Optimizing

Nutrition Therapy
dr. PAUL A DWIYANU PULMONOLOGIST,
CONSULTANT
 Prevalence of Malnutrition
Malnutrition occurs frequently in hospitalized patients it is associated with

01 Increased complication

Prolonged length of stay 02

03 Increased mortality
 Biochemical
parameter

Anthropometric
Assessment evaluated
nutritional status
measurement

Subjective Global
Assessment
 Subjective Global Assessment

over the last 6 months

during the past 2 weeks Nausea, Vomiting,
diarrhea,Anorexia
Weight changes
Gastrointestinal
symptom Illness and Nutritional
Requiremen
Dietary Intake
Fungtional
capacity
•No changes . Physical Exam
•Changes – Duration Dysfungtion – Duration
-Type - Type
- Inadequed conventional diet
( glosisitis, angular stomatitis,
( ambulatory/bedridden loss subcutan etc)
-Total liquid diet )
- Clear liquid diet (hypocaloric)
- Fasting
Nutrional Requirement
Composition
20
Lipid
%
68%
12 Carbohydrates
Protein
%
 Nutrional
Requirement
Stable patients Stressed patients

0,8 – 1,0 g/kgBW Protein 1,2 – 2.0 g/kgBW

20%-35% of
25%-30% of calories Lipids
calories

50%-65% of calories Carbohydrates

 Calculating Basal Energy Expenditure
Harris-Benedict Equatio Variables

gender, weight (kg), height (cm), age (years)

Men:
66.47 + (13.75 x weight) + (5 x height) - (6.76 x age
Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

“Rule of Tumb”

Calorie requirement = 25 to 30 kcal/kg/day

 “Rule of Tumb”

Calorie requirement = 25 to 30 kcal/kg/day

Nutrients kcal

01 Protein (4 kcal / g)

Carbohydrates
02 Enteral 4 kcal / g
Parental 3.4 kcal / g

03 Lipids (9 kcal / g)

Water
04
05 Vitamins (Water and fat soluble)

Minerals (Electrolytes , trace elements and ultra trace minerals)

06
 COOH
Chemical Structure of an Amino Acid
R

NH3

Nitrogen Balance

NB = IN – (UN + RNL)

NB : Nitrogen Balance
IN : Ingested Nitrogen
UN : 24-Hour Urine Nitrogen
RNL : Remaining Nitrogen Loss (3.1 g/l)
 Respiratory Quotient (RQ)

RQ = Vco2 - Glucose oxidation RQ

Vo2 1 glucose = 6 O2 = 6 CO2 + 6 H2O 6/6 = 1.0

- Fat oxidation
RQ : Respiratory Quotient 1 palmitate + 23 O2 = 16 CO2 + 16 H2O 16/23 = 0.7
Vco2 : Co2 Produced
Vo2 : Oxygen Consumed - Protein Oxidation
1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O 4.1/5.1 = 0.8

- Lipogenesis > 1.0 – 8.0

 ALGORITMA NUTRITIONS ROUTE

GOOD POOR

> 7 days < 7 days

> 6 weeks < 6 weeks

- aspiration + - aspiration +
 Enteral Nutritional

Oral Tube feeding

supplement

“ if the gut works use it”

Enteral Formula: Selection
Infusion Pump Indication
- Small intestine
- Fluid restrictions
- Risk of aspiration
- Need for precise flow
rate
- Nocturnal Feeding
- Infants and small
children

Gravity Infusion
- Suitable for intermittent
feeding
- Ambulatory patients
- Gastric feeding
Enteral Nutrition Category

Polymeric Olygomeric Disease

Formula Formula Specific
•commercial
formula
formula
•blenderized

01 02 03
Polymeric Formula
 Oligomeric Formula Categories
Hydrolyzed macronutrients facilitate digestion and absorption
component

Amino Acid Glucose polymers

( Glutamin, Argini )
08 01
Peptides Polyunsaturated
07 02 fatty acid (PUFA)

Monosaccharides Medium chain

06 03 triglycerides
Vitamins and
Disaccharides
05 04 minerals
Indication for use:
Non-Functional Hemodynamic
gastrointestinal tract instability

