Nutrisi Klinik

Pasien Cedera Kepala

Zafrullah Khany Jasa, dr.SpAn

KLASIFIKASI CEDERA
KEPALA
Cedera kepala ringan
15
Cedera kepala sedang
12
Cedera kepala berat

GCS 13 GCS 9 GCS 8

TIPE HEAD INJURY

Pattern of Injury

Focal Injury

Diffuse Injury

Mechanism of Injury
Contact Forces
Inertial Forces
Inertial Forces
(Translational Acceleration) (Rotational Acceleration)

Type of Injury Skull Fracture

Counter Coup Contusion
Concussion
Epidural Hematoma Intra Cerebral Hematoma Diffuse Axonal Injury
Coup Contusion
Subdural Hematoma
Intra Ventricular H
Subdural Hematoma Tissue Tear Hemorrhagic
Gliding Contusion
Sub Arachnoids Hemorrhagic
Skema1: Mechanism of particular types of head injury (Marion, 1999:2006)

Traumatic
Brain Injury

Patients with Neurologic Impairment

Are at nutrition risk and should
Undergo nutrition screening
ASPEN Guidelines

Infection

Neurology
Impairment
Degenerative
Process
Cerebro Vascular
Injury

COMPLEX CASCADE
METABOLIC
PHYSIOLOGIC
FUNCTIONAL
ALTERATION

Early Nutrition Support is

Important in the acutely
injured neurologically
impaired patients!

Operation

Radiotherap
y

Drugs

Antibiotic

SUCCESS
THERAPY

NUTRITION

NUTRITION

Cytokine Response
Counter Regularatory Hormone Released

HYPERMETABOLISM
HYPERCATABOLISM
NITROGEN WASTING
VISCERAL PROTEIN

TRAUMATIC
BRAIN
INJURY

NUTRITION
ASSESSMENT

SNS should be initiated early

In patients with moderate or
Severe TBI ASPEN Guidelines

NUTRITION ASSESSMENT

Energy Requirement
Non-protein calorie requirements:

If GCS < 5: 40 50 kcal/kg/day

If GCS 8 12: 30 35 kcal/kg/day
30-40% in the form of fat assist glycemic control.
May require insulin

Protein requirement:
1.5 2 g of protein/kg BW/day hypermetabolic
and hypercatabolic

Micronutrients requirements:
Zinc, Iron, and Copper play different roles in
immune functions & important in the recoevery of
HI patients

NUTRITION ASSESSMENT
Functional GI Tract
Yes

No

ENTERAL NUTRITION
LONG TERM
Gastrostomy
Jejunostomy

SHORT TERM
Nasogastric
Nasoduodenal
Nasojejunal

GI FUNCTION
NORMAL

COMPROMISED

STANDARD
NUTRIENTS

SPECIALITY
FORMULA

Nutrient
Tolerance

Adequate
Inadequate
Progres to
PN
Oral
Feedings Supplementation
Progres to
Enteral Feedings

PARENTERAL NUTRITION
SHORT TERM
PERIPHERAL
PN

LONG TERM or FLUID

RESTRICTION
CENTRAL
PN

GI FUNCTION
RETURNS

Adequate
NO
YES
Progres to More
Complex Diet
Guidelines for the Use of Parenteral and
And
Enteral Nutrition in Adults and Pediatric
Oral Feeding as
Patients. ASPEN Board of Directors & Clinical
Tolerated
Guidelines Task Force, JPEN, 26 (1) Suppl, 2002.

Enteral Nutrition

Enteral nutrition is the method of providing nourishment

using the alimentary tract, either naturally by feeding or
artificially by tube.

