Enteral Nutrition: Agus Prastowo

ENTERAL NUTRITION
AGUS PRASTOWO
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.”
Definition of malnutrition
• A body mass index (BMI) <18.5kg/m
• Unintentional weight loss >10% in 3 – 6

months
• A BMI <20kg/m and unintentional weight loss

>5% in 3 – 6 months
Why does malnutrition develop?
• Impaired intake
• Impaired digestion and absorption
• Altered nutritional requirements
• Excess nutrient losses

Consequences of malnutrition
• Weight loss
• Weakness and fatigue
• Impaired ventilatory drive

 DEATH
• Depression / apathy
• Poor wound healing
• Impaired immune function

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
ESPEN, 2018
RESPON METABOLIK PASIEN KRITIS
Why feed the critically ill?
• 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
Predictive Equations for Estimation of Energy
Needs in Critical Care
• Harris-Benedict x 1.3-1.5 for stress
• ASPEN Guidelines:
– 25 – 30 calories per kg per day*
Energy
• Enough but not too much
• Excess calories:
– Hyperglycemia
• Diuresis – complicates fluid/electrolyte balance
– Hepatic steatosis (fatty liver)
– Excess CO2 production
• Exacerbate respiratory insufficiency
• Prolong weaning from mechanical ventilation
Peningkatan kebutuhan energi
Nutrient Guidelines: Carbohydrate
• Should provide 60 – 70% calories
• Maximum rate of glucose oxidation =
~5 – 7 mg/kg/min or 7 g/kg/day*
• Blood glucose levels should be monitored and
nutrition regimen and insulin adjusted to
maintain glucose below 150 mg/dl
Lanj…
• Kebutuhan 100-150 g
• TPN  4-5 mg/kg/menit
• DM  2,5-4 mg/kg/menit
• 30-70%
Nutrient Guidelines: Fat
• Can be used to provide needed energy and
essential fatty acids
• Should provide 15 – 40% of calories
• Limit to 2.5g/kg/day or possibly 1 g/kg/day
IV*
• Caution with use of fats in stressed &
trauma pts
– There is evidence that high fat feedings
(especially LCT) cause immunosuppression
– New formulas focus on omega-3s
Nutrient Guidelines: Protein
• 08-1.2g/kg/day to start; monitor response
• Nonprotein calorie/gram of nitrogen ratio
for critically ill = 100:1
• Giving exogenous aa’s decreases negative N
balance by supplying liver aa’s for protein
synthesis
How much to give – general
recommendations
• 1.2g/kg/day protein more just gets excreted
• 30ml fluid/kg/24 hours. Add 100-200ml/day for each
degree of temperature
• Account for excess losses
• Adequate electrolytes, micronutrients etc

• Avoid overfeeding
• Obesity: feed to BMR no stress factor unless stress is
severe e.g. burns/trauma
Fluid and Electrolytes
Fluid
• 30-40 mL/kg or
• 1 to 1.5mL/kcal expended
Electrolytes/Vitamins/Trace Elements
• Enteral feedings: begin with RDA/AI values
• PN: use PN dosing guidelines
Rekomendasi
Kebutuhan elektrolit
Specialized Nutrients in Critical Care
• Include supplemental branched chain amino acids,
glutamine, arginine, omega-3 fatty acids, RNA, others
• Most studies used more than one nutrient, making
assessment of efficacy of specific supplements
impossible
• Immune-enhancing formulas may reduce infectious
complications in critically ill pts but not alter
mortality
• Mortality may actually be increased in some
subgroups (septic patients)
Contra indication Nutrition
Short term: Long term:
• Severe pancreatitis • Inflammatory bowel disease
• Mucositis post-chemo with • Radiation enteritis
intolerance of enteral nutrition • Motility disorders
• Gut failure • Extreme short bowel syndrome
• Prolonged nil by mouth (NBM) •
post major excisional surgery Chronic malabsorption
• High output or enterocutaneous
fistula
• Intractable vomiting
• Malnourished patient unable to
establish enteral nutrition
Enteral Nutrition
• Melalui saluran cerna

• Termasuk peroral dan tube feedings
Enteral Tube Feeding
• Nutritional support via hidung,

esophagus, lambung or intestines
(duodenum or jejunum)
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
Oral Supplements
• Diantara waktu makan
• Tambahan makan
• Penambahan cairan
• Meningkatkan asupan pada pasien
dengan asupan rendah
• Meningkatkan tumbang
Diagram of enteral tube placement.
Fig. 22-2. p. 468.

