dari
golongan sulfonilurea.
Menyebabkan hipoglikemia
Apidra
Solostar
Insulin kerja cepat (fast-
acting insulin)
Menyebabkan hipoglikemia
Ondansetron mengobati mual dan
muntah
Konstipasi.
Sakit perut.

143. REFERENCE STANDAR
•KEBUTUHAN :
•energi = 25 kkal/kg BBI = 1575 kkal
•Protein = 1 gram / kg BBI = 63 gram
(16%)
•Lemak = 35 % x keb. E = 61,25 gram
•KH =49% x keb E = 192,9 gram

144. DIAGNOSA GIZI
•KEKURANGAN INTAKE ENTERAL BERKAITAN
DENGAN KONDISI KLINIS PASIEN DITANDAI
DENGAN INTAKE ENTERAL HANYA 10%,
RESIDU COKLAT, RIWAYAT STRESS ULCER,
GLUKOSA RAPID TINGGI, GD2JPP TINGGI

145. RENCANA INTERVENSI
•TUJUAN
Meningkatkan asupan enteral secara bertahap dengan
target 30 % dalam 3 hari
•IMPLEMENTASI
-Jenis : Makanan Cair (Enteral) dan Parenteral
-Rute : NGT, CVC
-Frekuensi : enteral 4 x 50 ml (hari pertama)
-Parenteral Kabiven 1540 ml (1310 kkal, 51 gram
protein, Glukosa : 37,12 gram, 106 gram lemak)
-Kebutuhan (slide berikutnya)

146. KEBUTUHAN DASAR
•KEBUTUHAN DASAR:
•energi = 25 kkal/kg BBI = 1575 kkal
•Protein = 1 gram / kg BBI = 63 gram (16%)
•Lemak = 35 % x keb. E = 61,25 gram
•KH =49% x keb E = 192,9 gram
Pemberian DIMULAI berdasarkan kemampuan
saluran cerna:
ASPEN : 25 – 50 ml setiap kali pemberian dalam
24 jam

147. RQ = CO
2 eliminated / O
2 consumed
Karbohidrat = 1
Lemak = 0,7
Protein = 0,8 – 0,9
PERHATIKAN RQ

149. Rencana monev
•Asupan enteral parenteral setiap hari
•Residu setiap hari
•Gula Darah setiap hari

150. Daftar Pustaka
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors.
Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and
Pediatric Patients, 2009. JPEN J Parenter Enteral Nutr 2009;33:255–259.
Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines:
Nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr 2009;33:260–
276.
August D, Teitelbaum D, Albina J, et al. Guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr
2002;26(1 Suppl.):1SA–138SA.Erratum in JPEN J Parenter Enteral Nutr 2002;26:144.
Arsenault D, Brenn M, Kim S, et al. A.S.P.E.N. Clinical Guidelines: hyperglycemia and
hypoglycemia in the neonate receiving parenteral nutrition. JPEN J Parenter Enteral
Nutr 2012;36:81–95.
http://pen.sagepub.com/content/33/2/122.full.pdf+html
http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Guideline
s/
http://www.baxternutritionacademy.com/ie/parenteral_nutrition/parenteral_nutriti
on.html