Impossible to use the Ability to adequately

gastrointestinal tract receive and absorb
necessary foods orally
Need for intestinal or by gastric or enteral
tube
rest
Palliative use in
terminal patient is
controversial
Central Parenteral Nutrition

Selection depends on caloric requirements, volume to be administered and

patient condition, as well as final concentration or components:

Amino Dextros Lipids Includes Osmolali

Acids e > 20% vitamins ty > 700
> 5% , mOsm/k
minerals g H2O
, and
Peripheral Parenteral Nutrition

Selection of peripheral access depends on clinical situation requirements, tolerance

to volume, and final formula concentration

Osmolality Total kcal limited by Incude ½ of

< 700 concentration and ratio the
mOsm/kg to volume being recommende
administered d electrolytes
for PN
Parenteral Nutrition
Dextrose

Provides 3.4 kcal/kg Closely related to

solution osmolality

can be the only source of dextrose infusion rate should

energy not
exceed 5 mg/kg/min
 Formulas : Parenteral Nutrition
Amino Acids

Standard concentration Energy value of amino Nitrogen (g)

can vary between acids (4 kcal/kg) = protein (g) / 6.25
5% and15%
Formulas: Parenteral Nutrition
Lipids

Added to basic parenteral

Prevent essential fatty nutrition solitions or
acid deficiency administered
individually

Non-protein source of Includes as LCT or

kcal. Recommended dose a mix of MCT/LCT
1 g/kg/day at 10% and 20%
Available in 10%
20% and 30%
concentrations
Formulas: Parenteral Nutrition
• Lipids
Should be used
Less hyperglycemia
with care in:

Lower concentrations
- Hyperlipidemia
of serum insulin
- Symtomatic
atherosclerosis
- Acute
Less risk of hepatic pancreatitis with
damage hypertriglyceridem
ia

High doses can

interfere with immune
functions

High infusion rates

can affect respiratory
functions

ALLPPT.com _ Free Powerpoint Templates, Diagrams and Charts

Electrolytes

01 02 03
Calcium, magnesium, Forms and amounts Must consider calcium-
phosphorus, chloride, are titrated based on phosphate solubility
potassium, metabolic
sodium, and acetate status and
fluid/electrolyte
balance
Vitamin and Minerals

01 02 03
In general, amounts below Added daily to Acute illness, infection,
daily recommended parenteral nutrition preexisting malnutrition,
intake for healthy people, and
but nonetheless sufficient excessive fluid loss
to cover requirements, are increase vitamin
added to oral or enteral requirements
formulas
Disease Specific Formula Selection
Pulmonary disease with CO2 retention

1 Decreased carbohydrate content↓

2 Increased fat content↑

3 High caloric density↑

4 Intact proteins

5 Fiber supplement
Excess Glucose Metabolism

CO2
Cytoplasma

lipogenesis
Glucose Mithocondria

Glucose
Piruvat Siklus kreb
Cori Cycle
Piruvat Asetil COoA

ATP

Lactate Lactate
Cancer induced weight loss

Complex metabolite
syndrome ( anorexia,
significant weight loss & fatigue,
muscle wasting early satiety )

Cannot correct by
additional calories
etiology are pro
inflammatory cytokines,
acute phase response,
abnormal metabolism,
proteolysis inducing factor
 Cancer- Induced weight loss Recommendation :

High proteins and Zn to build Eicosapentaenoic acid

muscle↑ (EPA)

Low fat to avoid early Antioxidants (vitamins A C

satiety ↓ E & Se)

Low in sucrose for better Folate and iron for anemia

patient acceptance ↓

High in fermentable fiber ↑

Excess Fatty Acid Supply

Free Fatty Acid

Cytoplasma

Fatty acid
Mitochondria
Carnitin

Acetyl
Fatty acid
CoA
G-6-Oxidation

Low insulin

High insulin
Trigliserida
Ketone
 Disease-Specific Formula Selection:
Critical Care (Mechanical Ventilation)
Lung Injury / SIRS / ARDS

