Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 21 Mei 2012 1

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MNT for Critical Ill in

Surgical Patients

Leny Budhi HartiJurusan Gizi

Fakultas Kedokteran Universitas Brawijaya Malang

21 Mei 2012

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Content

Nutrient Access 4

Background 1

Stress Response 2

Nutrient Requirement3

Immunonutrient 5

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Background

20 – 60% Pasien RS Malnutrition Pasien ICU Pasca Bedah

Dukungan zat gizi mutlak diperlukan

Pedoman Penyelenggaraan Tim Terapi Gizi di Rumah Sakit. 2009. Direktorat Jendral Bina Pelayanan Medik Depkes RI

Cermin Dunia Kedokteran, No.42 ,1987

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Stress Response During Critical Ill

Children, similar to adults, rely on the metabolic breakdown and transfer of protein, carbohydrates, and lipid to meet the catabolic demands of critical illness

With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario,Canada: BC Decker Inc; 2008

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Burton, Deborah et al. Endocrine and metabolic response to surgery. The Board of Management and Trustees of the British Journal of Anaesthesia 2004, volume 4 number 5

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Hormonal Changes

Growth Hormone

Growth Hormone

Catabolic effect

Anabolic effect

Glycogenolysis Lipolysis Prevent protein

breakdown


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ACTH & Cortisol

Cortisol increases rapidly following the start of surgery

Concentrations increase to maximum at about 4 – 6 h depending on the severity of the surgical trauma

Surgery

ACTH ↑ Adrenal cortical

Cortisol ↑ Gluconeogenesis Lipolysis Blood glucose ↑

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Aldosteron & Renin

Aldosteron increase sodium reabsorbtion in the kidney

Renin conversion of angiotensin I to angiotensin II


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Insulin & Glucagon

Induce anaesthesia

During surgery After surgery

Insulin ↓ Glucagon ↑

Hyperglycemic respone

Glycogenolysis Gluconeogenesi

s

Not contribution to the hyperglicemic respone

British journal of anaesthesia 85 (1) : 109-17 (2000)

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Prolactin, Gonadotrophins, & Thyroid Hormones

Perioperative periode

Prolactin ↑

TSH, LH, & FSH do not change significantly


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The most important cytokine associated with surgery is IL-6 and peak circulating values are found 12–24 h after surgery. The size of IL-6 response reflects the degree of tissue damage which has occurred. IL-6, and other cytokines, cause the acute phase response

Cytokines


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Stress Metabolic

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Carbohydrate Metabolism

Hyperglycaemia. Glucose concentrations >12 mmol/ litre impair

wound healing and increase infection rates. There is also an increased risk of ischaemic

damage to the nervous system and myocardium


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Protein Metabolism

The metabolic response during surgical is characterized by the breakdown of skeletal muscle protein and transfer of amino acids to visceral or gans and the wound

Mobilization of acute-phase proteins

Rapid loss of lean body

mass

↑ negative nitrogen balance

↑ urinary losess of K, P,

Mg

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Lipid Metabolism

Surgery

Increased catecholamine, cortisol and glucagon secretion, in combination

with insulin deficiency

Triglyceridesoxidation of FFAs to

acyl CoA

FA

Gly

cer

ol

Acyl CoA ketone bodies


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Salt and water metabolism

Arginine vasopressin secretion results in water retention, concentrated urine, and potassium loss and may continue for 3–5 days after surgery


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Nitrogen Excretion in Various Condition

Long CL, et al. JPEN 1979;3:452-456

Nitro

gen

Excr

etio

n (g

/day

)

3228

24

20

16

12

8

4

0

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Nutrition for the pediatric surgical patient: approach in the peri-operative period. Rev. Hosp. Clín.Fac. Med. S. Paulo 57(6):299-308, 2002

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Nutrient Requirenment

during Surgery, Critical Ill, &

Metabolic Stress

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Nutritional Assessment

Anthropometric

Physical examination

Laboratory Past history

Malnourished/ well-

nourished

standard methods of nutritional assessment are either diffi cult to obtain or impossible to interpret in critically ill patients L.Kathleen Mahan, Sylvia Escott-Stump . Krause’s Food, Nutrition, & Diet

Therapy,, 11th Edition

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Anthropometry

Physical exam.

