3. Nutritional Assessent Functional GI Tract Yes No Enteral Nutrition Parenteral Nutrition GI Function Short Term Long Term or Fluid Restriction GI Function Returns Long Tern Gastrostomy Jejunostomy Short Term Nasogastric Nasoduodenal Nasojejunal INDIKASI NUTRISI ENTERAL DAN PARENTERAL Normal Standard Nutrients Compromised Speciality Formula Adequate Proceed To Oral Feedings Adequate Progress to More Complex Diet and Oral Feedings as Tolerated Progress to Enteral Feedings Yes No Nutrients Tolerance Peripheral PN Central PN Inadequate PN Supplementation Guidelines for the Use of Parenteral and Enteral Nutrition in Adults and Pediatric Patients. ASPEN Board of Directors & Clinical Guidelines Task Force, JPEN, 26 (1) Suppl, 2002.
4. Nutrisi enteral merupakan metoda pemenuhan zat gizi dengan menggunakan saluran pencernaan, baik secara alami melalui mulut ataupun dengan bantuan alat / tube feeding / Pipa Lambung WHEN THE GUT WORKS, USE IT ! Nutrisi Enteral :
7. PROTEN ® Vitamin: Vit A, B1, B12, C, D, dan E Mineral: Ca, P, I, Mg, Cu, Zn, Cl, K, Na, Mn, Fe 25% LEMAK (Soy bean oil) Anjuran Pemakaian: 1 – 4 saset / hari; dapat diberikan untuk pasien dewasa (infeksi, jantung, TB, malnutrisi) & anak (alergi susu sapi); bebas laktosa Cara Penyiapan: Tuangkan 1 saset Proten dan larutkan dalam 200 – 300 ml air; Diberikan per oral. 55% KARBOHIDRAT (Maltodextrin & Sukrosa) 20% PROTEIN (Soya Protein) % DARI TOTAL KALORI DISTRIBUSI KALORI
8. PAN ENTERAL ® Vitamin: Vit A, D, E, K, B1, B2, B6, B12, C, As Pantotenat, Niasin, As Folat, Biotin, Choline, Inositol Mineral: Ca, P, I, Fe, Mg, Cu, Mn, Zn, Cl, K, Na Cara penyiapan: Tuangkan 1 saset Pan Enteral dan larutkan dalam 200 – 300 ml air Dapat diberikan per oral atau dengan NGT (Fr 8) 44% LEMAK MCT : LCT = 48 : 52 Anjuran Pemakaian: 1 – 4 saset / hari; dapat diberikan untuk pasien dewasa & anak (bebas laktosa) Pan Enteral baik untuk kasus-kasus dengan gangguan absorpsi Lemak; gangguan respirasi; stroke; pasca operasi, kondisi-kondisi dimana asupan oral tidak dimungkinkan atau tidak mencukupi . 44% KARBOHIDRAT Dextrin : Sukrosa = 50 : 50 12% PROTEIN (Casein) % DARI TOTAL KALORI DISTRIBUSI KALORI
9. Positioning Statement PAN ENTERAL : Nutrisi Enteral Lengkap dan Seimbang, Kaya MCT dan Osmolaritas Rendah untuk memenuhi kebutuhan nutrisi pasien. PROTEN : Asupan Protein Harian untuk mengatasi Kurang Energi Protein (KEP) dan mempercepat penyembuhan. Target Pasien : PAN ENTERAL : Bayi, Anak, Dewasa dan Manula. · PROTEN : Anak, Dewasa, dan Manula Core Product Strategy PROTEN & PAN-ENTERAL
12. THE ROLE of FIELD FORCE DETAILING DELIVERING COLLECTING Medis ( Dokter ) Para medis ( Ahli Gizi ) Logistik Keuangan Pembelian MEDICAL REPRESENTATIVE . SALESMAN Taking / Repeat order Stock Monitoring MEDICAL FOODS REPRESENTATIVE PT-OI MUP
51. Asam Lemak Tak Jenuh Ganda Linoleic acid (18:2 w6) -Linolenic acid (13:3 W3) Arachidonic acid(20:4 w6) PG2 Series LT4 Series PG3 Series LT5 Series PG1 Series -6 Fatty Acid -3 Fatty Acids dihomo-γ-linoleic acid (20:3 w6) Docosahexaenoic acid (22:6 w3) (DHA) Eicosapentaenoic acid (20:5 w3) (EPA)
