Plenary

Plenary Discussion

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Member

Rima Karlina

Ihsan Orlando Harly

Fitri Ramadewi

Qorirah Summayah Indrapati

Fahjri Saputra

Fhathia Avisha

Hanna Nabila

Insaniah Mumtaz Nandihati

Yoga Gusthi Pangestu

Aishah S Putri

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Scenario

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Terminology

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Dehydration lack of fluid and electrolyte balance of the body, causing disorders of fluid and electrolytes in the body.

Ebb Phase The phase of metabolic stress that begins immediately after injury. It may last from 2 to 3 hours up to 24 hours, depending on the type and extent of injury. Which characterized by the decreased of metabolic rate, energy requirements ,blood pressure and cardiac output

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Dysphagia is the medical term for the symptom of difficulty in swallowing

Enteral giving nutrition through a pipe to the gastrointestinal tract.

Parenteral path giving nutrition through a vein (venous central / peripheral veins) and into the blood circulation.

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Identifying Problems

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Why Mr. Gozi and his son can survive in 14 days at sea?

In medic, human can survive without water and food for some time.

How Long?

- The physical human being can withstand thirst / without drinking water up to a maximum of 3-5 days. Because every day someone is going to lose a lot of fluid from sweat, urine, feces, even when breathing.

- To hold human hunger can last for 8 weeks with the record still consume water. But if the person is a good physical condition, it can make the person last much longer.

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What affects the length of a person to survive without food?

If within 14 days (in this scenario) did not get sufficient intake of energy needs, then people will use carbohydrate reserves in the body as a source of energy (glycogen), deposits body fat (lipolysis), and spare muscle protein (gluconeogenesis) as a source of glucose.

Metabolism and climate.

Hot climate Metabolism slow longer satiety body adapts to the existing conditions.

Cold climate rapid body burn energy that makes people quickly feel hungry.

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Why Mr. Gozi and his son found in dehydration, weak, and syncope condition?

There are two cases that can cause dehydration:

Because of the evaporation of body fluids that cause by heat they were stranded at sea for long time.

Because they drink sea water

In sea water there are so many salt they drink sea water for long time their bodies was flooded by salt fluid balance in their bodies disturbed salt will pulling the water from cell for neutralize salinity in extravascular.

In the other side, body will try to get rid of the excess salt with throw it through the kidneys ( we know that salt will pulling the water) a lot of water will also be removed through urine DEHYDRATION

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WEAK they didnt get nutrition for long time because they were stranded at sea for 14 days without food

If nervous system and blood circulation system change the amount of blood to the brain will decreases oxygen to the brain decrease too (hypoxia) SYNCOPE

There some cases that can cause syncope :

Dehydration and heat

Stress emotional

Hyphogliemia

Anemia

Cont.

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WHY PHYSICAL EXAMINATION RESULTS SHOWN MR. GOZI AND HIS SON LOST WEIGHT AND ALREADY SUFFERING MALNUTRITION?

WEIGHT LOSS:

BECAUSE LESS FOOD INTAKE / NOT TO OBTAIN THE FOOD, THE BODY WILL USE THE BACKUP SAVE FOOD STORED IN THE BODY PRIOR TO THE BODY IS STILL ABLE TO MAINTAIN ENERGY.

FIRST USE STORED CARBOHYDRATE RESERVES IN MUSCLE AND HEART,LATER, AFTER BACKUP OUT CARBOS, FOLLOWED STORED IN THE USE OF FATTY ADIPOSE TISSUE.LAST, USING PROTEIN DEPOSIT.

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ALREADY SUFFERING MALNUTRITION SEEN FROM THE SKINNY BODY WEIGHT AND WEIGHING LESS THAN NORMAL

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APPLICATION OF RESERVE ENERGY

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How many ideal nutrient requirements for Mr. Gozi?

Harris Benedict Formula

BEE calculation :

Men : 66,5 + (13,8 x Wt in kg) + (5 x Ht in cm) - (6,8 x Age)

Women : 65,1 + (9,6 x Wt in kg) + (1,8 x Ht in cm) - (4,7 x Age)

Total energy expenditure :

BEE x Activity Factor x Injury Factor

In Mr. gozi's case:

BEE = 66,5 + (13,8 x 50) + (5 x 160) - (6,8 x 31)

= 1346 kcal.

Activity Factor = bed rest = 1.2

Injury Factor = burns 40-100% BSA = 1,85

Total Energy Expenditure = 1346 x 1,2 x 1,85 = 2988 kcal

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First, burns patients should be treated pain management, wound care and infection controlInspite of those above, nutritional support is needed

In the first 24-48 hrs of treatment is to maintain electrolyte and fluid replacement.

To calculate the fluid needed, we can use the formula based on weight and age

As his age is 31 at that moment,

35ml/kg of Wt/d = 1750 ml

Feeding should be initiated as soon as the patient hydrated

Very early enteral feeding (4-12hrs after hospitalization) has proven to be successful in decreasing the hypercatabolic response, fastened the healing process, decreasing level of cathecolamines and glucagon, decrease weight loss abd shortening the length of hospitalization stays

HOW THE THERAPY FOR BURNS OF MR. GOZI?

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Why in the first few days after that burn, Mr. Gozi get hypothermia, increased pulse frequency, decreased blood pressure, and increased glucose (hyperglycemia)?

