The POWER of WHEY & MCT for Critically Ill Patients

7/27/2019 The POWER of WHEY & MCT for Critically Ill Patients

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The Power of Whey & MCT for Critically Ill Patients

Wid Adelies Oktavianda | FOE Central and East Java


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Make a difference:

Early Enteral Nutrition with Peptamen

Time is critical


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In Critically Ill Highly Stressed Patients


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Early Enteral Nutrition helps to1:

1. maintain gut integrity

2. modulate stress and the systemic immune response

3. attenuate disease severity and improve clinical outcomes

Time Makes the Difference in Critically Ill Patients

1. S. A. McClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) andAmerican Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009.


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Clinical study has shown that cumulative energydeficit is associated with worse clinical

outcomes2 Longer ICU length of stay

More days on mechanical ventilation

More complications

Cumulative Energy Deficit is AssociatedWith Worse Clinical Outcomes

2. Villet S et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005; 24:502-509.


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Nutrisi Enteral

Nutrisi enteral merupakan metodepemenuhan zat gizi dengan menggunakan

saluran pencernaan, baik secara alami

melalui mulut ataupun dengan bantuan

alat (tube/sonde)

Feed Your Gut Use it or Loose it


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SUSU vs NUTRISI ENTERAL

Terminologi susu:

Cairan berwarna putih opaque yang diproduksi oleh kelenjar mamae Cairan berwarna putih, tapi bukan berasal dari hewan, seperti susu kedelai

Formula bukan susu, sekalipun komponen-komponen zat nutrisi yang

terkandung mirip dengan susu

Susu Nutrisi Enteral

Protein Whey, Kasein Whey, Kasein, Protein Soya

Karbohidrat Laktosa Sukrosa, fruktosa, maltodekstrin,

oligosakarida

Lemak Jenuh, Tak Jenuh Nabati, jenuh, tidak jenuh tunggal

(MUFA), tak jenuh ganda (PUFA)Vitamin dan Mineral + +

Contoh ASI, susu sapi, susu

kambing

Nutrisi enteral

The Power of WHEY


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Nutrisi untuk Mencapai Kesehatan Optimal


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Formula Polimerik

Membutuhkan kerja salurancerna yang baik

Intact Nutrition

Formula standard, Fully

functional GI tract, Normaldigestion, Normal absorption

Macronutrients are intact andrequire digestion

Formula standar misalnyaNutren, Peptisol, Entramix,Ensure, dll

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Formula Mono/ Oligomerik

Nutrisinya lebih kecilmolekulnya

Absorpsi lebih mudah

Peptida, Mono/Disaccharides,

Glucose polymers, Mediumchain triglycerides (MCTs)

Elemental, semi-elemental,hydrolyzed, or chemiccalydefined formula

Formula: Peptamen

Formula Pilihan ?


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Whey and Casein: what is the difference?

(Mahe 1996)

2006NestlNutritionHealthCare,

Switzerland

Whey : Soluble protein

More accessible & faster to digest

Easily to absorb

'FAST'

Facilitates gastric emptying time

Casein : clots into stomach

Slower to digest & absorbSlower release of amino acid

Delays gastric emptying time

'SLOW'

Casein menggumpal pada pH asam

bersifat padat saat protein diasamkan

dalam lambung- dominan untuk formuladewasa

Whey protein kualitas tinggi kaya asam

amino essensial CYSTEIN, homogen

pada pH asam tetap berbentuk cairsehingga lebih mudah dicerna


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Whey Protein Casein Protein

Casein adalah protein utama dalam susu sapi (80%)

dan keju.

Whey protein: terdiri atas beta-lactoglobulin(~65%),

alpha-lactalbumin (~25%), & serum albumin (~8%)

Kaya asam amino essensial CYSTEIN Sebagai SumberAntioksidan yang baik

F i S l C d l h k i k tik k
http://en.wikipedia.org/wiki/Beta-lactoglobulinhttp://en.wikipedia.org/wiki/Alpha-lactalbuminhttp://en.wikipedia.org/wiki/Serum_albuminhttp://en.wikipedia.org/wiki/Serum_albuminhttp://en.wikipedia.org/wiki/Alpha-lactalbuminhttp://en.wikipedia.org/wiki/Alpha-lactalbuminhttp://en.wikipedia.org/wiki/Alpha-lactalbuminhttp://en.wikipedia.org/wiki/Beta-lactoglobulinhttp://en.wikipedia.org/wiki/Beta-lactoglobulinhttp://en.wikipedia.org/wiki/Beta-lactoglobulin


