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"Sepsis adalah keadaan infeksi yang disertai dengan respon infeksi secara sistemik yang merupakan salah satu penyebab morbiditas dan mortalitas pasien dengan penyakit kiritis Penyakit kritis dapat menyebabkan seorang pasien jatuh ke dalam kondisi malnutrisi Prevalensi malnutrisi pada pasien sakit kritis yang dirawat di unit perawatan intensif adalah 50 Tujuan penatalaksanaan nutrisi pasien sepsis adalah untuk menurunkan stres metabolik mencegah kerusakan sel akibat stres oksidatif dan memodulasi fungsi imun Penatalaksanaan nutrisi meliputi kegiatan skrining assessment terapi nutrisi pemantauan dan evaluasi Pasien pada serial kasus ini adalah pasien dewasa dengan diagnosis sepsis yang disebabkan oleh pneumonia 3 pasien dan infeksi intraabdomen 1 pasien Komplikasi sepsis terbanyak dalam serial kasus ini adalah acute kidney injury AKI Kebutuhan energi dihitung berdasarkan rule of thumb yaitu 20 25 kkal kg BB hari pada fase akut dan 25 30 kkal kg BB hari pada fase anabolik Pada pasien yang mendapat continuous renal replacement therapy CRRT diberikan energi 35 kkal kg BB hari Pemberian protein dengan jumlah minimal 1 5 gram kg BB hari diberikan kepada pasien tanpa AKI sementara pada pasien dengan CRRT diberikan protein 1 7 gram kg BB hari Pemantauan terapi nutrisi meliputi tanda klinis toleransi asupan makanan kapasitas fungsional balans cairan parameter laboratorium dan antropometri Selama pemantauan didapatkan semua pasien dapat mencapai kebutuhan energi total dalam waktu kurang dari tujuh hari namun karena terjadi beberapa efek samping seperti peningkatan volume residu lambung dan tekanan karbon dioksida maka dilakukan penurunan asupan pada 2 pasien Pemberian nutrisi pada pasien sakit kritis bersifat individual dan terintegrasi Tatalaksana nutrisi yang baik diharapkan dapat menurunkan laju morbiditas dan mortalitas pasien dengan sepsis

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Sepsis is a state of infection accompanied by systemic inflammatory response syndrome It often associated with increase morbidity and mortality rate in critically ill patient Fifty percent of critically patient admitted in intensive care unit were malnourished Aims of nutritional management of septic patients are to reduce metabolic stress prevent cell damage from oxidative stress and modulate immune function Nutrition intervention in septic patients are including nutrition screening and assessment nutrition therapy monitoring and evaluation Subjects were four adult septic patients caused by pneumonia infection 3 patients and intra abdominal infection 1 patient Most frequent septic complications in this serial case report were acute kidney injury AKI Energy requirementis calculated based on the rule of thumb which is 20 25 kcal kg BW day in the acute phase and 25 30 kcal kg BW day in the anabolic phase Patients whose receiving continuous renal replacement therapy CRRT were given an energy of 35 kcal kg BW day Minimal protein requirement for patient without AKI was 1 5g kg BW day and in patients with CRRT protein intake were 1 7 grams kg BW day Monitoring includes clinical symptoms tolerance of food intake functional capacity fluid balance laboratory and anthropometric findings All patients were able to obtain total energy requirement in less than seven days However reduction of total energy was appied in 2 patients after several days of treatment due to increased gastric residual volume and carbon dioxide pressure Nutrition therapy in critically ill patients is individualized and integrated Proper nutrition therapy may decrease of morbidity and mortality rate in septic patients "

