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Nutrisi Enteral - Lecture
Nutrisi Enteral - Lecture
Hasanul Arifin
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a functioning gastrointestinal tract at least 100 cm of small bowel condition of bowel adequate for absorption patient incapable of adequate oral intake
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II. Advantages
less potential risk of infection, metabolic complication favours intestinal integrity and function maintains GI tract functions [ IgA, hormones, GALT ] promotes gut motility reduces bacterial translocation from the gut less expensive product, delivery, monitoring
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III. Indications
pragmatic indications
severely stressed patients expected to be unable to eat for 5-7 days or more severe trauma , burn [following] small bowel resection resumption of GI activity & preparation for oral 7/25/2013 feeding
Obstruction of GI tract Protracted vomiting or diarrhea High output fistulas [> 500 ml] Diffuse peritonitis or ileus Acute bowel ischemia / gut necrosis Severe acute pancreatitis Severe short bowel syndrome [<100 cm]
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YES
NO
Are conditions to start EN present? YES NO
Start PN
Reduce infusion rate by 50% 4-6h, then progressive increase over 24-48 h
Jolliet.P et al, Enteral nutrition in intensive care patients : a practical approach. Intensive Care Med 1998;24(8):848-859
EN, administered by
Nasoenteric route Percutaneous route
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Nasoenteric route
Nasogastric, Nasoduodenal, Nasojejunal 2 - <4 weeks small diameter[6-12 Fr/Ch] Silicone, polyurethane [PUR], radioopaque stomach 90 cm, duodenum 110 cm, jejunum 120 cm prokinetic R/ metoclopropamide, erythromycine, cisapride inner stylets proper placement in stomach pH specimen aspirated <5.0
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Silicone
To soft
PUR
Adequate
Peggi Guenter: Delivery System Administration of Enteral Nutrition, in Rombeau JL, Clinical Nutrition, Enteral and Tube Feeding,1997:244.
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(NGT)
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Percutaneous route
PEG, PEJ, combined nasogastric jejunal PEG, procedure of choice for ICU patients. [ 4-6 weeks] 9-24Fr Relative CI, ascites, gastric cancer, gastric ulcer, previous laparotomy, coagulation disorder. Post-pyloric feeding PEJ.
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PEG
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R/ Panenteral, Nutren,
Diabetes
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Elemental
Chemically defined Glucose, oligosaccharides Crystalline amino-acids, peptide replace protein Medium Chain Triglyceride Specialized enteral formula [hepatic failure, renal failure, stress-hypercatabolic ] BCAA, Glutamine
R/ Peptivariant-2000 R/ Peptamen
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Immune enhanced
R/ NEOMUNE
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Perativ Stresson
e
Lipids
Safflower oil
MCT
Palm oil
Safflower oil Menhaden oil 3.3
Canola oil
Corn oil MCT 1.24
Vegetable oil
Fish oil Vegetable, fish 1.1
Omega-3-FA
g/L
0.02
Antioxidants
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yes
yes
yes
yes
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Intermittent (bolus)
naso gastric tube, gastrostomy
head up position 300 start gastric feeding of 150-200ml over 20-40 minutes,
followed by 30 ml warm water flush for sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.
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EN + PEN
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Monitoring,
Metabolic, gastrointestinal, mechanical assessment Routine dayli evaluation of intake,output, weight Acutely ill patients require daily to weekly serum electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph. Stable patients require weekly-monthly laboratory studies Elevate head of bed 300 during feeding Check stomach for high residuals to minimize aspiration risk
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Complications,
Metabolic : overhydration, dehydration, undernutrition, hyperglycemia, electrolyte imbalance Gastrointestinal : nausea, vomiting, constipation abd. discomfort, diarrhea Mechanical : misplaced, clogged feeding tube airway, GI tract injury with NG/NJ tube placement. Infectious : peritonitis, exit site infection, sinusitis, aspiration pneumonia
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Terima kasih
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