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TPN

Saluran Cerna

NormalSaluran Cerna

BermasalahSaluran Cerna

TIDAK

BERFUNGSI

Fungsi Saluran Cerna adalah kunci ketika akan

memberikan dukungan nutrisi

1-10

tahun


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The serum or watery part of milk that is separated from

the coagulable part or curd Rich in minerals and vitamins

Cows Milk: Higher in caseinHuman Mi lk: Higher in whey

Nilai Protein yang t ingg i

Casein

Whey

Pre-Digestion Post-Digestion

A high nutritional value protein containing a high

content of essential and branched amino acids

2006 Nestl Nutrition HealthCare, Switzerland

(AAP 1998)


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The Power of WHEY

The Power of WHEY

Whey adalah cairan yang tersisa setelah susu mengalami proses

penggumpalan.

Whey adalah salah satu protein berkualitas tertinggi karena profil

asam aminonya yang ideal, mudah dicerna dan manfaatnya bagi

kesehatan, mulai dari membantu perkembangan otot hingga

meningkatkan kekebalan untuk perlindungan terhadap penyakit

Wheydicerna dengan cepat, sehingga protein cepat diserap ke

dalam aliran darah, sedangkan kasein dicerna perlahan-lahan.

Whey tinggi asam amino rantai cabang atau BCAA (branched-chain amino acids) dan antioksidan yang penting, mencegah radikal

bebas dan perbaikan jaringan.


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Whey protein helps support

the bodys antioxidative

defense system

Cystein is the rate-limitingamino acid for the

synthesis of glutathione,a principal protective antioxidant

mechanism of the cells11,12

Whey is rich in cysteinand may be effective in maintaining or

repleting glutathione status12

Whey Protein Helps Supportthe Body's Antioxidative Defense System

11. Bounous G. et al. The antioxidant system. Anticancer Research 2003, 23 :1411-1416. 12. Rowe B.et al. Effect of whey and casein-based diets onglutathione and cysteine metabolism in ICU patients. J Am Nutr 1994;3(5) :535 (Abstract).

Adapted from Row B et al12


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MCT LCT

Gastric emptying

Pancreaticenzymes

Bile

Micelle formation

Absorptive route

Rapid

Little/No

No

No

Directly tothe liver

Delayed

Yes

Lymphatics Blood

liver

Yes

Yes

Comparison of MCT & LCT


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LCT digest ion & abso rpt ionOverview



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MCT Absorpt ion



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Whey protein facilitates gastric emptying to reduce potential for reflux5,6,7

Peptamen: 100% whey protein

Effects of whey-based formulas on gastric emptying time

Peptamen: Designed for Better Tolerance

5. Khoshoo V et al. Incidence of Gastroesophageal Reflux with Whey- and Casein-Based Formulas in Infantsand in Children with Severe Neurological Impairment. J Ped Gastroent Nutr. 1996, 22:48-55. 6. Fried MD etal. Decrease in gastric emptying time and episodes of regurgitation in children with spastic quadriplegia fed awhey-based formula. J Ped. 1992,120:569-572. 7. Khoshoo V and Brown S. Gastric emptying of two whey-

based formulas of different energy density and its clinical implication in children with volume intolerance. EurJ Clin Nutr. 2002, 56:1-3.

Adapted from Fried MD et al6


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PROOF 1

PEPTAMEN meningkatkan sin tesa pro tein

To test if a peptide-based diet improves hepatic proteinsynthesis in patients after trauma

(Zaloga 1992)

AIM

Measured serum transferrin, prealbumin and retinol-bindingprotein day 1, 3 and 7 after injury

Trauma patients (n=16)

Randomized to receive either Peptamen or Osmolite (Ross)within 24 hours after injury

PROOF


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PEPTAMEN imp roves pro tein syn thesis


(Zaloga 1992)