52. Meta-analisis: Immunonutrition Enteral Diet Beale, RJ et al. Immunonutrition in the critically ill: A Systematic review Of clinical outcome. Crit Care Med 1999 Vol 27, No 12. 12 uji klinis: 1482 pasien p < 0.05 = berbeda bermakna 0.04 Perlakuan vs Kontrol - 2.6 hari Lama Pemakaian Ventilator 0.0002 Perlakuan vs Kontrol - 2.9 hari Lama Perawatan di RS 0.005 Perlakuan vs Kontrol 0.60 Angka Kejadian Infeksi p Efek Perlakuan (CI 95%)
53. Meta-analisis:Immunonutrition Enteral Diet pada Pasien Bedah Digestif 6 uji klinis: 497 pasien; * = Berbeda Bermakna Infeksi yang dinilai: pneumonia, abses intra abdomen, infeksi luka, bakteriemia Heys S D et al. Enteral Nutrition Supplementation with Key Nutrients in Patients With Critical Illness and Cancer: Ann Surg Vol 229, No. 4, 467 – 477, 1999. - 2.4 hari * Lama Perawatan di RS 61/244 (25%) 32/243 (13%)* Angka Kejadian Infeksi 4/251 (2%) 6/246 (2%) Angka Mortalitas Kontrol Immunonutrition
54.
55. Immunonutrisi dan Trauma p < 0.001 p < 0.05 SIRS MOF Weinmann, 1998 Trauma (n = 32) p = 0.02 p = 0.02 p = 0.03 Komplikasi infeksi Pemakaian antibiotik Lama Perawatan Kudsk, 1996 Trauma (n = 35) p = 0.023 p = 0.023 Abses intraabdomen MOF Moore, 1994 Trauma (n = 98) Hasil (IMN vs SD) Uji Klinis
56. Immunonutrisi dan Luka Bakar Gottschlich M M, et al. Differential Effects of Three Enteral Dietary Regimen on Selected Outcome Variables in Burn Patients. JPEN 1990, Vol. 14, 3, 225-236 NS 0.03 0.06 0.07 NS NS NS 0.02 19 4 8 9 21 5.8 14 4.7 1.21 17 3 2 2 7 4.7 9 3.8 0.83 14 2 8 6 16 7.6 10 5.0 1.21 Jumlah Bakteriemia Infeksi luka Pneumonia Total Infeksi Antibiotik (hari) Ventilator (hari) Jumlah operasi Lama rawat inap/% LLB p < Grup 3 TRM Grup 2 IMN Grup 1 OSM
57. Pengaruh Pemberian IMN pada Pasien Sepsis di ICU n = 181; infeksi nosokomial: Infeksi saluran kemih, pneumonia, trakheobronkitis, infeksi kateter. Galban C, et al. An immune-enhance enteral diet reduces mortality rate and Episodes of bacteremia in septic ICU patients. Crit care Med 2000, vol 28, no. 3. p = 0.01 20% 6% Infeksi nosokomial > 1 p = 0.01 22% 8% Bakteriemia p = 0.02 28% 4% Mortalitas (APACHE II = 10 – 15) p = 0.05 32% 19% Mortalitas p Kontrol IMN
58. Dosis Pemberian IMN pada Pasien Critically-ill dan Sepsis 19 ml/kg BB/hari Sepsis Galban et al, Crit Care Med 2000; 28: 643 17 ml/kg BB/hari Critically - ill Atkinson et al, Crit Care Med 1998; 26:1164 18 ml/kg BB/hari Sepsis Bower et al Crit Care Med 1995; 23:436 Asupan rata-rata Kelompok
Slide-Eicosanoid Synthesis from Polyunsaturated Fatty Acids Now let us move to another important immune-enhancing nutrient, w-3 fatty acids. One of the mechanisms whereby fats may influence immunity is related to an alteration of eicosanoid synthesis pathway from prostaglandin 2 series to 3 series, and from leukotrien 4 series to 5 series. PG2 and LT4 series are derived from n-6 fatty acid found in safflower, corn, sunflower and soybean oil. In contrast, PG3 and LT5 series are derived from w-3 fatty acids found in fish oil. The 3-series PG are less inflammatory and less immunosuppressive than those of the 2-series. Therefore, in general, w-3 fatty acids improves cell-mediated immune response and increases resistance to infection.
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