NUTRITIONAL CARE IN

INFECTION-TROPISM
DISEASE
HAERANI RASYID
ANDI FARADILAH

Nutrition Department
Faculty of Medicine
2013
Sub-topic
 Nutrition in ICU
 Nutrition in HIV-AIDS
 Nutrition in Thypoid
 Importance
Cardiac function Pulmonary function
Intake

Microcirculation Energy provision

FOOD environment
• extracellullar Protein synthesis
• intracellular

Carbohydrates, Renal function

fats, protein,
electrolytes,
trace elements,
Body reserves
vitamins, special
Body reserves (malnourished)
substrates
(adequate fed)
Immune response during Inflammation and infection
Tissue inflammation,
SIRS Early organ failure and
TNF, IL-1, IL- death
Inflammatory balance

6, IL-12, IFN,
PRO

IL-3

days weeks
ANTI

IL-10, IL-4, IL-1ra,

Monocyte HLA-DR
Immunosuppression
suppression
Delayed
2 nd
Infections MOF and
CARS
Insult death
Griffiths, R. “Specialized nutrition support in the critically ill: For
(trauma, sepsis) whom and when? Clinical Nutrition: Early Intervention; Nestle
Nutrition Workshop Series
 Metabolic Response to Stress

 Involves most metabolic pathways

 Accelerated metabolism of lean body mass
 Negative nitrogen balance
 Muscle wasting

 Melibatkan banyak jalur metabolik

 Mempercepat metabolisme pengurusan berat badan
 Keseimbangan nitrogen negatif
 Pemborosan otot
 Hypermetabolic Response to Stress—
Pathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Ebb Phase Flow Phase

 Immediate—hypovolemia,  Follows fluid resuscitation
shock, tissue hypoxia and O2 transport
 Increased cardiac output

 Decreased cardiac output begins

 Decreased oxygen  Increased body temperature
consumption  Increased energy expenditure

 Lowered body temperature  Total body protein catabolism

 Insulin levels drop because begins
glucagon is elevated.  Marked increase in glucose
production, FFAs, circulating
insulin/glucagon/cortisol
 Hormonal Stress
Response

 Aldosterone— corticosteroid that causes renal sodium
retention

 Antidiuretic hormone (ADH) —stimulates renal tubular
water absorption

 These conserve water and salt to support circulating blood
volume

 ACTH— 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
Nutrition trials in ICU

 Small, underpowered
 Heterogeneous and complex patients
 Mixed nutritional status
 Different feeding regimens
 Underfeeding – failure to deliver nutrients
 Overfeeding – adverse metabolic effects
 Hyperglycaemia
 Scientific basis essential
What is the evidence in ICU?

 Early enteral feeding is best

 Hyperglycaemia/overfeeding are bad
 PN meta-analyses controversial
 Nutritional deficit a/w worse outcome
 EN a/w aspiration and VAP, PN infection
 EN and PN can be used to achieve goals
 Protocols improve delivery of feed
 Some nutrients show promising results
Nutritional management of severe sepsis
and septic shock

 Early 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 shock

 Such 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 detection
 Nutritional assessment
 Nutrition
screening (within 24 hours)
 Body mass index

 Subjective global assessment or mini-nutritional

assessment
 Weight loss > 10%
 Intake accounting (<70%, chronic)
Nutrient Guidelines: Carbohydrate
 Should 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: Fat
 Can be used to provide needed energy and essential
fatty acids
 Should provide 15 – 40% of calories
 Limit 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: Protein
 1.5 – 2.0 g/kg/day to start; monitor response
 Nonprotein calorie/gram of nitrogen ratio for critically
ill = 100:1
 Giving exogenous aa’s decreases negative N balance
by supplying liver aa’s for protein synthesis

ASPEN BOD. JPEN 26;22SA, 1992

Nutrient Guidelines: Protein

 In 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 Electrolytes
Fluid
 30-40 mL/kg or
 1 to 1.5mL/kcal expended

Electrolytes/Vitamins/Trace Elements
 Enteral feedings: begin with RDA/AI values
 PN: use PN dosing guidelines

ASPEN 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/burns
 Rough guide: 25 Kcal/kg/day total energy  Increase to 30 as
patient improves
 0.2g/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 losses
 Adequate electrolytes, micronutrients, vitamins
 Avoid overfeeding
 Obesity: feed to BMR, add stress factor only if severe i.e.
burns/trauma
Hypocaloric Feedings
 Hypocaloric feedings have been recommended in specific
patient populations
 Aggressive protein provision (1.5-2.0 gm/kg/day)

