Prof Burhan Nutrisi Perioperative Nutrition in Malnourished Children

8/6/2019 Prof Burhan Nutrisi Perioperative Nutrition in Malnourished Children

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PERIOPERATIVE NUTRITIONPERIOPERATIVE NUTRITIONIN MALNOURISHEDIN MALNOURISHED

CHILDRENCHILDREN

Boerhan HidajatBoerhan Hidajat

Department of Child HealthDepartment of Child Health

Medical Faculty/Dr.Soetomo General HospitalMedical Faculty/Dr.Soetomo General Hospital

Airlangga UniversityAirlangga UniversitySurabayaSurabaya


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MALNUTRITIONMALNUTRITION DeficiencyDeficiency

OverweightOverweight

LBWLBW

PREMATUREPREMATURE

DISEASESDISEASES

INADEQUATE INTAKEINADEQUATE INTAKE

DeficientDeficient

OverfeedingOverfeeding

HOSPITAL

Operation

30-55%

?


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FactorsthatcausehospitalFactorsthatcausehospital

malnutritionmalnutrition

Lack of nutrition care

Unawareness of malnutrition by physician

Inadequate skill, knowledge and

management strategies of nutrition therapy

High cost of nutrition support

Complication associated with nutritionsupport, etc


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Nutritioncareshould beaNutritioncareshould bea

routineandintegralpartofroutineandintegralpartofpatientcare!patientcare!

Medical care

Drugs or surgery Nursing care

Intensive care ?

Nutrition care goal ? Healthy child optimal growth & development

Outpatient child prevention of failure to thrive

Hospitalized child

prevention of hospitalmalnutrition


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Early Intervention

as Part ofInitial Care

Enteral Nutrition

Oral supplement

Tube feeding

Parenteral Nutrition

Total

peripheral

if the gut works,

use it!


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Malnutrition

+

Diseases

Feeding problems Ineffective metabolism

Increased requirement

Stress

Morbidity & Mortality

Nutritional

Intervention Enteral

Parenteral


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Sick Children

(Critically Ill)

Body composition

Biochemical data Clinical Assessement

SGA

Nutritional Status

Severely maln Mod/Mild Maln Wellnourish. Overweight

Recovery DietBalanced diet Limiting diet


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The important of nutrition careThe important of nutrition care

Energy of daily living

Maintenance of all body functions

Vital to growth and development(infant & children)

Therapeutic benefitsHealing

Prevention


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Malnutrition and Its ConsequencesMalnutrition and Its Consequences

Loss of weight

Slow wound healing

Impaired immunity Increase in length of hospital stays

Increase treatment costs

Increase in mortality


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Malnutrition and IncreasedMalnutrition and Increased

ComplicationsComplications

Many studies have shown that

complications are 2 to 20 times more

frequent in malnourished patients than inwell-nourished patients.

Buzby et al.Am J Surg1980

Hickman et al. JPEN1980

Klidjian et al. JPEN1982


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Malnutrition andMalnutrition and

Slow Wound HealingSlow Wound Healing

Foot Amputation

86% of well-nourished patients healed

without problems Only 20% of malnourished patients healed

successfully

Dickhaut SC et al. J Bone Joint Surg Am 1984


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Types of MalnutritionTypes of Malnutrition

1. Mild/Moderate malnutrition

2. Severe malnutrition

Marasmus

Kwashiorkor

Mixed

Because this is a disease with multipleetiologies, the best terminology would

probably be polydeficient malnutrition.

Green CJ.C

lin Nutr1999;18(s):3-28


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Nutritional Parameters:Nutritional Parameters:Change PerType of MalnutritionChange PerType of Malnutrition

Chronic

Malnutrition

Acute

Malnutrition Mixed

Weight

Immune Function

Albumin

Lymphocyte Count

Mid-arm Circumference


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METABOLIC RESPONSE TOMETABOLIC RESPONSE TO

STARVATION AND TRAUMA:STARVATION AND TRAUMA:NUTRITIONAL REQUIREMENTSNUTRITIONAL REQUIREMENTS

??

Malnutrition

+Operation


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Hormonal Changes DuringHormonal Changes During

FastingFasting

Fall in insulin levels

Reduced peripheral glucose uptake

Reduced protein synthesis


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Hormonal Changes DuringHormonal Changes During

Acute StarvationAcute Starvation Rise in catabolic hormones especially Glucagon& Catecholamines Hepatic glycogenolysis

Subsequent gluconeogenesis Amino acids

Glycerol

Lactate

Fatty Acid Release

Released from adipose tissue Consumed by

Heart & Skeletal Muscle

Converted to Ketones in Liver

Muscle, Brain etc.


