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

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Presentation on theme: "Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 21 Mei 2012 1."— Presentation transcript:

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

2 Content 2 Nutrient Access 4 Background 1 Stress Response 2 Nutrient Requirement 3 Immunonutrient 5

3 Background 3 20 – 60% Pasien RS Malnutrition  Pasien ICU Pasca Bedah Dukungan zat gizi mutlak diperlukan Pedoman Penyelenggaraan Tim Terapi Gizi di Rumah Sakit Direktorat Jendral Bina Pelayanan Medik Depkes RI Cermin Dunia Kedokteran, No.42,1987

4 4 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

5 5 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

6 6

7 Hormonal Changes 7 Growth Hormone Catabolic effect Anabolic effect GlycogenolysisLipolysis Prevent protein breakdown 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

8 8 Surgery ACTH ↑ Adrenal cortical Cortisol ↑  Gluconeogenesis  Lipolysis  Blood glucose ↑

9 9 Aldosteron  increase sodium reabsorbtion in the kidney Renin  conversion of angiotensin I to angiotensin II 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

10 10 Induce anaesthesiaDuring surgeryAfter surgery Insulin ↓ Glucagon ↑ Hyperglycemic respone Glycogenolysis Gluconeogenesis Not contribution to the hyperglicemic respone British journal of anaesthesia 85 (1) : (2000)

11 11 Perioperative periode Prolactin ↑ TSH, LH, & FSH do not change significantly 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

12 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 12 Cytokines 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

13 13 Stress Metabolic

14 Carbohydrate Metabolism  Hyperglycaemia  Hyperglycaemia. impair wound healing and increase infection rates  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 14 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

15 Protein Metabolism 15 Mobilization of acute-phase proteins Rapid loss of lean body mass ↑ negative nitrogen balance ↑ urinary losess of K, P, Mg

16 Lipid Metabolism 16 Surgery Increased catecholamine, cortisol and glucagon secretion, in combination with insulin deficiency Triglycerides oxidation of FFAs to acyl CoA FAGlycerol Acyl CoA  ketone bodies 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

17 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 17 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

18 Nitrogen Excretion in Various Condition 18 Long CL, et al. JPEN 1979;3: Nitrogen Excretion (g/day)

19 19 Nutrition for the pediatric surgical patient: approach in the peri-operative period. Rev. Hosp. Clín. Fac. Med. S. Paulo 57(6): , 2002

20 20

21 21 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

22 22 Nutritional Assessment 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

23 23 Nutritional Assessment

24 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 24 ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

25 Adult :  1,5 g/kg BB – 2,5 g/kg BB In PICU patient :  Infant : 2,5 – 3 g/kg/day  Older children : 2 – 2,5 g/kg/day  Adolescent : 1,5 – 2 g/kg/day 25 Protein ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

26 26 Protein

27 Contoh: Protein 50 g/hr memerlukan 1200 kal atau 300 g glukose Kalori: 1200 kal → 1200 kal Protein: 50 gram → 200 kal Lemak: 65,2 gram 1000 kal KH: 196,7 gram Kalori Non Protein

28 Rasio Nitrogen/Rasio Kalori Non Protein ~ 50 X N= ,25 ~ 8 X N = 1000 ~ N = 125  Jadi Rasio Nitrogen / Rasio Kalori Non Protein = 1 : 125

29 Fat 30% total calories 20% - 35% TEE, <10% SAFA, < 300mg Cholesterol Omega 3 is better than omega 6 29 Department of Surgical Education, Orlando Regional Medical Center, 2007 British Journal of Anastheasia 1996; 77:

30 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 30 Department of Surgical Education, Orlando Regional Medical Center, 2007 ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

31 Fluid Requirenment Infant & child:  1,5 – 1 ml/ kcal Adult:  20 – 40 ml/kg/day  1 – 1,5 ml/ kcal 31  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

32 Micronutrient 32 Eur J Surg Sci 2010;1(3):86-89

33 Nutrient Access in Critical Ill 33

34 34 “If the gut works, use it. If it isn't working, make it work.”

