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1
MNT for Critical Ill in
Surgical Patients
Leny Budhi HartiJurusan Gizi
Fakultas Kedokteran Universitas Brawijaya Malang
21 Mei 2012
2
Content
Nutrient Access 4
Background 1
Stress Response 2
Nutrient Requirement3
Immunonutrient 5
3
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
4
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
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
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Hormonal Changes
Growth Hormone
Growth Hormone
Catabolic effect
Anabolic effect
Glycogenolysis Lipolysis 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
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 ↑
9
Aldosteron & Renin
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
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
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
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
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
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
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
16
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
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
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
Long CL, et al. JPEN 1979;3:452-456
Nitro
gen
Excr
etio
n (g
/day
)
3228
24
20
16
12
8
4
0
19
Nutrition for the pediatric surgical patient: approach in the peri-operative period. Rev. Hosp. Clín.Fac. Med. S. Paulo 57(6):299-308, 2002
20
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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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
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
25
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
29
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
32
Micronutrient
Eur J Surg Sci 2010;1(3):86-89
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Nutrient Access in Critical Ill
34
“If the gut works, use it. If it isn't working, make it work.”
35
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
36
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
37
Rute Enteral Feeding
Krause’s Food & Nutrition Therapy, 12 edition
38
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
39
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
Working Group on Metabolism and Clinical Nutrition, 2003
40
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
41
Monitoring Enteral Feeding
42
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%
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
43
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
44
45
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
46
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)
47
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
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
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
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
49
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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√
√√
√
√
√
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√√
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
50
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
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)
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%
Working Group on Metabolism and Clinical Nutrition, 2003
53
Immunonutrient
Arginin
• Stimulate several hormon
• ↑ peripheral lymposite
Glutamine
• Fuel source for eritrocyte
• Precursor glutathion
Omega 3
• Improve immune & metaolic function
54
Terima Kasih
“If the gut works, use it. If it isn't working, make it work.”
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