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Prolonged Starvation (day 2+)Prolonged Starvation (day 2+)

Switch to ketone/fatty acid based economy

Ketone induced inhibition of glucose

oxidation independent of insulin Slow progressive loss in lean body mass

due to amino acid release

Ultimately Death


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Metabolic Reaction to StarvationMetabolic Reaction to Starvation

Hormone Source Changein Secretion

Norepinephrine Sympathetic Nervous System q q q

Norepinephrine Adrenal Gland o

Epinephrine Adrenal Gland o

Thyroid Hormone T4 Thyroid Gland (changes to T3 q q q

peripherally)

Landberg L, et al. N Engl J Med1978;298:1295


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Metabolic Response to Trauma:Metabolic Response to Trauma:

Ebb PhaseEbb Phase Characterized by hypovolemic shock

Priority is to maintain life/homeostasis

q Cardiac output

q Oxygen comsumption

q Blood pressure

q Tissue perfusion

qBody temperature

q Metabolic rate

Curthbertson DP, et al.AdvClin Chem 1969;12:1-55

Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997


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CharacteristicsCharacteristics -- EbbEbb

O2 consumption

Lactic acidaemia in

proportion to tissueanoxia

Plasma alanine as

peripheral protein

catabolism hepatic

gluconeogenesis starts

peripheral

lipolysis - from

glycerol and free

fatty acids

ketogenesis

Synthesis of

acute phase protein

rises


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CharacteristicsCharacteristics -- FlowFlow

oxygen uptake

Lipolysis & FFA

utilisation

Protein

breakdown &

urinary excretion

Acute phase

protein secreted by

the liver

Gluconeogenesis & hepatic

glucose output, independent of

exogenous glucose input

Development of controlled

ketosis & ketone body utilisation

if not suppressed by exogenous

glucose Protein synthesis variable

depending on circulating

albumin & other hepatic export

proteins


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Metabolic ResponseMetabolic Response

to Starvation and Traumato Starvation and Trauma

Starvation Trauma or Disease

Metabolic rate q o o

Body fuels conserved wasted

Body protein conserved wastedUrinary nitrogen q o o

Weight loss slow rapid

The body adapts to starvation, but not in the

Presence of critical injury or disease.

Popp MB, et al. In: Fischer JF. ed. Surgical Nutrition. 1983.


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InjuryInjury

Afferent Neural

activity

Tissue Hypoperfusion

& ReperfusionVascular,Endothelium

Neutrophils, Macrophage

CNSCNS CytokinesOxygen Free Radicals

Arachidonic Acid

Metabolites

Hormonal ActivityAnorexia, Pyrexia,

Immobility

Efferent Neural

activity

Local & distant

Tissue Effects

Changes in cellular hydration, Protein catabolism

Capillary leak, Organ dysfunction


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Hypothesis loss of lean body massHypothesis loss of lean body mass

Health 100%Health 100%

Decreased Muscle Mass: Skeletal, Cardiac, Smooth

Decreased Visceral Proteins: Albumin,

Lymphocytes Polymorphonuclear leukocytes

Impaired Immune response

Impaired wound healing

Impaired organ Function

Impaired adaptation

Nitrogen Death 70%Nitrogen Death 70%

40-50% weight loss


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Chronic UndernutritionChronic Undernutrition

In undernutrition, substrate utilisation isaltered In the fasted state - CHO oxidation

Fat oxidationProtein oxidation

Post-absorptive state is the only time proteinis conserved

There appears to be no preference for fatutilisation

In undernourished patients rates of proteinturnover were elevated in the fasted state


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Nutritional AssessmentNutritional Assessment

1. Body composition

2. Biochemical data

3. Clinical assessment SGA (Subjective Global Assessment)

Malnutrition?


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Growth IndicatorsGrowth Indicators

Weight

Failure to thrive

Malnutrition undernutrition/overnutrition

Height

Short stature < 3rd percentile height for age

Tall stature >97th percentile height for age Head circumference

Microcephaly

macrocephaly


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Standard Growth ChartStandard Growth Chart

The NCHS (2000) standards have been

recommended for worldwide use by the

WHO regardless of racial or ethnic origin Infants with a history of premature birth

should have their chronological age

corrected by gestational age until age 24 months for weight measurements,

40 months for length, and

18 months for head circumference


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NutritionalstatusinterpretationNutritionalstatusinterpretation

Ifall 4 modalitiescan beperformed moreaccuratediagnosiscan bedetermined

Thefact : verydifficultclinically + simpleanthropometry


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AssessmentanthropometricsforAssessmentanthropometricsfor

individualnutritionalstatusindividualnutritionalstatus

Weight for height

< 5th

percentile underweight 5th - 95th percentile normal variation

> 95 th percentile overweight

Percent ideal body weight

(Olsen et al, 2003)


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LevelsofassessmentofLevelsofassessmentof

nutritionalstatusinclinicnutritionalstatusinclinic

Dietary assessment

Laboratory assessment

Anthropometricassessment

Clinical assessment

Inadequateintake

Malabsorption

Increasedrequirements

Increasedexcretion Increaseddestruction

Depletionofreserves

Physiologicandmetabolic

alterations Wastingordecreasedgrowth

Spesificanatomiclesions


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IBWisusedasaclinicalweightgoalinIBWisusedasaclinicalweightgoalin

thenutritionrehabilitationthenutritionrehabilitation

Classification of Percent ofIBW

(McLaren & Read, 1972)

120%

obesity

110 -120% overweight

90-110% normal

80-90% mildmalnutrition

70

-80%

moderatemalnutrition 70% severemalnutrition.


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NutritionstatusassessmentNutritionstatusassessment

A , 2 y old boy

Wt : 10 kg (< P3)

Ht : 78 cm (3 cm

Prof Burhan Nutrisi Perioperative Nutrition in Malnourished Children

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