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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