Laboratory

Past history

Berat badan (actual dry body weight)

Hair, skin, eyes, mouth, edema, temperature,

tensi

Albumin, electrolite, blood urea nitrogen,

glucose, iron, Mg, Ca, P

Weight gain, dietary history, recent illness,

medications

With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario,Canada: BC Decker Inc; 2008

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Energy Requirenment in Critical Ill

Adult : 25 – 30 kcal/ kgBB

Children (PICU) : Energy requirenment can be estimate at 1 to

1,5 time REE, depending on nutritional status, activity, and stress

ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

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Adult : 1,5 g/kg BB – 2,5 g/kg BBIn PICU patient : Infant : 2,5 – 3 g/kg/day Older children : 2 – 2,5 g/kg/day Adolescent : 1,5 – 2 g/kg/day

Protein

ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

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Protein

Contoh:

Protein 50 g/hr memerlukan 1200 kal atau 300 g glukose

Kalori : 1200 kal → 1200 kalProtein : 50 gram → 200 kalLemak : 65,2 gram 1000 kalKH : 196,7 gram

Kalori Non Protein

Rasio Nitrogen/Rasio Kalori Non Protein

~ 50 X N = 1000 6,25

~ 8 X N = 1000~ N = 125

Jadi Rasio Nitrogen / Rasio Kalori Non Protein = 1 : 125

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Fat

• 30% total calories• 20% - 35% TEE, <10% SAFA, < 300mg

Cholesterol• Omega 3 is better than omega 6

Department of Surgical Education, Orlando Regional Medical Center, 2007British Journal of Anastheasia 1996; 77:118 - 127

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Carbohydrate

• Adult : At least 100 g/day needed to prevent ketosis

• Carbohydrate 70% TEE• Glucose intake should not

exceed 5 mg/kg/min

Pediatric : 50 – 100 g/day prevent

ketosis EN : 45 – 65 % of total E PN : 40 – 60% of total E

Department of Surgical Education, Orlando Regional Medical Center, 2007ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

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Fluid Requirenment

Infant & child: 1,5 – 1 ml/ kcal

Adult: 20 – 40 ml/kg/day 1 – 1,5 ml/ kcal

Additional fluids may be necessary for large insensible losses (fever, diarrhea, GI output, and tachypnea)

Fluid restriction may be necessary in CHF, renal failure, hepatic failure with ascites, CNS injury, and electrolyte abnormality

ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

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Micronutrient

Eur J Surg Sci 2010;1(3):86-89

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Nutrient Access in Critical Ill

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“If the gut works, use it. If it isn't working, make it work.”

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Enteral Vs Parenteral Nutrition

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Prefere route of nutrient intake

Lower rate of infections complication than PN

Used in Px for whom oral & EN is not feasible

“Enteral feeding is preferred over parenteral feeding, whenever it is possible”

Krause’s Food & Nutrition Therapy, 12 edition

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Faktor-Faktor yang Perlu Dipertimbangkan dalam Pemberian EF

1. Keadaan pasien2. Penempatan ujung pipa3. Jangka waktu pemberian4. Potensi komplikasi5. Informed consent

Working Group on Metabolism and Clinical Nutrition, 2003

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Rute Enteral Feeding


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Metode Pemberian EF/EN

Continuous gravity feeding

(kontiniu)

Intermittent

Bolus

pemberian EN secara terus

menerus selama 24 jam

pemberian EN sebanyak 200 – 300 ml selama 30 – 60 menit setiap 4 – 6

jam

pemberian EN sebanyak 24o ml

setiap 3 jam


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Feeding Protocol

Sesegera mungkin setelah operasi antara 24 – 48 jam

Awal : 10 – 50 ml/jam, dengan cara tetesan

Toleransi baik pemberian ditingkatkan secara bertahap 10 – 20 ml tiap 4 – 8 jam sampai kebutuhan kalori tercapai

• Pada pasien kritis, EF diberikan setelah resusitasi adekuat

• Pemberian EN sejak dini kebutuhan kalori dapat tercapai pada hari ketiga


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Monitoring Enteral Feeding

Residual < 200 ml, clear

Residual >= 200 ml(NGT), or >=100 ml

(Gastrostomy tube

Volume exceed twice the hoursly infusion during continous feeding or exceed 50% infusion volume during bolus

feeding

Checking residual : prior to

each intermittent feeding or 4 hours

with continous

feed

EF

Intolerance to be

assessed

Slowing/stoping feeding


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Monitoring Enteral Feeding

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Enteral Formulation

Energi : adult : 1 – 1,5 Kcal/cc

infant : 0,67 – 0,8 kcal/cc

Carbohydrateadult : 30% - 90%

infant : 40% - 54%

pediatric : 42% - 58%

Protein :adult : 6% - 32%

pediatric : 12%

infant : 8% - 13%

Fat : adult : 20% - 55%

pediatric : 25% - 46%

infant : 35% - 50%


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Enteral Formulation

Energy

Water

0,67 – 0,8 kcal/cc

1 kcal/cc

2 kcal/cc

88 – 90% 75 – 85%

70%

Fiber 0 -22g/L (adult), 0 -8g/L (pediatric)

