NUTRISI PADA PASIEN KRITIS

DIKI ARDIANSYAH

DEPARTEMEN KEPERAWATAN KRITIS, GADAR BENCANA

PROGRAM STUDI KEPERAWATN (D-3)
STIKES JENDERAL A. YANI CIMAHI
 Respon Tubuh Pasien Kritis

Glukosa & Metabolisme

Metabolik
Protein Lemak

Cairan,
Elektrolit, Inflamasi
Endokrin
 Metabolisme
Respon STRESS

1. Physical injury
2.
3.
Mechanical disruption
Chemical changes
STATUS
4. Emotional factors NUTRISI
McClave, S. A., Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., ... & Cresci, G. (2009). Guidelines for the provision and assessment of
nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition
(ASPEN). Journal of Parenteral and Enteral Nutrition, 33(3), 277-316.
 Respon Metabolik
(Surgery, Pneumonia, MI (HF))

Counter-regulatory:
1. Cortisol
2. Glucagon
3. Catecholamin
4. Growth hormon
5. Aldosteron
6. Vasopressin
Biebuyck, J. F., & Phil, D. (1990). The metabolic response to stress: an overview and update. Anesthesiology, 73(4), 308-327.
Desborough, J. P. (2000). The stress response to trauma and surgery. British journal of anaesthesia, 85(1), 109-117.
 2 fase metabolic Respons
Fase 1
Catecholamine
• Dimulai 12-24 jam
(tergantung berat dan R. B1
R. A &
B2
jantung
keadekuatan resusitasi) Contractility perifer
vasokontriksi
HR
• CO Hipoperfusi
• metabolisme
menyeluruh Perbaikan: BP, Jantung, Venous
return

Sekresi catecholamine
Cuthbertson, B. H., Hull, A., Strachan, M., & Scott, J. (2004). Post-traumatic stress disorder after critical illness requiring general intensive care.
Intensive care medicine, 30(3), 450-455.
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
 Hyperglikemia
Derjat hyperglicemia tergantung injury dan stress

Peningkatan AA dan FFA  sekresi insulin  imbalance K dan P

Cuthbertson, B. H., Hull, A., Strachan, M., & Scott, J. (2004). Post-traumatic stress disorder after critical illness requiring
general intensive care. Intensive care medicine, 30(3), 450-455.
 2 fase metabolic Respons
Fase 2
Durasi tertinggi 3 – 5 hari (tergantung berat
injury, infeksi da komplikasi)
• Flow phase
• Terdiri dari katabolisme dan anabolisme

Adanya peningkatan CO  O2 substrat metabolik ke jaringan

Cuthbertson, B. H., Hull, A., Strachan, M., & Scott, J. (2004). Post-traumatic stress disorder after critical illness requiring
general intensive care. Intensive care medicine, 30(3), 450-455.
 Perubahan Metabolisme
Glukosa dan Protein
1. Injury
2. Trauma Glukoneogenesis tetap berjalan
3. Glukosa >>

Pemberian glukosa lewat IV akan

menghambat glukoneogeneisis di hepar pada
pasien puasa

Biebuyck, J. F., & Phil, D. (1990). The metabolic response to stress: an overview and update. Anesthesiology, 73(4), 308-327.
Desborough, J. P. (2000). The stress response to trauma and surgery. British journal of anaesthesia, 85(1), 109-117.
 Perubahan Metabolisme Lemak
Lypolisis
• Intake lipid <<
• Anoreksia
Trigliserid  glycerol • Kebutuhan energi tinggi

KETON

Biebuyck, J. F., & Phil, D. (1990). The metabolic response to stress: an overview and update. Anesthesiology, 73(4), 308-327.
Desborough, J. P. (2000). The stress response to trauma and surgery. British journal of anaesthesia, 85(1), 109-117.
 Respon Cairan, Elektrolit, Endokrin
2 jam setelah trauma
1. TNF Aktivasi limfosit T
dan B
2. IL-6

Serum T3
TSH
T4

Biebuyck, J. F., & Phil, D. (1990). The metabolic response to stress: an overview and update. Anesthesiology, 73(4), 308-327.
Desborough, J. P. (2000). The stress response to trauma and surgery. British journal of anaesthesia, 85(1), 109-117.
 Respons Inflamasi
• Melokalisir kerusakan
• Menetralisir dan menghancurkan agent
pathogen
• Warning sign adanya cidera jaringan
• Proses penyembuhan jaringan
• Mengembalikan keadaan homeostatis
 Berhasil

• Systemic inflammatory response

Gagal
?
syndrome (SIRS)
• SIRS d/ berkembang menjadi multiple
organ dysfunction syndrome (MODS),
yang dapat menimbulkan kematian.

