NUTRISI_TROPIS

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     ANDI FARADILAH ANDI FARADILAH

    Nutrition DepartmentNutrition Department

    Faculty of MedicineFaculty of Medicine

    20120133 

    NUTRITIONAL CARE ININFECTION-TROPISM

    DISEASE

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    Sub-topic

    Nutrition in ICUNutrition in HIV-AIDS

    Nutrition in Thypoid

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    ImportanceImportance

    Renal function

    Microcirculation

    environment 

    extracellullar 

      intracellular

    Cardiac function Pulmonary function

    Energy provision

    Protein synthesis

     OOD

    Carbohydrates

    fats proteinelectrolytes

    trace elements

    vitamins special

    substrates!ody reserve

    s

    "ade#uate fed$

    !ody reserves

    "malnourished$

    %nta&e

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    Immune response during Inflammation and infectionImmune response during Inflammation and infection

    SIRS TNFα, IL-1β,IL-6, IL-12,IFNγ , IL-3

    IL-10, IL-4, IL-1r, !ono"yt#

    HLA-D$%uppr#%%ion

    CARS

    dy%

    %nsult

    "trauma sepsis$

       %  n   f   l  a  m  m  a   t

      o  r  y   b  a   l  a  n  c  e

         '     (     )     %

         P     R     O

    )issue inflammation

    Early organ failure anddeath

    #'%

    I((uno%uppr#%%ion

    *nd %nfectionsDelayed

    MOF and

    deathGriffiths, R. “Specialized nutrition support in the critically ill: For

    whom and when? Clinical Nutrition: arly !nter"ention# Nestle

    Nutrition $or%shop Series

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    Metabolic Response to Stress

    In)o*)#% (o%t (#t+o*i" pth&y%

    A""#*#rt#d (#t+o*i%( o *#n +ody (%%

    N#ti)# nitro#n +*n"# !u%"*# &%tin

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    Hypermetabolic Response to Stress— Pathophysiology

    'lgorithm content developed by +ohn 'nderson PhD and ,anford C- .arner PhD *///-

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    Ebb Phase Flow Phase

    I((#dit#.hypo)o*#(i, %ho"',ti%%u# hypo/i

    D#"r#%#d "rdi"output

    D#"r#%#d o/y#n"on%u(ption

    Lor#d +odyt#(p#rtur# In%u*in *#)#*% drop

    +#"u%# *u"on i%#*#)t#d

    Fo**o&% uid r#%u%"ittionnd 2 trn%port

    In"r#%#d "rdi" output

    +#in% In"r#%#d +ody

    t#(p#rtur# In"r#%#d #n#ry

    #/p#nditur# Tot* +ody prot#in

    "t+o*i%( +#in% !r'#d in"r#%# in *u"o%#

    produ"tion, FFA%,"ir"u*tinin%u*in*u"on"orti%o*

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    Hormonal Stress Response Aldosterone— "orti"o%t#roid tht "u%#% r#n*%odiu( r#t#ntion

    Antidiuretic hormone ADH5 .%ti(u*t#% r#n*tu+u*r &t#r +%orption

     Th#%# "on%#r)# &t#r nd %*t to %upport"ir"u*tin +*ood )o*u(#

    ACTH— "t% on dr#n* "ort#/ to r#*#%# "orti%o*(o+i*i#% (ino "id% ro( %'#*#t* (u%"*#%5

    Catecholamines .#pin#phrin# ndnor#pin#phrin# ro( r#n* (#du** to %ti(u*t#h#pti" *y"o#no*y%i%, t (o+i*ition,*u"on#o#n#%i%

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    Nutrition trials in ICU

    S(**, und#rpor#d H#t#ro#n#ou% nd "o(p*#/ pti#nt% !i/#d nutrition* %ttu%

    Di7#r#nt ##din r#i(#n% Und#r##din 8 i*ur# to d#*i)#r nutri#nt% )#r##din 8 d)#r%# (#t+o*i" #7#"t% Hyp#r*y"#(i

    S"i#nti9" +%i% #%%#nti*

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     What is the evidence in ICU?