PROOF

PROOF


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PEPTAMEN suppo rts grow th

"Nutrition intervention in gastrointestinal

motility"Brackett et al, ASPEN 2000


PROOF


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PEPTAMEN meningkatkan s intesa

protein

Meningkatkan respon protein hepaticdengan protein hidrolisat dibandingkan

dengan intact protein"

Zaloga et al, Crit Care Med 1992; 20:S94

PROOF

Improved hepatic protein responseswith hydrolyzed protein versus intactprotein diets after trauma


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Whey is r ich in Branched-Chain Am ino Acids

(Tome 2001) 2006 Nestl Nutrition HealthCare, Switzerland


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Prevalence of ref lux

Pediatrics:

Healthy children2 18% have symptoms

associated with reflux

Young children tend to have

higher reflux

Neurologically disabled

7/10 children (up to 70%) have

pathological reflux

Adults:

Healthy adults

3 23% (varies per

race)Intellectually disabled

50 65%

(Nelson 2000; Schwarz 2000; Bohmer 1999&2000; Colletti 2003) 2006 Nestl Nutrition HealthCare, Switzerland


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Gastric residual volumes

Prevalence of ref lux among the sick

Puts the patient at increased risk for reflux oraspiration pneumonia

Definition: amount of formula left in the stomach over a

period of time

Can increase with certain diseases or conditions such ascritical illness due to: Disease process itself

Medications

Body position

Plus Often delays the advancement of feeds or feeds

This Puts patient at risk for poor nutrition



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ensures optimal protein absorption during

times of stress and critical illness



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Lipid blend-Rich in MCT oi l



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Peptamen: Nutritional Profile

Peptamen can be reconstituted to flexible caloric densities 0.5 2.0 kcal/ml

It is nutritionally complete:

40 g protein/L

100% whey peptides 300 mOsm/L

70% of fat as MCT

Omega 6

BCAA

Vitamins and minerals meet 100% of the US RDA with 1500 mL(1500 kcal)

Gluten free, Lactose free

38

16%

34%

50%

CHO

Protein

Fat


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Peptides can be helpful to manage diarrhoea1,8

Peptamen: peptide-based formula

Peptamen has low osmolarity: 300 mOsm/L

Incidence of diarrhoea8

Peptamen: Designed for Better Tolerance

1. S. A. McClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) andAmerican Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009 8. Meredith JW et al. Visceralprotein levels in trauma patients are greater with peptide diet than with intact protein diet. J Trauma 1990, 30;825-829.

Adapted from Meredith JW et al8


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Amino acid carriers decrease

During times of stress

Peptide carriers remain intact

Decreased amino acid absorption

Amino acid diets associated withgut atrophy

Peptide absorption is preserved

Primary mechanism for protein absorption

(Grimble 2000; Zaloga 1993; Vazquez 1985) 2006 Nestl Nutrition HealthCare, Switzerland

Brush border

Amino ac idcarr ier

Peptidecarr ier


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P tid b t i


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Pept ide absorp t iona dual transpo rt syst em



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Designed for better tolerance for early nutrition

100% whey formula to help manage oxidative stress and

catabolism

Peptamen is a Specific Enteral Nutrition FormulaDesigned for Early Feeding in Critically Ill Patients

With PEPTAMEN


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Do not miss

the window of opportunityearly after admission to ICU

With PEPTAMEN

A Specific Enteral Nutrition Formula Designed for Early Feedingin Critically Ill Patients

P i C iti ll Ill l k i M k


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Pasien Critically Ill perlu mengkonsumsi Makanan

Sarat Nutrisi

Pasien Critically Ill seringkali terjadi :

Penurunan antioksidan alami tubuh

Terjadi hipermetabolisme

Menyebabkan penurunan kadar protein

visceral plasma Hipoalbuminemia

Penurunan Lean Body Mass.

Para pasien Critically Ill yang sedang menjalani terapi dan yang sudah selesai

terapi dianjurkan mengkonsumsi makanan yang sehat dengan gizi yang seimbang.

Status nutrisi pada pasien kanker memiliki peranan penting dalam

mempertahankan kualitas hidup

The Power of WHEY


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In summary


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Thank You!

Team Nestle Health Science Semarang

1. Wid Adelies (0811466811)

2. Desi Nurwahyuni

The POWER of WHEY & MCT for Critically Ill Patients

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