Eicosapentaenoic Gamma-linolenic
acid (EPA) Acid (GLA)
01 02

No arginine 05 03
supplementation
04

High caloric Antioxidants

density ↑
Inflamasi Respond

Cytoplasma

glucose Asetil CoA

Mitochondria
Glucose
piruvat Siklus kreb

piruvat ATP
Cori cycle

lactate

lactate
Blockage TNF α,
IL, Leucotrien
Fatty Acid Metabolism

Blockage TNF α, IL
Pembuluh darah
Cytoplasma

Fatty
acid Mitochondria
Trigliserida
Carnitin

Fatty
acid ATP
Fatty acid
G-6-Oxidation

trigliserida
Glicerol
Disease­Specific Formula Selection 
Critical Care
Nutrient Choices
 Disease-Specific Formula Selection:
Advanced AIDS (with weight loss)

Weight loss > 5% below normal

CD4 < 400

Serum albumin < 3.0 g/dL

Diarrhea

Impaired immune function

Opportunistic infection
Disease-Specific Formula Selection :
Advanced AIDS (with weight loss)

Recommendations

Increased Low fat for Added fiber EPA to down Increased

protein ↑ improved regulate levels of anti
tolerance ↓ metabolic oxidants
changes (beta-
associated carotene,
with cachexia vitamin E, C)
and B vitamin
(B6, B12) ↑
thank’s
BEE dikalikan 1,2 pada kondisi :

1.Demam. BEE x 1,1 untuk setiap kenaikan 1 derjad C diatas

suhu normal tubuh
2.Stress ringan. BEE x 1,2
3.Stress sedang . BEE x 1,4
4.Stress berat. BEE x 1,6
Persaman haris Benedict dapat pula menghitung BEE

PRIA — BEE = 66.47 + (13.75 x weight) + (5 x height)

– (6.76 x Age)
WANITA— BEE = 655.1 + (9.56 x weight) + (1.8 x
height) – (4.68 x Age)
• KH diperkirakan 70% dari total kalori yang
diperlukan
• Protein. Diperlukan protein yang lebih besar
dari normal dikarenakan proses
hiperkatabolisme pada pasien penyakit kritis
• Lemak. Diperlukan 30% dari total energy
harian yang diperlukan
• Cairan. Kebutuhan cairan diperkirakan
mencapai 30 ml/KgBB
• Vitamin
 Intake total harus mencukupi untuk

Energi, aktivitas dan Toleransi GIT,

protein, kondisi yang ketidakstabila
mineral, mendasari n metabolik
mikronutrien,s penyakit
erat, cairan
Cara pemberian
nutrisi
Parenteral
Enteral
Nutrisi enteral
Komposisi pemberian enteral
Komplikasi pemberian nutrisi enteral
Nutrisi parenteral
Jenis yang Cairan Dextrose
digunakan

Cairan asam amino elektrolit

Emulsi lemak
Komplikasi pemberian nutrisi parenteral
Monitoring pada pasien yang diberikan nutrisi
parenteral
 Farmakonutrien

Suplemen arginin Glutamin

Prebiotik dan Hormon seperti

probiotik kolesistokinin dan
peptide YY
 Pemeriksaan fisik
You can simply impress your audience and add a
unique zing and appeal to your Presentations.

Penentuan
status
nutrisi
dilakukan Tes biokimia
melalui You can simply impress your audience and add a
unique zing and appeal to your Presentations.
Tujuan pemberian nutrisi pada pasien ICU
Nutritional Requirement
Fatty Acid Metabolism

Blockage
TNF α, IL
Pembuluh darah

Cytoplasma

Fatty
acid Mitochondria
Trigliserida Carnitin

Fatty
acid ATP
Fatty acid
G-6-Oxidation

trigliserida
glicerol
 Ideal weight

Actual weight

In malnutrition, energy expenditure must be calculated based on actual body weight

 Early Detection of Malnutrition

Elderly

Alcoholism

Hipermetabolik

History of chronic disease

Gastrointestinal disease
Chronic renal insufficiency
BMI <18,5 Cancer
COPD
Alat uji untuk mengukur nutrisi

MUST MNA NRS-2002

SGA MST NRI