Dampak Masalah Kesehatan/ Komplikasi Bayi Baru Lahir terhadap Kelangsungan & Kualitas Hidup Anak

PERIOPERATIVE NUTRITIONAL CARE IN NEONATESRinawati Rohsiswatmo

BackgroundAdvances in the perioperative care of neonates affected especially by congenital gastrointestinal malformations have dramatically decreased the morbidity and mortality rate.Refined nutrition careMODERN NUTRITIONAL SUPPORT FOR THE SURGICAL NEONATES INCLUDE :Nutritional assessmentNutritional requirementsNutritional therapy

Serial measurements of CRP, pre-albumin are good predictors of post operative infective complications.Clinical historyClinical examinationAnthropometry Biochemical evaluation (albumin, pre-albumin, transferin, and retinol binding protein)

Nutritional assessmentNutritional requirementsNutritional therapy

Energy reservesRenal physiologyEnergy, water, amino acid, electrolyte, mineral, vitamin, and trace element requirementsNutritional assessmentNutritional requirementsNutritional therapy

Parenteral nutritionEnteral nutrition Energy reserve aga neonates25-28 weeksTerm Fat content1 %15-17 %Protein content25 g250 gGlycogen < 5 % of body weightTable-1Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364

Energy requirementsNewborn infants have a higher metabolic rate and energy requirement per Kg BW

TPN require less energy due to lower energy losses by the alimentary tract

No substantial increase in REE. Except for the first 6 post operative hours

Energy requirementsNeonates after surgery have a decreased amount of gluconeogenesis

Energy expenditure for growth is also diminished

Whole body protein turn over do not increase indicating a change of protein synthesis then growth to tissue repair

Over feeding after an operation fluid retention and respiratory/ cardiac complication

Neonates after surgery have a decreased amount of gluconeogenesis

Energy expenditure for growth is also diminished

Whole body protein turn over do not increase indicating a change of protein synthesis then growth to tissue repair

Over feeding after an operation fluid retention and respiratory/ cardiac complication

Renal physiologyTerm at bornOne year of ageTBW85-90% (25-28 weeks)70-75% (at term)

5%

Extracellular water45 %

20-25 %

GFR20-25ml/min/1.73 m2 (25% of the adults)

Adult function by 2-year-old

Table-2Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364

GFRElectrolyte physiology Term infants, like adult, can retain sodium in the face of a negative sodium balance

Have a diminished capacity to excrete excess sodium when in positive balance

No potassium given in the first two postnatal days or immediately after surgery due to fear of immature kidneys leading to hyperkalaemia

In critically ill, many factors, including increased steroid and prostaglandin secretions, high urine output and the use of diuretics, lead to hypokalaemia

Table 3 Basal requirements of some minerals after the 3rd postnatal dayDaily electrolyte requirements

Mmol/kg/24 hSodium 2.0-3.0Potassium

2.5-3.5

Chloride

2.0-3.0

Acetate

1.0-4.0

Magnesium

0.1-0.3

Calcium (gluconate)1.0-2.0 (-4.0 Preterm)Phosphate

0.25-1.6

Meurling S. Scand J Nutr/Nringsforskning.2000; 44:8-11

Cardiovascular considerations in neonatesSensitive to hypovolaemia due to incomplete development of the myocardium and the immature sympathetic nervous system

Anesthetic depression of cardiovascular function

Maintenance of effective vascular volume in neonates is essential to sustain circulatory function and vital organ perfusion in the perioperative periodFluid managementThis is divided into 3 phases :Deficit therapyThis refers to management of fluid and electrolyte losses that occur prior to presentation for surgeryFour pertinent investigation that will confirm the type of dehydrationTable -4 : Assessment of dehydration severity in neonates and infants Sign & SymptomsMildModerateSevere Weight loss 3-5%6-9 %> 10%General condition Alert, restlessThirsty, lethargicCold, sweaty, limpPulse Normal rate, volumeRapid, weakRapid, feebleRespiration NormalDeep, rapidDeep, rapidAnt. FontanelleNormalSunkenVery sunkenSystolic pressureNormalNormal or lowLow, unrecordableSkin tugorNormalDecreasedMarkedly decreasedEyes NormalSunken, dryGrossly sunkenMucus membraneMoistDryVery dryUrine output AdequateLess, darkOliguria, anuriaCapillary refillNormal< 2sec>3 secEstimated deficit30-50 mlKg-160-90 mlKg-1100 mgkg-1Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364Fluid deficitTable-5 : Electrolyte composition of body fluids