"[ABSTRAKSerial kasus ini bertujuan untuk mempelajari dan menerapkan terapi nutrisi sebagai bagian dari terapi tuberkulosis (TB) paru. Komplikasi yang menyertai TB paru dapat meningkatkan morbiditas dan mortalitas. Seluruh pasien serial kasus ini dalam kondisi malnutrisi dan terdapat komplikasi yang menyertai masingmasing kasus berupa drug-induced hepatotoxicity, peritonitis TB, diabetes melitus tipe 2, dan pneumotoraks dengan dispepsia. Pemberian nutrisi disesuaikan dengan kondisi, penyakit penyerta, dan kebutuhan yang bersifat individual. Kebutuhan energi basal dihitung dengan persamaan Harris-Benedict dengan kebutuhan energi total setara dengan 35?40 kkal/kg BB. Makronutrien diberikan dalam komposisi seimbang dengan protein 15?20% kebutuhan energi (1,2?1,5 g/kg BB). Saran pemberian mikronutrien minimal mencapai angka kecukupan gizi. Pasien yang mendapat obat antituberkulosis berupa isoniazid disarankan mendapat suplementasi vitamin B6 dengan dosis tertentu untuk mencegah neuritis perifer. Outcome yang dinilai meliputi kondisi klinis, asupan, dan toleransi asupan. Pemberian terapi nutrisi sebagian besar pasien dimulai dari kebutuhan energi basal yang pada akhir masa perawatan dapat mencapai target kebutuhan energi total. Pemantauan jangka panjang pasca rawat inap, disarankan tidak hanya menilai outcome berdasarkan perubahan berat badan, namun dilakukan penilaian komposisi tubuh, terutama massa lemak, karena pada kasus TB terjadi abnormalitas metabolisme yang disebut anabolic block.

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ABSTRACTThe aim of this case series was to study and apply nutrition therapy as integral part of pulmonary tuberculosis (TB) therapy. Pulmonary TB with complications was associated with increased of morbidity and mortality. Malnutrition was coexisted with several complications such as drug-induced hepatotoxicity, peritoneal TB, type 2 diabetes mellitus, and pneumothorax with dyspepsia. HarrisBenedict equation was used to calculate basal energy requirement with total energy requirement equivalent to 35?40 kcal/body weight. Balanced macronutrient composition was given with protein 15?20% energy requirement (1,2?1,5 g/body weight). Micronutrient recommendation was given to fulfill one fold recommended daily allowance. Patients with isoniazid therapy needed to get pyridoxine supplementation to prevent peripheral neuritis. Outcome measurements included clinical condition, amount of intake, and intake tolerance. Most patients were given initial nutrition therapy from basal energy requirement and has shown increment. At the end of hospitalization, all of patients could achieve total energy requirement. Due to abnormality of metabolism, usually termed as anabolic block, it was recommended not only to measure body weight as primary outcome, but also body composition., The aim of this case series was to study and apply nutrition therapy as integral part of pulmonary tuberculosis (TB) therapy. Pulmonary TB with complications was associated with increased of morbidity and mortality. Malnutrition was coexisted with several complications such as drug-induced hepatotoxicity, peritoneal TB, type 2 diabetes mellitus, and pneumothorax with dyspepsia. HarrisBenedict equation was used to calculate basal energy requirement with total energy requirement equivalent to 35–40 kcal/body weight. Balanced macronutrient composition was given with protein 15–20% energy requirement (1,2–1,5 g/body weight). Micronutrient recommendation was given to fulfill one fold recommended daily allowance. Patients with isoniazid therapy needed to get pyridoxine supplementation to prevent peripheral neuritis. Outcome measurements included clinical condition, amount of intake, and intake tolerance. Most patients were given initial nutrition therapy from basal energy requirement and has shown increment. At the end of hospitalization, all of patients could achieve total energy requirement. Due to abnormality of metabolism, usually termed as anabolic block, it was recommended not only to measure body weight as primary outcome, but also body composition.]"

"Malnutrisi dan tuberkulosis seringkali ditemukan secara bersamaan, Adanya malnutrisi pada tuberkulosis meningkatkan morbiditas dan mortalitas. Serial kasus ini bertujuan mempelajari efek terapi nutrisi pada pasien TB paru dengan malnutrisi. Pada serial kasus ini tiga orang pasien mengalami malnutrisi berat dan satu pasien mengalami malnutrisi ringan. Nutrisi tahap awal diberikan ≤ 50% kebutuhan energi total (KET) dan ditingkatkan bertahap. Pada akhir masa perawatan, nutrisi dapat mencapai 90% KET. Protein diberikan sebesar 15-20% total kalori. Konseling gizi diberikan pada akhir masa rawat pada pasien dan keluarga. Terapi nutrisi sebaiknya harus menjadi bagian integral dari terapi tuberkulosis.