35 Enteral Vs Parenteral Nutrition 35 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

36 Faktor-Faktor yang Perlu Dipertimbangkan dalam Pemberian EF 1. Keadaan pasien 2. Penempatan ujung pipa 3. Jangka waktu pemberian 4. Potensi komplikasi 5. Informed consent 36 Working Group on Metabolism and Clinical Nutrition, 2003

37 Rute Enteral Feeding 37 Krause’s Food & Nutrition Therapy, 12 edition

38 38 Metode Pemberian EF/EN ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

39 Feeding Protocol 39 Sesegera mungkin setelah operasi antara 24 – 48 jam Awal : 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 Working Group on Metabolism and Clinical Nutrition, 2003

40 Monitoring Enteral Feeding 40 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/stopi ng feeding ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

41 41 Monitoring Enteral Feeding

42 Enteral Formulation  Energi : adult : 1 – 1,5 Kcal/cc infant : 0,67 – 0,8 kcal/cc  Carbohydrate adult : 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% 42 ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

43 Enteral Formulation 43 Energy Water 0,67 – 0,8 kcal/cc1 kcal/cc2 kcal/cc 88 – 90%75 – 85%70% Fiber 0 -22g/L (adult), 0 -8g/L (pediatric) Osmolaritas : 375 – 630 mOsm per kg of water ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

44 44

45 45 Suggested Nutrient Intake for Adult Patients on Parenteral Nutrition NutrientCritical illStable Pateints Protein Carbohydrate Lipid Total calories Fluid 1.2 – 1.5 g/kg/L Not > 4 mg/kg/min 1 g/kg/d 25 – 30 kcal/ kg/d Minimum needed to deliver adequate miacronutrient 0.8 – 1.0 g/kg/L Not > 7 mg/kg/min 1 g/kg/d 30 – 35 kcal/ kg/d 30 – 40 ml/kg/d ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

46 Daily Energy Requirenments for Pediatric Patient on Parenteral Nutrition 46 AgeKcal/kg < 6 mos 6 – 12 mos >1 – 7 yrs >7 – 12 yrs >12 – 18 yrs 85 – – – – – 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/d ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

47 Trace Element Daily Requirenment* 47 TracePreterm Neonetus (3 kg) Term neonatus, infants (3-10 kg) Children ( kg) Adolescent (>40 kg) Zinc (mg) – Copper (mcg)20 5 – – 500 Manganese (mcg) – 100 Chromium (mcg)0.05 – – 0.25 – 15 Selenium (mcg) – 60 ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) *assumed normal age related organ function.

48 Recommended Trace Element Intake in Adult Px on PN 48 TraceStandard daily intake Zinc (mg)2.5 – 5 Copper (mg)0.3 – 0.5 Manganese (mcg)60 – 100 Chromium (mcg)10 – 15 Selenium (mcg) ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

49 Monitoring-Neonatus/ Pediatric on PN 49 ParameterInitialDailyWeekly Anthropometric -Weight -Length -Head circumference Physical Fluid balance Metabolic assessment -Na,K,Cl, CO2 -Ca,P, Mg -Glucose -UN/Cr -Lver Profile -TG -Urine Glucose -Complete blood count -Prealbumin √√√√√√√√√√√√√√√√√√√√√√√√√√√√ √√√√√√√√√√√√ √√√√√√√√√√√√√√√√√√√√ ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

50 Monitoring – Adult Px on PN 50 ParameterBaselineCritical illStable Chemistry screen (Ca, Mg, P) Electrolyte, BUN, Cr Serum TG Capilary Glucose Weight Intake and output Nitrogen balance Yes 3x/d If posible Daily As needed 2 – 3x/wk Daily Weekly 3x/d Daily As needed Weekly 1 – 2x/wk Weekly 3x/d 2 – 3x/wk Daily As needed ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

51 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) 51 Krause’s Food & Nutrition Therapy, 12 edition

52 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% 52 Working Group on Metabolism and Clinical Nutrition, 2003

53 Immunonutrient 53 Arginin Stimulate several hormon ↑ peripheral lymposite Glutamine Fuel source for eritrocyte Precursor glutathion Omega 3 Improve immune & metaolic function

54 54 “If the gut works, use it. If it isn't working, make it work.”


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