MNT for Critical Ill in Surgical Patients Leny

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MNT for Critical Ill in Surgical Patients Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran

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

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

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

Background 20 – 60% Pasien RS Malnutrition Pasien ICU Pasca Bedah Dukungan zat gizi

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 3

Stress Response During Critical Ill Children, similar to adults, rely on the metabolic breakdown

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. 4 th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008 4

Burton, Deborah et al. Endocrine and metabolic response to surgery. The Board of Management

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 5

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Hormonal Changes Growth Hormone Anabolic effect Growth Hormone Catabolic effect Prevent protein breakdown Glycogenolysis

Hormonal Changes Growth Hormone Anabolic effect Growth Hormone Catabolic effect Prevent protein breakdown Glycogenolysis Lipolysis 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 Ø Gluconeogenesis Ø Lipolysis Ø Blood

ACTH & Cortisol Surgery ACTH ↑ Adrenal cortical Ø Gluconeogenesis Ø Lipolysis Ø Blood glucose ↑ Cortisol ↑ Ø Cortisol increases rapidly following the start of surgery Ø 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

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 Insulin ↓ Hyperglycemic respone After surgery Glucagon

Insulin & Glucagon Induce anaesthesia During surgery Insulin ↓ Hyperglycemic respone After surgery Glucagon ↑ ü Glycogenolysis ü Gluconeogenesis 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

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-6 and peak circulating values

Cytokines 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 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

Stress Metabolic 13

Carbohydrate Metabolism Hyperglycaemia Glucose concentrations >12 mmol/ litre impair wound healing and increase infection

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 14

Protein Metabolism The metabolic response during surgical is characterized by the breakdown of skeletal

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 15

Lipid Metabolism Surgery Increased catecholamine, cortisol and glucagon secretion, in combination with insulin deficiency

Lipid Metabolism Surgery Increased catecholamine, cortisol and glucagon secretion, in combination with insulin deficiency oxidation of FFAs to acyl Co. A Glycerol FA Triglycerides Acyl Co. A 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, concentrated urine, and

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 17

Nitrogen Excretion in Various Condition 32 28 Nitrogen Excretion (g/day) 24 20 16 12

Nitrogen Excretion in Various Condition 32 28 Nitrogen Excretion (g/day) 24 20 16 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.

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

Nutrient Requirenment during Surgery, Critical Ill, & Metabolic Stress 20

Nutritional Assessment Anthropometric Physical examination Laboratory Past history Malnourished/ well-nourished standard methods of nutritional

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, , 11 th Edition 21

Nutritional Assessment Anthropometry Berat badan (actual dry body weight) Physical exam. Hair, skin, eyes,

Nutritional Assessment Anthropometry Berat badan (actual dry body weight) 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. 4 th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008 22

Nutritional Assessment 23

Nutritional Assessment 23

Energy Requirenment in Critical Ill Adult : 25 – 30 kcal/ kg. BB Children

Energy Requirenment in Critical Ill Adult : 25 – 30 kcal/ kg. BB 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

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

Protein 26

Contoh: Protein 50 g/hr memerlukan 1200 kal atau 300 g glukose Kalori Protein Lemak

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

Rasio Nitrogen/Rasio Kalori Non Protein ~ 50 X N = 1000 6, 25 ~

Rasio Nitrogen/Rasio Kalori Non Protein ~ 50 X N = 1000 6, 25 ~ 8 X N = 1000 ~ N = 125 v Jadi Rasio Nitrogen / Rasio Kalori Non Protein = 1 : 125

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

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

Fluid Requirenment Infant & child: 1, 5 – 1 ml/ kcal Adult: 20 – 40 ml/kg/day 1 – 1, 5 ml/ kcal Ø Additional fluids may be necessary for large insensible losses (fever, diarrhea, GI output, and tachypnea) Ø 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 31

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

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

Nutrient Access in Critical Ill 33

Nutrient Access in Critical Ill 33

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

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

Enteral Vs Parenteral Nutrition Prefere route of nutrient intake Oral Nutrition Lower rate of

Enteral Vs Parenteral Nutrition 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 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 1. 2. 3. 4. 5. Keadaan pasien

Faktor-Faktor yang Perlu Dipertimbangkan dalam Pemberian EF 1. 2. 3. 4. 5. 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

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

Metode Pemberian EF/EN Continuous gravity feeding (kontiniu) pemberian EN secara terus menerus selama 24