Osmolaritas : 375 – 630 mOsm per kg of water


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Suggested Nutrient Intake for Adult Patients on Parenteral Nutrition

Nutrient Critical ill Stable Pateints

ProteinCarbohydrateLipidTotal caloriesFluid

1.2 – 1.5 g/kg/LNot > 4 mg/kg/min1 g/kg/d25 – 30 kcal/ kg/dMinimum needed to deliver adequate miacronutrient

0.8 – 1.0 g/kg/LNot > 7 mg/kg/min1 g/kg/d30 – 35 kcal/ kg/d30 – 40 ml/kg/d


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Daily Energy Requirenments for Pediatric Patient on Parenteral Nutrition

Age Kcal/kg

< 6 mos6 – 12 mos

>1 – 7 yrs>7 – 12

yrs>12 – 18

yrs

85 – 105 80 – 100 75 – 90 50 – 75 30 – 50

Protein requirenment for neonatus and infants : 1 – 2 g/kg/day and are increased daily by 0.5 – 1 g/kg/d

Glucose : 6 – 8 mg/kg/menit , are increased gradually until energy goal are achieved or max 12 – 14 mg/kg/menit

IVFE : 0.5 – 1 g/kg/dASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

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Trace Element Daily Requirenment*

Trace Preterm Neonetus

(3 kg)

Term neonatus,

infants (3-10 kg)

Children (10-40

kg)

Adolescent (>40

kg)

Zinc (mg) 400 50 - 250 50 – 125 2 - 5

Copper (mcg) 20 20 5 – 20 200 – 500

Manganese (mcg)

1 1 1 40 – 100

Chromium (mcg)

0.05 – 0.2 0.2 0.14 – 0.2 5 – 15

Selenium (mcg)

1.5 - 2 2 1 - 2 40 – 60


*assumed normal age related organ function.

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Recommended Trace Element Intake in Adult Px on PN

Trace Standard daily intake

Zinc (mg) 2.5 – 5

Copper (mg) 0.3 – 0.5

Manganese (mcg) 60 – 100

Chromium (mcg) 10 – 15

Selenium (mcg) 20 - 60


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Monitoring-Neonatus/ Pediatric on PNParameter Initial Daily Weekly

Anthropometric-Weight-Length-Head circumferencePhysicalFluid balanceMetabolic assessment-Na,K,Cl, CO2-Ca,P, Mg-Glucose-UN/Cr-Lver Profile-TG-Urine Glucose-Complete blood count-Prealbumin

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Monitoring – Adult Px on PN

Parameter Baseline Critical ill

Stable

Chemistry screen (Ca, Mg, P)Electrolyte, BUN, CrSerum TGCapilary GlucoseWeightIntake and outputNitrogen balance

YesYesYes3x/d

If posibleDaily

As needed

2 – 3x/wkDaily

Weekly3x/dDailyDaily

As needed

Weekly1 –

2x/wkWeekly

3x/d2 –

3x/wkDaily

As needed


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Refeeding Syndrome

Aggresive administration of nutrition particularly via iv refeeding syndrome

Occur when KH introduced into plasma of anabolic Px electrolyte accross to intracelluler low serum electrolyte (K,P,Mg)


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Immunonutrient

Imuninutrient : zat gizi spesifik yang dapat memperbaiki imunitas pasien dengan meningkatkan ataupun menekan sistem imun

Imunonutrient : arginin, glutamin, omega 3

Indikasi : bedah mayor GIT, bedah mayor kepala & leher, pasien luka bakar 30%


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Immunonutrient

Arginin

• Stimulate several hormon

• ↑ peripheral lymposite

Glutamine

• Fuel source for eritrocyte

• Precursor glutathion

Omega 3

• Improve immune & metaolic function

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Terima Kasih

“If the gut works, use it. If it isn't working, make it work.”

Documents

Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 21 Mei 2012 1