RSD dr SOEBANDI

KSM ANESTESIOLOGI DAN

TERAPI INTENSIF

Manajemen Terapi Intensif

Suparno Adi Santika., dr., SpAn., KIC., MH

 RSD dr SOEBANDI
Tahapan Resusitasi
Bantuan hidup dasar Airway (Bebaskan jalan nafas)
(Basic Life-support) Breathing (Pulihkan
Mechanical Ventilation
napas/ventilasi)
IGD – LOC 1-2-3 Circulation (Perbaiki sirkulasi)
Bantuan hidup tingkat Drugs and Fluid (Obat dan cairan)
lanjut (Advanced Life- Electrocardiography (Periksa SURGIKAL
support) Jantung)
Fibrilation (Atasi ggn impuls
jantung)
OK – HCU – ICCU –
Dukungan Bantuan
LOC 2 Gauging (Penilaian, terapi
Hidup (Prolonged Life- lanjutan)
support) Human Mentation (jaga fungsi
normal) MEDIKAL
Intensive Care (Perawatan Intensif)
ICU -- RICU
Intensive O2 Therapy
17/03/2023 2
 RSD dr SOEBANDI

Stabilisasi
Mechanical Ventilation
Elemen penting dalam stabilisasi pasien adalah :

• Menjamin bebasnya jalan nafas, pemulihan sistem

respirasi dan sirkulasi SURGIKAL
• Mengganti cairan tubuh yang hilang
• Menghentikan/mencegah kejang
• Menghentikan sumber perdarahan atau infeksi
• Mempertahankan suhu tubuh
• Memperbaiki kadar gula darah MEDIKAL
• Mengatasi rasa nyeri atau gelisah
• Memperbaiki perfusi jaringan

Intensive O2 Therapy
17/03/2023 3
RSD dr SOEBANDI
 Common modes of ventilation - TLC classification (Kapadia)
RSD dr SOEBANDI
Mode Trigger Limit Cycling
INDIKASI
Continuous Mechanical Ventilation Assist (CMVa) Ventilator or Patient Flow Volume (Time controls pause)
=Assist-Control(A/C)
= Volume-Control-Assist (VCa)
HANYA DOKTER
Pressure Control Ventilation (PCV) Ventilator or Patient Pressure Time (Time also controls pause) dan
PERAWAT
volume-cycled
Ventilator or Patient
Flow
Volume (mandatory breath)
TERDIDIK
Synchronised-Intermittent-Mandatory Ventilation (mandatory
(SIMV) breath)
YANG
PAHAM
pressure-limited SIMV Ventilator or Patient
Pressure
Time (mandatory breath)
PERAWATAN
(mandatory
breath)
VENTILATOR

Pressure Support (PS) Patient Pressure Flow

MANAJEMEN
CPAP Patient Pressure Flow
KLINIS
CPAP + PS Patient Pressure Flow
KONTINYUITAS
A combination of synchronised intermittent mandatory ventilation (with the
SIMV + PS
appropriate characteristics of the mandatory breaths) and pressure support
(with its characteristics). Note that either type of SIMV mentioned above may
be used.
PASKA
PERAWATAN
Note that where CPAP is combined with ventilator triggered modes, confusing terminology kicks in again - CPAP is then called
"PEEP" (Positive End-Expiratory Pressure).
 Monitoring Kontinyu
+ RSD dr SOEBANDI

AMAN ????
 Monitoring Kontinyu
+ RSD dr SOEBANDI

AMAN ????
RSD dr SOEBANDI
 HOW TO KEEP PARESTESI Without Wall and SOPHISTICATED ?
EDUCATED Patient Out PAV. KAMBOJA
PARESTESI
CARE UNIT
S PREVILEGE -- HPK
D
SOPHISTICATED
Traditional KRITERIA WMP INTENSIVE PORSI YANG
Care
PARESTESI
Anesthesia- BAKU R LAYAK
LI Rawat Inap
Intensive Care Unit EWS A
CARE UNIT O
AR PR
T
VVIP / TS
L YIT IBS RA
TRAINED L A
AS
NI
S
FASKES
PINDAHAN LN
PARESTESI IGD O
CARE UNIT K R
O
P
FASKES RUJUKAN
IT
R BALIK
Patient In AT
SE
Mobile – PARESTESI FASKES RUJUKAN
R
RSD dr SOEBANDI

