1. PARENTERAL - ENTERAL NUTRITION pada PASIEN dengan MALNUTRISI
Fitri Vidyastuti dr, Sp.GK

2. Definition of Malnutrition
Malnutrition can be defined as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease”
Cederholm T, et al., ESPEN guidelines on definitions and terminology of clinical nutrition, Clinical Nutrition (2016)

3. Etiology of Malnutrition
The Academy of Nutrition and Dietetics/The American Society for Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics: Application in Practice; Nutr Clin Pract. 2013;28:

4. Route of Nutritional Intervention
ASPEN; 1998

5. Indication EN
If “under nutrition” already exist  nutritionally problems
Unintentional weight loss
Insufficient to meet requirement to metabolic demand
If it is anticipated that the patient will be unable to eat more than requirement
If an inadequate food intake ( < 80 % of estimated energy expenditure) is anticipated for more than requirement

6. Route of Enteral Nutrition Protein and energy enriched
Oral
Sip feeding
Naso gastric*
Pharyngostomy
Gastric
Percutaneous endoscopic gastromy (PEG) or G-tube (button)
Enteral Nutrition
Oesophagostomy
Gastronomy*
Radiological Inserted gastronomy (RIG)*
Surgical gastronomy
Nasoduodenal*
Tube Feeding
Duodenal
Extended gastronomy*
Naso jejunal
Jejunal
Extended gastronomy*
Direct access
Surgical jejunostomy
Fine needle catheter

7. Enteral Nutrition Products
KALBE NUTRITIONAL PRODUCTS
NUTRISI ENTERAL
NUTRISI PARENTERAL
ANAK
TINGGI PROTEIN
GANGGUAN
HATI
GANGGUAN GINJAL
ENTRAKID
PEPTISOL
HEPATOSOL/
HEPATOSOL
LOLA
NEPHRISOL/
NEPHRISOL-D
KANKER
NUTRICAN
SEIMBANG
ENTRAMIX
NEUROLOGI
PEPTIBREN
SISTEM IMUN
PEPTIMUNE

8. Indication PN
If early EN is not feasible or available over the first 7 days after admission.
More than 10% involuntary weight loss over a 2-3 months period.
Less than 75% of ideal or usual body weight
Serum prealbumin less than 10 mg/dl serum transferrin less than 100 mg/dl
History of inadequate oral intake for more than 7 days .

9. Route of PN > 900 mOsm/L Amino acid > 5 % Dextrose > 20 %
Lipids
Includes vitamins, minerals, and trace elements
PN for > 7 – 14 days
600 – 900 mOsm/L
PN for short-term < 7 – 14 days

10. Complications PN (Catheter-Related)
Insertion
pneumothorax
chylothorax
hematothorax
air embolus
arterial puncture
nerve injury
Mechanical
poor catheter placement
phlebitis
thrombosis
catheter occlusion
rupture
embolus
Infection
catheter insertion site
subcutaneous tunnel
colonization
bacterimia
sepsis

11. Complications PN Metabolic Hyperglycemia Electrolyte imbalance
Prerenal azotemia
Abnormal acid-basa balance
Overfeeding
Hepatic steatosis
Increased CO2 production
Respiratory distress syndrome
Gastrointestinal
Liver function disorder
Gastrointestinal atropy

12. Monitoring PN Glucose Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholesterol
Body weight
Nitrogen balance
Plasma protein
Creatinine/height index

13. Guidelines for Nutritional Monitoring
Test Initial Stable Hospitalized Patient Home Patient
Body weight daily daily twice weekly
Output : urin every 8 hours daily twice weekly
stool daily twice weekly
Urine glucose every 6 hours every 6 hours twice weekly
Blood :
Glucose daily every other day weekly
Electrolytes daily every other day monthly
BUN, creatinine daily weekly monthly
Total protein, weekly weekly monthly
Albumin
transferrin
Calcium, weekly weekly monthly
phoshorus
LDH, AST, Bilirubin weekly weekly monthly
Alkaline phosphatase
TIBC,iron Weekly weekly monthly
CBC, differential, weekly weekly monthly
prothrombin time
Anthropometrics monthly monthly
Nitrogen balance twice weekly weekly monthly

14. Parenteral Nutrition Products
KALBE NUTRITIONAL PRODUCTS
NUTRISI PARENTERAL
NUTRISI ENTERAL
KARBOHIDRAT
LARUTAN ASAM AMINO
EMULSI LEMAK
MULTICHAMBER BAG
TRIOFUSIN
AMINOFUSIN L-600
KALBAMIN
DISEASE SPECIFIC
AMINOFUSIN HEPAR
COMAFUSIN HEPAR
RENXAMIN
CLINOLEIC
CLINIMIX

15. PRODUK
KARBOHIDRAT
PROTEIN
LEMAK
VITAMIN & MINERAL
Triofusin 500, 1000, 1600 √ -
Triofusin E1000
Aminofusin L-600
Kalbamin 10%
Aminofusin Hepar
Comafusin Hepar
Renxamin 9%
Clinoleic 20%
Clinimix N9G15E
Clinimix N9G20E

19. Terima Kasih