Biebuyck, J. F., & Phil, D. (1990). The metabolic response to stress: an overview and update. Anesthesiology, 73(4), 308-327.
Desborough, J. P. (2000). The stress response to trauma and surgery. British journal of anaesthesia, 85(1), 109-117.
 Why it is important?
25 • 40% of hospital patients
20 malnourished on admission and
nutritional state usually
15
deteriorates in hospital.
10
• Critically ill are often
5 malnourished
0 • Hypermetabolisme
Complications No Complications
Poor Intermediate Good
• Pemberian nutrisi bukan prioritas
selama fase resusitasi
• Risiko infeksi dan komplikasi

McWhirter, J. P., Hambling, C. E., & Pennington, C. R. (1994). The nutritional status of patients receiving home enteral
feeding. Clinical nutrition, 13(4), 207-211.
 Diseases and Conditions Predisposing to
Malnutrition
Hypermetabolic
Difficult eating State
Excessive
activity
Medication

Cytokines Nutrient Nutrient utilization

intake

Anorexia
Physiologic Demand
Depression
Nutrient Loss
dementia

Socioeconomic
Malabsorption
 Effects of Undernutrition
Psychology –
Ventilation - loss of depression & apathy
muscle & hypoxic
Immunity – Increased risk
responses
of infection
liver fatty change,
functional decline Decreased Cardiac output
necrosis, fibrosis
Renal function - loss of
Impaired wound ability to excrete
healing Na & H2O

Hypothermia
Impaired gut
integrity and
immunity Loss of strength

Anorexia
? Micronutrient deficiency
 Tujuan Pemberian Nutrisi
Traditionally Recently
• Mempertahankan masa • Berfokus pada nutrition
tubuh therapy
• Maintain immune function • Menurunkan respon
• Mencegah komplikasi metabolik terhadap stress
metabolik • Prevent cedera seluler
• Mempercepat penyembuhan oksidatif
luka • Perbaikan respon imun
• Perbaikan struktur & fungsi
GI track (oral & enteral)

McClave, S. A., Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., ... & Cresci, G. (2009). Guidelines for the provision and
assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 33(3), 277-316.
 Pemberian Nutrisi

Metoda
Kebutuhan
Assassment

Urden, Linda D, et al. 2010. Critical Care Nursing: Diagnosis And Management. Miss souri: Elsevier. Inc.
Mueller C, et al. A.S.P.E.N. Clinical guidelines, nutrition screening, assessment, and intervention in adult. JPEN J Parenter
NRS 2002
 INTERPRETASI
• NRS 2002 >3  RISK
• NRS 2002 ≥5  HIGH RISK
• NUTRIC SCORE ≥5  HIGH RISK
Jika IL-6 tidak tersedia NUTRIC SCORE >6
merupakan “HIGH RISK”

Heyland et al SCORE ≥5  HIGH RISK

Heyland DK, Dhaliwal R, Wang M, Day AG. The prevalence of iatrogenic underfeeding in the nutritionally “at-
risk” critically ill patient: results of an international, multicenter, prospective study [published online July
19,2014]. Clin Nutr.

Heyland DK, Dhaliwal R, Jiang X, Day AG. 2011;15(6):R268.

Hubner M, Cerantola Y, Grass F, Bertrand PC, Schafer M, Demartines N. 2012
 Assessing Nutritional Status
Comorbid conditions
Anthropometric

Determaining
Nutrition Needs
Biochimical
Data
Fungsi GI track

Risiko Aspirasi
Evaluating
Clinical Sign
Finding
ASPEN SUGGEST NOT
Diet and Health
USING TRADITIONAL
History NUTRITION INDICATOR