Metode Pemberian EF/EN Continuous gravity feeding (kontiniu) pemberian EN secara terus menerus selama 24 jam Intermittent pemberian EN sebanyak 200 – 300 ml selama 30 – 60 menit setiap 4 – 6 jam Bolus pemberian EN sebanyak 24 o ml setiap 3 jam ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) 38

Feeding Protocol Sesegera mungkin setelah operasi antara 24 – 48 jam Awal : 10

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 Checking residual : prior to each intermittent feeding or 4 hours

Monitoring Enteral Feeding Checking residual : prior to each intermittent feeding or 4 hours with continous feed Residual < 200 ml, clear EF Residual >= 200 ml(NGT), or >=100 ml (Gastrostomy tube Intolerance to be assessed Volume exceed twice the hoursly infusion during continous feeding or exceed 50% infusion volume during bolus feeding Slowing/stopi ng feeding ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) 40

Monitoring Enteral Feeding 41

Monitoring Enteral Feeding 41

Enteral Formulation Energi : Protein : adult : 1 – 1, 5 Kcal/cc adult

Enteral Formulation Energi : Protein : adult : 1 – 1, 5 Kcal/cc adult : 6% - 32% infant : 0, 67 – 0, 8 kcal/cc pediatric : 12% infant : 8% - 13% Carbohydrate adult : 30% - 90% Fat : infant : 40% - 54% pediatric : 42% - 58% ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) adult : 20% - 55% pediatric : 25% - 46% infant : 35% - 50% 42

Enteral Formulation Water Fiber Energy 0, 67 – 0, 8 kcal/cc 1 kcal/cc 2

Enteral Formulation Water Fiber Energy 0, 67 – 0, 8 kcal/cc 1 kcal/cc 2 kcal/cc 88 – 90% 75 – 85% 70% 0 -22 g/L (adult), 0 -8 g/L (pediatric) Osmolaritas : 375 – 630 m. Osm per kg of water ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) 43

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Suggested Nutrient Intake for Adult Patients on Parenteral Nutrition Nutrient Protein Carbohydrate Lipid Total

Suggested Nutrient Intake for Adult Patients on Parenteral Nutrition Nutrient Protein Carbohydrate Lipid Total calories Fluid Critical ill 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 Stable Pateints 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) 45

Daily Energy Requirenments for Pediatric Patient on Parenteral Nutrition Age < 6 mos 6

Daily Energy Requirenments for Pediatric Patient on Parenteral Nutrition Age < 6 mos 6 – 12 mos >1 – 7 yrs >7 – 12 yrs >12 – 18 yrs Kcal/kg 85 – 105 80 – 100 75 – 90 50 – 75 30 – 50 Ø Protein requirenment for neonatus and infants : 1 – 2 g/kg/day and are increased daily by 0. 5 – 1 g/kg/d Ø Glucose : 6 – 8 mg/kg/menit , are increased gradually until energy goal are achieved or max 12 – 14 mg/kg/menit Ø IVFE : 0. 5 – 1 g/kg/d ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) 46

Trace Element Daily Requirenment* Trace Preterm Neonetus (3 kg) Term neonatus, infants (3 -10

Trace Element Daily Requirenment* Trace Preterm Neonetus (3 kg) Term neonatus, infants (3 -10 kg) Children (1040 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. 14 – 0. 2 5 – 15 Selenium (mcg) 1. 5 - 2 2 1 -2 40 – 60 *assumed normal age related organ function. ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005) 47

Recommended Trace Element Intake in Adult Px on PN Trace Standard daily intake Zinc

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) 48

Monitoring-Neonatus/ Pediatric on PN Parameter Anthropometric -Weight -Length -Head circumference Physical Fluid balance Metabolic

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

Monitoring – Adult Px on PN Parameter Chemistry screen (Ca, Mg, P) Electrolyte, BUN,

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

Refeeding Syndrome Aggresive administration of nutrition particularly via iv refeeding syndrome Occur when KH

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 51

Immunonutrient Imuninutrient : zat gizi spesifik yang dapat memperbaiki imunitas pasien dengan meningkatkan ataupun

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 52

Immunonutrient Arginin • Stimulate several hormon • ↑ peripheral lymposite Glutamine Omega 3 •

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

Terima Kasih “If the gut works, use it. If it isn't working, make it

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