Tatalaksana Nutrisi

pada Pasien Kritis

Bambang Pujo Semedi
Dept. Anestesiologi dan Terapi Intensif
RSUD Dr Soetomo – Universita Airlangga
SURABAYA
 1 dari 3

1. The Alliance to Advance Patient Nutrition. Coats KG et al. J Am Diet Assoc 1993; 93: 27-33.
2. Giner M et al. Nutrition 1996; 12: 23-29;
3. Thomas DR et al. Am J Clin Nutr 2002; 75: 308-313.
 What is malnutrition?
“Malnutrition is a state of nutrition in
which a deficiency or excess (or
imbalance) of energy, protein and other
nutrients cause measurable adverse
effects on tissue/body form (body
shape, size and composition) function
and clinical outcome.”
Elia, (2000)
Objective Criteria of MALNUTRITION
• A body mass index (BMI) < 18.5 kg/m

• Unintentional weight loss > 10 % in 3 – 6

months

• A BMI < 20 kg/m2 and unintentional weight

loss > 5% in 3 – 6 months
 Many studies have shown that
complications are 2 to 20 times more
frequent in malnourished patients than
in well-nourished patients.

Buzby et al. Am J Surg 1980

Hickman et al. JPEN 1980
Klidjian et al. JPEN 1982
 Starvation is
the most extreme form of
malnutrition.
STARVATION is the most
common form of
malnutrition in hospital
MALNUTRISI di RS
adalah…
Ketidakcukupan asupan
kalori dan/atau protein
dalam periode waktu
cukup lama yang
mengakibatkan
hilangnya cadangan
lemak dan/atau massa
otot 1
 Malnutrition in Hospital
• Many people are malnourished prior to
admission to hospital
• People in hospital are at risk of becoming
malnourished or further malnourished
• Prevalence of malnutrition in hospital has
been quoted as 40% (McWhirter & Pennington, 1994)
• Up to 43% of patients in ICU are malnourished
(Giner et al, 1996)
Identify Malnutrition
is KEY POINT
Screening should be done
on admission
 Prevalence of Malnutrition in
Hospitalized Patients
Percentage of malnourished patients at
time of admission :
• 46% of general medicine patients
• 45% of patients with respiratory problems
• 27% of surgical patients
• 43% of elderly patients
In a published British study

McWhirter et al. Br Med J 1994

 Malnutrition Universal Screening Tool
(MUST)

• ANTICIPATE/PREVENT malnutrition
• Confirm malnutrition
• To facilitate planning of appropriate nutritional
support
• To act as a method of monitoring progress
• Takes into account the past, present and future
• Can be used across a variety of settings
 MUST
• To be completed for each patient on
admission and rescreen weekly (or more
often if indicated)
• ACTION to be taken according to the high,
medium or low risk score
• Completed assessment forms to be kept
with patient documentation
Subjective Global Assessment
 Penilaian status nutrisi pada pasien kritis
sangat krusial
“Nutritional evaluation of the ICU patient is mostly based on parameters, which include comorbidities, medical and nutritional history,
information on weight loss and functional ability prior to the hospitalization, BMI, digestive function, and physical examina tion to
assess loss of muscle mass and fat stores. Biochemical parameters such as CRP, albumin, and prealbumin are affected by the inflammatory

“Every critically ill patient staying for more than

process and therefore are not indicators of malnutrition. It is recommended to use validated screening tools such as the NUTRIC score,
MUST, SGA, and GLIM criteria” –Israeli Dietetic Association, 2020-
“Malnutrition and muscle wasting generally occur during ICU stay due to the effect of catabolic hormones, an imbalance between intake
48 h in the ICU should be considered at risk for
and requirements but also as a result of physical immobilization. No validated tool is available but lean body mass evaluated by
ultrasound, computerized tomography (CT) scan, bioelectric impedance or even stable isotopes might be performed to evaluate this loss.

malnutrition” (ESPEN, 2019)