Electrolytes Gastric Pancreatic Bile Ileostomy Diarrhoea Na+(mEq-1)7014012013050K+(mEq-1)5-155515-2035Cl-(mEq-1)12050-10010012040HCO3- (mEq-1)0354025-3050Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364

Maintenance fluid WeightDay 1-2 Day 3-15 Day >15 >2500 g 70 130 130+ 1501-2500g80110 130+ 1251-1500g 90120 130+1001-1250g100130140+ 750-1000g105 140 150+Table-7 Anderson D and Pittard WB. Parenteral Nutrition for Neonates. In: Baker R, Baker S and Cavis A eds.Pediatric Parenteral Nutrition international thomson Publishing: New York 3001-314, 1997.TFI =(IWL + Urine + stool water) + growth(cc/kg/d)GA(wk)IWLUrineFecalTotal34-404030-505-1075-10030-3460-12030-505-1095-180 6 mlkg-1hr-1Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364Sick newborns usually have increase calorie requirementsGeneral guidelinesMinimal calorie requirements to prevent catabolism are at least 40 kcal/kg/dFor growth, minimal requirement are 80 kcal/kg/day and protein intake of > 2g/kg/day. for adequate growth, aim for 100 kcal/kg/day and protein intake of 3 kcal/kg/day for term infants and 3,5g/kg/day for preterm infantsNutrition support should ne initiated within 3 days of birth and should include protein

The highest ratio of weight gain in fetus are at week 26 to 36Optimal growth for the premature is the growth curve intra uterine, this requires the nutrients to be digestable and absorbable.6th World Congress Perinatal Medicine In Developing Countries, Jakarta, March 9th, 2010

Aggressive early total parenteral nutrition in low birth-weight infants3,5 g/kg-day amino acids3g/kg-day of 20% Intralipid (IL), starting within 1 hour after birth

2g/kg-day of AA and 0,5 g/kg-day of IL each increased by 0,5 g/kg-day to a maximum of 3,5 and 3 g/kg-day, respectively.

The Early Total Parenteral Nutrition (ETPN) groupThe Late Total Parenteral Group Nutrition (LTPN):32 ventilator-dependent preterm infants were prospectively randomized into two groupsIbrahim et al. J Perinatol.2004 Aug;24(8):482-626Aggressive early TPN....Plasma level of cholesterol, triglycerides, bicarbonate, blood urea nitrogen, creatinine, and pH were similar in both groups during the study period.

aggressive intake of AA and IL can be tolerated immediately after birth by VLBW infants.

Early TPN significantly increased positive nitrogen balance and calori intake, without increasing the risk of metabolic acidosis, hypercholesterolemia, or hypertriglyceridemia.Ibrahim et al. J Perinatol.2004 Aug;24(8):482-627Nutrition Post OperativePostoperative calorie needs may reach 180 kcal / kg / dayDistribusi:8-12% Protein 2,5-3,5 g/kg/hariSources of energy, the synthesis of enzymes and hormones, wound healing35-55% Karbohidrat GIR: preterm 4-6, term Normal brain metabolism35-55% Fat 3-4 g/kg/day (not more > 60%)Growth, metabolism, muscle activity

