dr.

Iyan Darmawan
Medical Director, PT Otsuka Indonesia
www.otsuka.co.id
Importance of
PN Supplementation
Glukosa Saja Tidak Cukup
11/28/2013
NS/RL/D5
KAENMG3
PAN AMIN G
AMIPAREN
AMINOLEBAN
KIDMIN
AMINOFLUID
Na
+
77
MAINTENANCE SOLUTIONS
1
st
generation 2
nd
generation 3
rd
generation
Na
+
, K
+
,Micromineral,
3% Amino Acids,glucose
KAEN 3B AMINOFLUID
Days of fasting
1 2 3 4 5 6
100
200
300
400
0
0 g
(Starvation)
50 g
100 g
200 g
Starvation
- CHO tends to block portein catabolism
- 100 g glucose/day reduces protein
catabolism by 50%.
- Sole NPC cannot fully inhibit protein
catabolism
Protein-Sparing effect of glucose
J AMES L.GAMBLE 1957p134147
The importance of adding Amino acids
P
r
o
t
e
i
n

l
o
s
s

(
g
)
200g
100g
50g
100
200
300
400
1 2 3 4 5 6
(GAMBLE)
The significance ofinfusing amino acid
Starvation
At least 100 g of glucose is
necessary per day
P
r
o
t
e
i
n

l
o
s
s

(
g
)
Period of starvation (days)
Glucose
0g
Starved
unavoidable nitrogen loss quantity
FAO/WHO
mgN/kg/day TOTAL
Urine 37
54mg/kg/day
Stool 12
Skin 3
Others 2
When I convert it into
an amino acid
50kg in weight
26.3 g /day