EN remains the preferred method for

neurologically impaired patients because
of relative ease of use and lower cost

Benefits of Enteral Nutrition:

a lesser risk of infection and metabolic abnormality
may facilitate the restoration of digestives enzymes
Psychologically better for patients
Less expensive

Enteral Formulas

Polymeric Formula
Commerical preparations
Hospital (blenderized) preparations
Oligomeric Formula
Disease specific Formula:
Immunonutrition
Modular Formula

Beberapa Nutrisi yang

berguna bagi cedera kepala

Trauma and Arginine

Trauma is associated with a decrease in plasma
arginine concentration
Possible explanation
10-fold increase in L-arginine destruction
by arginase activity in immune cells

Arginine
Ornithine
Glutamine

Proline

Immuno-enhancing

arginase

Polyamine

Wound healing

Protein

Energy metabolism

Omega-3

PRO INFLAMMATION

ANTI INFLAMMATION

Omega-3 Fatty Acid

-linolenic acid (C18:3)

Eicosapentaenoic acid (EPA)
(C20:5)
Docosahexaenoic acid (DHA)
(C22:6)
Ditemukan dalam kadar tinggi pada:
Minyak ikan
Rape seed (canola oil)
Penting untuk perkembangan retina
dan otak pada awal masa
pertumbuhan.
Tidak merangsang sistem imunitas
Berkompetisi dengan asam
arakidonat
Mencegah pembentukkan
bekuan
Menyebabkan vasodilatasi

Immune-enhanced Diet

An Immune-enhancing nutrient is a
substance that provides identifiable
salutary effects upon the immune system.
L-arginine
L-glutamine
Nucleotides
LC-PUFA: EPA, DHA & AA

Glutamine

Most abundant free amino acid in plasma,

skeletal muscle, and the body
Primarily synthesized in the skeletal muscle
Substrate for gluconeogenesis and
ureagenesis
Precursor for nucleotide and glutathione
Fuel for enterocytes and immune cells
Non essential in normal conditions
Conditionally essential during catabolic state

Immune Enhancing Diets

and Head Injury

Study compare a commercial immune

modulated enteral formula and Standard
formula, delivered through a feeding tube..

Neomune

Group: Immunonutrition
48 gram/sachet
Composition per sachet
CHO: 25.01 g
Fructose + Maltodextrin
F: 5.79 g
MCT + Fish Oil + Corn
Oil
P: 12.5 g
Casein + Arginin +
Glutamin
Fibre (+)
Free lactose
1 kcal/ml
Total Calorie: 200 Kcal/sachet

Neomune
% calorie

% W/W

g/1000 kcal

Protein
Kasein 70%
Arginine 20%
Glutamine 10%

25

26.1

62.5

Fat
MCT 50%
Corn Oil 30%
Fish Oil 20%

25

Carbohydrate
Dextrin 90%
Fructose 10%

50

Composition

Synthetic Soluble Fiber

Polydextrose

12.5
6.25
12.1

28
5.55

52.1

125

10

Vitamin: Vit A, -caroten; Vit D, E, B1, B2, B6, B12, C, Pantotenat acid, Niasin, Folic
acid, Biotin, Choline, Vit K, Taurine, L-carnitine.
Mineral: Ca, P, I, Fe, Mg, Cu, Zn, Mn, Cl, K, Na

Neomune

Recommended Administration
To be given 4 to 5 sachet per day for 7 14
days continuously.

For elective surgery with malnutrition, 5 7

days prior of operation and to be continued
7 days post operation.
Preparation:
Pour 1 sachet into 200 300 warm water
Can be given orally or NGT (Fr 8)

Effects of Neo-Mune on Outcome in Severe Injury

days

ICU days

Respirator Wean-off days

Trauma 16 cases
Burn 20 cases

Traumacal: High protein, hypercaloric

Neo-Mune: Immunoenhancing

Dr. Chomchark: Siriraj Hospital

5
4
3
2
1
0
Traumacal Neo-mune

Traumacal Neo-mune

Gastric Motility Abnormalities

Difficulty in Delivering Enteral Nutrients

To patients following Head Injury

Use Parenteral Nutrition

Parenteral Nutrition

Parenteral nutrition remains the feeding method

of choice for patients who are malnourished or
are at risk for malnutrition because of their
inability to achieve adequate intake through oral
or enteral route.

