ANDI FARADILAH

Nutrition DepartmentFaculty of Medicine2014

NUTRITIONAL CARE IN INFECTION-TROPISM DISEASE

Sub-topic Nutrition in ICUNutrition in HIV-AIDSNutrition in Thypoid

Importance

Immune response during Inflammation and infection

Metabolic Response to StressInvolves most metabolic pathwaysAccelerated metabolism of lean body massNegative nitrogen balanceMuscle wasting

Hypermetabolic Response to StressPathophysiologyAlgorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

Ebb PhaseFlow PhaseImmediatehypovolemia, shock, tissue hypoxiaDecreased cardiac outputDecreased oxygen consumptionLowered body temperatureInsulin levels drop because glucagon is elevated.Follows fluid resuscitation and O2 transportIncreased cardiac output beginsIncreased body temperatureIncreased energy expenditureTotal body protein catabolism beginsMarked increase in glucose production, FFAs, circulating insulin/glucagon/cortisol

Hormonal Stress Response

Aldosterone corticosteroid that causes renal sodium retentionAntidiuretic hormone (ADH) stimulates renal tubular water absorption These conserve water and salt to support circulating blood volumeACTH acts on adrenal cortex to release cortisol (mobilizes amino acids from skeletal muscles)Catecholamines epinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis

Consequences of malnutrition

Increased morbidity and mortalityProlonged hospital stayImpaired tissue function and wound healingDefective muscle function, reduced respiratory and cardiac functionImmuno-suppression, increased risk of infection

CytokinesInterleukin-1, interleukin-6, and tumor necrosis factor (TNF)

Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals

Nutrition trials in ICUSmall, underpoweredHeterogeneous and complex patientsMixed nutritional statusDifferent feeding regimensUnderfeeding failure to deliver nutrients Overfeeding adverse metabolic effectsHyperglycaemiaScientific basis essential

What is the evidence in ICU?Early enteral feeding is best Hyperglycaemia/overfeeding are badPN meta-analyses controversial Nutritional deficit a/w worse outcomeEN a/w aspiration and VAP, PN infection EN and PN can be used to achieve goalsProtocols improve delivery of feedSome nutrients show promising results

Unanswered questionsShould we aim for full calorific delivery ASAP using EN + PN?What are the best lipids to use in PN?What is the role of small bowel feeding?Are probiotics helpful?Which patients will benefit from immuno-nutrition?The future: targeted Nutrition Therapy?

Nutritional management of severe sepsis and septic shockEarly nutritional support improves wound healing and the susceptibility of critically ill patients to infection

Early enteral nutrition may offer more benefit in preventing sepsis than parenteral nutrition

Immune-enhancing nutrients and antioxidants, including arginine and glutamine

Evidence-based analysis of nutrition support in sepsis. In: Clinical Trials for the treatment of sepsis, Sibbald, WJ, Vincent, JL (Eds), Springer Verlag, Berlin, 1995, p. 223.

Nutritional management of severe sepsis and septic shockSuch enteral formulas may favorably affect the resistance of the gut to bacterial translocation or exert direct effects on the behavior of intraluminal bacteria

Oral glutamine decreases bacterial translocation and improves survival in experimental gut-origin sepsis. JPEN J Parenter Enteral Nutr 1995; 19:69

(Mal)nutrition detectionNutritional assessmentNutrition screening (within 24 hours)Body mass index

Subjective global assessment or mini-nutritional assessmentWeight loss > 10%Intake accounting (

Nutrient Guidelines: CarbohydrateShould provide 60 70% calories Maximum rate of glucose oxidation = ~5 7 mg/kg/min or 7 g/kg/day*Blood glucose levels should be monitored and nutrition regimen and insulin adjusted to maintain glucose below 150 mg/dl

*ASPEN BOD. JPEN 26;22SA, 1992

Nutrient Guidelines: FatCan be used to provide needed energy and essential fatty acidsShould provide 15 40% of caloriesLimit to 2.5g/kg/day or possibly 1 g/kg/day IV*Caution with use of fats in stressed & trauma pts There is evidence that high fat feedings caused immunosuppression New formulas focus on omega-3s

*ASPEN BOD. JPEN 26;22SA, 1992

Nutrient Guidelines: Protein1.5 2.0 g/kg/day to start; monitor responseNonprotein calorie/gram of nitrogen ratio for critically ill = 100:1Giving exogenous aas decreases negative N balance by supplying liver aas for protein synthesis

ASPEN BOD. JPEN 26;22SA, 1992

Nutrient Guidelines: ProteinIn critically ill patients undergoing continuous renal replacement therapy, a single study indicates that protein intake > 2.0 g per kg per day is more likely to promote positive N balance (P=0.0001).

And, while a more positive N balance is associated with decreased mortality, a higher protein intake was not associated with mortality.

