1. dr Iyan Darmawan

2. Hospital Malnutrition in USA 1. 1327 patients surveyed 2. 40-55% among them were malnourished 3. 12% severe malnutrition 4. complication rate 2-3 x >> 5. Length of stay 90% 2 Gallagher-Allred et al: J Am Diet Assoc 1996 Apr; 96(4):361-366 3. Effect of Single and Combined Observations on Morbidity and Mortality Observation Complications Death Albumin < 3.5 4 x 6 x TLC < 1500 2 x 4 x Albumin + TLC 4 x 20 x 3 Seltzer MH. Bastides AJ. Cooper DM et al. Instant Nutritional Assessment. J. Perenter Enteral Nutr 1979:3:157-159 TLC= total lymphocyte count 4. 4 Energy source Muscle protein 75 g Adipose Trigly ceride 160 g AA Glycerol 16 g FA 160 g Glycogen Glucose Hemopoe- tic sissue Heart Kidney Muscle Lactate + Pyruvate 40 g 120 g Keton 60 g 36 g 180 g 144 g Consumed Gluconeogenesis FASTING (1-2 DAYS) Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992 5. 5 Sumber energi Protein Muscle 20 g Triglyce- ride 150 g AA Glycerol 15 g FA 150 g Glycogen Glucose Heart Kidney Muscle Lactate + Pyruvate 36 g 112 g Keton 57 g 50 g 80 g 44 g 36g Keton 47 g Gluconeogenesis FASTING (5-6 weeks) Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992 Hemopoe- tic sissue 6. 6 Muscle protein 180 g TG 160 g AA Glycerol 30 g GlycogenGlycogen Glucose WOUND Lactate 320 g 114 g 76g 130 g 8 g 104g Gluconeogenesis MAJOR TRAUMA Energy source Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992 7. 7 Sumber energi Protein Muscle 250 g Adipose Tissue GluconeogenesisGluconeogenesis AA Glycerol 30 g Glucose Inflammed mass Lactate 360 g 114 g 76g Consumed 170 g 8 g 136g Fatty acid SERIOUS SEPSIS Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992 8. 8 Prolonged administration on iv glucose in the absence of protein Growth hormone & glucagon Insulin Fat mobilization Amino acid uptake by skeletal muscle at the expense of visceral protein synthesis Hypoalbuminemia and edema Mizock BA, Troglia Sarah: Nutritional Support of the hospitalized patient. Disease-a-Month. Mosby Vol 43 No6 June 1997. p.360 9. Classification of (PEM) 9 PEM MARASMUSMARASMUS KWASHIORKORKWASHIORKOR MARASMIC KWASHIORKOR MARASMIC KWASHIORKOR 10. Marasmus Severe chronic calorie def Wasting appearance Body weight < 80% TSF < 3 mm MAMC < 15 cm Associated illness: Cancer, COPD, anorexia nervosa Immune function is less suppressed as in Kwashiorkor 10 11. Kwashiorkor Protein intake in stressed conditions May occur within a few weeks May appear well-nourished; falling hair, Edema Serum albumin < 2,8 g/dl TIBC < 200 g/dl TLC < 1500/mm3 Anergy Poor healing wounds 11 12. Marasmic KwashiorkorWhen acute stress due to surgery, trauma and infection occurs in already chronically malnourished The most severe and life-threatening form Patients with marasmic kwashiorkor are hypometabolic and at high risk of overfeeding 12 13. 13 14. 14 Indirect calorimeter In vivo neutron activation analyser Scale Clinical Nutrition Lab Courtesy of Professor G.L Hill, Auckland University hospital. dept of surgery 15. Assessment of nutritional status Anthropometry Hematology and urine biochemistry Immunocompetence Indirrect calorimetry Measurement of muscle strength 15 16. Anthropometry Normal Body mass index ( BB/TB) Triceps skin fold (TSF)* Arm Circumference** AMC=AC - TSF x 3,14 16 18-25 12,5 mm 16,5 mm AMC= Arm Muscle Circumference (lingkar Muscle lengan atas) kg/m2 17. 17 Bishop C.W. et al: Norms for Nutritional Assessment of American adults by upper arm Anthropometry the American Journal of Clinical Nutrition 34: November 1981 pp 2530-2539. 