PN should be administered to patients with

TBI if SNS is indicated and EN does not
meet the nutritional requirements.
Studies recommend PN for the first 10 14
days post head injury because of delayed
gastric emptying.

Types of Parenteral Nutrition

Carbohydrate solutions
PPN: Trifluid , KaEn MG3 , Otsu-D5, Otsu-D10
TPN: Triparen 1 & 2

Amino Acid solutions:

Pan Amin G , Aminovel , Amiparen , Kidmin
, Aminoleban

Lipid solution:
Otsu-Lip

Vitamins:
OMVI

OSMOLARITY
Peripheral PN
Central PN

900

Amino Acid Solution enriched

with BCAA

BCAA consists of 3
essential amino
acids:
L-isoleucine
L-leucine
L-valine

GLUCONEOGENESIS

Pan Amin G: BCAA = 27%

Aminovel: BCAA
= 17%
Amiparen: BCAA = 30%

Fluids in Brain Injury

Normal

saline
Gelatins
Hydroxyethyl starch
Hypertonic saline
Hypotonic fluid
Mannitol

OSMOLALITY of Replacement Fluids

Fluid
7.5% NaCl
25% Mannitol
0.9% NaCl
6% Heta Starch
Plasma
Lactated Ringers
5% Dextrose

Osmolality mosm/l
2400
1100
308
310
285
250-260
252

Important in determining their

efficacy & safety for use in the
presence of neurologic injury

Arun K. Gupta 2001

Neurointensive Care

Osmolarity and Oncotic Pressure of

Commonly Used Intravenous Fluids
F l u i d

Osmolarity
(mOsm/L)

Oncotic
Pressure

Lactated Ringers Solution

273

(mmHg)
0

D5 lactated Ringers Solution

525

0.9% Saline

308

D5-0.45% Saline

406

0.45% Saline

154

20% Mannitol

1098

HES-6% (MW: 200.000-480.000)

310

3116

Dextran 40(10%)(MW:40.000)

300

16926

Dextran 70(6%)(MW:70.000)

300

1926

Albumin 5% (MW: 69.000)

290

19

Plasma

290

21

Saline (NacL 0,9%)

Similar

concent. of sodium as plasma

Isotonik
Osmolarity 308 m.osm/l
Volume expansion, requires 4x blood
lost to restore Haemodynamic
parameters
Resuscitative fluid
intravascular volume brain
volume

Gelatins : (modified collagen

derivatives)

moll. Weight 35,000 Da (approx)

Plasma expanders in (N-S)
Intravascular life : 2-3 hrs
Rapid renal elimination
Anaphylactoid reaction
Large volume depression of
fibrinoectin & dilutional
coagulopathy possible

Hydroxyethyl Starch Solution :

HaES 6%, 10%

69,000 Da (6% in NS)

Osmolarity 310 mosm/l
90% on infusion eliminated in 42
days
Plasma expander effects 3-24 hrs
Dose limit : 1500 ml/20ml/kg/day
Risk of intracranial bleeding better
limit 500 ml

Hypertonic Saline
in ICP in resistant intracranial
hypertension brain
C.O
Peripheral & cerebrovascular resistance
Economical benefit
Plasma osmolarity
Sodium & Chloride
Potassium
- Cerebral dehydration Possible due to
rapid
change in serum Na+
- Close monitoring Na+ levels & osm.
Effective

Hypotonic Fluids
Traditionally

preoperative : to
prevent hypoglycemia
Prevent protein catabolism
Hyperglycemia in neurosurgery :
worse outcome in ischemic &
traumatic brain injury
Dextrose rapidly metabolized free
water brain water

Mannitol (6-carbon sugar-osm

diuretic)

