-------------------- Nutrition Needs in Normal Condition
1. 1. Estimating caloric needs
Formulas TEE = BEE x AF x SF
TEE = total energy expenditure
BEE = basal energy expenditure
AF = activity factor
SF = stress factor
Empirical formula: 30-35 kcal / kg / day
BEE by Harris Benedict equation
Male
BEE = 66.47 + (13.75 x BB MLP kg) + (5.0 x TB MLP cm) - (6.67 x age in the year)
Woman
+ BEE = 655.1 (9.56 x BW MLP kg) + (1.85 cm x TB MLP) - (4.68 X age in the year)
1. 2. Estimating protein requirements
Age of amino acids
(G / kg / day)
Preterm neonates 3.0
Infants 0-1 years 05.02
Children 2-13 years 1.5 - 2.0
Teenagers 1.0 - 1.5
Adult 0.8 - 1.0
1. 3. Estimating the lipid requirement
Requirements of fat = 20% from the total caloric needs
Unsaturated fats: saturated fat = 2: 1
Composition: monounsaturated FA and essential fatty
Parenteral nutrition: fat as a source of calories and essential fatty acids (glycerol)
Dose: 1-3 g / kg / day
Not given when the blood triglyceride levels> 400 mg / dl
1. 4. Estimating the needs of vitamins and minerals
2. 5. Estimating fluid requirements
Age (years) liquid Needs
(Ml / kg / day)
Active young adults 16-30 40
Adults average 25-55 35
Patients older than 55-65 30
Elderly> 65 25
---------------- Nutritional Needs of Specific Clinical Condition
General Metabolic Stress - Trauma
Overall, the physiological response to trauma is an increase in biochemical and metabolic processes of normal, so that usually an increase in nutrient needs are quite large. If not received adequate nutritional support, many patients will lose weight and there complications that often prove fatal. The main objective of nutrition support therapy is to keep weight to a minimum in hopes of preventing complications and reducing morbidity and mortality.
Nutrition and energy needs
Energy requirement / total daily calories can be calculated from the sum of basal caloric needs (BMR), stress factors, physical activity, and specific dynamic action (SDA).
KK = JSC + FS + AF + SDA
KK = the total caloric requirement
CLA = basal caloric requirement
FS = factor of stress
AF = Physical activity
SDA = specific dynamic action
Basal caloric requirement is obtained by calculating BMR based on Harris-Benedict equation.
Stress factors assessed based on the assessment of nutritional status and metabolic status. To simplify, stress factors are categorized in:
* The degree of 10-30%, mild stress
* The degree of stress being 31-50%
* The degree of stress weight ³ 51%
Traumatic stress is classified into, so the stress factor for trauma is 31-50%. Multiple traumatic stress factor is 50%.
Physical activity: when a patient should be in bed, physical activity 10%, while when not in bed, physical activity was 20%.
SDA of food depending on the type of food provided. SDA parenteral nutrition is 0% while the SDA for enteral formulas and food peroral approximately 10-20%.
Protein
In the trauma occurred relatively constant protein catabolism that is 10-20% of energy output. Input protein for healthy people (0.8 to 1 g / kg / hr) did not provide for patients who are experiencing trauma because of an increase in protein turnover. Protein needs for patients with trauma when there is no kidney and liver disorders are 1.5 to 2 g / kg / hr, with non-nitrogen ratio of calories: nitrogen = 100:1.
Fat
Fat serves as a source of energy. Various studies indicate that administration of lipid emulsion for 30-40% of total calories is the optimal amount. To prevent deficiency of essential fatty acids, essential fatty acids need to be given as much of 4-8% of total calories daily.
Carbohydrate
Carbs also function as an energy source. Given the number of carbohydrates is reduced need for total calories derived from fat. In patients with trauma, carbohydrate is 40% of total daily calories.
Fluids and Electrolytes
Fluid requirements are ± 1 500 ml per m2 body surface area per day, then added if there was an increased insensible loss through perspiration, diarrhea, or feeding tubes.
Intracellular saline and electrolytes should be administered in adequate amounts. Levels of potassium, phosphorus and magnesium in plasma and whole body should be maintained to remain normal in order to get the expected response with the provision of nutritional support.