Urden, Linda D, et al. 2010. Critical Care Nursing: Diagnosis And Management. Miss souri: Elsevier. Inc.
Mueller C, et al. A.S.P.E.N. Clinical guidelines, nutrition screening, assessment, and intervention in adult. JPEN J Parenter
 Pasien Risiko Malnutrisi
• Kehilangan berat badan secara segnifikan
(>10%/BB/6 bulan, >5%/1 bulan)
• Penyakit kronis
• Chronic use of a modified diet
• Peningkatan kebutuhan metabolik
• Illness or surgery yg memperngaruhi intake
• Inadequate intake >7 hari
• Regular penggunaan 3/lebih obat
• Poverty
Mueller C, et al. A.S.P.E.N. Clinical guidelines, nutrition screening, assessment, and intervention
in adult. JPEN J Parenter Enteral Nutr. 2009;35(1):16.
 Antropometric Meassurement
• Pasca resusitasi
• Edema anasarka
KURANG AKURAT
• Efusi pleura
• Dll Klasifikasi BMI
Underweight <18,5
Normal 18,5 – 24,99
Overweight ≥25
Pre-obes 25 – 29,99
Obese I 30 – 34,99
Obese II 35 – 39.99
Obese III ≥40

Urden, Linda D, et al. 2010. Critical Care Nursing: Diagnosis And Management. Miss souri: Elsevier. Inc.
World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Concultation. WHO
 Biochemical Data
Hipoalbuminemia yg lama meningkatkan
morbiditas & mortalitas
• Albumin
 << pada intake yg kurang&liver failure
 << respon terhadap trauma dan infeksi
 >> prealbumin <4ml/1 minggu (prognosis buruk)

Raguso C., et al. The role of visceral proteins in the nutritional assessment of intensive care unit patient. Curr
Opin Nutrn Mtab Care. 2003;6:211
 Traditionally meassurement
• Albumin
• Pre albumin Not validited in critical care
• Antropometri

Sebelum inisiasi feeding harus dilakukan evaluasi

kehilangan BB dan Intake sebelumnya, keparahan
penyakit, comorbid condition, fungsi GI

Martindale RG, Maerz LL. Management of perioperative nutrition support. Curr Opin Crit Care. 2006;12:290-294.
Raguso CA, Dupertuis YM, Pichard C. The role of visceral proteins in the nutritional assessment of intensive care unit
 Nutritional Ass Urine urea nitrogen (UUN) excretion in gms per day may
be used to evaluate degree of hypermetabolism essment

Balans N = intake N – output N

Intake n = ∑ intake protein (gram/hari) Output N = urea nitrogen dalam urine

6,25gram protein/gram N (diperiksa dari urine 24 jam ) + 4

Nilai Interpretasi
0–5 Normo metabolisme
5 – 10 Mild hypermetabolisme (Level 1 stress)
10 – 15 Moderete Hypermetabolism (Level 2 Stress)
>15 Severe Hypermetabolsm (Level 3 Stress)

Mueller C, et al. A.S.P.E.N. Clinical guidelines, nutrition screening, assessment, and intervention in adult.
JPEN J Parenter Enteral Nutr. 2009;35(1):16.
 Indirect caloremetry
Parameter yang diukur :
1. Konsumsi O2 (VO2)
2. CO2 yang dihasilkan (VCO2)

Nutrition History Information

Perubahan asupan nutisi sebelum dan sesudah
sakit dan dibandingkan dengan yang
seharusnya

Academy of Nutrition and Dietetics. Evidence Analysis Library. Estimating RMR wih predictive equation.
Satchell MA. Nutrition in critical illness: calorimetry. Pediatric Critical Care Study Guide. 2012:452
 Pemeriksaan Fisik
• Tanda gejala kekurangan atau kelebihan nutrisi
1) Tingkat kesadaran
2) Pemapilan umum
3) Kondisi rongga mulut
4) Kemampuan menelan Apakah pasien bisa
5) Pem. Abdomen makan atau tidak
6) Fungsi organ
7) Dampak penyakit

Urden, Linda D, et al. 2010. Critical Care Nursing: Diagnosis And Management. Miss souri: Elsevier. Inc.
Kebutuhan Nutrisi

Energi KH

Lemak Protein

Mikronutien
 What is the best method for determining energy
needs in the critically ill adult patient?