Such loss in muscle is associated with a prolonged hospital stay and interferes with quality of life and functional capacity . Muscle
function may also be assessed by various tools such as a handgrip dynamometer if the patient is conscious, being an especially good
prognostic factor in conscious patients with Adult Respiratory Distress Syndrome (ARDS) - Clinical Nutrition, 2019-
 Saat mengalami sakit…
Fase respons akut Perubahan hormonal
• Perubahan distribusi & ▪ Resistensi insulin :
metabolisme • ↑ kadar kortisol, CAs,
• ↑ sintesa globulin Glucagon dan GH
• ↑ gluconeogenesis serum.
• ↓ kadar besi dan Zn • ↓ oksidasi glukosa, ↑
• ↑ kadar Cu dan laju produksi glukosa
ceruloplasmin hepar
• ↑ laju oksidasi
▪ Sick euthyroid syndrome:
Katabolisme & ↑ UUN • ↑ T₄ menjadi rT₃
• ↑ pemecahan protein sehingga menyebabkan
• 1 g UUN = N₂ dlm 6,25 g protein ↓ T₃ (respons
• Normal : 10-12 gm penghematan energi)
• Sakit kritis : 16-20 g ®DR GEETANJALI S VERMA
Tatalaksana nutrisi yang tepat sejak
awal pada pasien kritis sangat
mempengaruhi luaran..
Tatalaksana nutrisi yang tidak tepat
pada pasien sakit kritis akan
memperburuk outcome
Dampak pemberian kalori yang
berlebihan pada pasien kritis

• Peningkatan laju metabolik

• Memberi beban terhadap sistim respirasi

sulit lepas ventilator

BEE pada Pasien Kritis dipengaruhi….

• Injuri
• Demam
• Cemas
• Nyeri
• Work of Breathing
• Underlying Diseases
• Tirah baring
• Ventilator
• Dll..
REE : Aktual vs Prediktif
Ada 4 pertanyaan yang harus dijawab
saat merencanakan pemberian nutrisi
pada seoran pasien kritis……
Apa yang
diberikan?

Nutrisi
pada
Kapan? Siapa?
pasien
sakit kritis

Bagaimana?
Respons Metabolik terhadap Injuri
Ebb Phase

Flow Phase

INJURI “Katabolik”

0 12 24 1 2 3
Jam Mingg
u
 Mengapa terjadi “starvation”
pada pasien kritis ?
• Impaired intake
• Kegagalan dalam mencerna dan
absorpsi makanan
• Excess nutrient losses
• Perubahan kebutuhan nutrisi
 Aim of nutritional support in
critically ill patients
• Provide nutritional substrates to meet
protein and energy requirements
• Help protect vital organs and reduce break
down of skeletal muscle
• To provide nutrients needed for repair and
healing of wounds and injuries
• To maintain gut barrier function
• To modulate stress response and improve
outcome
Malnutrisi pada pasien kritis sering
menyebabkan….
• Kelemahan umum, terutama otot-otot
pernafasan
• Hilangnya tonus diafragma
• Bisa berdampak terhadap fungsi kognitif

1. Fiaccadori E, Zambrelli P, Tortorella G. Physiopathology of respiratory

muscles in malnutrition. Minerva Anestesiol. 1995 Mar;61(3):93-9.
2. Dureuil B, Matuszczak Y. Alteration in nutritional status and diaphragm
muscle function. Reproduction Nutrition Development, EDP Sciences,
1998, 38 (2), pp.175-180.
 Konsekuensi malnutrisi

• Penurunan berat badan

• Kelemahan umum dan mudah
lelah
• Impaired ventilatory drive Meninggal
• Depresi/apatis
• Gangguan penyembuhan luka
• Kegagalan fungsi imun tubuh
Webb (1999), Garrad (1996)
 Syok Trauma Luka bakar Sepsis

Hipermetabolisme & katabolisme

Nutrisi yang tepat

Protein Utilization Depends
on Energy Availability

+10 Rombeau J.L. 1990

-10

-20

-2 0 +2 +4 +6
Energy Balance (kcal/kg/d)
O2 consumption &
resting metabolic
rate in sepsis,
sepsis syndrome &
septic shock

Kreymann G et al,
CCM 1993; 21:1012

30 patients
118 determinations
Tatalaksana Nutrisi
pada Pasie Kritis
 Assessment
Alur pemberian nutrisi
GIT Function Adequate
NO
YES YES
Short breath
Dysphagia
Oral Contraindication? PN
Severe illness/Critically ill
≤2 weeks >2 weeks

EN Per OS PN Perifer PN Central

Intake Evaluation 3x24

GIT Adequate?

