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MNT for Critical Ill in Surgical Patients

MNT for Critical Ill in Surgical Patients. Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 21 Mei 2012. 1. Background . 2. Stress Response . 3. Nutrient Requirement. 4. Nutrient Access . 5. Immunonutrient . Content . Background.

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MNT for Critical Ill in Surgical Patients

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  1. MNT for Critical Ill in Surgical Patients Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 21 Mei 2012

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

  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. Hormonal Changes Growth Hormone Anabolic effect Growth Hormone Catabolic 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

  7. ACTH & Cortisol Surgery ACTH ↑ Adrenal cortical • Gluconeogenesis • Lipolysis • Blood glucose ↑ 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

  8. 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

  9. Insulin & Glucagon Induce anaesthesia During surgery After surgery Glucagon ↑ Insulin ↓ • Glycogenolysis • Gluconeogenesis Hyperglycemic respone Not contribution to the hyperglicemic respone British journal of anaesthesia 85 (1) : 109-17 (2000)

  10. 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

  11. Cytokines • The most important cytokine associated with surgery is IL-6and peak circulating values are found 12–24 h after surgery. • Thesize of IL-6 response reflects the degree of tissue damage which hasoccurred. • IL-6, and other cytokines, cause the acute phase response 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. Stress Metabolic

  13. Carbohydrate Metabolism • Hyperglycaemia. • Glucose concentrations >12 mmol/ litre impair wound healing and increase infection rates. • There is also an increased riskof 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

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

  15. Lipid Metabolism Surgery Increased catecholamine, cortisol and glucagon secretion, in combination with insulin deficiency Triglycerides oxidation of FFAs to acyl CoA FA Glycerol AcylCoA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

  16. Salt and water metabolism • Arginine vasopressin secretion results in water retention, concentratedurine, 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

  17. Nitrogen Excretion in Various Condition 32 28 24 20 16 Nitrogen Excretion (g/day) 12 8 4 0 Long CL, et al. JPEN 1979;3:452-456

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

  19. Nutrient Requirenment during Surgery, Critical Ill, & Metabolic Stress

  20. 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

  21. Nutritional Assessment Berat badan (actual dry body weight) Anthropometry Physical exam. Hair, skin, eyes, mouth, edema, temperature, tensi Laboratory Albumin, electrolite, blood urea nitrogen, glucose, iron, Mg, Ca, P Past history 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

  22. Nutritional Assessment

  23. 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)

  24. Protein 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 ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

  25. Protein

  26. 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

  27. Rasio Nitrogen/RasioKalori Non Protein ~ 50 X N = 1000 6,25 ~ 8 X N = 1000 ~ N = 125 • JadiRasio Nitrogen / RasioKalori Non Protein = 1 : 125

  28. 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, 2007 British Journal of Anastheasia 1996; 77:118 - 127

  29. Carbohydrate • Adult : At least 100 g/day needed to prevent ketosis • Carbohydrate 70% TEE • Glucose intake should not exceed5 mg/kg/min • Pediatric : • 50 – 100 g/day  prevent ketosis • EN : 45 – 65 % of total E • PN : 40 – 60% of total E ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005 Department of Surgical Education, Orlando Regional Medical Center, 2007

  30. 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 failurewith ascites, CNS injury, and electrolyte abnormality ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005

  31. Micronutrient Eur J SurgSci 2010;1(3):86-89

  32. Nutrient Access in Critical Ill

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

  34. Prefere route of nutrient intake Oral Nutrition Lower rate of infections complication than PN Enteral Nutrition Used in Px for whom oral & EN is not feasible Parenteral Nutrition Enteral Vs Parenteral Nutrition “Enteral feeding is preferred over parenteral feeding, whenever it is possible” Krause’s Food & Nutrition Therapy, 12 edition

  35. Faktor-Faktor yang Perlu Dipertimbangkan dalam Pemberian EF • Keadaan pasien • Penempatan ujung pipa • Jangka waktu pemberian • Potensi komplikasi • Informed consent Working Group on Metabolism and Clinical Nutrition, 2003

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

  37. Metode Pemberian EF/EN pemberian EN secara terus menerus selama 24 jam Continuous gravity feeding (kontiniu) pemberian EN sebanyak 200 – 300 ml selama 30 – 60 menit setiap 4 – 6 jam Intermittent pemberian EN sebanyak 24o ml setiap 3 jam Bolus ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  38. 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

  39. Monitoring Enteral Feeding Residual < 200 ml, clear EF Checking residual : prior to each intermittent feeding or 4 hours with continous feed Intolerance to be assessed 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 Slowing/stoping feeding ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  40. Monitoring Enteral Feeding

  41. 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% ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  42. Enteral Formulation Osmolaritas : 375 – 630 mOsm per kg of water ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  43. Suggested Nutrient Intake for Adult Patients on Parenteral Nutrition ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  44. Daily Energy Requirenments for Pediatric Patient on Parenteral Nutrition • 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)

  45. Trace Element Daily Requirenment* *assumed normal age related organ function. ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  46. Recommended Trace Element Intake in Adult Px on PN ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  47. Monitoring-Neonatus/ Pediatric on PN ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  48. Monitoring – Adult Px on PN ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

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