MEDICAL NUTRITION THERAPY FOR METABOLIC STRESS : SEPSIS,TRAUMA,BURNS, AND SURGERY

DIKERJAKAN OLEH :DEWI SOPHIA25010110120134MAHASISWI UNIVERSITAS DIPONEGORO SEMARANG

PREFACE TRAUMA FROM MOTOR VEHICLE

ACCIDENTS,GUNSHOTS,WOUNDS,FALLS, AND BURNS ARE MAJOR CAUSES OF DISABILITY AND DEATH .

MAJOR CAUSES OF DEATH :1. HEART DISEASE2. CANCER3. STROKE4. CHRONIC LOWER RESPIRATORY DISEASE5. UNINTENTIONAL INJURIES (METABOLIC STRESS)

HORMONAL RESPONSE

1. FLOW PHASE :a. ACUTE RESPONSE CATABOLISM PREDOMINATESb. ADAPTIVE RESPONSE ANABOLISM PREDOMINATES2. EBB PHASE : HYPOVOLEMIC SHOCK

STARVATION VERSUS STRESS STARVATION DIFFERENT WITH STRESS RELATED TO OUR

METABOLIC1. STARVASI DECREASED ENERGY EXPENDITURE,DIMINISHED

GLUCONEOGENESIS,INCREASED KETONE PRODUCTION,DECREASED UREAGENESIS

2. STRESS ENERGY EXPENDITURE INCREASED,AS ARE

GLUCONEOGENESIS,PROTEOLISIS, AND UREAGENESISSTARVATION :2. EARLY STARVATION3. ADAPTIVE STARVATION4. LATE STARVATION

I . Sepsis (Infeksi)

patient has a documented infection and an identifiable organism. It’s toxins lead to a strongeer inflammatory ressponse (they are : viruses,fungi and parasites).

Therapy for these patients are :1. Medical nutrition therapy2. Nutrition Support therapy

( additional )

Medical Nutrition Therapy critically ill patient enters an intensive

care unit (ICU) cause of cardiopulmonary diagnosis,intra-operative or post-operative complication,multiple trauma,burn injury or sepsis.

Severely injured patient is usually enable to provide a dietary history.

Serum albumin should not be used as a marker of nutritional status.

Prealbumin and transferin often drop precipitiously inflammation induced decrease in hepatic synthesis and changes.

Assesment focuses on the preadmission,preoperative,preinjury nutrition status,presence of any organ system dysfunction,the need for early support therapy , and optionsthat exist for PN or EN.

When monitoring critically ill patients,one must focus on laboratory data,not to define or determine nutrition status but to design the nutrition prescription.

Nutrition Support Therapy Incorporates early EN when feasible,appropriate

macro and micronutrients delivery,and glycemic control.

Goals :1. Minimalization of starvation2. Prevention or correction of spesific nutrient

deficiencies3. Provision of adequate calories4. Minimizing associated metabolic complications5. Fluid and electrolyte management6. Maintain adequate urine output and normal

homeostasis7. Modulating immune response

ICU Establishing hemodynamic stability Important to :a. Follow the patients heart rateb. Blood pressurec. Cardiac ouputd. Mean arterial pressuree. Oxygen saturationThese are key factors to asses hmodynamic

stability and whether nutrition support therapy can commence. Dietitians must recognize the significant contributions of dextrose in PN and its influence on glycemic control.

Nutritional Requirements1. EnergyOxygen consumption is an essential

component in the determination of energy expenditure. Energy requirements may be calculated as 25-30 kcal/kg/day.

Avoidance of overfeeding in the critically ill patients is important.

Excess calories can result in complications.

2. Protein

Determination of protein requirements is difficult for critically ill patients. Patients typically requires 1,2-2 g/kg/day depending on their baseline nutritional status,degree of injury,metabolic demand, and abnormal losses.

Excessive amounts of proteins will not decrease the characteristic net.

3. Vitamin,mineral and “trace elements” No spesific guidelines exist. Micronutrient needs are elevated

during acute illness. Increased need for B

vitamins,particularly thiamin and niacin.

Fluids and electrolytes should be provid to maintain adequate urine output and normal serum electrolytes.

4. Feeding Strategies

1. Oral dietary2. Often requires combinatons of oral

nutrition supplement,enteral tube nutrtion,and PN.

3. When EN failed,PN support should be initiated.

5. Timing and route of feeding1. Within the first 24-48 hours of ICU

admission and advanced toward goal during the next 48-72 hours.

2. Intake of 50%-65 % of goal calories during the first week of hospitalization.

II. Trauma (post-surgery falls ,fractures or caesar)

abdominal trauma,bowel distention,and states of shock,some patients experienced intra-abdominal pressure leading to hypoperfusion and ischemia of the intestines and other peritoneal and retropertoneal structures. Patients has severe metabolic alterations.

III. Major Burns

Severe trauma,energy requirements can increase as mush as 100% above resting energy expenditures depends on the extent and depth of the injury.

Medical Managements : Fluid and Electrolyte Repletion for the first

24-48 hours. The volume of fluid needed is based on the

age and weight of the patient and the length,depth of injury.

Medical Therapy Nutrition Needs increased

energy,carbohydrates,proteins,fats,vitamins,minerals and antioxidants to heal and prevent detrimental sequelae.

Enteral feeding Adequate surgical care,infection

control,and nutrition should be available as soon as possible after the burn.

1. Energy

Increasing energy requirements by 20% to 30%is necessary.

Additional calories needed because of fever,sepsis,multiple traumas or the stress of surgery.

Weight maintenance should be the goal for overweight patients.

2. Protein

Providing 20% to 25% of total calories as protein of high biological value is also recommended.

Best evaluated through monitoring wound healing,”graft take”,and basic nutrition assesment parameters.

Wound healing may be delayed if weight loss exceeds 10%.

The Goals1. Minimize metabolic stress response by : Controlling environmental temperature Maintaining fluid and electrolyte balance Controlling pain and anxiety Covering wounds early

2. Meet nutritioanl needs by : Providing adequate calories to prevent weight loss. Providing adequate protein for positive nitrogen balance

and maintenance. Providing vitamins and mineral supplementation as

indicated

3. Providing “curling stress ulcer” by : Providing antacids or continous enteral feedings

Methods of Nutrition Support therapy With feeding tube or PN. PN may be needed to prevent

interuption from feeding tube.

IV. Surgery

is a matter of life and deathin surgical and critical care unit. Obese patient has a higher surgical risk.

PN sshould be initiated 5-7 days before preoperatively and continued into the post-oprative period.

Medical Nutrition Therapy1. Preoperative nutrition care Witholding solids for 6 hours pre-

operatively and clear liquids for 2 hours prior to introduction of anesthesia.

Pre-operative fasting is not possible and surgery should be timed according to urgency,patients are treated as if the stomach is full.

2. Post operative nutrition care Should receive early EN unless there is an

absolute contraindication. If oral feeding is not possible, or an extended NPO

period is anticipated,an access device for EN feeding should be inserted at the time of surgery.

The timing of introduction of solid food fter surgery depends on the patients degree of alertness and condition of GI tract.

Clear liquids to full liquids and finally solid foods. Surgical patients can be fed a regular solid foods

diet than a clear liquid diet.

Thank you for your attention

Q&A