Vitamins and Trace Elements
Therefore an increase in metabolism, the need vitamn B increases. Thiamine and niacin needs related to caloric intake. In trauma, there is increased excretion of zinc (zinc) are assumed to come from the catabolism of muscle tissue. This condition can cause zinc deficiency, so that trauma patients need to receive supplemental trace elements.
Special Metabolic Stress
To be able to perform the role and functions in the body, nutrients through metabolic processes in stages, namely:
- Digestion (digestion)
- Uptake (absorption)
- Change (Degradation)
- The use of organs / cells (utilization)
- Spending the remaining substances (excretion)
Each phase of metabolism carried out by different organs, such as stage of digestion and absorption by the gastrointestinal organs. Changes are made primarily by the liver; use by all organs; expenditure remaining substances mainly by the kidneys and lower gastrointestinal tract.
1. A. Digestibility Channels Organ Disorders
The main function of the GI tract are digestion and absorption by secreting enzymes specific for each nutrient. Upper gastrointestinal tract mainly absorb major nutrients; whereas lower GI tract mainly absorbs water, minerals and some vitamins.
1. B. Liver Disorders
Liver is an important organ in the process of degradation of nutrients because it is a major organ that metabolizes nutrients and secreting enzymes that play a role in the metabolism of carbohydrates, proteins and fats and are responsible for 20% basal metabolism. Liver to synthesize several plasma proteins that are important and bile salts and play a role in detoksikasi.
Penyekit liver disorders can be grouped into
- Acute liver disease such as hepatitis virus
- Chronic liver disease such as liver cirrhosis
1. C. Kidney Disorders
Renal excretion represents the largest organ and also as an organ regulating body fluid balance. Disturbances in the kidneys will cause interference with the excretion of the remains of the metabolism especially the metabolism of protein and fluid and electrolyte disturbances.
Enteral Nutrition Therapy -----------------------------
Enteral nutrition compared to parenteral Benefits
1. Physiological
Enteral nutrition is physiological, because the food enters the body through normal digestive tract, so that the function and structure of the digestive equipment is maintained. In contrast, total parenteral nutrition can cause atrophy of the small intestine mucosa and pancreas, especially in providing long because the food into your hearts beyond the appliance digestibility (by pass from the outside in the liver).
1. More effective
Enteral nutrition is more effective. This is evidenced by rapid weight gain and N balance are fast becoming positive. In addition, the rapid increase in the immunity will be found on enteral nutrition.
1. Less complications
Complications of enteral nutrition is much lower when compared with parenteral nutrition. Parenteral nutrition in addition to requiring strict monitoring, complication-komplkasi of sepsis, thrombosis, hematoma, metabolic disorders such as pneumothoraks and hypoglycemia or hyperglycemia was not uncommon.
1. High calorie convenient
With high-calorie enteral nutrition needs of more than 3000 kcal / day which can be easily filled with parenteral very difficult to achieve without complications and a watchful eye. This high caloric needs in patients with hipermetabolik such as sepsis, multiple trauma, or burns. In addition, the provision of high-calorie parenteral nutrition often cause fatty liver are not observed in enteral nutrition.
1. The technique is easy
Installation of gastric sonde can be easily performed by any doctor or nurse without stringent sterility requirements. While parenteral administration must be given through a large vein that is located profundal with high sterility. IBHS only be done by a trained doctor.
1. Low costs
Enteral nutrition on average 10-20 times cheaper than parenteral nutrition.
Terms of enteral nutrition
1. Has a caloric density tnggi
Because enteral nutrition should be given through a small sonde, it must be liquid so easily through the sonde. In order for this liquid enteral nutrition still have enough calories, then it must have a high caloric density. Thus, with the volume that is not too large, the number of calories was achieved. The ideal calorie density is 1 kcal / ml liquid.
1. Balanced nutritional content
That is, the minimum amount for basic needs (2000 kcal) should already contain all the components of essential nutrients such as proteins, amino acids, fats, vitamins, electrolytes and other elements in accordance with the number of needs.
1. Has the same osmolarity osmolarity of body fluids
An enteral nutrition which has a high osmolarity easily cause diarrhea because your body fluids will be drawn into lumen of the intestine. Therefore, the ideal osmolarity is 350-400 m osmol, according to the osmolarity of extracellular fluids.