    :r*y #nt#r* ##din i% +#%t Hyp#r*y"#(io)#r##din r# +d ;N (#t-n*y%#% "ontro)#r%i*

    Nutrition* d#9"it & &or%# out"o(# :N & %pirtion nd VA;, ;N in#"tion :N nd ;N "n +# u%#d to "hi#)# o*% ;roto"o*% i(pro)# d#*i)#ry o ##d So(# nutri#nt% %ho& pro(i%in r#%u*t%

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    Nutritional management of severe sepsisand septic shock

    :r*y nutrition* %upport i(pro)#% &ound h#*innd

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    Nutritional management of severe sepsisand septic shock

    Su"h #nt#r* or(u*% (y )or+*y 7#"tth# r#%i%tn"# o th# ut to +"t#ri*trn%*o"tion or #/#rt dir#"t #7#"t% on th#+#h)ior o intr*u(in* +"t#ri

    +ral $lutamine decreases bacterial translocation and improvessurvival in eperimental $ut-ori$in sepsis. JE J arenter

    Enteral utr &''(/ &':0' 

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    (Mal)nutrition detection(Mal)nutrition detection

    Nutritional assessmentNutrition screening (within 24 hours)

    Body mass index

    Subjective global assessment or mini-

    nutritional assessment

    Weight loss > 10%Intae accounting (!"0%# chronic)

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    Nutrient Guidelines: Carbohydrate

    Shou*d pro)id# 60 8 =0> "*ori#%

    !/i(u( rt# o *u"o%# o/idtion ?

    @ 8 = ('(in or = 'dyB

    *ood *u"o%# *#)#*% %hou*d +# (onitor#d ndnutrition r#i(#n nd in%u*in du%t#d to(intin *u"o%# +#*o& 10 (d*

    0',PE( !OD- +PE( *12**,' 344*

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    Nutrient Guidelines: Fat

    Cn +# u%#d to pro)id# n##d#d #n#ry nd#%%#nti* tty "id%

    Shou*d pro)id# 1 8 40> o "*ori#% Li(it to 2'dy or po%%i+*y 1 'dy

    IVB Cution &ith u%# o t% in %tr#%%#d E

    tru( pt%  Th#r# i% #)id#n"# tht hih t ##din% "u%#d

    i((uno%uppr#%%ion N#& or(u*% o"u% on o(#-3%

    0',PE( !OD- +PE( *12**,' 344*

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    Nutrient Guidelines: Protein

    1 8 20 'dy to %trt (onitor r#%pon%#

    Nonprot#in "*ori#r( o nitro#n rtio or"riti"**y i** ? 100G1

    i)in #/o#nou% % d#"r#%#% n#ti)#N +*n"# +y %upp*yin *i)#r % or prot#in%ynth#%i%

     

    AS;:N D J;:N 2622SA, 1KK2

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    Nutrient Guidelines: Protein

    In "riti"**y i** pti#nt% und#roin "ontinuou%r#n* r#p*"#(#nt th#rpy, %in*# %tudyindi"t#% tht protein intake !"# $ per k$per da% i% (or# *i'#*y to pro(ot# po%iti)# N

    +*n"# ;?000015

    And, &hi*# (or# po%iti)# N +*n"# i%%%o"it#d &ith d#"r#%#d (ort*ity, hih#r

    prot#in int'# &% not %%o"it#d &ith(ort*ity.

    ADA :AL 11-2=-0=

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    Fluid and Electrolytes

    1luid 30-40 (L' or

    1 to 1(L'"* #/p#nd#d

    Electrolytes2itamins2Trace Elements

    :nt#r* ##din%G +#in &ith $DAAI )*u#%

    ;NG u%# ;N do%in uid#*in#%

    ',PE( !OD- +PE( *12*5,' 344*

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    How much to give in ICU?

    S"ho9#*d #utionHrri% #n#di"t Add A"ti)ity nd Str#%% "tor% # 10> or

    +#d+ound M 20-60> or %#p%i%+urn% $ouh uid#G 2 "*'dy tot* #n#ry  

    In"r#%# to 30 % pti#nt i(pro)#% 02dy o Nitro#n 12'dy prot#in5

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    How much to give?