0.054(g) 7.5
*
50(kg)1.3
**
26.3(g)
*convert nitrogen into quantity of amino acid6.251.2
**usually increase by 30% in consideration of
individual difference
Amino acids
With NPC
Without NPC
Utilized for protein synthesis
Consumed as an expensive
energy source
Changes in body weight
(%)
0
-10
-20 *
*
Nitrogen balance
-3000
-2000
-1000
0
(mgN/kg)
*
*
Mean S.D.
Tukeys group comparison test
*: p < 0.05 vs. the amino acid, glucose, and electrolyte solution group
Urabe H, et al. Yakuri To Chiryo 1994;22 (Supplement):S835
3% Amino
acid solution
group
Electrolyte
solution with
10% glucose
group
(n=10) (n=7) (n=10)
Amino acid,
glucose, and
electrolyte
solution group
(n=10) (n=7) (n=10)
Amino acid,
glucose, and
electrolyte
solution group
3% Amino
acid solution
group
Electrolyte
solution with
10% glucose
group
Combined versus separate administration
11/28/2013
Limited !!
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Energy source
Muscle
protein
75 g
Adipose
Trigly
ceride
160 g
AA
Glycerol
16 g
FA
160 g
Glycogen
Glucose
Hemopoe-
tic sissue
Heart
Kidney
Muscle
Lactate + Pyruvate
40 g
120 g
Keton
60 g
36 g
180 g
144 g
Consumed
Gluconeogenesis
FASTING (1-2 DAYS)
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992
11/28/2013
Energy souce
Muscle
Protein
20 g
Triglyce-
ride
150 g
AA
Glycerol
15 g
FA
150 g
Glycogen
Glucose
Hemopoi-
etic tissue
Heart
Kidney
Muscle
Lactate + Pyruvate
36 g
112 g
Keton
57 g
50 g
80 g
44 g
36g
Keton 47 g
Gluconeogenesis
FASTING (5-6 weeks)
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992
11/28/2013
Muscle
protein
180 g
TG
160 g
AA
Glycerol
30 g
Glycogen
Glucose
Kidney
WOUND
Lactate
320 g
114 g
76g
130 g
8 g
104g
Gluconeogenesis
MAJOR TRAUMA
Energy source
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992
11/28/2013
Energy source
Muscle
protein
250 g
Adipose
Tissue
Gluconeogenesis
AA
Glycerol
30 g
Glucose
Kidney
Inflammed
mass
Lactate
360 g
114 g
76g
Consumed
170 g
8 g
136g
Fatty acid
SERIOUS SEPSIS
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992
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& FFA
.
METABOLIC RESPONSE TO TRAUMA
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MAJOR TRAUMA (180 g/day)
SEPSIS (250 g/day)
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992
PROTEOLYSIS
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Determining Protein Requirements
Body weight, age, types of protein
Daily requirements :
Healthy : 0.8 1.0 g/kg/day
Stressed state : 1.0 to 2.0 g/kg/day depending
on condition
25 30% of protein intake should tipically be
provided by essential amino acids
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Most economical PN Supplement
but need addition of electrolytes
10-20 kcal.kg ideal selama fase flow, pasokan glukosa moderat mencegah
perburukan hiperglikemia karena stres(1)
Pasien dengan stres moderat dan tidak bisa asupan oral kurang dari 7 hari
hanya butuh 500-600 kcal/hari (2)
Asam amino dalam kombinasi dengan glukosa dibutuhkan untuk
memperbaiki imbang Nitrogen dan mengatasi letih pasca operasi(3)
Zinc memacu penyembuhan luka, mendukung fungsi sistem imun,
pertumbuhan sel dan penting dalam sistem antioksidan tubuh (4)
Na
+
dalam jumlah moderat mencegah retensi air dan kelebihan cairan
iatrogenik; K
+
mencegah deplesi lebih lanjut
Mengapa Aminofluid baik untuk pasien
pasca bedah
Indikasi Aminofluid
Straightforward surgery:
MILD STRESS /GOOD NUTRITION STATUS
Ovarian cystectomy
Laparoscopic surgery(in undernourished)
Appendectomy without peritonitis
Cholecystectomy
Herniotomy
Hemorroidectomy
Caesarean section
Fracture of femur
Indikasi Aminofluid
As initiating support for Complicated surgery or
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MODERATE TO SEVERE STRESS
Typhoid perforation
Head injury
Bowel resection + Sepsis, or already malnourished
Acute pancreatitis
Empyema
Hysterectomy
Entero cutaneus fistula
Gastrectomy, Esophagectomy, Pancreato-duodenotomy
2
Normal
Diet
4 3 6 5 8 7
15 yeas ago The fluid & nutrition therapy for Gastric and Colon
resection
Energy
(kcal)
- -

910Discharge
Volume of
infusion(mL)
Rice
Gruel
ay
MF
2000
mL
Normal
Diet
Liquid
Diet
MF
1000
mL
Traditional
Maintenance
FLUID
2000mL
MF
1500mL
MF
1000mL

2
Normal
Diet
4 3 6 5 8 7
Energy
(kcal)
- -

910Discharge
Volume of
infusion(mL)
Aminofluid

infusion
2000mL
AF
1000mL
Rice
Gruel
ay
AF
2000
mL
AF
1000
mL
Normal
Diet
Liquid
Diet
NowThe fluid & nutrition therapy for Gastric and Colon
resection

Terima Kasih
Biaya Terapi per 1000 ml
ALTERNATIF CHO AA Total calorie Price
(gr) (gr) (kcal) (Rp)
AMINOFLUID 1000 ml 75 30 420 152000
AMINOFLUID 500 ml 37.5 15 210 91000
AMIPAREN 500 ml 50 200 106000
TOTAL 37.5 65 410 197000
AMIPAREN 500 ml 50 200 106000
KAEN-MG3 50 200 15531
TOTAL 50 50 400 121531
AMINOVEL 500 ml 50 25 300 72000
KAEN MG3 500 ml 50 200 15531
TOTAL 100 25 500 87531
PAN-AMIN 500 ml 25 13.6 154.4 43000
KAEN-MG3 500 ml 50 200 15531
TOTAL 75 13.6 354.4 58531