Intake ≥60% daily Intake ≤60% daily

calorie target calorie target Yes No

Cont oral/EN diet PN Per OS

supplementation

Oral + Oral Nutrition Supplement > EN > PN

“Early provision of EN (within 48 h of ICU admission) in patients
who are mechanically ventilated is an established standard of
care and supported by all clinical guidelines ” (Lambell et al, 2020)
 Enteral feeding is more natural
“If the gut works – use it”

• Nasogastric (NG)
• Nasojejunal (NJ)
• Percutaneous Endoscopic Gastrostomy (PEG)
• Percutaneous Endoscopic Jejunostomy (PEJ)
• Radiologically Inserted Gastrostomy (RIG)
• Surgical Gastrostomy
• Surgical Jejunostomy (JEJ)
 ESPEN Guidelines on Parenteral Nutrition: Intensive Care
Singer P. et al. Clin Nutr 2009, 28: 387-400

1. EN should be given to all ICU patients not expected

to be taking a full oral diet within 3d.

2. Initiate EN within the first 24 h.

 ESPEN Guidelines on Enteral Nutrition: Intensive Care

EN should be given to “ all ICU patients “ …

• Once hemodynamically stabilized
• Without mechanical gut obstruction
• And remember the risk of refeeding
syndrome
Berapa
banyak ?
 Nutritional Requirements
Energy
Calculation of basal metabolic rate with additional factors
for:
– Stress
– Activity
– Energy required to metabolise food (diet induced thermogenesis)
Protein
Typically 0.8 – 1,2 g protein/kgBB, increased during stress
Fluid
20-25 ml/kg for > 60 yrs and 30 ml/kg for < 60 yrs
 ESPEN Guidelines on Parenteral Nutrition: Intensive Care
Singer P. et al. Clin Nutr 2009, 28: 387-400

Initial acute phase :

max. 20-25 kcal/kg BW/day, then….
25 – 30 kcal/kg BW/day
 ESPEN Guidelines on Enteral Nutrition: Intensive Care

“Body weight” corrected for water & fat excess!

• In absence of indirect calorimetry :
• 3 first days, 20 kcal/kg/d
• Then, 25-30 kcal/kg/d
• And in obese patients
• 11–14 kcal/kg actual BW or 22–25 kcal/kg
ideal BW
 Kebutuhan Protein pada Pasien
”Most patients can be appropriatelyKritis
fed by a standard diet. Even in case of small
bowel access e.g. by a NCJ no oligopeptide diet is required”
(ESPEN Guidelines on Surgery, 2017)

ICU patients with 1.2-1.5

g/kg/d delivered protein had Guidelines Protein Needs
reduced 28-day mortality ASPEN / SCCM 1,2-2 g/kgBB/ hari
(Weijs et al, 2012) (2016)
Obesitas :
Patients with higher protein BMI 30-40 = 2g/kgBB/hari
intake were significantly more BMI > 40 = 2,5 g/kgBB/hari
likely to be discharged alive
from the ICU than those with ESPEN (2019) 1,3 g/kgBB/hari (pregresive)
the lowest protein intake
(Allingstrup et al, 2012) Obesitas = 1,3/kgBB ABW/hari

Patients who received adequate protein were more likely to be weaned from the
ventilator and had a lower ICU and overall in-hospital mortality and greater 60-day
survival than those who did not meet protein needs even when the overall energy
adequate (Song et al, 2017)
 Karbohidrat dan Lemak

ESPEN expert statement 2020 :