FORUM ILMIAH Melibatkan PPDS dan Unit Kerja

• DISKUSI KASUS SULIT MULTIDISIPLIN INTENSIF
• DISKUSI KASUS SULIT MULTIDISIPLIN KOMED DAN IBS
• MORNING REPORT di IGD
RSD dr SOEBANDI
RSD dr SOEBANDI
KONSEP PENILAIAN dan TINDAKAN
SENSE OF CRITICAL
+ RSD dr SOEBANDI

NON COVID 19
+ RSD dr SOEBANDI

SKOR 0 COVID 19
Monitor Rutin / 12 Jam
+ RSD dr SOEBANDI

MANAJEMEN
LOC SESUAI EWS
 RSD dr SOEBANDI
IMPLEMENTASI EWS PRA INTENSIF

1. RR < 20 x/m
2. Spo2 > 95 %
RUANGAN
3. HR < 100 x/m BIASA
1. RR 20-30 x/m
2. Spo2 90-93 %
3. HR 100-120
x/m
1. RR 30-40 x/m
2. Spo2 80-90 %
3. HR 120-130
x/m

1. RR > 40 x/m
2. Spo2 < 80 %
3. HR > 130 x/m RICU

POST CARDIAC
ARREST

Sun et al. Ann. Intensive Care (2020) 10:33 https://doi.org/10.1186/s13613-

020-00650-2
Ruang HCU
 FUNGSI SISTEM RESUSITASI DI RS
INI YANG
DIBUTUHKAN
PASIEN
ALERT-CARE CODE BLUE
EMERGENCY STATE

TIM MEDIS TIM CODE BLUE

EMERGENCY
 INI YANG
DIBUTUHKAN
FUNGSI SISTEM RESUSITASI DI RS
ALERT-CARE
PASIEN
TIM ASUHAN KEPERAWATAN DAN MEDIK CODE BLUE
KEGAWATAN
1. KIE bersama PX KRITIS
2. Konsultasi DPJP terkait kegawatan medik (ggx nafas,
syok, perdarahan, hemoptoe, anuria, ACS, Herniasi, ggx
asam basa, ggx koagulasi) EMERGENCY
3. RJPO px witness Cardiac Arrest STATE
4. Pendampingan klinis px kritis Op, CT, MRI,
Tracheostomy, Echo, HD
5. Kontinyuitas pelayanan assessment klinis medis, asuhan
keperawatan dan pelaksanaan MEWS, SOFA, APACHE
6. FASHUG BIDS, EGDT SEPSIS, Pengamanan airway
7. Ekskalasi dan Deekskalasi Terapi Overlap

TIM MEDIS TIM CODE BLUE

EMERGENCY
RANCANGAN TRIASE EWS CODEBLUE

RANAP-
INTENSIF
IGD
PONEK
PICU-NICU
SESUAI
SARPRAS
Secara tradisional, hiperlaktatemia pada pasien
syok diinterpretasikan sebagai tanda (marker)
adanya metabolisme anaerob sekunder akibat
tidak adekuatnya transpor oksigen ke sel yang
menyebabkan kerusakan sel
 SIRKULASI NORMAL VS SIRKULASI ABNORMAL

Seberapa rendah Hb yang masih CUKUP

 Perfusi perifer  hangat, kering

 Warna akral  pink / merah muda
 Capillary refill  < 2 detik,
bandingkan dengan tangan
pemeriksa
Hangat
Kering
Merah
Perfusi Dingin
waktu shock Basah
Pucat
23
NORMAL VITAL SIGN

60

80
70
 + SEPSIS

RESUSITA
SI atau
PALIATIF ?
 Anda PERSIAPAN
Butuh PERIOPERATIF
TOOLS
Conox
Vigileo
MostCARE
HOW TO RESUSCITATE
SEPSIS ???