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Malnutrition has been found to coexist with tuberculosis (TB). Malnutrition is associated with increased morbidity and mortality in those with TB. Objective of this case serial is to review the impact of nutritional therapy in pulmonary TB patient with malnutrition. All of four patients were malnourished and had pulmonary TB, of which 3 were severely malnourished. Initially, nutrition therapy commenced with ≤ 50% estimated energy requirement (EER) and incrementally increased to 90% EER at the end of hospitalization. Protein was given 15–20% of total calories. Bedside counseling was provided prior to discharge. Nutrition therapy should be considered as integral part of TB treatment."

"Latar Belakang: Mycobacterium tuberculosis merupakan penyebab tuberkulosis pada paru dan organ lain, seperti meningen meningitis tuberkulosis . Meningitis tuberkulosis dapat merupakan komplikasi tuberkulosis primer, yang bersifat laten/asimptomatik, namun risiko reaktivasi meningkat pada penurunan sistem imun/malnutrisi. Disfagia, defisit kognitif, hemiparese, dan ketidakmampuan makan mandiri juga dapat menyebabkan malnutrisi, sehingga akan meningkatkan lama rawat dan mengganggu perbaikan kapasitas fungsional. Tatalaksana nutrisi diperlukan untuk meminimalisasi kehilangan berat badan, mendapatkan imbang nitrogen positif, dan menyediakan nutrisi untuk membangun system imun. Pada pelaksanaannya, pemberian nutrisi harus memperhatikan kondisi klinis serta komplikasi berupa peningkatan tekanan intrakranial dan defisit neurologi yang terjadi. Metode: Laporan serial kasus ini menguraikan empat kasus meningitis tuberkulosis dengan tuberkulosis paru. Semua pasien datang dengan penurunan kesadaran dan telah terdiagnosis tuberkulosis paru sebelumnya, namun pasien minum obat tidak sesuai dengan anjuran dokter. Status gizi keempat pasien adalah malnutrisi ringan dan berat, obes 1 dan normal. Selama dirawat, tatalaksana nutrisi diberikan sesuai pedoman terapi nutrisi untuk penderita tuberkulosis. Asupan makronutrien diberikan meningkat bertahap sesuai kondisi klinis dan toleransi pasien. Suplementasi mikronutrien juga diberikan. Pemantauan meliputi keluhan subjektif, hemodinamik, analisis dan toleransi asupan, pemeriksaan laboratorium, antropometri, keseimbangan cairan, dan kapasitas fungsional. Hasil: Dua orang pasien menunjukkan perbaikan klinis, kapasitas fungsional, hasil laboratorium, toleransi asupan, dan outcome, sedangkan dua orang lainnya mengalami perburukan dan meninggal pada hari perawatan ke-44 dan ke-24. Kesimpulan: Dukungan nutrisi infeksi tuberkulosis pada paru dan susunan saraf, dapat memberikan manfaat untuk pemulihan pasien.

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Objective: Mycobacterium tuberculosis is the cause of tuberculous in the lung and other organs, such as the meninges tuberculous meningitis . Tuberculous meningitis can be a complication of primary tuberculous, latent asymptomatic, but the risk of reactivation increases to a decrease in the immune system malnutrition. Dysphagia, defisit kognitif, hemiparese, and inability to eat independently can also cause malnutrition, thereby increasing the length of stay and interfere with the functional capacity improvement. Management of nutrients needed to minimize the lose weight, get a positive nitrogen balance, and provide nutrients for building the immune system. In practice, the nutrition must consider the clinical condition and the complications in the form of increased intracranial pressure and neurological deficits that occur.