Patients with respiratory
deficiency
Carbohydrate : Fat = 50:50
 p<0,001

Membandingkan efek nutrisi enteral

tinggi lemak dan rendah karbohidrat
vs nutrisi enteral isokalori standar
terhadap PaCO2 arteri dan lama Hasil pada grup B:
penggunaan ventilator pada gagal
• Mengalami penurunan PaCO2
napas tipe II sekunder akibat penyakit
paru yang memerlukan ventilator
sebesar 16%, dan minute volume
mekanik & nutrisi enteral sebesar 8% saat weaning dari
ventilator
• Grup A: (n=50) nutrisi iso-kalori
standar dengan karbohidrat (53,3%), • Waktu rata-rata penggunaan
lemak (30%) dan protein (16,7%). ventilator 62 jam lebih singkat
• Grup B: (n=50) nutrisi iso-kalori dibanding grup A
tinggi lemak rendah karbohidrat
 Kebutuhan Mikronutrien
Vitamin Jumlah
Vit A 650 Pria RE /hari
600 RE /hari
Vit B1 Severe / critical illness:
IV: 100 mg / 24 jam secara perlahan
Vit B6 25-100 mg /hari
Vit C Severe / critical illness: 1 jam pertama: IV 4 g in 100 cc Nacl 0.9%
drips. Diikuti dengan: IV 1 g / 8 jam dlm 50 mL Dextrose 5% atau 50
cc NaCl 0.9%
Vit D <70 yo: 600 IU / hari
> 70 yo: 800 IU / hari
Vit E 400 IU/hari Mineral Jumlah
Selenium 200 ug/hari
Zinc 20-40 mg/hari
Calcium Critical condition: 600 mg/hari
24-Hour energy expenditure in healthy subjects

100
Physical activity
88
Thermogenesis
75

%
Basal metabolism

0
Energy
Expenditure:

prediction
 Definisi
• Energy Expenditure : jumlah kalori yang
dikonsumsi berdasarkan suatu periode waktu
tertentu, biasanya dalam 24 jam
• Resting Energy Expenditure : kalkulasi dari
jumlah kalori yang diperlukan seorang pasien,
dan diukur dengan melihat beda kadar O2 dan
CO2 antara ekspirasi dan inspirasi
• Basal Energy Expenditure : jumlah energi
minimum yang diperlukan untuk menjaga fungsi
tubuh
– Ditentukan : BB, TB, Usia, Jenis Kelamin
 54

Energy Expenditure
50

Laki-laki
46 Perempuan
kcal/ m2/ jam

Fleisch A. Helv Med Acta 1951;1:23-44

42

38

34

30
0 10 20 30 40 50 60 70 80 Tahun
 Determining energy requirements in the intensive care unit
Guttormsen AB et al. Curr Opin Clin Nutr Metab Care 2014, 17: 171-176

Indirect calorimetry: a guide to optimizing nutritional support in

ICU - CHILDREN
Sion-Sarid R et al. Nutrition 2013, 29: 1094-1099

i s he d
p u b l
20 0 l a
> r m u
fo
The influence of caloric & protein intake upon nitrogen balance
Elwyn DH et al. Crit Care Med 1980; 8:9-20
Observe sign of overfeeding syndrome
Metabolic consequences of overfeeding
• Hyperlipidemia (increased • Fluid overload
fat levels in the blood) • Hepatic dysfunction
• Azotemia (increased urea) (abnormal liver function
tests, fatty deposits in the
• Hyperglycaemia (high blood liver)
sugar levels) • Excess CO2 production
• Respiratory compromise
Klein (1998)
 Beda pasien…beda kebutuhan..
• Pasien COPD → perlu limitasi karbohidrat
• Pasien luka bakar → REE tinggi → perlu kalori
dan protein lebih besar
– Berapa banyak kalori yang dibutuhkan????
Adjust in Obese Patient…
Nutrition therapy of the severely obese, critically ill patient:
summation of conclusions and recommendations
Martindale RG et al. JPEN 2011; 35: 80S-87S

Soc Crit Care Med (SCCM) /Am Soc Par Ent Nut (ASPEN)

Caloric requirements estimated by the weight-based equations :

11–14 kcal/kg actual BW or 22–25 kcal/kg ideal BW.