Wide use in head injury management

NEVER subjected to randomized control trial
against placebo
Method & timing of admin. very widely
Significant benefit on ICP, CBF, Brain
metabolism
Immediate action : - Expands circulation
(after bolus)
- Blood viscosity
CBF
Cerebral O2 delivery
Osmotic effect 15-30

Mannitol

PROLONGED ACTION :
Exacerbate cerebral edema
ICP
Breakdown BBB
BEST : - in acute fase to ICP
Cave : - ATN : Shock sepsis, nefrotoxic
drugs
- Hypervolumic condition

Fluid balance lower than 594

ml, was associated with an
adverse effect on outcome after
severe brain injury independent
of its relationship to ICP, MAP,
CPP
NABIS Crit Care Med 2002

Dextrose Solutions,
Hyperglycemia

Hyperglycemia worsens neurologic

outcome.
Mechanism ?, lactic acid
neurotoxic effect neuronal death.

Clinical implication
Hyperglycemia should be avoided in patients
who are at risk for an ischemic event.
Dextrose solutions should not be infused in
patients undergoing neurosurgical
procedures, unless they are needed for the
treatment or prevention of hypoglycemia.

Chopp et al., (1988). Stroke, 19.

Lanier et al., (1987). Anesthesiology, 66.
Ljunggren et al. (1974). Brain Research, 77.
Myers et al., (1976). Journal of Neuropathology and Experiemental Neurology, 35
Smith et al. (1986). Journal of Cerebral Blood Flow and Metabolism, 6.
Natale et al. (1990). Resuscitation, 19.

Intraoperative Fluids,
Crystalloids

Equi(iso)osmolar to normal plasma (290-295

mOsm/L)
Osmolarity
F l u i d
Lactated Ringers Solution

(mOsm/L)
273

Acetate Ringers Solution

273

Ringers Solution

310

0.9% Saline

308

0.45% Saline

154

20% Mannitol

1098

Acetate Ringers Solution+MgSO4

290-295

Intraoperative Fluids,
Colloids
F l u i d

Osmolarity
(mOsm/L)

Oncotic
Pressure

HES-6% (MW: 200.000-480.000)

310

(mmHg)
3116

Dextran 40(10%)(MW:40.000)

300

16926

Dextran 70(6%)(MW:70.000)

300

1926

Albumin 5% (MW: 69.000)

290

19

Polygeline (Haemaccel)

310

21

Plasma

290

21

Specific Neurosurgical Challenges

Diabetes Insipidus

Production of large volumes of dilute urine

in the face of a normal or elevated plasma
osmolarity.
Rehydration with 0.45% saline until
euvolemia is established.
Normal saline should not be used.
R/ Vasopressin (5-10 units, iv or im)
R/ Desmopressin (1-4 ug, sc)

Specific Neurosurgical Challenges

Head-Injured Trauma patient

Some of patients present in hemorrhagic

shock and require immediate volume
resuscitation .
The question is ; How to rapidly restore ivvolume and organ perfusion while
minimizing cerebral edema formation.
HES, Dextran coagulopathy
Albumin expensive, does not reduce
cerebral edema

Specific Neurosurgical Challenges

Head-Injured Trauma patient

Normal saline good choice, mildly

hyperosmolar, inexpensive, can be given
with PRC.
Acetate Ringers Solution + MgSO4 (290-295
mOsm/L) central vein catheter.

Pointers

Early detection and correction of fluid

abnormalities helps minimizing cerebral
edema
Do not fluid restrict, unless the patient is fluid
overloaded or has SIADH
Osmotic gradients occur across the BBB
Isotonic solutions (crystalloids and colloids)
are good resuscitative fluids.
A greater volume of crystalloid is required
due to redistribution
Hypertonic saline is useful in reducing
cerebral edema and ICP after brain injury
Avoid glucose containing fluids except in
hypoglycemia

THANK YOU