18. Triceps Skinfold in Adults 18 Morgan Sarah: Fundamentals in Clinical Nutrition. Mosby 1998. p 179 Adequate Borderline Severely depleted Calorie reserves% standard Men (cm) Women (cm) 100 12.5 16.5 90 11.0 15.0 80 10.0 13.0 70 9.0 11.5 60 7.5 10.0 50 6.0 8.0 40 5.0 6.5 30 4.0 5.0 20 2.5 3.0 19. MAMC in Adults 19 Morgan Sarah: Fundamentals of Clinical Nutrition.Mosby 1998. p 179 Calorie reserves Adequate Borderline Severely depleted % standard Men (cm) Women (cm) 100 25.5 23.0 90 23.0 21.0 80 20.0 18.5 70 18.0 16.0 60 15.0 14.0 50 12.5 11.5 40 10.0 9.0 20. Hematology Albumin Transferrin Prealbumin Retinol binding protein Serum creatinine 20 Parameter Normal 3.5 - 5 g/dl 200 - 400 mg/dl 22 mg/dl 4.5 - 7 mg/dl 0.6 1.6 mg/dl 21. Other tests Creatinine-height index comparing patients 24-hr urinary creatinine excretion with reference values from persons of ther same height and gender Total lymphocyte count Delayed Hipersensitivity Skin Test 21 22. When to suspect PEM? Weight loss > 10% within 6 months Organ dysfunction Body mass index* (BB/TB) < 18 kg/m2 Serum albumin < 3,5 g/dl NRI (nutritional risk index) < 90 NRI= 1,59 x (serum albumin g/l) + 0,417 (current BW/ usual BW within the past 6 months) x 100 Bruce Ryan Bistrian.Proceeding 3rd Pensa Congress. Thailand October-1 November 1997 22 23. Assessment of severity History and PE Weight loss (%) % ideal body weight 5 10 80-90 10 20 60-80 > 20 < 60 Anthropometry MAMC (percentile) Triceps skin fold (percentile) - - 5th 10th 5th 10th < 5th < 5th Serum protein Albumin (g/dl) Transferrin (mg/dl) 3.0 3.5 150 - 200 2.1- 3 100 - 150 < 2.1 < 100 Immunology TLC (total lymphocyte count (cell/mm3 ) Delayed hypersensitivty skin testing 1200 1500 Reactive 800 1200 +/- < 800 Unreactive Creatinine height index (%) 80 90 60 80 < 60 23 Degree of malnutrition Mild Moderate Severe Forse R.A.: Diet, Nutrition and Immunity. CRC Press Inc 1994 p 11 24. 24 25. Physiological stress In stress, the inflammed white cells secrete cytokines The cytokines (tumor necrosis factor, interleukin-1 and interleukin-6) stimulates cathecolamines, Glucagon and cortisol Promote gluconeogenesis from amino acids Depressed appetite Stmulate lipogenesis Promote the synthesis of acute phase protein in the liver 25 26. How to examine the presence of metabolic stress? Clinical: trauma or major operation, sepsis Temp> 38 o C, pulse > 100/min Respiratory rate > 30/min Leucocyte > 12000 or < 3000 Positive blood culture Active IBD (inflammatory bowel disease) Confirmed focus of infection 26 27. To measure metabolic stress Objective: * RME (indirect calorimeter) * Catabolic index (CI) CI= UUN (g) - N diet (g) 27 2 + 3 If CI < 0 No stress CI 0-5 Moderate stress CI > 5 Severe stress Note: UUN = urinary urea nitrogen 1 g Nitrogen = 6.25 g protein 28. Protein Catabolic rate Protein catabolic rate (g/day)= [24-hr UUN (g) + 4] x 6.25 28 29. Stress factors Malnutrition 0,7 Chronic renal failure, nondialysis Hemodyalisis 1-1,05 Uncomplicated elective surgery 1,1 Peritonitis 1,15 Soft tissue injury 1,15 Fracture 1,3 Mild infection 1 Moderate infection 1,2-1,3 Severe infectiot 1,4-1,5 Burn, 0-20% BSA 1-1,5 Burn, 20-40% BSA 1,5-1,8 Burn, > 40% BSA 1,8-2 Head injury 1,6 29 30. 30 31. Calorie requirement in children Age Estimate requirement Neonates: (kcal/kg/day) Low birth weight 150 Normal birth weight 100-120 Children: 0-10 kg 100 11-20 kg 1000 kcal + 50 kcal/kg > 20 kg 1500 kcal + 20 kcal/kg 33 Pitono Suparto, Like S. Djupri, Subijanto MS: Gastroenterologi Anak. GRAMIK. FK Airlangga. 1997 Adopted from Ament ME. 32. Dosage of amino acid for children Newborn : initially 0,5 g/kg/day Infant and young children: initial dose 1 g/kg/day 34 increased to 2 g/kg/day Sakiio Suita, Tomoru Sakaguki: Amino Acids in Pediatric Nutrition AMINO ACIDS VIDEO SERIES No. 9 33. 35 34. 