Protein requirements based on BMI:
Class I - II (BMI 30 – 39.9) : 2.0 g/kg Ideal BW
Class III (BMI ≥ 40) : 2.5 g/kg Ideal BW
Are patients fed appropriately according
to their caloric requirements ?
McClave SA et al, JPEN 1998, 22: 375-381

Distribution of measured EE in 335 patients on MV

as % of predicted EE (HB)
Keep a Balance…
Energy balance in ICU patients

TWO SOURCES :

• Endogenous substrates

• Nutrition support & therapy

 Indirect Calorimetri

Deltatrac Quark-RMR CCM Express

IC measures parameters directly related to
patient’s EE → support weaning and help
determine contribution of metabolism to
ventilation
Respiratory Quotient
Rasio antara produksi CO2 dan
konsumsi O2, dan bila diukur lewat
mulut disebut sebagai respiratory
exchange ratio (RER)
Reflects which of three fuels is
being used to supply energy the
patients requires
 Indirect Calorimetry memberi informasi …

REE
Berapa banyak
“kalori” yang
dibutuhkan

memilih “proper mixture” dan

membantu menentukan komposisi
RQ lemak-karbohidrat-protein yang
tepat untuk pasien
 O2 (ml) CO2 (ml) RQ
Glucose 828.8 828.8 1.00
Lipids 2019.3 1427.3 0.70
Proteins 966.3 773.9 0.80

RQ = O2 consumption / CO2 production

Interpretation 0.7 - 0.85 lipolysis

0.7 - 0.95 glycolysis
≥ 1.0 lipogenesis

Guttormsen AB, Pichard C. Determining energy requirements in the intensive care unit.
Curr Opin Clin Nutr Metab Care 2014 17: 171-176
 Monitoring
• Kesadaran
• Respon asupan: pencapaian target energi, sisa makanan
• Residu lambung (gastric residual volume) : volume residu
gaster diukur selama 24 jam. Jika volume residu gaster < 500
ml/24 jam, masih dapat diberikan EN, peroral atau via NGT
• Hemodinamik : Terapi nutrisi harus mempertimbangkan
kondisi hemodinamik. Bila hemodinamik tidak stabil,
pemberian terapi gizi dapat ditunda.
• Keseimbangan cairan : keseimbangan (balans) cairan
dilakukan per 24 jam, dengan mengukur urin output, jumlah
cairan yang masuk dan keluar.
• Nilai laboratorium meliputi darah rutin, glukosa darah,
elektrolit, ureum, kreatinin, analisa gas darah, albumin dan
profil lipid (bila diperlukan).
 Evaluasi
• Kondisi pasien yaitu fungsi vital, fungsi kardiovaskuler,
fungsi respirasi, fungsi gastro intestinal, fungsi ginjal
dan status glikemik.
• Kebutuhan energi : asupan energi dapat ditunda,
diturunkan ataupun dinaikkan sesuai dengan fase sakit
kritis pada pasien, fase inisial atau fase penyembuhan
dan hemodinamik
• Kebutuhan makronutrien : pemberian seperti
karbohidrat dan protein dapat dinaikkan ataupun
diturunkan menyesuaikan hasil evaluasi nilai
laboratorium dan fungsi respirasi
• Kebutuhan mikronutrien
• Kebutuhan cairan
Contoh kasus
Kesimpulan
ESPEN expert statement 2020 :
Patients with respiratory
deficiency
Carbohydrate : Fat = 50:50
 Take home message
• Penilaian status nutrisi saat pasien masuk RS/ICU
sangat penting untuk mencegah malnutrisi di RS
• Hypo/hypercaloric feeding dapat memperburuk
outcome → sesuaikan dengan kebutuhan pasien
• EN lebih baik dari PN → if the gut works, use it..
• Jumlah cairan, total energi, elektrolit, mikronutrien,
dan komposisi makronutrien seharusnya
disesuaikan dengan kondisi pasien
• Pada pasien dengan gangguan pernafasan yang
susah lepas dari ventilator → atur ulang komposisi
karbohidrat dan lemak
Thank you