ADA EAL 11-27-07

Fluid and ElectrolytesFluid30-40 mL/kg or1 to 1.5mL/kcal expended

Electrolytes/Vitamins/Trace ElementsEnteral feedings: begin with RDA/AI valuesPN: use PN dosing guidelinesASPEN BOD. JPEN 26;23SA, 1992

How much to give in ICU?Schofield equation/Harris Benedict Add Activity and Stress factors e.g. 10% for bedbound + 20-60% for sepsis/burnsRough guide: 25 Kcal/kg/day total energy Increase to 30 as patient improves0.2g/Kg/day of Nitrogen (1.25g/kg/day protein)

How much to give?30 35ml fluid/kg/24 hours baseline Add 2-2.5ml/kg/day of fluid for each degree of temperature Account for excess fluid lossesAdequate electrolytes, micronutrients, vitaminsAvoid overfeeding Obesity: feed to BMR, add stress factor only if severe i.e. burns/trauma

Hypocaloric FeedingsHypocaloric feedings have been recommended in specific patient populationsAggressive protein provision (1.5-2.0 gm/kg/day)

ASPEN Nutrition Support Practice Manual, 2nd Edition, p. 279Zaloga GD. Permissive underfeeding. New Horizons 1994

Nutrition management in HIV

IL-6IL-1Reduced Subcutaneous fatDecreased NPYANOREXIAPOOR NUTRITIONAL STATUSIncreased lipolysis

Gejala klinis dan keterkaitan dengan gangguan gizi (1)Anoreksia & disfagiaObat ARV penurunan nafsu makanInfeksi jamur pada mulut sulit menelan Hal ini memerlukan terapi diet lunak, makanan tidakmerangsang, makanan dingin, minum melalui sedotan Khusus

Diare akut/malabsorbsiHilangnya zat gizi seperti vitamin & mineral Perlu cairan, buah buahan rendah serat, tinggi kalium & magnesiumHindari makanan berlemak dan jus berlebihanSesak nafasmakanan tinggi lemak rendah KHmengurangi CO2Porsi kecil tapi sering

Gangguan penyerapan lemakDiet rendah nabatiKonsumsi minyak nabati (minyak kedelai, minyak jagung, minyak sawit)Tambahan vit. A,D,E, K.

Gejala klinis dan keterkaitan dengan gangguan gizi (2)DemamKebutuhan protein meningkatMakanan lunak porsi kecil, jumlah lebih dari biasaMinum lebih dari 2 liter/8 gelas sehariPenurunan BBDicari penyebabnyaPastikan apa ada infeksi opurtunistikMakanan TKTP porsi kecil sering, rendah serat

HIV AIDSNutritional therapy is indicated when significant weight loss (45% in 3 months)Nutritional therapy should be considered when the BMI is o18.5 kg/m2.Diarrhoea and/or malabsorption are no contraindication to EN, because: Diarrhoea does not prevent a positive effect of oral nutritional supplements or TF on nutritional status.

ESPEN RECOMMENDATION

The combination of normal food and enteral nutrition is appropriate in many cases If oral intake is possible, nutritional intervention should be implemented according the following scheme.nutritional counsellingoral nutritional supplementstube feeding (TF)PNEach of the steps should be tried for 48 weeks before the next step is initiated.ESPEN RECOMMENDATION

HIV AIDS

Nutritional intervention

EnergyEnergy requirements are no different from other patient groupsThe Harris and Bennedict determine BEEEnergi requirements increase 13% for every degree Celcius above normalA general range for estimated energy 2200-2800 Calori (35-40 Cal/gr BW)t

ProteinProtein intake should achieve 1.2 g/kg bw/day in stable phases ; increased to 1.5 g/kg bw/day during acute illness.

FatIn patients with diarrhoea and severe undernutrition MCT containing formulae are advantageous.

Fluid

Fluid needs are the same as those of well individuals, except in the presence of severe diarrhea, nausea and vomiting and prolonged fever

Vitamin & mineral

follow RDA

FOOD AND NUTRITION MANAGEMENT PACKAGE

INTERVENSI MAKANAN BERDASARKAN MAKANAN YANG TERSEDIA DI INDONESIATempeTinggi protein dan vit. B12Bactericidedapat obati dan cegah diare

KelapaMengandung medium chains trygliceridesSumber energi yang efektif untuk meningkatkan pembentukan sel T4Mudah diserap dan NO diarrhoea effect

WortelTinggi kandungan B-carotentingkatkan immune bodies dengan tingkat CD4+Bersama dengan vitamin E, Cantioksidan (menangkal radikal bebas)

Brokoli & kembang kolTinggi kandungan mineral : ZN, Mn, Fe, SeMencegah defisiensi spesifikBerfungsi sebagai antioksidanPembentuk CD4+

DEVELOPMENT OF FOOD INTERVENTION BASE ON INDONESIAN FOOR FOR ODHA

Sayuran hijau dan kacang kacanganMengandung vitamin B dan trace elementsTinggi kalsiumMeningkatkan CD4+

AlpukatKandungan lemak (60%) tertinggi dari buah16% MUFA (Mono-Unsaturated Fatty Acid)sumber energi terbaikKonsentrasi Gluthation tertinggi sebagai antioksidanstop replikasi HIV

DEMAM TIFOIDMetode KonvensionalMulai bubur saringMenurunkan beban kerja ususMenurunkan perdarahanNetralisasi asam lambung

Diet yang dipakai sekarang

Makanan padat, rendah serat - Defekasi bulk forming - BB naik - Jumlah kalori segera terpenuhi - Dipersiapkan lebih mudah - meningkatkan selera makan

DIET ENERGI TINGGI PROTEIN TINGGIDiet yang mengandung energi dan protein diatas kebutuhan normal

Tujuan diet : - Memenuhi kebutuhan energi dan protein untuk mencegah kerusakan tubuh - Menambah BB hingga mencapai BB normal

Syarat diet ETPT :Energi 40-45 kkql/kg BBProtein 2-2,5 g/kgBBLemak 10-20% dari kebutuhan energi tot.Karbohidrat, vitamin , mineral cukup

SUMMARYSpecialized nutrient needs of the INFECTION patient:Increased calories to cover energy costs of hypermetabolicHigh fat diets.Adequate protein levels to support anabolism and the maintenance of lean body mass..Supplemental antioxidants to prevent or attenuate oxidative damage to tissue

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