Act Brief
Think Wise
DAMPAK PEMBERIAN CAIRAN TIDAK TERUKUR

Kenapa ?
FAKTA

DATA

Kita Klinisi
 MEKANISME
MALDISTRIBUSI
DO pd SEPSIS

(Occlusion of capillaries)

A complex interplay of neural, hormonal and endothelial-derived factors regulates the balance of gastrointestinal
perfusion between vasodilatation and vasoconstriction. Question marks indicate possible interactions; dashed
lines indicate endothelium-derived production. ACh, acetylcholine; CCK, cholecystokinin; CGRP, calcitonin
generelated peptide; EDHF, endothelium-derived hyperpolarizing factor; 5-HT, 5-hydroxytryptamine; PG,
prostaglandin; VIP, vasoactive intestinal peptide.
Ackland, Crit Care 2000,
 DO EVERYTHING – DO SOMETHING – DO NOTHING
K
VAP PROSES BERJALAN PRO
A P
P A
L P
A I
A R
N T I
I
F O
K
R
I
I
T
T
A
RESUSITASI (2-8 hari) A
9
S
???
PASIEN MASUK AKAN BERKORELASI DENGAN PASIEN KELUAR
 MENGAPA SISTIM RESPIRASI PENTING ????!!!!!!

1. Merupakan salah satu sistem (yang awal) yang berfungsi

untuk mencukupi kandungan oksigen dalam darah untuk
proses oksigenasi jaringan (sel).
2. Merupakan sistem yang paling sering mengalami penyulit
akibat berbagai penyebab (termasuk pembedahan).
3. Paru merupakan organ kedua penyebab MODS.
Intensive O2 Therapy

D02 = CO x {(1,34 x Hb x SaO2)+ (0,003 x PaO2)}

RSD dr SOEBANDI

Penilaian awal (EWS) R

E

Respiratory Distress
S
P
I
R
A
Tingkat kesadaran T
O
Tentukan apakah Penampakan dan tekstur kulit R
pasien sadar atau Tanda vital Y
tidak
1. Tekanan darah
Bila pasien tidak Sianosis D
sadar, tentukan 2. Frekuensi
Pucat jantung I
hingga seberapa
Diaforesis S
pasien dapat 3. Suhu
dibangunkan T
4. Frekuensi napas R
5. Status oksigenasi E
S
S
 RSD dr SOEBANDI

Gagal Napas Akut

Acute Respiratory
Failure
■ Ketidakmampuan untuk mempertahankan
kadar PaO2, PaCO2, dan pH normal
– PaO2 di bawah kisaran normal < 70
mmHg .
– PaCO2 > 50 mmHg
– pH ≤ 7.25 mmHg

Kriteria Berlin Menentukan Gagal Nafas Akut

(Juga diterapkan oleh BPJS)
RSD dr SOEBANDI
KRITERIA GAGAL NAFAS AKUT
 PROTOKOL TERAPI O2
Kriteria
RR > 30 x/m, HR > 120 x/mnt KONVENSIONAL PADA
SpO2 < 95 % Tanpa O2 PASIEN NON COVID-19
EWS > 5 Dgn poin merah Respirasi
RSD DR SOEBANDI  Ruangan Tekanan Natural
Lanjutkan NC : JEMBER  Masker wajah/Nasal kanul yg pas
O2 NC 4 lpm tdk
• Tx Definitif selesai Membaik dengan oro-nasal
SaO2 < 95 % • ADL mandiri  Masker Non Ventilasi
ya  Penilaian kondisi pasien
berdasarkan EWS Ruangan
Ganti Simple Masker (tanpa reservoir bag) 6-10
lpm bertahap naik 2 lpm/30 mnt, turun 2 lpm/8 Lanjutkan SM 24 Jam
jam • SpO2 > 95%
 Tujuan (SpO2 > 95% / RR < 30) Berespon • RR < 30
 Monitoring intermitten ~ NEWS < 5
 Assess ulang 4 jam
Berespon

