Nutrition in Sepsis

Nutrition in Sepsis

Dhani Redhono
Divisi Tropik Infeksi
Ilmu Penyakit Dalam RS Moewardi _ FK UNS
 Pendahuluan
Pendahuluan

• Malnutrisi → masalah .. 40% pd pasien di

RS.
• Penyebab : Defisiensi asupan nutrien,
Gangguan metabolism,

Keterlambatan pemberian
• Critical ill → status metabolik & nutrisi :
 ↑ sitokin pro inflamasi IL-1, IL-6, dan TNF)
 ↑ produksi “counter regulatory hormone”

( katekolamin, kortisol, glukagon,

 Malnutrisi pada Critical Ill
Malnutrisi pada Critical Ill

David S Warner, et al. Promoting Perioperative Metabolic and Nutritional Care. Anesthesiology 2015; 123:1455-72
 Resting Energy Expenditure
Resting Energy Expenditure

• Resting Energy Expenditure (REE) → dilakukan

sebelum memberikan nutrisi.
• REE adalah pengukuran jumlah energi yang
dikeluarkan untuk mempertahankan kehidupan
pada kondisi istirahat & 12 – 18 jam setelah
makan.
• Disebut jg BMR (Basal Metabolic Rate), BER (Basal
Energy Requirement), atau BEE (Basal Energy
Expenditure).
• Perkiraan REE yang akurat dapat membantu
mengurangi komplikasi akibat kelebihan
pemberian nutrisi (overfeeding).
 Pemberian Nutrisi
Pemberian Nutrisi

• Mencegah terjadinya keseimbangan energi &

protein yang negatif.
• Mencegah kehilangan masa otot akibat
starvation.
• Memelihara fungsi jaringan terutama hepar.
• Menjaga sistem imun, otot skeletal dan otot
nafas.
• Mempercepat penyembuhan pasca perawatan di
ICU.

Singer P, et al. ESPEN guidelines on parenteral nutrition: Intensive care. Clin Nutr. 2009;28(4):387-400.
 Sepsis Berat
Sepsis Berat
Fuel Source Fuel Consumption

Muscle 144g
Brain
Protein Amino acid
250g
Glucose
360g 76g

Glycerol
30g Glucose- Kidney
genesis
170g
Adipose tissue 8g
160g

Inflammatory Mass
Fatty acid

Lactate 136g

6
Kebutuhan energi pada kondisi stres
metabolik
 Metabolisme protein
• Apa yang terjadi
pada saat stress
metabolik?
• Metabolic rate ↑
 hipermetabolik
• Keseimbangan
nitrogen 
negatif
• Resistensi insulin
• Hiperglikemia
 Tingkat Keparahan Trauma: Efek terhadap
Kehilangan Nitrogen dan Metabolic Rate

Major
Cirugía
mayor
Surgery

Moderate
Quemadurato Severe
moderadaBurn
a grave
Nitrogen Loss in Urine

Sepsis
Severe
Infección
Infection grave
Sepsis

Cirugía
Elective
electiva
Surgery

Basal Metabolic Rate

Adapted from Long CL, et al. JPEN 1979;3:452-456
 Keseimbangan Nitrogen
Keseimbangan Nitrogen

• Keseimbangan nitrogen dihitung dgn formula

yang mempertimbangkan nitrogen urin 24 jam,
(urine urea nitrogen/UUN) & nitrogen dari
protein dalam makanan :

((dietary protein/6,25)- (UUN/0,8) +4)

Protein mengandung 16% nitrogen, maka jumlah

nitrogen dalam makanan bisa dihitung dengan
membagi jumlah protein terukur dengan 6,25. Faktor
koreksi 4 ditambahkan untuk mengkompensasi
kehilangan nitrogen pada feses, air liur dan kulit
Metabolisme protein Critical Ill

Critical ill (trauma, sepsis, luka bakar, postop)  protein otot dipecah
kemudian diubah menjadi AA dan AA ini dipakai untuk sintesis protein dan
glukoneogenesis.
Metabolisme protein abnormal

Pada fase flow terjadi :

• Resting Energi Ekspenditur ↑
• Katabolisme protein ↑

Manajemen nutrisi :
• Meminimalkan katabolisme
• Penuhi kebutuhan protein, energi, mikronutrien
• Menjaga keseimbangan cairan dan elektrolit
• Rencana jalur pemberian nutrisinya
 Protein Catabolism
PERUBAHAN REE
EKSKRESI NITROGEN URIN
METABOLIK INCREASES

Uncomplicated Surgery 10% < 15 g/day

25 – 30% 15 – 20 g/day
Trauma Berat (median survival 15 ( lean tissue lost 750
days) g/day)

100 – 200% 30 -40 g/day

Luka Bakar Berat (median survival ( lean tissue lost 1500
7 – 10 days) g/day)

50 – 80%
20 – 30 g/day
Sepsis (median survival 10
days)

Cancer dengan PCM 20 – 30%

Basal Energy Expanditure
Basal Energy Expanditure
 Kebutuhan Energi
Kebutuhan Energi