• INDIRECT CALORIMETRY
[Quality of Evidence: Very Low)
• 25 – 30 kcal/kg/d
Multiple RCT (161 sample)
1. Menurunkan mortalitas
2. << durasi penggunaan venilator
Tetapi IC harus di evaluasi setiap minggu  optimalkan
pemberian kalori protein
Saffle JR, Larson CM, Sullivan J. A randomized trial of indirect calorimetry- based feedings in thermal injury. J Trauma. 1990;30(7):776-782.
Singer P, Anbar R, Cohen J, et al. The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of Saffle JR, Larson CM,
Sullivan J. A randomized trial of indirect calorimetry- based feedings in thermal injury. J Trauma. 1990;30(7):776-782.
 KARBOHIDRAT
• Kebutuhan 30 – 70% dari total kalori
• Pemberian yg optimal  memaksimalkan
penyimpanan protein
• << KH  meningkatkan glukoneogenesis 
penurunan masa otot dan protein organ ciscera
1. Penyembuhan luka yg buruk
2. Penurunan respon kekebalan
3. Penurunan fungsi fisiologis\
• Hipergilkemia ketidakseimbangan elektrolit shift
cairan
 KARBOHIDRAT
Kelebihan KH diidentifikasi dari retensi CO2:
1. Peningkatan minute volume
2. Kesulitan fase weaning dari ventilator
3. Asidosis respiratorik akut
4. Alkalosis metabolik (monitoring gula darah)
 PROTEIN
• Kompenn penting pada sel
• Kebutuhan: 1,2 – 2 g/kgBB/hari, kecuali:
1. Luka bakar luas
2. Kehilangan melalui gastrointestinal
[Quality of Evidence: Very Low]
• Pemberian >1,5 g/kgBB/hari pada luka bakar sampai
penyembuhan luka
• Capaian 15 – 20% dari total kalori yang dibutuhkan
1. Healing wounds
2. Supporting imune function
3. Meningkatkan fungsi otot

Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition,
2016 33(3), 277-316.
Weijs PJ, Sauerwein HP, Kondrup J. Protein recommendations in the ICU: G protein/kg body weight—which body weight for underweight and obese patients?
 PROTEIN
Pemberian protein kurang:
1. Penggunaan protein tubuh
2. Meningkatkan kehilangan nitrogen
Pemberian protein lebih:
1. Digunakan sbg sumber energi  peningkatan
UREA
2. > 1,5 g/kgBB  azotemia pd pasien lanjut usia
 Lemak
• Simpanan glukosa <<  lemak jadi sumber utama
kalori
• 20 – 40% total kalori  max 2,5 g/kgBB/hr
• Pemberian lemak berlebih → hipertrigliserida dan fat
overload
1. Distress pernafasan,
2. coagulopati,
3. abnormal fungsi hepar
4. gangguan fungsi sistem retikuloendothelial supresi sistem
kekebalan
 METODA PEMBERIAN

ORAL ENTERAL PARENTERAL

PREVENTION AND MANAGEMENT OF

MALNUTRITION IN CRITICALLY ILL PATIENT
CCN MUST HAVE:
Understanding : indication – prevention – management
complication

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., ... & Gervasio, J. M. (2016). Guidelines for
the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
 Enteral Nutrition

• Mencegah atropi vili usus (INTEGRITY OF THE GUT)

• ↓ Respon metabolik thd stress
• ↓ Kejadian infeksi nosokomial
• ↑ Balans nitrogen (+)
• ↑ Sintesis protein visceral
• Pengaturan glukosa darah lebih baik
• ↓ Cost
• STIMULASI BLOD FLOW
Braunschweig CL, et al. Enteral compered with parenteral nutrition: a meta-analysis. Am J Clin Nutr. 2001;74(4):534
Langkamp-Henken B. If the gut works, use it: but what if you can’t? Nutr Clin Pract. 2003;18:449
Jabbar A, Chang WK, Dryden GW, McClave SA. Gut immunology and the differential response to feeding and starvation. Nutr Clin Pract. 2003;18(6):461
Kang W, Kudsk KA. Is there evidence that the gut contributes to mucosal immunity in humans? JPEN J Parenter Enteral Nutr. 2007;31(3):246-258.
 PERTIMBANGAN EN
GI contractility factors should be evaluated when
initiating EN (not be required prior to initiation
of EN)
GI INTOLERANCE:
• Absence/abnormal bowel sound
• Vomating
EN LAYAK DAN SAFETY
• Bowel dilatation DIBERIKAN 36-48 JAM
• Diare AWAL ICU TANPA ADANYA
BOWEL SOUND
• GI bleeding
• >> GRV
Stechmiller JK, Treloar D, Allen N. Gut dysfunction in critically ill patients: a review of the literature. Am J Crit Care. 1997;6(3):204-209
Reintam A, Parm P, Kitus R, Kern H, Starkopf J. Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiol Scand. 2009;53(3):318-324.
Nguyen T, Frenette AJ, Johanson C, et al. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J Crit Care.
2013;28(4):537.e11-537.e17.
 Pertimbangan EN
• Fase resusitasi/unstabil?
• Penggunaan vasopresor
• Hipotensi (MAP <50
mmHg)
• Cetoclemain agent
(norepineprin, epineprin,
?
dobutamin)

Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with
gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med. 2000;28(6):1742-1746
Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit
Care. 2010;19(3):261-268.
 Tropic Feeding in Critical Ill
Pada pasien ARDS/ALI dgn Ventilator ≥72 jam

Tropic feeding  10-20 ml/jam atau sampai 500

kkal/d sampai 6 hari & protein 0.6-0,8 g/kg/d

Lower incidence of GI intolerance over the first

week of hospitalization in the ICU than full EN
+ shorter LOS + goal nutrisi
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Rice TW, Wheeler AP, Thompson BT, et al.
Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8): 795-803.
Rice TW, Mogan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically
ventilated patients with acute respiratory failure. Crit Care Med. 2011;39(5):967-974.
 Full Feeding in Criticall Ill
Full feeding diberikan minggu pertama dirawat:
1. High Nutrition Risk
2. Severely Malnutrished

GOAL
24 – 48 JAM
>80% goal energy dan protein dalam 48-78 jam

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Rice TW, Wheeler AP, Thompson BT, et al.
Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8): 795-803.
Rice TW, Mogan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically
ventilated patients with acute respiratory failure. Crit Care Med. 2011;39(5):967-974.
 ENTERAL NUTRITION

END POINT :
The Delivery Of Immune-modulating Agnet
Stress Ulcer Prophylaxis

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., ... & Gervasio, J. M. (2016). Guidelines for the provision
and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and
Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice
guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355-373.
Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29(12):2264-2270.
Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission,
significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. Intensive Care Med. 2009;35(12): 2018-2027.
 Metoda Enteral

• KONTINYU  dimulai dg 10 – 20 ml/jam,

setap 4 ja dinaikan 10 – 20 ml/jam (sesuai
keadaa pasien)
• INTERMITEN  200 – 250 ml dalam 30-60
menit, diberikan 5-8 kali perhari. Dimulai
50% dari dosis hari pertama  naikan 100%
selama 72 jam
• BOLUS  200 – 300 cc dlm 15 – 60 menit
 Monitring Residu Lambung
• Diperiksa setiap 4 jam sekali (COEX, 2017)
• Diperiksa setiap hari (ASPEN, 2016)
• Bila terdapat volume makanan >50% maka terjadi retensi
• GRV  200 – 250 ml
• RETENSI  istirahatkan 1 – 2 jam ata laju tetesan
diperlambat

Penghentina EN scr cepat DIHINDARI 

membatasi penyebaran ileus + inadequate nutrisi
Metheny NA, Stewart BJ, Mills AC. Blind insertion of feeding tubes in intensive care units: a national survey. Am J Crit Care. 2012;21(5) 352-360.
McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., ... & Gervasio, J. M. (2016). Guidelines for the provision
and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and
Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386-
Pinilla JC, Samphire J, Arnold C, Liu L, Thiessen B. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective,
randomized controlled trial. JPEN J Parenter Enteral Nutr. 2001;25(2):81-86
 Pencegahan Aspirasi
• Assassment risiko aspirasi
• Postpyloric enteral access [Quality of Evidence:
Moderate to High]

• Bolus gastric EN  Continous infusion EN

• Agent to promote mitility (prokinetic
medication) [Quality of Evidence: Low]
• Elevated 30-40
• Chlorhexidine mouthwash
 Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in
mechanically ventilated patients: a randomised trial. Lancet. 1999;354(9193):1851-1858.
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-
associated pneumonia: a randomized study. Crit Care Med. 2006;34(2):396-402.