Ganti NRBM (dengan reservoir bag) Man Perawatan Kritis

Tdk Berespon 10-15 lpm bertahap
naik 2 lpm/2 jam, turun 2 lpm/8 jam : Masuk Protokol HFNC
 Tujuan (SpO2 > 95% / RR < 30) PALIATIF / RESUSITATIF
 Monitoring intermitten ~ NEWS < 7
 Assess ulang 2 jam Monitoring Ketat CVC - ABP
  Ruangan Intensif
Kriteria :
RR > 30 x/m, HR > 120 x/mnt PROTOKOL  ROX Index > 5 / 12 jam (Responsif)
> 9.2 (Optimal)
SpO2 < 95 % Dgn O2 NRM 15 lpm TERAPI HFNC  Penilaian kondisi pasien berdasarkan NEWS
EWS > 5 Dgn poin merah Respirasi
QSOFA > 2 – SOFA > 2 PADA PASIEN NON  Penilaian prognosa pasien masuk berdasarkan SOFA-
QSOFA
COVID-19  Penilaian pasien harian skor APACHE

Berespon Lanjutkan Membaik dan

HFNC 20 lpm, FIO2
Protokol O2 NEWS < 7
100, T ~ Px
Konvensional

 Flow 20-40 lpm/bertahap

 2 lpm/4 Jam,  2 lpm/8 jam Berespon HFNC 20 lpm FIO2 60%
 FiO2 60 – 100 %/bertahap • SpO2 > 95%
 4 %/4 Jam,  4 %/8 jam • RR < 30
 Tujuan (SpO2 > 95% / RR < 30)
Berespon
 Monitoring intermitten / 4 jam Masuk Protokol NIV
RESUSITATIF
 Resusitatif : Terakhir Flow 40 lpm/100%  Langsung
Tdk Berespon Man Perawatan Kritis
melanjutkan Algoritma NIV s/d Intubasi
 Paliatif : Flow  2 lpm/4 Jam  40-60 lpm Monitoring Ketat CVC - ABP
FIO2 100%
 Parameter Responsif : Masuk Protokol NIV
 ROX indeks > 5  Laktat < 2  SOFA < 7 PALIATIF
 PROTOKOL  Ruangan Intensif
Kriteria  Masker wajah yg pas dengan oro-
RR > 30-35 x/m TERAPI NIV RSD nasal
SpO2 < 93 %
FiO2 > 50 %
DR SOEBANDI  Vented mask
PF Ratio < 250 JEMBER  Filter viral/bakterial (posisi dan
Masuk perubahan / 24 jam)
Tracheostomy
PROTOKOL  Langkah lanjutan
ya Surgical / TDP
Masker NIV on → ventilator on
Masalah Airway MV
Ventilator Mati → Masker NIV Mati
tdk Tracheostomy
Surgical / TDP
Tracheostomy
Mulai NIPPV Tdk Berespon Surgical / TDP
 PEEP 5-10; PS 5-10 Resusitatif 1. Memastikan patensi jalan nafas
2. Memastikan O2 100% masuk Paru
 Tujuan (SpO2 > 92% / RR < 30) 3. Mencegah aspirasi pneumonia
 Monitoring Ketat ~ EWS 4. Menurunkan Kecemasan & kejadian
 Assess ulang 1–2 jam / 2-6 jam ETT tercabut
Paliatif 5. Menjamin

Man Perawatan
Berespon Kritis Menurunkan FiO2  berespon
Terapi O2
Lanjutkan NIPPV 24 - 48 h PS/PEEP  Intermitten Konvensional
• Goal (SpO2 >92%, RR < 30) Enteral (2-4 jam/hari)
feeding
 Gagal Napas Akut dan
Indikasi Ventilasi Mekanik
Ventilasi
Nilai Normal Nilai Kritis
pH 7.35-7.45 <7.25
PaCO2 35-45 >55 dan
meningkat
Rasio ruang rugi/volume 0.3-0.4 >0.6
tidal (V0/V1)