One of the functions of skin is to regulate body temperature. So, if the skin is damaged quite a lot body temperature cant defended can cause HYPHOTERMIA

Cardiovascular responses to burns :

When burns sympathetic nervous will release catecholamines ( epinefrin, norepinefrin ) increased peripheral resistance (vasokonstriksi) and increased pulse frequency decreased cardiac output (also caused by fluid loss ) DECREASED BLOOD PRESURE

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When metabolic stress will occur HYPERGLYCEMIA

When burns release catecholamines ( epinefrin, norepinefrin) catecholamines will inhibit pancreatic beta cells to produce insulin increased glucose and decreased insulin HYPERGLICEMIA

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Oedem

: the destruction of the vascular causes the increasing of permeability

: the skin surface is also destroyed which causes the additional loss of fluid by excessive evaporating

Blood glucose 220 mg/dL

:due to the effect of Ebb Phase (start from 12 24 hours, max. 3 days)

: in this case, insulin levels drop because glucagon is elevated

What is the interpretation from Mr. Gozi condition such as oedem, blood glucose 220 mg/dL, leucocytes 24.000/mm3 and 24 hour urine is 800 cc (weight : 50 kg)?

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Leucocytes 24.000/mm3

:the compensation from the body to release cytokines such as IL 1, IL 6 and TNF

: released by phagocytes in response to tissue damage, infection, inflammation and some drugs and chemicals in this case was burns cause damage of consistency or loss of the skin that causes the loss of the body's first barrier in blocking the bacteria that enter. Infection burn is a good medium for the growth of microorganisms.

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24 hour urine is 800 cc : the normal production of urine by renal

= 1 ml/kgBB/hour = 1 ml x 50 kg x 24 hours = 1.200 ml per day

Because in the scenario, it says that the total urine is only 800cc which means the number is below the normal. It can be caused by the compensation of the body to prevent the further complications from hypovolemic.

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Why doctor said that Mr. Gozi in the Ebb Phase?

Severe stress, divided into 2 phases :

1. EBB PHASE

Also called as early phase. Occur immediately after injury and in 12-48 hrs.

Identified by decreased in oxygen consumption, hypothermia, lethargy, decreased of cardiac output that results in decreased of plasma volume. There also decreased of insuline levels that cause hyperglicemia. And also increased actibities of cathecolamines, glucago , and cortisol

In this phase, body doesnt respond to the stress yet, so there are no feedback from the body to maintain the homeostasis

The medical concern is to maintain the cardiovascular and tissue perfusion

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2. FLOW PHASE

Occur after EBB PHASE, which means 36-48 hrs after injury

Characterized as increased in oxygen consumption, hyperthermia, increased of nitrogen excretion, hypermetabolism of macronutrients and micromutrients. Increased of cardiac output that followed by increased of plasma volume

This phase may last for days, weeks, or even months until the injury is healed

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what kind of treatments could given to Mr. Gozi in his ebb phase ?

The first treatment is to ensure the management of tissue oxygenation as soon as possible to fix the intravascular volume with liquid electrolytes, colloid, or blood. If necessary with vasoactive drugs. Without adequate circulation and good tissue perfusion , other treatment efforts would be useless where the patient will fall on a condition that is irreversible.

Further surgery can be done to handle the source of infection or surgery that is resuscitative

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During this phase is not advisable to forcegiving nutrition. Giving glucose in large quantities could be dangerous because of causing hyperglycemia

After the crisis phase (phase ebb) is passed, usually within 24-48 hours, nutrition is very important. Amino acids are essential to overcome the loss of many proteins simultaneously with sufficient amounts of glucose as a source of calories.

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Why can occur dysphagia due to burns?

There are 2 kinds of dysphagia:

Dysphagia esophageal

Dysphagia oropharingeal

If burns occur in that areas ( esophagus, mouth, pharynx) DYSPHAGIA

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How to give parenteral & enteral nutrition ?

Parenteral Nutrition :

Provided when thegastrointestinal tractis nonfunctional because of an interruption in its continuity (it is blocked, or has a leak - afistula) or because its absorptive capacity is impaired.It has been used forcomatose patients, althoughenteral feedingis usually preferable, and less prone to complications. Parenteral nutrition is used to prevent malnutrition in patients who are unable to obtain adequate nutrients by oral orenteral routes.

Parenteral nutrition is administered through a needle or catheter. This is placed in a large vein that goes to the heart. It is usually used for 10 to 12 hours a day, five to seven times a week. Most intravenous feedings are completed at home.

Route of administration : 1. peripheral

2. central

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Enteral Nutrition :

The route of administration

1. NGT ( Nasogastric Tube) easy to do

2. Transpilorik

3. Gastrostomi

4. Jejunostomi

The Mode of administration

1. Bolus

2. Intermitten Practical, patients can move freely

3. Continued It is recommended for babies premature with respiratory instability

Better for direct administration nto the duodenum / jejunum

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SCHEME

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Learning Objective

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Total caloric intake of macronutrients and micronutrients in children and adults

Total caloric intake of macronutrients and micronutrients in children and adults when metabolic stress

The implementation of realimentation programs when metabolic stress

The mode of administration parenteral & enteral feeding

Nutrition on long treatment at the hospital

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