DeRiso AJ 2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of tota
nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109(6):1556-1561.
Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing
prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 2002;11(6):567-570.
 Nursing management of ETF complication
Prevention & Correction
Pulmonary Cek tube sebelum pemberian (4-8 jam), eleveasi kepala 30-45 (unless
aspiration contraindication), lateral (right lateral), prone (< vomitus), evaluasi FI (2jam),
abdominal radiographs
Diarrhea Evaluasi medikasi yg diberikan, Use continuous feeding (MCT/soluble fiber),
evaluasi prosedur pemberian (continuously/intermiten infusion), teknik bersih
hygine, steril water (immunocompromised), ganti tempat setiap 24 jam, hang
formula tdk lebih 4-8 jam  prepackaged in steril sets, digital rectal exam, use
lactose-formula

Contipation Fiber-containing formula, pastikan cairan adequate

Tube Jika obat diberikan lewat tube: hindari crush tablets, irigasi tube 4-8 jam selama
Occlusion continuous feeding & setelah intermitten feeding. Irigasi 20-30 cc of warn water
(3-4 jam sekali), cranbery juice
Gastric Cari penyebab, konsultasi penggunaan postpyloric feeding or prokinetic agent
Retention (stimulate gastric emptying), Abdominal Massage, right lateral position.
McClave, S. A.. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 33(3), 277-316.
Uysal, N., Eser, I., & Akpinar, H. (2012). The effect of abdominal massage on gastric residual volume: A randomized controlled trial. Gastroenterology Nursing, 35(2),
117-123.
Lord LM. Restoring and maintaining patency of enteral feeding tubes. Nutr Clin Pract.2003;18:422
Metheny Na, et al. A Survey of bedside methods used to detect pulmonary aspiration of enteral formula in intubeted tube-fed pasten. Am J Crit Care. 1999;8:160
 Feeding Intolerance
• Bloating
• Abdominal distantion and pain
• Lack of stool and flatus
• Diminished or absent bowel sounds
• Tense abdomen
• Increased tympany
• Nausea and vomating
• Residual volume >200 cc (NG), >100 cc (gastrotomy
tube)
Lord LM. Restoring and maintaining patency of enteral feeding tubes. Nutr Clin Pract.2003;18:422
Metheny Na, et al. A Survey of bedside methods used to detect pulmonary aspiration of enteral formula in intubeted tube-fed pasten. Am J Crit Care. 1999;8:160
Metheny Na. Rsik factors for aspiration. JPEN J Partener Enteral Nutr. 2002;26(6 suppl):S26
 Total Parenteral Nutrition
• Diberikan pada pasien dengan kondisi saluran cerna
yang tidak berfungsi
• Jumlah nutrisi sesuai dengan yang dibutuhkan secara
konsisten
• Cairan high consentration
• Dextrose (25-70% 1800 mOsm/L)  vena central
• Dextrose (5-10%)  PPN (<2 minggu)
• Pasien NRS ≤3 atau NUTRIC score ≤5 [Quality of Evidence:
Very Low]

Dilakukan 7 hari pertama apabila tdk mmpu

mempertahankan asupan + EN tidak Layak
Urden, Linda D, et al. 2010. Critical Care Nursing: Diagnosis And Management. Miss souri: Elsevier. Inc.
McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., ... & Gervasio, J. M. (2016). Guidelines for
the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
 Total Parenteral Nutrition
• Patient high nutrition risk (eg, NRS 2002 ≥5 or
NUTRIC score ≥5) or severely malnourished,
when EN is not feasible initiating PN as
soon as possible following ICU admission.
• PN tambahan dipertimbangkan setelah 7-10
hari jika tidak dapat memenuhi> 60% dari
kebutuhan energi dan protein dengan rute
enteral. [Quality of Evidence: Moderate]
McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., ... & Gervasio, J. M. (2016). Guidelines for
the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211.
Metoda TPN
 Pertimbang SEPSIS
 EN target 24-48 jam setelah stabil/resusitasi (sepsis,
syok sepsis)
 Tropic feeding (24-48 jam)  target >80% target
energi
 Protein 1,2-2 g/kg/d
 monitoring elektrolit berkala
 Hiperglikemia → diperlukan pemberian insulin
 Hipertrigliseridemia dengan peningkatan serum lipid
→perlu pembatasan asupan lemak.
Worthington P, et al. Parenteral nutrition for the acutely ill. AACN Clin Issues. 2000;11(4):559.
 Simpson F, Doig GS. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to
treat principle. Intensive Care Med. 2005;31(1):12-23.
Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition
in hospitalized patients. Crit Care Med. 2005;33(1):213-220.
 Pertimbang Respiratory failure
• High-fat/low-KH → CO2 >>> (gagal nafas)
• Kecuali saat menggunakan ventilator
• Akan bermasalah bagi pasien pada fase weaning dari
ventilator