Oksigenasi
Nilai Normal Nilai Kritis
PaO2 80-100 <70 (on O2 ≥ 0.6)
P(A-a)O2
5-20 >450 (dengan O2)
PaO2/PAO2 0.75 <0.15
PaO2/FiO2 475 200
 Common modes of ventilation - TLC classification (Kapadia)

Mode Trigger Limit Cycling

Continuous Mechanical Ventilation Assist (CMVa) Ventilator or Patient Flow Volume (Time controls pause)
=Assist-Control(A/C)
= Volume-Control-Assist (VCa)

Pressure Control Ventilation (PCV) Ventilator or Patient Pressure Time (Time also controls pause)

volume-cycled Flow
Ventilator or Patient Volume (mandatory breath)
Synchronised-Intermittent-Mandatory Ventilation (mandatory
(SIMV) breath)

Pressure
pressure-limited SIMV Ventilator or Patient Time (mandatory breath)
(mandatory
breath)

Pressure Support (PS) Patient Pressure Flow

CPAP Patient Pressure Flow

CPAP + PS Patient Pressure Flow

A combination of synchronised intermittent mandatory ventilation (with the

SIMV + PS
appropriate characteristics of the mandatory breaths) and pressure support
(with its characteristics). Note that either type of SIMV mentioned above may
be used.

Note that where CPAP is combined with ventilator triggered modes, confusing terminology kicks in again - CPAP is then called
"PEEP" (Positive End-Expiratory Pressure).
RSD dr SOEBANDI
Spontaneous Breathing Trials
SBTs do not guarantee that airway is stable or pt can self-clear secretions
• Settings Causes of Failed Treatments
• PEEP = 5, PS = 0 – 5, FiO2 < 40% SBTs
Anxiety/Agitation Benzodiazepines or haldol
• Breathe independently for 30 –
Infection Diagnosis and tx
120 min
Electrolyte abnormalities Correction
• ABG obtained at end of SBT (K+, PO4-)
• Failed SBT Criteria Pulmonary edema, cardiac Diuretics and nitrates
ischemia
• RR > 35 for >5 min Deconditioning, Aggressive nutrition
• SaO2 <90% for >30 sec malnutrition
Neuromuscular disease Bronchopulmonary hygiene,
• HR > 140 early consideration of trach
• Systolic BP > 180 or < 90mm Hg Increased intra-abdominal Semirecumbent positioning,
pressure NGT
• Sustained increased work of
Hypothyroidism Thyroid replacement
breathing
Excessive auto-PEEP Bronchodilator therapy
• Cardiac dysrhythmia (COPD, asthma)
• pH < 7.32 Sena et al, ACS Surgery: Principles and Practice
(2005).
RSD dr SOEBANDI
Indications for extubation
No weaning parameter completely accurate when used alone
• Clinical parameters Numerical Normal Weaning
Parameters Range Threshold
• Resolution/Stabilization of
P/F > 400 > 200
disease process
Tidal volume 5 - 7 ml/kg 5 ml/kg
• Hemodynamically stable
Respiratory rate 14 - 18 breaths/min < 40 breaths/min
• Intact cough/gag reflex Vital capacity 65 - 75 ml/kg 10 ml/kg
• Spontaneous respirations Minute volume 5 - 7 L/min < 10 L/min
• Acceptable vent settings
Greater Predictive Normal Weaning
• FiO2< 50%, PEEP < 8, PaO2 > Value Range Threshold
75, pH > 7.25 NIF (Negative > - 90 cm H2O > - 25 cm H2O
Inspiratory Force)
• General approaches RSBI (Rapid < 50 < 100
• SIMV Weaning Shallow Breathing
Index) (RR/TV)
• Pressure Support Ventilation
Marino P, The ICU Book (2/e). 1998.
(PSV) Weaning
• Spontaneous breathing trials
RSD dr SOEBANDI
Ventilator management algorithim
Modified from Sena et al, ACS Surgery: Principles
and Practice (2005). Initial intubation
• FiO2 = 50% • RR = 12 – 15
• PEEP = 5 • VT = 8 – 10 ml/kg

