Modul 13

NUTRISI PARENTERAL

Dept. Anestesiologi & Terapi Intensif

FK-USU/RSUP H.Adam Malik- Medan

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 DEFINITION
Parenteral nutrition is partial or total
nutrition administered intravenously. A
peripheral or central vein is used for access

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SUPPORT NUTRITION

• ORAL NUTRITION
• ENTERAL NUTRITION
• PARENTERAL NUTRITION

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PARENTERAL NUTRITION

• Diberikan lewat intravena

• Vena perifir (PPN)
• Vena sentral (TPN)

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 INDICATIONS
• Non-functional GI-tract
• Impossible to use the GI-tract
• Intestinal obstruction
• Peritonitis
• Intractable vomiting
• Severe diarrhea
• High output enterocutaneus fistula
• Short bowel syndrome (<70 cm)
• Severe malabsorption
• Need for intestinal rest
Palliative use in terminal patients is controversial

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 CONTRAINDICATIONS

• Ability to adequately receive and absorb

necessary foods orally or by gastric or
enteral tube
• Hemodynamic instability

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 CENTRAL PARENTERAL
NUTRITION
• Selection depends on caloric
requirement,volume to be administered and
patient condition, as well as final concentration
of components:
• Amino acid > 5 %
• Dextrose > 20%
• Lipids
• Includes vitamins, minerals and trace elements
• Osmolality > 700 mosm / kg H20

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 FORMULAS :
• Dextrose
– Provide 3,4 kcal /kg
– Can be the only source of energy
– Dextrose infusion rate should not exceed
5mg/kg/min
– Closely related to solution osmolality

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 FORMULAS :

• Amino acids
– Standart concentrations can vary between 5
% and 15 %
– Energy value of amino acids ( 4 kcal /g )
– Nitrogen ( g ) = protein ( g )/ 6.25

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 FORMULAS :
• Lipids
– Prevents essential fatty acid deficiency
– Non protein source of kacal remcommend
local 1 g / kcal
– Available in 10%,20%, and 30%
concentrations
– Included as LCT or a mix of MCT/ LCT at 10
% and 20%
– Added to basic parenteral nutrition solutions
or administered individualy

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 FORMULAS :
• Lipids
– Less hyperglicemia
– Lower concentration of serum insulin
– Less risk of hepatic damage
– High doses can interfere with immune functions
– High infusions rates can affect respiratory functions
– Should be used with care in :
• Hyperlipidemia
• Symptomatic atherosclerosis
• Acute pancreatitis with hypertriglyceridemia

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 FORMULAS:
• Electrolytes:
– Calcium, magnesium, phosporus, chloride,
potassium, sodium, and acetate
– Forms and amounts are titrated based on
metabolic status and fluid / electrolyte balance
– Must consider calcium phospate solubility

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 FORMULAS:
Vitamins and minerals
- In general, amounts below daily recommend
intake for healty people but nonetheless
sufficeint to cover requirements are added to
oral or enteral formulas
- Added daily to parenteral nutritions
- Acute illnes infections preexisting
malnutritions and excessive fluid loss
increase vitamin requirements

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 FORMULAS :
• TRACE ELEMENTS
– Include daily zinc, copper, chromium,
and manganese for patients with kidney
or liver failure
– Different requirement dictated by
patients and pathology
– Patients under extended parenteral
nutritions require the addition of iron
and selenium

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 PERIPHERAL PARENTERAL
NUTRITION
• Selection of peripheral access depends on
clinical situation requirements, tolerance to
volume and final formula concentration
– Osmolality < 900 (700) mosm/kg
– Total kcal limited by concentration and ratio to
volume being administered
– Include ½ of the recommend electrolytes for
PN

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PN : TYPES OF INFUSION
• Continous – total volume of formula is
administered over a 24 hour period
• Cyclic – volume is administered in one
period, with infusion adjustment and a
period of rest
• Selection of infusion type depends on
patient’s condition
• Use a parenteral infusion pump

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 Recommendation for Clinical
Practice

• STABLE HAEMODYNAMIC
(DO2)
• START LOW GO SLOW END
SLOW

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VOLUME
50 ml /kg/day

2500-3000 ml/day

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 VO2 oxygen consumption

ENERGY VCO2
• HARRIS BENEDICT
• INDIRECT CALORIMETRI

Rule of Thumb
BEE = 25-30 k.cal/kg/d
REE = [ 1.2-1.3 ] x BEE

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SUMBER ENERGI

CHO & LIPID

60:40
50:50 20
Osmolarity

PPN
900 mOsm/L
TPN (700 mOsm/L)