1. Easy resorption
Raw materials an enteral nutrition should consist of the components ready absorbed or at least very little need for digestive activity can be absorbed. In other words, the molecules are small.
1. Without or less contain fiber and lactose
An enteral nutrition should have little or no contain fiber to be effective and efficient. Enteral nutrition that contains a lot of fiber will be the bulk which in turn will increase the frequency of defecation.
To avoid lactose intolerance often occurs in people with malnutrition, enteral nutrition should be a less or without containing lactose, or lactose content of only the highest 0.5% of the total karbohdrat.
1. Enteral nutrition that is free from materials that contain purine and cholesterol
Technical procedures enteral nutrition / diet sonde
1. Election sonde
Before the 1980s sonde which is available generally made of polyethylene, PVC or latex. Lack of-sonde sonde is in addition to a large diameter, sonde easily become stiff after pelemasnya substances discharged (after 24 hours of usage), is also not resistant to the influence of gastric or duodenal fluid. Which becomes rigid sonde will be very annoying because apart from the patient feels uncomfortable can also cause erosion or airway injury, or gastrointestinal tract.
Currently-sonde sonde used for enteral nutrition made from silicone or polyurethane, which in addition to the small diameter (2.5 mm), supple and long-lasting flexibility and resistance to gastric fluid and duodenal fluid.
1. Techniques of enteral nutrition
Techniques of a drop is the most secure. Old patterns that give scara bolus contains many complications such as vomiting, regurgitation to aspiration into the lungs, especially in patients with a decreased consciousness or in patients who lie down. In order to reduce the above complications, the patient should be positioned a half-sitting for enteral nutrition.
To maintain accuracy and drops of liquid enteral nutrition assessment can be used in a portable pump. In order to keep receiving bowel tolerance, enteral nutrition fluid levels should be increased gradually. Starting with a dilution of ½ on the first day, then dilutions of two thirds on the second day and full dose on the third day onwards, while supervising and evaluating complaints and symptoms that arise.
1. Caloric requirement
Basal metabolic needs can be calculated with Broca index, as follows:
BMR = stress index (height - 100) x 20
Stress index: - post-surgical + 10% BMR
- Fracture of multiple + 25-30% BMR
- Sepsis, each increase of 1 ° +10% BMR
So, a 165 cm height without stress has a BMR (165-100) x20 = 1300 kcal. By adding 10-20% of the required BMR caloric requirements can be obtained when the activity is very limited. While at a high catabolic state required the addition of 30-100% of BMR requirements.
1. Monitoring
Progress or deterioration of general condition patients were evaluated every day, including fluid and electrolyte balance when there are facilities. Measurement of weight or upper arm circumference (lla) each week represents an objective parameter.
In addition, laboratory examination is necessary, among others:
a. Blood: Hb, Hmt, leukocyte
b. Serum: glucose, urea, total protein, albumin, total
c. Routine urine volume and
Indications of enteral nutrition
Surgical indications, ie, post-surgical:
- Mouth
- Esophagus
- Gastric
- Bile duct
- Colon
Non-surgical indications:
- Anorexia
- Severe depression
- Traumatic head / brain
- Extensive burns
- Sepsis
- Cancer patients
- Malabsorption / maldigesti
- Fistulas
- Patients with extreme calorie needs
Enteral nutrition Kontrandikasi
- Vomiting
- Ileus
- An acute gastrointestinal bleeding
- Peritonitis
- Post-surgical Atoni
Complications of enteral nutrition
1. Mechanical complications
Mechanical complications associated with sondenya own that can be experienced dislocation or obstruction.
1. Complications of chemical
This is related to the osmolarity and chemical composition of enteral nutrition fluids that are too high. Nausea to vomiting and stomach cramps or diarrhea is a prominent symptom.
1. Complications bacteriological
Contamination with gram-negative bacteria at the time of the provision of enteral nutrition or plastic bags can cause septic shock.
1. Metabolic complications
Hypertonic dehydration can occur if the composition of nutrients enteralnya memilki high osmolarity. Giving levels gradually can reduce this complication.