    30 8 3(* uid'24 hour% +%#*in# Add 2-2(*'dy o uid or #"h d#r## o

    t#(p#rtur#

    A""ount or #/"#%% uid *o%%#%

    Ad#ut# #*#"tro*yt#%, (i"ronutri#nt%, )it(in% A)oid o)#r##din

    +#%ityG ##d to !$, dd %tr#%% "tor on*y i%#)#r# i# +urn%tru(

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    Hypocaloric Feedings

    Hypo"*ori" ##din% h)# +##nr#"o((#nd#d in %p#"i9" pti#nt popu*tion%

    Ar#%%i)# prot#in pro)i%ion 1-20('dy5

    ',PE( (utrition ,upport Practice Manual *nd Edition p- *64

    7aloga .D- Permissive underfeeding- (e8 9ori:ons 344;

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    Increased

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    C%tokine

     release &increase 'ree

    radicals

    I()* I()+

    ReducedSubcutaneous

    'at

    Decrease

    d ,P- 

    '(ORE

    ,)')=,

    Increasedproteol%sis

    &decreased

    protein

    s%nthesis &. replikasi

    /irus

    Stress

    oksidati' 

    Increasedlipol%sis

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    HIV – AIDS (ESPEN RECOMMENDATION)

    Nutrition* th#rpy i% indi"t#d &h#n%ini9"nt iht *o%% 4> in 3 (onth%5

    Nutrition* th#rpy %hou*d +# "on%id#r#d&h#n th# !I i% o1O '(2

    Dirrho# ndor (*+%orption r# no"ontrindi"tion to :N, +#"u%#GDirrho# do#% not pr#)#nt po%iti)##7#"t o or* nutrition* %upp*#(#nt% or TF

    on nutrition* %ttu%

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     Th# "o(+intion o nor(* ood nd #nt#r*nutrition i% pproprit# in (ny "%#%

    I or* int'# i% po%%i+*#, nutrition*int#r)#ntion %hou*d +# i(p*#(#nt#d ""ordin

    th# o**o&in %"h#(# nutrition* "oun%#**in

    or* nutrition* %upp*#(#nt%

    tu+# ##din TF5

    ;N :"h o th# %t#p% %hou*d +# tri#d or 48O

    #'% +#or# th# n#/t %t#p i% initit#d

    HIV – AIDS (ESPEN RECOMMENDATION)

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    Nutritional interventionNutritional intervention 

    EnergyEnergy Energy requirements are no different from other

    patient groups

    The Harris and BennedictThe Harris and Bennedict  determine BEEdetermine BEE

    Energi requirements increase 13% for every degreeEnergi requirements increase 13% for every degree

    Celcius above normalCelcius above normal

     A general range for estimated energy A general range for estimated energy  !!"#!!!!"#!!

    Calori $3"&! Cal'gr B()Calori $3"&! Cal'gr B()tt

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    ProteinProtein

    *rotein inta+e should achieve 1, g'+g b-'day in

    stable phases . increased to 1, g'+g b-'day during

    acute illness, 

    Fat

    /n patients -ith diarrhoea and severe undernutrition

    0CT containing formulae are advantageous,

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    Fluid

     luid needs are the same as those of -ellindividuals2 ecept in the presence of severediarrhea2 nausea and vomiting and prolonged fever 

    Vitamin & mineral

      0egadoses of vitamin and mineral should be

    avoided

     

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    FOOD AND NUTRITION MANAGEMENTPACKAGE

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    INTERVENSI MAKANAN BERDASARKANMAKANAN YANG TERSEDIA DI INDONESIA

    Tempe-  Tini prot#in dn )it

    12- "t#ri"id#dpt o+ti

    dn "#h dir#

    0elapa- !#nndun (#diu(

    "hin% try*i"#rid#%- Su(+#r #n#ri yn

    ##'ti untu'(#nin't'np#(+#ntu'n %#* T4

    - !udh di%#rp dn PNdirrho# #7#"t

    1ortel-  Tini 'ndunn -

    "rot#ntin't'n i((un#+odi#% d#nn tin't CD4M

    - #r%( d#nn )it(in :,Cntio'%idn (#nn'*

    rdi'* +#+%5

    2rokoli 3 kemban$ kol-  Tini 'ndunn (in#r* G

    QN, !n, F#, S#

    - !#n"#h d#9%i#n%i %p#%i9'

    - #run%i %#+i ntio'%idn

    - ;#(+#ntu' CD4M

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    DEVELOPMENT OF FOOD INTERVENTION BASEON INDONESIAN FOOR FOR ODHA