36 Nutritional assessment Decision to initiate Specialized Nutrition Support Functional GI Tract Yes No NUTRISI ENTERAL PARENTERAL GI Function Short-term Long-term (> 7 days) Intact Nutrient Defined Formula GI function returns Adequate Inadequate Adequate Nutrient tolerance Normal Compromised Long-term Gastrostomy Jejunostomy Short-term Nasogastric Nasoduodenal Nasojejunal (obstruction, peritonitis, intractable vomiting, acute pancreatitis, short bowel sindrome, ileus) Progress to oral feeding PN Supplementation Progress to more complex Diet and oral feeding Yes No PPN TPN 35. 37 36. 38 Economical Promotes secretion of digestive hormones Prevents villous atrophy Inhibits bacterial overgrowth and translocation No risk of catheter-related sepsis and phlebitis 37. 39 Nasogastric, nasoduodenal Jejunostomy Gastrostomy PEG (percutaneous endoscopic gastrostomy) Hill G.L: Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill Livingstone 1992. 38. 40 Intact Hydrolysate Crystalline Special Modular 39. Intact protein Intact protein: Caseinate-based or soya-based products; lactose-free and low residue. Generally contain oligosaccdaydes and LCT (MCT) Calorie content 1 kcal/ml Additional: fibres 41 Examples: Proten , Pan Enteral, Ensure, Isocal, Osmolite 40. Protein hydrolysate Also called chemically defined formulas Partially predigested; low-residue and free-lactose Protein may take form as peptides or free amino acids Carbohydrate: oligo or dissacdaydes Low fat content 42 Examples: Pepti-2000, Criticare HM, Tolorex 41. Protein hydrolysate Useful for patients with GIT dysfunction and impaired absorption of protein, such as catabolic states associated with Hypoalbuminemia and Crohns disease. Expensive, not palatable 43 42. Crystalline Protein Also named elemental formula Protein source is free amino acids Most products contain oligosaccharides/ Glucose as NPC source with low LCT 44 Patients with GIT dysfunction Examples: Tolorex, Vivonex 43. Sepcialized formula For specialized conditions (eg, metabolic stress, liver disease, renal disease, glucose intolerance) May contain immunonutrients (eg. glutamine, arginine, etc) 45 Examples:Kidmin, Aminoleban, Neomune Pulmocare, Traumacal 44. Modular Formula Contains solely one nutrient, eg: : calcium caseinate, whey protein, maltodextrin, glucose polimers 46 Examples: Casec, Polycose liquid, Sumacal 45. 47 46. Entry sites of CV Catheters V. subclavia infraclavicular (most commonly used) V. subclavia supraclavicular V. jugularis interna 48 47. Procedure Right sided is preferred owing to absence of throacic duct Trendelenburg position Cleanse the area and apply povidone iodine. Select a point at midclavicular line for insertion and inject local anesthetics as fas as clavocular peiosteum In fossa supraclavicular space, using fore finger press down to first rib. Insert needle (22-G ) toward the rib pointed by fore finger 49 Tsugushiko Tashiro MD, Head of Surgical Metabolism Unit The First Department of Surgery Chiba University Medical School Site of puncture for subclavicular approach Direction of puncture 48. Procedure (contd) Insert 14-G until 2 mm deep and aspirate the blood. Patient is instructed to hold breathing, release the syringe nad insert catheter via needle access site into subclavian vein. Caution: hypovolemia may cause air emboli. Withdraw catheter until only 15 cm remaining inside. Fix the cataheter with silk suture. Connect the catheter to infusion line 50 49. 51 Insertion of Arrow CVC set Courtesy of Dr Irwan Amin,SpAn KIC 50. 