ASPEN Nutrition Support Practice Manual, 2nd Edition, p. 279

Zaloga GD. Permissive underfeeding. New Horizons 1994
 POOR
Increased
proteolysis + NUTRITIONAL ANOREXIA
decreased STATUS
Decreased
protein
NPY
synthesis + ↑
replikasi virus

IL-6 IL-1

Stress Increased
oksidatif
lipolysis Cytokine
release +
increase free
radicals
Reduced
Subcutaneous fat
FOOD AND NUTRITION MANAGEMENT
PACKAGE
Gejala klinis dan keterkaitan dengan
gangguan gizi (1)
 Anoreksia & disfagia  Sesak nafas
- Obat ARV penurunan nafsu makan - makanan tinggi lemak rendah
- Infeksi jamur pada mulut sulit KHmengurangi CO2
menelan
Hal ini memerlukan terapi diet lunak, - Porsi kecil tapi sering
makanan tidak merangsang, makanan
dingin, minum melalui sedotan
Khusus  Gangguan penyerapan lemak
- Diet rendah nabati
 Diare akut/malabsorbsi - Konsumsi minyak nabati (minyak
- Hilangnya zat gizi seperti vitamin & kedelai, minyak jagung, minyak sawit)
mineral
Perlu cairan, buah buahan rendah
- Tambahan vit. A,D,E, K.
serat, tinggi kalium & magnesium
Hindari makanan berlemak dan jus
berlebihan
Gejala klinis dan keterkaitan dengan
gangguan gizi (3)
 Demam
- Kebutuhan protein meningkat
- Makanan lunak porsi kecil, jumlah lebih dari biasa
- Minum lebih dari 2 liter/8 gelas sehari
 Penurunan BB
- Dicari penyebabnya
- Pastikan apa ada infeksi opurtunistik
- Makanan TKTP porsi kecil sering, rendah serat
HIV – AIDS (ESPEN RECOMMENDATION)

 Nutritional 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.
HIV – AIDS (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 counselling
 oral nutritional supplements
 tube feeding (TF)
 PN
 Each of the steps should be tried for 4–8 weeks before the
next step is initiated.
Nutritional intervention

Energy
 Energy requirements are no different from other
patient groups
 The Harris and Bennedict  determine BEE
 Energi requirements increase 13% for every degree
Celcius above normal
 A general range for estimated energy  2200-2800
Calori (35-40 Cal/gr BW)t
Protein
 Protein intake should achieve 1.2 g/kg bw/day in
stable phases ; increased to 1.5 g/kg bw/day during
acute illness.

Fat
 In 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

 Megadoses of vitamin and mineral should be

avoided
INTERVENSI MAKANAN BERDASARKAN
MAKANAN YANG TERSEDIA DI INDONESIA
 Tempe
- Tinggi protein dan vit. B12
- Bactericidedapat obati dan
cegah diare
 Kelapa
- Mengandung medium chains
tryglicerides
- Sumber energi yang efektif
untuk meningkatkan
pembentukan sel T4
- Mudah diserap dan “NO
diarrhoea effect’
Wortel
- Tinggi kandungan B-
carotentingkatkan immune bodies
dengan tingkat CD4+
- Bersama dengan vitamin E,
Cantioksidan (menangkal radikal
bebas)
Brokoli & kembang kol
- Tinggi kandungan mineral : ZN,
Mn, Fe, Se
- Mencegah defisiensi spesifik
- Berfungsi sebagai antioksidan
- Pembentuk CD4+
DEVELOPMENT OF FOOD INTERVENTION BASE
ON INDONESIAN FOOR FOR ODHA
Sayuran hijau dan kacang kacangan
- Mengandung vitamin B dan trace elements
- Tinggi kalsium
- Meningkatkan CD4+

Alpukat
- Kandungan lemak (60%) tertinggi dari buah
- 16% MUFA (Mono-Unsaturated Fatty Acid)sumber energi terbaik
- Konsentrasi Gluthation tertinggi sebagai antioksidanstop replikasi HIV
DEMAM TIFOID

Metode Konvensional
 Mulai bubur saring (dahulu) sekarang makanan
padat rendah serat
 Menurunkan beban kerja usus
 Menurunkan perdarahan
 Netralisasi 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 TINGGI
 Diet 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 BB
- Protein 2-2,5 g/kgBB
- Lemak 10-20% dari kebutuhan energi tot.
- Karbohidrat, vitamin , mineral cukup
SUMMARY
Specialized nutrient needs of the INFECTION patient:
 Increased calories to cover energy costs of
hypermetabolic
 High 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