NUTRITIONAL CARE IN

INFECTION-TROPISM
DISEASE
ANDI FARADILAH
Nutrition Department
Faculty of Medicine
2013

Sub-topic
Nutrition

in ICU
Nutrition in HIV-AIDS
Nutrition in Thypoid

Importance
Cardiac function

Intake
FOOD

Carbohydrates,

fats, protein,
electrolytes,
trace elements,
vitamins, special
substrates

Pulmonary function

Microcirculation
environment
extracellullar
intracellular

Energy provision

Protein synthesis

Renal function

Body reserves
(adequate fed)

Body reserves
(malnourished)

Inflammatory balance

ANTI

PRO

Immune response during Inflammation and infection

SIRS
TNF, IL-1,
IL-6, IL-12,
IFN, IL-3

Tissue inflammation,
Early organ failure and
death

days

weeks

IL-10, IL-4, IL1ra, Monocyte

HLA-DR
suppression

Immunosuppression

CARS

Insult
(trauma, sepsis)

nd

Infections

Delayed
MOF and
death

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

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

Hypermetabolic Response to Stress

Pathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

Ebb Phase

Immediate
hypovolemia, shock,
tissue hypoxia
Decreased cardiac
output
Decreased oxygen
consumption
Lowered body
temperature
Insulin levels drop
because glucagon is
elevated.

Flow Phase

Follows fluid resuscitation

and O2 transport
Increased cardiac output
begins
Increased body
temperature
Increased energy
expenditure
Total body protein
catabolism begins
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 mininutritional 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 aas decreases negative
N balance by supplying liver aas 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, 2 nd Edition, p. 279

Zaloga GD. Permissive underfeeding. New Horizons 1994

Increased
proteolysis
+
decreased
protein
synthesis +
replikasi
virus

POOR
NUTRITIONAL
STATUS

IL-6

Stress
oksidatif

Increased
lipolysis

Reduced
Subcutaneous
fat

ANOREXIA
Decrease
d NPY

IL-1

Cytokine
release +
increase free
radicals

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 48

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

FOOD AND NUTRITION MANAGEMENT

PACKAGE

INTERVENSI MAKANAN BERDASARKAN

MAKANAN YANG TERSEDIA DI INDONESIA

Tempe

Wortel

Tinggi protein dan vit.

B12
Bactericidedapat obati
dan cegah diare

Tinggi kandungan Bcarotentingkatkan immune

bodies dengan tingkat CD4+

Bersama dengan vitamin E,

Cantioksidan (menangkal
radikal bebas)

Kelapa

Mengandung medium
chains tryglicerides
Sumber energi yang
efektif untuk
meningkatkan
pembentukan sel T4
Mudah diserap dan NO
diarrhoea effect

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 antioksidanstop
replikasi HIV

Gejala klinis dan keterkaitan dengan

gangguan gizi (1)

Anoreksia & disfagia

Sesak nafas

Obat ARV penurunan nafsu

makan
Infeksi jamur pada mulut
sulit menelan
Hal ini memerlukan terapi diet
lunak, makanan tidak
merangsang, makanan dingin,
minum melalui sedotan Khusus

makanan tinggi lemak rendah

KHmengurangi CO2

Porsi kecil tapi sering

Gangguan penyerapan
lemak

Diet rendah nabati

Diare akut/malabsorbsi

Hilangnya zat gizi seperti

vitamin & mineral
Perlu cairan, buah buahan
rendah serat, tinggi kalium &
magnesium
Hindari makanan berlemak dan
jus berlebihan

Konsumsi minyak nabati

(minyak kedelai, minyak
jagung, minyak sawit)

Tambahan vit. A,D,E, K.

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

DEMAM TIFOID
Metode Konvensional

Mulai bubur saring

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