SaO2 < 90% SaO2 > 90%

SaO2 < 90% SaO2 > 90%

• Increase FiO2 (keep SaO2>90%) No injury • Adjust RR to maintain PaCO2 = 40 Pass SBT
• Increase PEEP to max 20 • Reduce FiO2 < 50% as tolerated Extubate
• Airway stable
Identify possible acute lung injury • Reduce PEEP < 8 as tolerated
• Identify respiratory failure causes • Assess criteria for SBT daily
Acute lung injury Fail SBT
Airway stable

Acute lung injury Persistently fail SBT

• Low TV (lung-protective) settings • Consider tracheostomy Pass SBT
• Reduce TV to 6 ml/kg • Resume daily SBTs with CPAP or
• Increase RR up to 35 to keep tracheostomy collar
pH > 7.2, PaCO2 < 50
• Adjust PEEP to keep FiO2 < 60% Intubated > 2 wks

SaO2 < 90% SaO2 > 90%

Prolonged ventilator dependence
SaO2 < 90% SaO2 > 90% Pass SBT
• Dx/Tx associated conditions • Continue lung-protective • Consider PSV wean (gradual
(PTX, hemothorax, hydrothorax) ventilation until: reduction of pressure support)
• Consider adjunct measures •PaO2/FiO2 > 300 • Consider gradual increases in SBT
(prone positioning, HFOV, IRV) •Criteria met for SBT duration until endurance improves
RSD dr SOEBANDI

Shock = gangguan oksigenasi jaringan / sel

Ventilasi & distribusi

O2
udara Difusi
alveoli
Sirkulasi
kapiler
paru Sirkulasi
arterial
Difusi
kapiler
SHOCK
jaringan
O2
intra-sel

2b_Circulation 43
RSD dr SOEBANDI
KRISIS SIRKULASI
• Hipovolemia :
PERIOPERATIF
1. Hypovolemic: Kehilangan volume
• Shock hipovolemik

• perdarahan darah
• Shock kardiogenik
• muntaber
• Gagal jantung 2. Cardiogenic:• Shock
Gangguan
distributif
kerja jantung
• decomp. cordis
• infark miokard luas • Shock obstruktif

• Anafilaksis, Cedera 3. Distributive: Gangguan distribusi

spinal, Sepsis darah di perifer
• Pericardial tamponade, 4. Obstructive: Gangguan aliran darah
tension pneumothorax masuk dan keluar jantung

44
 RSD dr SOEBANDI

transport O2 normal
SYOK HIPOVOLEMIA Hb 7-15
– PERDARAHAN—

Sunder-Plasman 1968
Transport Oksigen
selama anemia

17/03/2023 45
RSD dr SOEBANDI

100% NORMAL

Cardiac Output HIPOTENSI

50% SHOCK

Hipoksia, acidosis

20% CARDIAC ARREST

Anoksia, sel otak mati

2b_Circulation 46
 Pasien wanita 25 th, HPP
RSD dr SOEBANDI Tensi 60, nadi lemah teraba 160 / menit
Telapak tangan dingin basah, Hb 6

#4 : HES
#2 : RL

#3 : RL
#5 : Transfusi

#1 Posisi Syok

17/03/2023 47
Posisi shock
RSD dr SOEBANDI & Resusitasi Cairan Terukur
Derajat I Derajat II Derajat III Derajat IV

Kehilangan darah ml < 750 750-1500 1500-2000 >2000

% <15 15-30 30-40 >40

Frekuensi jantung <100 >100 >120 >140

Tekanan darah sistolik Normal Normal Menurun Menurun

ANGKAT
KEDUA TUNGKAI
Tekanan nadi Normal Menurun Menurun Menurun

Capilarry refil Normal Melambat Melambat Melambat

Frekunsi nafas 14-20 20-30 30-40 >35

Produksi urin(ml/jam) >30 20-30 5-15 Minimal

Kesadaran Sedikit cemas Cemas Bingung Bingung & Letargi

300 - 500 cc darah dari kaki pindah ke

sirkulasi sentral 48
 1. Segera atasi sumber perdarahan
RSD dr SOEBANDI
2. Bila perlu anestesia, gunakan ketamine
(bila tidak ada kontraindikasi)