52 Central Venous Catheterization Set (ARROW) Indwelling Catheter: 14 Ga. x 6" (16 cm) Radiopaque Polyurethane with Blue FlexTip, Integral Extension Line, Extension Line Clamp, Side Holes, Integral Suture Wing One: Spring-Wire Guide, Marked: .032" (.81 mm) dia. x 17-13/16" (45 cm) (Straight Soft Tip on One End - "J" Tip on Other) with Arrow Advancer One: Fastener: Catheter Clamp One: Introducer Needle: 18 Ga. x 2-1/2" (6.35 cm) XTW One: Pressure Transduction Probe One: Arrow Raulerson Spring-Wire Introduction Syringe*: 5 cc One: Clamp: Catheter One: Vessel Dilator 51. 53 52. 54 Introduction syringe Vessel dilator Catheter Guide wire Catheter clamp 53. 55 Apply antiseptic on the right chest 54. 56 Povisone iodine wiped with alcohol gauze 55. 57 Supraclavicular method External jugular vein Internal jugular vein Subclavian vein First rib NeedleClavicle V. innominata John Windsor. Total Parenteral Nutrition. New Ethicals October 1988. (Modified by Irwan Amin) 56. 58 Operating area covered with sterile cloth 57. 59 2 ml Lidocain HCL withdrawn from ampule 58. 60 Lidocaine HCL injected to skin surrounding access site 59. 61 Once Lidocaine HCl has been injected out, the same needle is directed toward vena innominata and pushed deeper, blood is then aspirated 60. 62 Introduction syringe is passed through entry site of local anesthetics blood is aspurated from central vein Note: Introduction syringe is not syringe of Lidocain HCl 61. 63 Guide wire is inserted into central vein. The tip is hooked to avoid injury) 62. 64 Guide wire moved on 63. 65 Guide wire is seen 64. 66 Entry site of guide wire is dilated by vessel dilator 65. 67 Catheter is inserted along the guide wire 66. 68 Catheter passed down the guide wire 67. 69 Catheter length is almost inside 68. 70 Guide wire is released 69. 71 Blood is aspirated to ensure the catheter is correctly located in central vein 70. 72 Syringe is left in situ before disconnected and preparation of infusion set 71. 73 Catheter is already connected to infusion line 72. 74 Catheter clamp is not sutured to the skin because patient was agitated 73. 75 TPN insertion finished 74. 76 John A Windsor. Total Parenteral Nutrition. New Ethicals October 1988. A patient on TPN with catheter insertion via subclavian vein to superior vena cava 75. 77 Tsugushiko Tashiro MD, Head of Surgical Metabolism Unit The First Department of Surgery Chiba University Medical School Water 2000 ml/day Protein 1-2 g/kg/day TEE 30-40 kcal/kg/day Na 1-2 mEq/kg/day K 1-2 mEq/Kg/day Mg 0.2-0.5 mEq/kg/day Ca 0.2-0.3 mEq/kg/day P 0.5-1 mEq/kg/day Cl 1.0-2.0 mEq/kg/day Vitamints & trace elements 76. 78 Amiparen Triparen OMVI 77. To determine nutrient requirement Water: Maintenance 25-35 ml/kg/day or approx. 2000-2500 ml/day Patients with intestinal obstruction, fistulae and fever are dehydrated and may require more water. 79 78. Dosage of Nutrients Energy : 30 kcal/kg/day in nonstressed and 40 kcal/kg/day in stressed conditions. (Note: the whole requirement cannot be fulfilled instantly. Titration is mandatory) Fat emusion 20% of total NPC to alleviate metabolic load of the liver. Yet, sole glucose is sufficient for TPN of 2-4 weeks. When TPN > 4 weeks: 200 ml of 10% fat emulsion is recommended High BCAA is recommended in metabolic stress 80 79. 81 80. 82 Supply calory of less than 1000 kcal/day Generally < 7 day in patients whose gut function has not resumed to normal or as supplement to oral/enteral route Osmolarity should be less than 900 mOsm/L 81. 83 82. Assessment of Nutritional Status Clinical: General appearance: skinny face, promonent cheek bone, flat buttock, pointed shoulder bone Body fat stores (pinch triceps/biceps) positive finger- thumb test Body protein stores (prominent tendon of scapula) positive tendon-bone test Hypoalbuminemia Physiological function: poor wound healing, weak hand grip; inability to blow a sheet of paper; dyspnea 84 Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill Livingstone. 