Pertimbang Hepatic failure

Amoniak >>> akibat siklus urea terganggu
→ Perlu pertimbangan khusus dalam asupan protein
Gunakan BB kering (asites, <<Vol IV, edema, HT
portal, hipoalbumin)

McClave, Stephen A., et al. "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care
Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)." Journal of Parenteral and Enteral Nutrition 40.2 (2016): 159-211.
Kerwin AJ, Nussbaum MS. Adjuvant nutrition management of patients with liver failure, including transplant. Surg Clin North Am. 2011;91(3):565-578.
 Respiratpry Failure

al-Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and
reduces the period of ventilation in artificially ventilated patients. Intensive Care Med. 1989;15(5):290-295.
Radrizzani D, Iapichino G. Nutrition and lung function in the critically ill patient. Clin Nutr. 1998;17(1):7-10.
 Pertimbang Acute Renal Failure
• Protein 1,2 - 2 gram/kg BB(aktual)/hari, kecuali
• Energy 25-30 Kkal/kgBB/d
• HD/CRRT >> protein max 2,5 g/kgBB/d

Pertimbang Acute Pankreatitis

• Status nutrisi secara cepat berubah  reassessment
(feeding tolerance dan kebutuhan nutrisi)
• Oral, 7 hari tidak mampu -> specilized nutrition therapy
(mild) [Quality of Evidence: Very Low]
• Naso/orogastric tube  EN (tropic) sampai resusitasi
cairan selesai (24-48 jam) [Quality of Evidence: Very Low]
McClave, Stephen A., et al. "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill
patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)."
Journal of Parenteral and Enteral Nutrition 40.2 (2016): 159-211.
Worthington P, et al. Parenteral nutrition for the acutely ill. AACN Clin Issues. 2000;11(4):559.
 Pancreatitis berat haruskah PN

Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response
and improves disease severity in acute pancreatitis. Gut. 1998;42(3):431-435.
Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe
 Nursing management of TPN complication
Prevention & Correction
Catheter- Use aseptic technique (catehter, IV tubing, TPN solution), hang a bottle tdk lebih
related sepsis dr 24 jam, lipid tdk >12-24 jam, Use an in-line 0,22 micron (remove
microorganisme), hindari akses blood
Air embolism Use luer-lok connection, in-line air-eliminating, if pastient on ventilaor rubah
tubing scara cepat (ekspirasi), pertahankan occlusive dressing 24 jam (prevent
air entry catheter track). Jika AE is suspected, posisikan pasien lateral decubitus
dan tendenburg , oxygen or CPR
Pneumothorax Penjelasan prosedur, xray after insertion
Thrmbus Jika infus distop sementara lakukan flushing wit saline or heparine salin, jika
terbukti ada oklusi, aspirasi oklusi, jika gagagl berika antri trombus
Hypoglikemia Monior glukosa sampai satabil. Hypoglikemi  oral karbo atau bolus dextro
(unconcious)
Hyperglikemi Insulin, hyperglikemia indikasi sepsis
Hypertrigliser Monitoring 6 jam setelah peberian lipid dan 3 jam sekali sampai stabil. Rate
ida dikurangi dan pemberian low-dose heparin
Worthington P, et al. Parenteral nutrition for the acutely ill. AACN Clin Issues. 2000;11(4):559.
Dobbins BM, et al. Each lumen is a potential source of central venous catheter-releated bloodstream infection. Crit Cave Med.2003:31(6):1688
Orr ME. The peripherally inserted central catheter: what are the current indications for its use?. Nutr Clin Pract.2002;17:99
Speerhas, R., Wong, J., Seidner, D., & Steiger, E. (2003). Maintaining normal blood glucose concentrations with total parenteral nutrition: Is it necessary to taper total
parenteral nutrition?. Nutrition in clinical practice, 18(5), 414-416.
 EN vs PN in Critical Ill
the use of EN over PN in critically ill patients who require
nutrition support therapy.
[Quality of Evidence: Low to Very Low]

• << mortality
• << infectious morbidity
(generally, oneumonia,
Central line infection,
abdominal abses in trauma
patients
• << LOS

Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for
nutrition support in mechanically ventilated, critically ill adult patients.2003
Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med.
2005;33(1):213-220.
Simpson F, Doig GS. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med.
2005;31(1):12-23.
Semoga Bermanfaat