Conditions yang membutuhkan “Specialized Nutrition
Support”
• Enteral
—Impaired ingestion
—Inability to consume adequate nutrition
orally
—Impaired digestion, absorption,
metabolism
—Severe wasting or depressed growth
• Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral
tolerance or accessibility
Enteral feeding
“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)
Indications for Enteral Nutrition
Malnutrisi dg asupan kurang >5-7 days

Status gizi normal dengan asupan kurang
>7-9 days
Adaptive phase of short bowel syndrome
Increased needs that cannot be met
through oral intake (burns, trauma)
Inadequate oral intake pada penyembuhan
penyakit yang membutuhkan waktu lama
Contraindications for EN
Severe acute pancreatitis

High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
Contraindications for EN
Inadequate resuscitation or
hypotension; hemodynamic instability
Ileus
Intestinal obstruction
Severe G.I. Bleed
Advantages - Enteral vs PN
 Menjaga integritas saluran cerna

 Mencegah translokasi bakteri
 Menjaga fungsi imun saluran cerna
 Menurunkan biaya
 Mencegah komplikasi infeksi
Advantages—Enteral Nutrition
• Monitoring asupan lbh mudah

• Alternaatif jika oral tdk aduquate
Disadvantages—Enteral Nutrition
 GI, metabolic, and mechanical complication

tube migration; increased risk of bacterial
contamination; tube obstruction;
pneumothorax
 Costs more than oral diets (not necessarily)
 Less “palatable/normal”: patient/family
resistance
 Labor-intensive assessment, administration,
tube patency and site care, monitoring
 Bentuk cair atau bubuk sekali pakai
Enteral Formulas
• Bentuknya cair atau bubuk sekali pakai

• Designed to meet variety of medical and
nutrition needs
• Can be used alone or given with foods
Formula Selection
The suitability of a feeding formula should be evaluated
based on

 Functional status of GI tract

 Physical characteristics of formula (osmolality,
fiber content, caloric density, viscosity)

 Macronutrient ratios

 Digestion and absorption capability of patient

 Specific metabolic needs

 Contribution of the feeding to fluid and electrolyte
needs or restriction

 Cost effectiveness
Enteral Formula Categories
• Polymeric
• Monomeric
• Fiber-containing
• Disease-specific
• Rehydration
• Modular
Polymeric
• Whole protein nitrogen source
• For use in patients with normal or near
normal GI function
– Protein isolate formulas
– Protein that has been separated from a food (casein
from milk, albumin from egg)
– Blenderized formulas
• May contain pureed meat, vegetables, fruits,
milk, starches with v/m added
• Made at home or purchased commercially
Monomeric
• Elemental/hydrolyzed
• Predigested nutrients
• Free amino acids and/or short peptide
chains
• Has low fat content or high percentage
of MCT, LCT, structured lipids
Monomeric
• Untuk pasien dengan kelemahan saluran
cerna dan gangguan absorbsi
• hyperosmolar because of small particle
size
Enteral Formulas: Calorie tinggi
• Untuk pasien dengan kebutuhan gizi

meningkat
• Digunakan pada pasien dengan
pembatasan cairan
• Digunakan pada pasien yang
membutuhkan makan sampai malam
• Calorie density ranges from 1.3 to 2
kcals/ml
• Monitor fluid/hydration status
Disease Specific Formulas
Immune-Enhancing
• “immune-enhancing” nutrients :
– arginine,
– glutamine,
– omega-3 fatty acids,
– nucleotides
Enteral Formulas Nutrient Sources
Protein
Arginine: conditionally essential amino acid
with immune-enhancing properties.
Research suggests some benefit in wound
healing (rat studies and biochemical
changes.) Recent research suggests may be
harmful in septic patients
Glutamine: may enhance small intestine
growth and repair; however, available
research done with parenteral glutamine;
enteral delivery not well studied
Enteral Formulas: Nutrient Sources
Protein
 Branched-Chain Amino Acids: evaluated in
critical care and liver failure patients in the 70s
and 80s
 Thought to prevent or treat hepatic
encephalopathy and prevent muscle catabolism
 Studies using BCAA have been inconclusive
 Effectiveness of therapy cannot be evaluated
based on current research
 BCAA sometimes recommended for refactory
encephalopathy
TERIMA KASIH

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ENTERAL NUTRITION

• “Malnutrition is a state of nutrition in which a

• Unintentional weight loss >10% in 3 – 6

• A BMI <20kg/m and unintentional weight loss

• Impaired digestion and absorption

• Altered nutritional requirements

• Excess nutrient losses

• Weakness and fatigue

• Impaired ventilatory drive

• Poor wound healing

• Impaired immune function

• To be completed for each patient on admission and

• ACTION to be taken according to the high, medium or

• Completed assessment forms to be kept with patient

• Provide nutritional substrates to meet protein and

• Adequate electrolytes, micronutrients etc

• Melalui saluran cerna

• Nutritional support via hidung,

Fig. 22-2. p. 468.

Malnutrisi dg asupan kurang >5-7 days

Severe acute pancreatitis

 Menjaga integritas saluran cerna

• Monitoring asupan lbh mudah

 GI, metabolic, and mechanical complication

• Bentuknya cair atau bubuk sekali pakai

• Untuk pasien dengan kebutuhan gizi

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