Parenteral Nutrition Therapy ---------------------------
Parenteral nutrition is the delivery of nutrients through the veins. Mode of administration can be via a peripheral vein (peripheral parenteral nutrist) or central vein (total parenteral nutrition).
The conditions require parenteral nutrition
- Ileus obstruction
- Peritonitis
- Fistulas enterokutan
- Severe malabsorption syndrome
- Vomitus
- Severe diarrhea
- Malnutrition protein or protein-calorie
- Malignancy
Indications of parenteral nutrition
- Disturbed gastrointestinal function (not able to digest or absorb food)
- NPO> 3-5 days
- Supplementation of enteral nutrition
Contraindication to parenteral nutrition
Parenteral nutrition should not be given in circumstances of crisis such as hemodynamic shock or dehydration are not yet resolved
The approach used in parenteral nutrition is 4 Right - 1 Alert
1. Right patient
Every patient that is not enough or no oral intake, parenteral nutrition should immediately get (NPE). NPE total dose should be given more slowly (beginning the third day) because a large metabolic load. This is true in patients with trauma, sepsis, extensive post-surgical, preeclampsia, eklampsi, etc..
1. Precise indication
When should NPE can be given? When not given? When selected NPE NPE total and partial when selected?
NPE partial doses can be given very early, ie 24 hours after trauma or crisis can be overcome gravity. This 24-hour period is a time of Ebb-phase, a period of stabilization in which the stress hormone levels are still high. Cells resistant to insulin and glucose levels increased. In severe cases the patient's condition, the more slowly the total NPE can begin. Before the relaxed state is achieved, the total NPE will only add stress to the patient. Quiet phase was characterized by decreasing levels of cortisol, catecholamines and glucagon.
1. Appropriate drugs / substrates
Materials used nutrients are carbohydrates, amino acids, fat emulsion, minerals and vitamins.
1. Right dose
Quebbeman (1982) found in patients with severe trauma and sepsis are experiencing catabolism, resting energy expenditure ranged kkal/m2/hari 1000. This is equivalent to 1700 kcal in patients 70 kg with 1.73 m2 of body area or approximately 25 kcal / day. In order to draw N is not too negative, given a minimum of 20 kcal / kg / day. Appropriate dose should be measured. Dose can then be increased gradually by observing changes in blood sugar levels, the general state of the patient, examination of the concentration of potassium and sodium.
For the avoidance of hyperglycemia, increased glucose 5% to 20% must be gradual "start low, go slow". Glucose load stimulates pancreatic insulin release. If other fluids interspersed glucose solution then likely fluctuating blood sugar levels insulin karean overshoot from time to time. So that fluctuations in blood sugar levels vary as minimum as possible, divided equally carbohydrate solution in 24 hours.
1. Wary of side effects
In contrast to healthy people who can manage the balance of food and her own needs, of patients with special nutritional assistance was forced to accept all that is given. If options or incorrect dose, or by giving false, complications that may arise will cause morbidity and even death.
1. Frequently encountered complication is hyperglycemia
Hyperglycemia generally occurs if the pattern of "start low, go slow" is not followed. This disorder can be accompanied by an osmotic diuresis and hyperosmolar state. In extreme cases, coma can occur.
1. Tromboflebitis easy to follow inflammatory irritation
Plasma osmolarity of 300 mOsm. The higher the osmolarity, the easier it happened tromboflebitis, even thromboembolism. Peripheral venous can receive up to 900 mOsm. For liquids> 900-1000 mOsm if necessary more than five days, should use central venous (vena cava, subclavia, jugular) in which the blood flows so fast that the speed of the dense liquid droplets NPE could not damage the vein. 900-1000 mOsm fluids for short term 3-5 days can still be given via the venous hand but do not give through leg veins. Prone to venous leg deep vein thrombosis and thromboembolism. Osmolarity can be reduced by mixing liquids using infusion sets branched.
Complications of parenteral nutrition
- Technical complications associated with catheterization, such as pneumothoraks, air embolism
- Complications of infection characterized by fever as phlebitis, infection at the installation site
- Complications associated with metabolic disorders of glucose balance (hyper / hypo), electrolytes (hypokalemia, hyperkalemia)
