id nutrition supplementation in surgery

dr. Iyan DarmawanMedical Director, PT Otsuka Indonesia

www.otsuka.co.id

Importance of PN Supplementation

Glukosa Saja Tidak Cukup

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=pC8YS8XZykCy_M&tbnid=13Y3q5fHXCMqOM:&ved=0CAUQjRw&url=http://tandoorcurry.com/tandoorcurry/?product=plain-rice&ei=p_GTUpeIFsnArAfWvIDQAw&psig=AFQjCNFamZtfez0rOeh7pBGhDxvPskhmFQ&ust=1385513679248526

11/28/2013

NS/RL/D5

KAENMG3PAN AMIN G

AMIPARENAMINOLEBANKIDMIN

AMINOFLUID

Na+ 77

MAINTENANCE SOLUTIONS

1st generation 2nd generation 3rd generation

Na+, K+,Micromineral, 3% Amino Acids,glucose

KAEN 3B AMINOFLUID

http://www.otsukakj.jp/med_nutrition/dikj/hoso/amf/amf10a1ab.jpg

Days of fasting1 2 3 4 5 6

100

200

300

400

0

0 g(Starvation)

50 g

100 g

200 g

Starvation- CHO tends to block portein catabolism- 100 g glucose/day reduces protein

catabolism by 50%.- Sole NPC cannot fully inhibit protein

catabolism

Protein-Sparing effect of glucose

JAMES L.GAMBLE：水と電解質，医歯薬出版 1957：p134－147より

The importance of adding Amino acids

Prot

ein

loss

(g)

Presenter

Presentation Notes

The data (humans) from a study by Gamble who investigated the body proteins-sparing effect of glukosa administration during starvation are explained here. During starvation, sekitarimately 70 g/day, or sekitarimately 400 g for six days, of proteins was lost due to the catabolism of body proteins. This is equivalent to sekitarimately 2 kg of muscle. After glukosa administration, the protein catabolism was inhibited. The protein loss at a glukosa dose of 100 g/day was sekitarimately �40 g/day or sekitarimately 200 g for six days. This means, glukosa administration inhibited the protein loss to sekitarimately 50% of that during starvation. When glukosa was administered at 200 g, the degree of protein catabolism was similar to that at 100 g. This indicates that administration of glukosa, i.e., an energy source, alone cannot fully inhibit the catabolism of body proteins. sekitarimately 40 g of proteins at minimum is necessary as a daily average intake to maintenance N-balances under no stress conditions. For this purpose, 100 g/day of glukosa is required at minimum. Under stress conditions such as surgery, the energy demand is increased and protein catabolism is further enhanced. It becomes more difficult to inhibit protein catabolism by glukosa administration alone. In this case, supplementation of not only energy sources (carbohydrates and fats) but also amino acids that are used for protein synthesis is important to improve N-balance and protein metabolism and then inhibit the catabolism of body proteins.

200g

100g

50g

100

200

300

400

1 2 3 4 5 6

(GAMBLE)

The significance of infusing amino acid

Starvation

At least 100 g of glucose is necessary per day

Pro

tein

loss

(g)

Period of starvation (days)

Glucose

0g（Starved）

unavoidable nitrogen loss quantity

（FAO/WHO）

mgN/kg/day TOTALUrine 37 54mg/kg/dayStool 12Skin 3Others 2

When I convert it intoan amino acid

（ 50kg in weight ）26.3 g /day※

※：0.054(g) ×7.5*×50(kg)×1.3**＝26.3(g)*： convert nitrogen into quantity of amino acid （6.25×1.2）**： usually increase by 30% in consideration of individual difference

Presenter

Presentation Notes

And after AMINOFLUID and also BFLUID were on the market in Japan, we had been strongly suggesting to doctors the significance of infusing amino acid, by using this slide. As you know, this is the data of GAMBLE, we say like, during starvation, at least 100g of glucose is necessary per day, but if you get 200g of glucose, the protein loss could not be improve any more. So, the patient needs not only glucose but also amino acid. And this is the unavoidable nitrogen loss quantity for the healthy person. We are loosing about 30g of amino acid per day. Therefore, especially for the patient, they need at least 2 bags of BFLUID which include 30g of amino acid.