SURGICAL
RESUSCITATION

17/03/2023 49
+

Manajemen
Cairan Dasar
+ Manajemen Cairan Rumatan
51

 Ceklist Kebutuhan Pasien Dewasa:

 PASANG IV line
 Cairan Preop minimal (diberikan iv saat px dipuasakan)
 Maintentance :
 Pengganti Puasa  Jam 1 (50%) – Jam II (25%) – Jam III (25%) +
 Durante Op : Holiday Segar – Oh / Jam +
 Koefisien Operasi : Ringan (2-4 ml/kg/jam), Sedang (4-6 ml/kg/jam), Berat (6-10
ml/kg/jam)
+ 52

Manajemen Cairan Rumatan

 Cairan Bayi BBLR 1 hari preop (PERINA)

6jam Preop  4 ml/kgBB

Cegah HIPOTERMI (UKUR SUHU BERKALA) (ASIDOSIS-
KOAGULOPATI ~ TRIAS KEMATIAN)
Nutrition in the ICU
 BASIC KNOWLEDGE
1. Hitung Kebutuhan kalori perhari
a. 20-25 kkal/kgbb/hari (basal)  30 max
b. Kenaikan suhu 1 C menaikkan kebutuhan 10% kalori
dan cairan
c. Hari ke 1-4  Ebb Phase 40-60% kalori
d. Hari ke 5 s/d seterusnya  Metabolik Phase 80-
100% tergantung kondisi klinis pasien
2. Hitung Kebutuhan masing-masing elemen
a. Karbohidrat 40-60%  1 gram = 4 kkal
b. Lemak 20-40%  1 gram = 9 kkal
c. Protein Tidak Dihitung sebagai Enersi
3. Hitung Protein sebagai kebutuhan harian : 1,2-2
gram/kg/hari
 Nutrisi pada critically ill patient
• Perlu memberi nutrisi:
– ↑ prognois,↓ lama rawat, ↓ infeksi (total kalori > 25%), mempercepat
ekstubasi ( total kalori ≥ 66%)
Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)
Nutr Clin Pract 2010 25: 205
• Kapan?
• Jalur pemberian nutrisi? : enteral/ parenteral
• Berapa banyak?
• Komposisi?
Jalur pemberian
 Enteral nutrisi
• Yang harus diperhatikan:
– Osmolaritas:
• isotonik 300 mOsm/L
• 1 cc = 1 kalori
• Semi elemental osmolaritas > 400 mOsm/L
– Tidak semua standar enteral nutrisi berkomposisi
sama: 12- 15% protein,25- 30% lemak, pemberian
modulen protein di ICU merupakan rekomendasi
– Typical hanging time:
• Formula dari powder: < 4 jam
• Formula cair: 8-12 jam
57
 Cara Cara pemberian EN
Cara Definisi Keuntungan Kerugian
Bolus 200-400 mL dlm 20-30 •Mobilitas pts >>> •↑ Diare, mual,
menit bbrp x/hr •Wkt pemberian < kembung, kram
Mmki siring/gravity •Tdk perlu pompa perut, nyeri perut
Kecep tidak > 30 mL/mnt

Intermiten >500 mL dlm 30-90 •Mobilitas pts > •Perlu reflex

menit; 3-5 x/hr •Lebih fisiologis menelan
Pemberian malam > •↑ Aspirasi, mual,
Mmki pump/gravity muntah, distensi
abd, delayed
gastric emptying

Kontinu/ EN terus-menerus 20-24 •Toleransi > thdp Mobititas tgg

siklik jam/hr hipertonik formula
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