Methods: This case series report outlines four cases of tuberculous meningitis with pulmonary tuberculous. All patients present with loss of consciousness and have been diagnosed with pulmonary tuberculous before, but patients taking the medicine does not comply with doctor's advice. Nutritional status of the four patients was mild and severe malnutrition, obese and normal one. During the treatment, management of nutrition was given according to the guidelines of nutrition therapy for patients with tuberculosis. Macronutrient intake increased gradually given appropriate clinical condition and patient tolerance. Micronutrient supplementation are also given. Monitoring included subjective complaints, hemodynamic, analysis and tolerance intake, laboratory tests, anthropometric, fluid balance, and functional capacity.

Results: Two patients showed clinical improvement, functional capacity, laboratory results, tolerance intake, and outcome, while two other people suffered deterioration and died on the 44th and 24th day of treatment.

Conclusion: Nutritional support tuberkulosis infection in the lungs and nervous system, can provide benefit to the patient's recovery."

"Luka bakar berat berhubungan dengan tingginya angka morbiditas dan mortalitas. Tatalaksana nutrisi pada luka bakar berat diutamakan pada pemberian nutrisi enteral dini (NED). Nutrisi enteral dini diberikan sedini mungkin setelah resusitasi tercapai, bermanfaat sebagai trophic feeding yang terbukti mencegah terjadinya atrofi vili-vili mukosa sebagai upaya mengatasi dampak hipoperfusi splangnikus. Pemberian nutrisi ditingkatkan bertahap sesuai asupan, toleransi, dan keadaan klinis pasien. Serial kasus ini terdiri dari tiga kasus dengan penyebab api dan satu yang disebabkan oleh listrik. Dua kasus dengan trauma inhalasi dan dua kasus dengan kegagalan ginjal akut (AKI). Dua kasus masuk pada hari pertama pasca trauma, dan dua kasus pada hari ke enam dan delapan pasca trauma. Keempat kasus masih dalam keadaan resusitasi cairan, sehingga pemberian nutrisi ditujukan untuk pemberian NED. Monitoring dilakukan pada klinis, asupan dan toleransi, dan laboratorium terutama darah perifer lengkap, elektrolit, analisis gas darah, laktat, albumin, dan fungsi ginjal. Asupan keempat kasus tidak pernah mencapai total karena berulang kali dipuasakan untuk pembedahan. Aliran balik yang tinggi menunjukkan intoleransi saluran cerna sehingga perlu diberikan prokinetik. Pemberian antibiotik sebagai suatu kebutuhan mutlak perlu memperhatikan interaksinya dengan nutrien. Pemberian analgetika dan sedatif perlu memperhatikan interaksi dan efek terhadap kebutuhan nutrisi. Trombositopenia yang terjadi pada tiga kasus berhubungan dengan sepsis dan mortalitas. Koagulopati bersama dengan hipotermia dan asidosis menjadi komponen Triad of Death. Hiperlaktatemia harus dinilai bersamaan dengan parameter lain untuk menilai adanya hipoksia jaringan. Dua kasus berkomplikasi menjadi AKI, tatalaksana nutrisi memperhatikan terapi yang didapat pasien. Pemberian medikamentosa untuk perbaikan sirkulasi juga memperhatikan interaksi obat.

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Severe burns associated with high morbidity and mortality. Nutritional management of severe burns priority on early enteral nutrition (EEN). Early enteral nutrition is given as early as possible after resuscitation achieved, useful as trophic feeding are proven to prevent the occurrence of mucosal villous atrophy as the effort to overcome the effects of splanchnic hypoperfusion. Providing appropriate nutrition intake gradually increased, due to tolerance, and clinical condition of patients. This case series consisted of three cases the cause of the fire and one caused by electricity. Two cases with inhalation injury and two cases with acute renal failure (ARF). Two cases admitted on the first day after trauma, and two cases in the sixth and eighth days after trauma. The four cases are still in a state of fluid resuscitation, thus giving nutrition aimed at giving EEN. Monitoring conducted in clinical condition, caloric intake and tolerance, and laboratories especially equipped peripheral blood, electrolytes, blood gases analysis, lactate, albumin, and kidney function.