Nair SG, Balachandran R. Indian J. Anaesth.2004 ; 48(5) : 355-364 Nutrition Post OperativeThere is no real increased in REE excluded the first 6 hours post-surgeryLipid important source energy for infants who underwent surgery begins on the first day after surgery and increase graduallyThe risk of hyperglycemia more often encountered during anesthesia and surgery Nutrition Post OperativeStable babies who underwent elective surgery without complications do not need proteinProtein begins with 0.5-1 g / kg / 24 hoursBabies can gain 2.5 g / kg / day of protein on the first day after surgery with minimal risk and the positive effects of nitrogen balance (Anderson et al)Enteral feedingThe enteral route should be used as soon as possibleA few ml of breast milk can be given before the bowel starts to functionParenteral nutrition should gradually be decreased and the dextrose infusion can be reduced faster than the amino acid and the fat emulsion infusionPN maybe stopped when the infant is tolerating 100-120 ml/kg/d of enteral feedingSometimes it is helpful to stimulate the rectum or to give an enemaBreast-feeding/ expressed breast milk (EBM Breast-feeding/ expressed breast milk (EBM) should be encouraged in all babies, especially premature babies and babies with surgical problems. Those with antenatally detected conditions will already have been counselled to this effect if time allowed before delivery

Special circumstances influencing choice of enteral feed for surgical babies in NICUSummary of enteral feeding decision making for small or preterm surgical babies (2g/kg/day if infant has jaundice requiring phototherapyLipid/fatPreparation of 20% emulsion is better than 10 %2 solutions of lipid : 50% MCT/50% LCT; 100 % LCT

The use heparin at 0,5 to 1 units/ml of TPN solutions (max 137 units/day) can facilitate lipoprotein lipase activity to help stabilize serum triglyceride values

Lipid clearance monitored by plasma triglyceride levels (maximum triglyceride concentration ranges from 150mg/dl to 200mg/dl)

Lipid/fatPotential complication /risks include :

Table -10: infusion of 20 % intravenous fat emulsion g/kg/day (ml/kg/day)Preterm and SGA inf

Fullterm neonates

infants

Initial dose

0.5 (2.5)

1 (5)

2 (10)

Daily increase0.5 (2.5)

1 (5)

1 (5)

Maximum dose

3 (15)

4 (20)

4 (20)

Meurling S. Scand J Nutr/Nringsforskning.2000; 44:8-11Minerals and fat and water soluble vitaminsMinerals and fat and water soluble vitaminsMinerals and fat and water soluble vitaminsMinerals and fat and water soluble vitaminsTrace elements are recommended as 0.2 mL/kg/d of trace element solution containing zinc, manganese, copper, and chromium

Minerals and fat and water soluble vitaminsTable- 12 : Parenteral Calcium and Phosphorus Doses :

Calcium (mEq/kg)Phosphorus (mmol/kg)Initiate2 mEq/kg1 mmol/kgAdvance every 1-2 days0.5 mEq/kg0.3-0.5 mmol/kgGoal 3 mEq/kg (preterm)2mEq/kg (term)1.5 mmol/kg (preterm)1.2 mmol/kg (preterm)Anonymous. Neonatal Parenteral Nutrition. Intensive care Nursery House Staff Manual 2004; 136-142Table-11 : Daily requirements of electrolytes, trace elements, and vitamins (per kg of body weight)

Sodium 3-5 mEqPotassium 3-5 mEqMagnesium 0.3-0.5 mEqCalcium 2-4 mEq (preterm, 5-6 mEq)Phosporous 1-2 mEqZinc 150-200 mg (preterm, 400-600 mg)Copper 10-20 mgIron 1 mgVitamin A233 unitsVitamin C6 mgVitamin D66 unitsVitamin E0.66 unitsVitamin B 1 (thiamine) 0.055 mgVitamin B2 (riboflavine)0.07 mgVitamin B3 (niacine)0.9 mgVitamin B5 (panthotenic acid)0.3 mgVitamin B6 (pyridoxine)0.05 mgBiotine (Vitamin B7)30 mgFolic acid (vitamin B9)8 mgVitamin B12 (cyanocobalamine)0.04 mgFalco MC, Tannuri U. Rev.Hosp.Clin.Fac.Med.S.Paulo 2002; 57(6) : 299-308Overview of daily IV fluid requirements in the NICU

57Day 0 60 80 mL/kgDay 1 60 80 mL/kgDay 2 80 100 mL/kgDay 3 100 120 mL/kgDay 4 120 140 mL/kgDay 5 140 150 mL/kgRWH 200757