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 OSMOLARITAS [m.Osm/L]

Osmolaritas Campuran :

V1.O1 + V2.O2 + V3.O3

=
V1 + V2 + V3

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Triofusin-E.1000(1000 ml) , Kalbamin-10%
(500 ml) Ivelip-10% (500ml)

Osmolaritas campuran =
1400x1 + 880x0.5 + 265x0.5
1 + 0.5 + 0.5
= 986,5 mOsm/L

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 Pemilihan Cairan Nutrisi

Sumber
Sumber Lemak,
Karbo- Hidrat,
kcal/L?
kcal/L?

Osmolaritas
mOsm/L Vitamine,
Mineral

Sumber Asam
- Amino, gr/L? 24
 NPC As.Amino
k.cal/L mOsm/L
gr/l
TRIOFUSIN-500 500 800
TRIOFUSIN E-1000 1000 1400
TRIOFUSIN-1600 1600 2500
DEXTROSE-20% 800 1100
IVELIP-20% 2000 270
INTRAFUSIN 3,5% 35 600
INTRAFUSIN-10% 100 880
Kalbamin-10% 100 880
CLINIMIX-N9G15E 410 28 845
CLINIMIX-N9G20E 510 28 980

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 Tetes bersama 24 jam
• Semua substrat terbagi merata
• Mengurangi osmolaritas
• Protein sparing effect
• Cegah hypoglikemia
• Fluktuasi insulin
• Cegah side effect

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PARENTERAL
NUTRITITION

tetes bersama

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Triofusin
intrafusin IVELIP
-500 -10% -10%
VOLUME : 2000 ml
NPC : 1000 k.cal
A.ACIDS : 50 gr
OSMOL. : 686 mOsm/L

THREE WAY
STOPCOCK
PPN
24 HOURS

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Triofusin Intrafusin IVELIP
E-1000 10% -10%
VOLUME : 2000 ml
NPC : 1500 k.cal
A.ACIDS : 50 gr
OSMOL. : 986.5 mOsm/L

THREE WAY TPN

STOPCOCK
24 HOURS

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Teknik Pemberian,

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Teknik Pemberian,
All in One [AiO]

R/ Clinimix

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 1000 kcal
NPC

60%-70%, KH 40%-30%, lemak

500 kcal 500 kcal

TRIOFUSIN Ivelip 20%

500

250 mL,

1000 mL, 500 kcal,

500 kcal, 270 mOsm/L
800mOsm/L
4 tetes/men. 33
15 tetes/men.
Asam Amino,
35 gr

INTRAFUSIN
3.5%

1000 mL,
As.amino 35 gr
600 mOsm/L
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 TRIOFUSIN
IVELIP-20%
500 INTRAFUSIN
3.5%

250 mL,
500 kcal, 1000 mL,
1000 mL,
500 kcal, 265 mOsm/L As.amino 35 gr
600 mOsm/L
800mOsm/L
4 tetes/men 15 tetes/menit
15 tetes/men

2250 mL, 1000 kcal (NPC), 35gr as.amino ,650 mOsm/L

tetes bersama 24 jam vena perifir
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Triofusin E- IVELIP KALBAMIN
1000 10%
20%

Three way
stop cock
VOLUME : 2000 ml
NPC : 2000k .cal Vena
A.ACIDS : 50 gr centralis
OSMOL. : 987.5 mOsm/L
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KOMPLIKASI
METABOLIK
• OVER DOSIS SUBSTRAT
• LAJU INFUSI YANG TERLALU CEPAT
• PEMAKAIAN LAMA

MEKANIK
• ARTERIAL PUNCTURE
• PNEUMOTHORAX
• HEMOTHORAX
• THROMBOPHLEBITIS,
• DLL

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 MONITORING PATIENT OF
PARENTERAL NUTRITION

• Metabolic
– Glucose
– Fluid and electrolyte balance
– Renal and hepatic function
– Triglycerides and cholestrol

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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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• Assesment
– Body weight
– Nitrogen balance
– Plasma protein
– Creatinine height index

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 Terima kasih atas perhatian anda
Semoga Tuhan selalu memberkahi kita semua
Amin
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 Nutrisi Parenteral Skill

• Menghitung kebutuhan dan

menentukan pilihan jenis/komposisi
nutrisi yang sesuai dengan pasien.

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