    Sa%uran hi4au dan kacan$ kacan$an- !#nndun )it(in dn tr"# #*#(#nt%-  Tini '*%iu(- !#nin't'n CD4M

    Alpukat- ndunn *#(' 60>5 t#rtini dri +uh- 16> !UFA !ono-Un%turt#d Ftty A"id5%u(+#r #n#ri

    t#r+i'- on%#ntr%i 5luthation t#rtini %#+i ntio'%idn%top

    r#p*i'%i HIV

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    Gejala klinis dan keterkaitan dengangangguan gizi (1) Anoreksia 3 dis'a$ia- +t A$V p#nurunn n%u

    ('n- In#'%i (ur pd (u*ut%u*it (#n#*n

      H* ini (#(#r*u'n t#rpi di#t*un', ('nn tid'

    (#rn%n, ('nn dinin,(inu( (#**ui %#dotn hu%u%

    Diare akut6malabsorbsi- Hi*nny t ii %#p#rti

    )it(in E (in#r*

    ;#r*u "irn, +uh +uhnr#ndh %#rt, tini '*iu( E(n#%iu(

    Hindri ('nn +#r*#(' dn u% +#r*#+ihn

    Sesak na'as

    - ('nn tini *#(' r#ndhH(#nurni C2

    - ;or%i '#"i* tpi %#rin

    5an$$uan pen%erapanlemak 

    - Di#t r#ndh n+ti

    - on%u(%i (iny' n+ti(iny' '#d#*i, (iny' un, (iny' %&it5

    -  T(+hn )it A,D,:,

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    Gejala klinis dan keterkaitan dengangangguan gizi (3)

    Demam- #+utuhn prot#in (#nin't

    - !'nn *un' por%i '#"i*, u(*h *#+ih dri +i%

    - !inu( *#+ih dri 2 *it#rO #*% %#hri Penurunan 22

    - Di"ri p#ny#++ny- ;%ti'n p d in#'%i opurtuni%ti'

    - !'nn TT; por%i '#"i* %#rin, r#ndh %#rt

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    DEMAM TIFOID

    MetodeMetode KonvensionalKonvensional

    Mulai bubur sarinMulai bubur saringg

    MMenurunkan beban kerja ususenurunkan beban kerja usus

    MMenurunkan perdarahanenurunkan perdarahan Netralisasi asam lambungNetralisasi asam lambung

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      DDiet yang dipakai sekarangiet yang dipakai sekarang

    Makanan padat, rendah seratMakanan padat, rendah serat

      -- DDefekasiefekasi bulk formingbulk forming  - BB naik- BB naik

    - Jumlah kalori segera terpenuhi- Jumlah kalori segera terpenuhi

      -- DDipersiapkan lebih mudahipersiapkan lebih mudah

      - meningkatkan selera makan- meningkatkan selera makan

     

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    DE! ENE"# !N## $"%!EN !N##DE! ENE"# !N## $"%!EN !N##

      Diet yang mengandung energi dan protein diatasDiet yang mengandung energi dan protein diataskebutuhan normalkebutuhan normal

      !ujuan diet &!ujuan diet &

      - Memenuhi kebutuhan energi- Memenuhi kebutuhan energi dan protein untuk men'egahdan protein untuk men'egah

    kerusakan tubuhkerusakan tubuh-   -- Menambah BB hingga men'apai BB normalMenambah BB hingga men'apai BB normal

    (yarat diet E!$! &(yarat diet E!$! &- Energi )*-)+ kklkg BBEnergi )*-)+ kklkg BB

    - $rotein .-.,+ gkgBB$rotein .-.,+ gkgBB- /emak 0*-.*1 dari kebutuhan energi tot2/emak 0*-.*1 dari kebutuhan energi tot2- Karbohidrat, vitamin , mineral 'ukupKarbohidrat, vitamin , mineral 'ukup

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    SUMMARY

    Speciali7ed nutrient needs o' the I,FECTI8,patient9

    Increased calories to co/er ener$% costs o'h%permetabolic

    Hi$h 'at diets" Ade:uate protein le/els to support

    anabolism and the maintenance o' leanbod% mass""

    Supplemental antio;idants to pre/ent orattenuate o;idati/e dama$e to tissue

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