1992. 83. Determination of metabolic stress Clinic and catabolic index Objective (indirect calorimetry): RME (kcal/24 hour) = 13.6 x FFM (fat-free mass) + 550 Mean (+ SD) ratio of measured RME to calculated RME. Normal subject :1,00 + 0,09 Ratio of > 1,18 is considered metabolic stress 85 Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill Livingstone. 1992. 84. Goal of nutrition support Marasmus Recovery of fat and protein store and normalisation of body hydration Major trauma or serious sepsis (kwashiorkor) limit protein loss , partially normalize hydration and improvement of physiological function Marasmic kwashiorkor: replete protein. In the presence of sepsis, focus of sepsis must be eliminated first. 86 85. Total Energy Requirement . 87 25 kcal/kg/day Saito H. Perioperative Nutritional Support. In Tienboon P., Chuntrasakul C. Nutrition and Metabolic Support in Clinical Practice. Pensa 1998. pp 159-174. 86. Protein requirement Maintenance : 1,0 - 1,5 g/kg/day Replacement : 1,5 - 2,0 g/kg/day Repletion of massive loss : 2,0 - 2,5 g/kg/day 88 Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill Livingstone. 1992. 87. Water and mineral requirements in adults Patient group (16-25 th) (25-55 th) (56-65 th) (> 65 th) Water 40 ml/kg 35 ml/kg 30 ml/kg 25 ml/kg Natrium 60-100 mmol 60-100 mmol 60+ mmol 50+ mmol Kalium 60+ mmol 60+ mmol 60+ mmol 50+ mmol Calcium 15 mEq 15 mEq 20-50 mEq 20-50 mEq Phosphate 20-50 mmol 20-50 mmol 20-50 mmol 20-50 mmol Magnesium 8-20 mEq 8-20 mEq 8-20 mEq 8-20 mEq 89 Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill Livingstone. 1992. 88. Indications of enteral nutrition support of surgical patients Moderate to severe PEMwhere oral intake is impossible in preceeding 3 days Mild PEM where less than 50% of dietary requirement is met since the preceeding 7-10 days Disphagia to all nutrients but fluid Massive enterectomy in recovery period Distal enterocutaneous fistulas Major trauma Prolonged postoperative care IBD (inflammatory bowel disease) 90 89. Contraindications of enteral nutrition Total small intestinal obstruction Ileus Severe diarrhea Proximal small bowel fistula Severe pancreatitis Shock 91 90. 92 91. Metabolic response Hypermetabolism Proteolysis and nitrogen loss Accelerated gluconeogenesis and utilization of glucose 93 92. 94 180 160 140 120 100 80 60 10 20 30 40 50 60 70 Restingmetabolism(%normal) day Major burn Peritonitis Fracture Partial starvation Total starvationl Kisaran normal Long CL, Schaffel N. Geiger JW, et al: Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimeter and nitrogen balance, JPEN 3:452.1979.) Changes in metabolic rate and nitrogen excretion with physiological stress 93. 95 Nitrogenexcretion(g/day) 28 24 20 16 12 8 4 0 10 20 30 40 Major burn Skeletal trauma Severe Sepsis Infection Elective surgery Partial starvation Total starvation day Changes in metabolic rate and nitrogen excretion with physiological stress Long CL, Schaffel N. Geiger JW, et al: Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimeter and nitrogen balance, JPEN 3:452.1979.) Normal range 94. 96 95. Definition of Sepsis Syndrome one of the following: Temp > 38,3o C RR > 20/minute or mechanical ventilation Heart rate > 90 /minute Clinical evidence of infection Positive blood culture after 48 hours 97 Screening criteria 96. Calorie and protein requirement in sepsis Total energy requirement 25 kcal/kg/day Protein : 1,5-2 g/kg/day 98 The Journal of Critical Care Nutrition/Volume 5 No 1 1998 97. Thanks 99