• Pada pasien sepsis, Total Energy Expenditure (TEE) pada

minggu I ± 25 kcal/kg/ hari & pada minggu kedua ↑ .
• Kalorimetri indirek → cara terbaik untuk menghitung.
• Glukosa : 4 – 5 mg/kg/menit dan memenuhi 50 – 60%
kalori total atau 60 – 70% dari kalori non protein.
• Lemak : 25 – 30% dari kebutuhan total kalori & 30 –
40% kalori non protein.
• Protein : 1,2 g/kg/protein/hari, memenuhi 15 – 20%
dari kalori total.
 Pemberian Protein Exogen
Pemberian Protein Exogen
Tujuan :
• Protein atau asam amino exogen
→ agar proses glukoneogenesis &
sintesis protein tidak menggunakan
protein endogen.
Permasalahan :
• Pada keadaan stress, protein exogen tdk
sepenuhnya dapat digunakan sampai
terjadi stage convalescent.
Charles Weissman, Nutrition in the ICU, R68 Critical Care 1999, Vol 3 No 1
 Protein Exogen
Protein Exogen

• Pada katabolic state direkomendasikan

masukan protein sebesar 1.2–1.5
g/kg/hari,

• Jumlah yg lebih besar tdk akan menyebabkan

retensi protein yg lebih baik lagi.

• Kelebihan pemberian protein dlm diit akan

dimetabolisme menjadi urea  BUN ↑
Charles Weissman, Nutrition in the ICU, R68 Critical Care 1999, Vol 3 No 1
 Apa yg harus dilakukan?
Apa yg harus dilakukan?

Source control Antibiotik Yang Sesuai etc

(Source control
SURGERY) Antibiotik
(timing, dosing,Yang
kind,Sesuai
pk-pd) etc
( SURGERY) (timing, dosing, kind, pk-pd)

Hypercatabolic state
Hypercatabolic state
Anabolic state
Anabolic state

Support nutrition
Support nutrition
+ balance-N
+ balance-N
 Nutrient
Nutrient
• Protein
• Kalori (NPC)
• Karbohidrat
• enteral 4 kcal/g
• parenteral 3.4 kcal/g
• Lipids 9 kcal/g
• Air
• Vitamins
• Larut air
• Larut lemak
• Mineral
• Elektrolit
• Trace elements and ultra trace minerals
Key Vitamins and Minerals
Key Vitamins and Minerals
 BCAA
BCAA
• Asam amino esensial:
• Valin
• Leusin
• Isoleusin
• Meningkatkan sintesis protein
• Dari penelitian pemberian BCAA 45% selama 7
hari
post-operatif  meningkatkan jumlah limfosit.
• Pemberian BCAA pada sepsis dan stres metabolic

 menurunkan mortalitas.
Phillip C. Calder. Branched-Chain Amino Acids and Immunity. J. Nutr. 2006;136:288S–293S.
 Komplikasi overfeeding
Komplikasi overfeeding
• Azotemia
• Hepatic steatosis
• Hiperkapni  prolonged weaning dari
ventilasi mekanik
• Hyperglycemia
• Hyperlipidemia
• Kelebihan cairan
• Micronutrient is an important element which are needed by body in
small amount that only 100 mg/day or less than 1 % weight.

• Micronutriens consists of micromineral & vitamins. Micromineral has

iron, cobalt, chromium, bronze iodine, manganese, selenium, zinc and
molybdenum as its subtance.

• Although mineral needs can only 5 % obtained from food, but it is very
useful for body organs.
• Sepsis led to an increasing production of Reactive Oxygen Species (ROS) as an impact of

increasing oxidative metabolism which can damage cell, mainly on unsaturated fatty acids

which are found in the cell membrane & nucleus.

• Zinc, iron and selenium are absorbed in duodenum and jejunum while chromium and copper

are absorbed in ileum.

• Micronutrient take part on helping the body to neutralize the negative effects of free radicals.

• Deficiency micronutrient usually accompanied by more than one drawbacks except zinc, iron

and vitamin A. Some interactions could happen in provision of micronutrient.

• Zinc decrease the absorption of copper while iron decrease the absorption Cu and zinc.
Recommendation for Trace
Elements in Critical Illness

Source: S Afr J Clin Nutr 2010;23(1) Supplement: S60

• Zinc is co-factor of more than several enzymes that have a role in the
immune system, regeneration new cells & balancing acid bases.
Normal level is between 70-150 mcg/dl. The low alkaline phosphatase
(ALP) can be used as a parameter that the body has low level of zinc.

• In sepsis occurs the improvement production of hepsidin so can block

Fe transportation. Neutrofil and macrophages need the iron to do
phagocytosis and killing bacteria.

• Copper is an essential component of several enzymes e.g. superoxide

dismutase (SOD). Copper inhibits the activity of anticoagulant and
protein C which has been activated. Recommended Dietary Allowance
(RDA) for copper in adults is 900 mcg and parenteral dosage is 300-
500 mcg per day
• Selenium uniqueness is having a dual function as prooxidant and
anti-oxidant. Granting high doses selenium in sepsis for 9
consecutive days and decrease the dose every 3 days may lower
mortality rates, decrease the score of APACHE III and creatinin
serum.

• Maximum dose of selenium 400 μg (5μg/kg BB/day) but even

granting 800 μg is considered has no side effects report.

• Vitamin C can lowered the iNOS expression. Vitamin B1 (thiamin) is

co-factor of pyruphate dehidrogenase, theenzyme which is
responsible for pyruphate conversion into asetil-coenzim A.
 Ringkasan
Ringkasan
• Manajemen nutrisi menjadi bagian penting dari
perawatan pada pasien Critical III.

• Malnutrisi pada pasien sakit kritis dapat

meningkatkan morbiditas dan mortalitas.

• Selain makronutrien & mikronutrien, pasien

sakit kritis membutuhkan nutrien spesifik yang
dapat membantu meningkatkan sistem imun,
seperti BCAA.
 THANK YOU

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