Amino acids

With NPC

Without NPC

Utilized for protein synthesis

Consumed as an expensive energy source

Changes in body weight

(%)0

-10

-20 *

*

Nitrogen balance

-3000

-2000

-1000

0(mgN/kg)

* *Mean ± S.D.Tukey’s group comparison test*: p < 0.05 vs. the amino acid, glucose, and electrolyte solution group

Urabe H, et al. Yakuri To Chiryo 1994;22 (Supplement):S835

3% Amino acid solution group

Electrolyte solution with 10% glucose group

(n=10) (n=7) (n=10)

Amino acid, glucose, and electrolyte solution group

(n=10) (n=7) (n=10)

Amino acid, glucose, and electrolyte solution group

3% Amino acid solution group

Electrolyte solution with 10% glucose group

Combined versus separate administration

11/28/2013 Limited !!

Presenter

Presentation Notes

The glycogen store contains only 700 g of carbohydrate which will be exhausted soon in patient after an overnight fast

11/28/2013

Energy source

Muscleprotein

75 g

AdiposeTriglyceride160 g

AA

Glycerol16 g

FA160 g

GlycogenGlucose

Hemopoe-tic sissue

HeartKidneyMuscle

Lactate + Pyruvate40 g

120 g

Keton60 g

36 g

180 g

144 g

Consumed

Gluconeogenesis

FASTING (1-2 DAYS)

Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992

Presenter

Presentation Notes

After 24 to 48 hours of fasting, the body utilized the energy by breaking down muscle protein and adipose tissue as substrates for gluconeogenesis. This will provide basal requirement for the brain and hemopoeitic tissue.

11/28/2013

Energy souce

MuscleProtein

20 g

Triglyce-ride150 g

AA

Glycerol15 g

FA150 g

Glycogen Glucose

Hemopoi-etic tissue

HeartKidneyMuscle

Lactate + Pyruvate36 g

112 g

Keton57 g

50 g

80 g

44 g

36g

Keton 47 g

Gluconeogenesis

FASTING (5-6 weeks)


Presenter

Presentation Notes

During prolonged starvation, adaptive mechanism ensues by which the proteolysis decreases to 20 g daily and ketogenesis is stimulated to provide alternative energy

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Muscle protein

180 g

TG160 g

AA

Glycerol30 g

GlycogenGlucose

Kidney

WOUND

Lactate

320 g

114 g

76g

130 g

8 g

104g

Gluconeogenesis

MAJOR TRAUMA

Energy source


Presenter

Presentation Notes

In major trauma or surgery, the protein breakdown is bigger, that is 180 g daily

11/28/2013

Energy source

Muscleprotein250 g

AdiposeTissue

Gluconeogenesis

AA

Glycerol30 g

Glucose

Kidney

Inflammed mass

Lactate

360 g

114 g

76g

Consumed

170 g

8 g

136gFatty acid

SERIOUS SEPSIS


Presenter

Presentation Notes

Proteolysis is even more massive during sepsis. Up to 250 g is catabolized daily due to neuroendocrine stimulation by inflammatory cytokines

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& FFA

.METABOLIC RESPONSE TO TRAUMA

Presenter

Presentation Notes

Metabolic response to trauma , including major surgery, is characterized by increased influx of alanine and glycerol for hepatic gluconeogenesis to provide energy for the brain, hemopoietic tissue and wound sites

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• MAJOR TRAUMA (180 g/day)• SEPSIS (250 g/day)


PROTEOLYSIS

Presenter

Presentation Notes

Professor Hill of Auckland University quantified the proteolysis due to surgery and sepsis. Brain Chain amino acids are consumed to a greatest extent during surgery and sepsis.

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Determining Protein Requirements

Body weight, age, types of protein

Daily requirements : Healthy : 0.8 – 1.0 g/kg/day Stressed state : 1.0 to 2.0 g/kg/day depending

on condition 25 – 30% of protein intake should tipically be

provided by essential amino acids

11/28/2013

Most economical PN Supplementbut need addition of electrolytes

• 10-20 kcal.kg ideal selama fase flow, pasokan glukosa moderat mencegah perburukan hiperglikemia karena stres(1)

• Pasien dengan stres moderat dan tidak bisa asupan oral kurang dari 7 hari hanya butuh 500-600 kcal/hari (2)

• Asam amino dalam kombinasi dengan glukosa dibutuhkan untuk memperbaiki imbang Nitrogen dan mengatasi letih pasca operasi(3)

• Zinc memacu penyembuhan luka, mendukung fungsi sistem imun, pertumbuhan sel dan penting dalam sistem antioksidan tubuh (4)

• Na+ dalam jumlah moderat mencegah retensi air dan kelebihan cairan iatrogenik; K+ mencegah deplesi lebih lanjut

Mengapa Aminofluid baik untuk pasien pasca bedah

Indikasi Aminofluid

• Straightforward surgery:MILD STRESS /GOOD NUTRITION STATUS• Ovarian cystectomy• Laparoscopic surgery(in undernourished)• Appendectomy without peritonitis• Cholecystectomy• Herniotomy• Hemorroidectomy• Caesarean section• Fracture of femur

Indikasi Aminofluid• As initiating support for Complicated surgery or

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MODERATE TO SEVERE STRESS •Typhoid perforation•Head injury•Bowel resection + Sepsis, or already malnourished•Acute pancreatitis•Empyema•Hysterectomy•Entero cutaneus fistula•Gastrectomy, Esophagectomy, Pancreato-duodenotomy

2ＰＯＤ

NormalDiet

１ＰＯＤ 4ＰＯＤ3ＰＯＤ 6ＰＯＤ5ＰＯＤ 8ＰＯＤ7ＰＯＤ

15 yeas ago… The fluid & nutrition therapy for Gastric and Colon resection

Energy(kcal)

-１ＰＯＤ-２ＰＯＤＯＰＥ

７５０

１５００

２２５０

9ＰＯＤ 10ＰＯＤDischarge

Volume ofinfusion(mL)

RiceGruel

Ｄay

MF2000mL

NormalDiet

LiquidDiet

MF1000mL

Traditional Maintenance

FLUID2000mL

MF1500mL MF

1000mL

１５００

１０００

５００

Presenter

Presentation Notes

This slide shows that about 15 years ago, before the AMINOFULUID was on the market in Japan, The fluid & nutrition therapy for gastric and colon resection is like this graph（gantt chart）. The vertical axis of the left side shows the volume of energy. The right side and red line shows the volume of infusion. At this time, the doctors usually use maintenance fluid for patient’s fasting period after operation. However, the patient could not get enough energy & amino acid for 1to5 post-operative period. The patient could get just only 340 kcal/day for at least 3to5 days. As you can see, this was not good enough fluid & nutrition therapy.

2ＰＯＤ

NormalDiet

１ＰＯＤ 4ＰＯＤ3ＰＯＤ 6ＰＯＤ5ＰＯＤ 8ＰＯＤ7ＰＯＤ

Energy(kcal)

-１ＰＯＤ-２ＰＯＤＯＰＥ

７５０

１５００

２２５０

9ＰＯＤ 10ＰＯＤDischarge

Volume ofinfusion(mL)

Aminofluid ® infusion2000mL AF

1000mL

RiceGruel

Ｄay

AF2000mL

AF1000mL

NormalDiet

LiquidDiet

Now… The fluid & nutrition therapy for Gastric and Colon resection

１５００

１０００

５００

Presenter

Presentation Notes

Because of our suggesting BFLUID infusion therapy, at the present time, the fluid therapy for gastric and colon resection could be changed like this gantt chart. BFLUID is in use for the day before the operation, and also be in use during the fasting period about 1POD to 5POD or more after surgery. So the patient could have almost enough energy and amino acid during fasting period nowadays.

Terima Kasih

Biaya Terapi per 1000 mlALTERNATIF CHO AA Total calorie Price

(gr) (gr) (kcal) (Rp)

AMINOFLUID 1000 ml 75 30 420 152000

AMINOFLUID 500 ml 37.5 15 210 91000AMIPAREN 500 ml 50 200 106000TOTAL 37.5 65 410 197000

AMIPAREN 500 ml 50 200 106000KAEN-MG3 50 200 15531TOTAL 50 50 400 121531

AMINOVEL 500 ml 50 25 300 72000KAEN MG3 500 ml 50 200 15531TOTAL 100 25 500 87531

PAN-AMIN 500 ml 25 13.6 154.4 43000KAEN-MG3 500 ml 50 200 15531TOTAL 75 13.6 354.4 58531

id nutrition supplementation in surgery

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