Intake of four cases never reach the total due to repeated fasting for surgery. High-flow indicates that gastrointestinal intolerance should be given prokinetic agent. Giving antibiotics as an absolute necessity need to consider interactions with nutrients. Giving analgesics and sedatives need to consider interactions and effects on nutritional requirements. Thrombocytopenia occurred in three cases and mortality associated with sepsis. Coagulopathy with hypothermia and acidosis become components Triad of Death. Hyperlactatemia should be assessed in conjunction with other parameters to assess the presence of tissue hypoxia. Two cases complicated to AKI, nutritional management of patients gained attention therapy. Giving drug therapy for improved circulation also consider drug interactions."

"Malnutrisi energi dan protein merupakan suatu masalah umum yang ditemukan pada pasien rawat inap di rumah sakit. Berbagai studi menunjukkan sebanyak 40% pasien bedah sudah mengalami malnutrisi pada saat masuk ke rumah sakit. Studi tersebut menunjukkan terdapat hubungan langsung antara penurunan berat badan pra bedah dengan laju mortalitas pasca bedah. Terapi nutrisi perioperatif yang adekuat telah dilaporkan dapat menurunkan laju morbiditas dan menurunkan masa rawat inap secara bermakna. Serial kasus ini terdiri atas empat kasus terapi nutrisi perioperatif pada pasien malnutrisi dengan kanker periampular yang menjalani pembedahan pankreatikoduodenektomi. Pasien adalah laki-laki, berusia antara 40-60 tahun, dengan kanker periampular (pankreas dan ampula Vateri). Keempat pasien kasus ini mengalami sindrom kaheksia-kanker, yaitu ditemukan penurunan BB sebesar 10-15% dalam ena bulan terakhir, anemia, fatigue, dan hipoalbuminemia. Kebutuhan energi total dihitung dengan menggunakan persamaan Harris-Bennedict dengan menambahkan faktor stres sebesar 1,5. Pemberian kalori dan nutrisi dilakukan secara bertahap dan ditingkatkan sesuai dengan perbaikan keadaan klinis, gastrointestinal, dan toleransi asupan pasien. Pemantauan dan evaluasi pasien dilakukan sesuai dengan perubahan subyektif dan obyektif. Selain itu, konseling dan edukasi mengenai terapi nutrisi diberikan setiap hari pada pasien. Selama perawatan, keempat pasien serial kasus ini menunjukkan perbaikan, baik secara subyektif maupun obyektif. Kebutuhan energi total tercapai selama periode pra bedah dan tujuh hingga sembilan hari pasca bedah. Masa rawat pasien ini adalah 12-20 hari. Perbaikan status nutrisi tidak tercapai pada pasien ini, namun terjadi perbaikan kapasitas fungsional dan proses penyembuhan luka yang adekuat. Terapi nutrisi perioperatif yang diberikan diharapkan mampu meningkatkan atau mempertahankan status nutrisi pasien, prognosis pasca bedah, serta meningkatkan kapasitas fungsional dan kualitas hidup pasien secara keseluruhan.

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Energy and protein malnutrition are common issues in hospitalized patient worldwide. Various studies had reported that 40% of surgical patient were already malnutrition when admitted to the hospital. The study reported that there were direct relationships between lost of body weight with mortality rate post surgery. Adequate perioperative nutritional therapy had been reported could decrease the morbidity rate and length of stay significantly. This case series consist of four perioperative nutritional management cases in malnourished patients with periampullary cancer that undergone pancreaticoduodenectomy surgery. Patients were male, age between 40-60 years, with periampullary cancer (pancreas & ampulla of Vatery). This four patients were having cancer-cahexia syndrome, which was characterized by lost of body weight 10-15% in the last six months, anemia, fatigue, and hypoalbuminemia. Total energy requirement were calculated with Harris-Bennedict equation with stress factor equal to 1,5. Energy and nutrition were given gradually and increased according to the improvement of clinical & gastrointestinal condition, and food intake tolerance of the patients. Monitoring and evaluation of the patients were applied according to the changes of subjective and objective parameter. Besides that, counseling and education were also given everyday to all of the patients. During the hospitalization, this four case series patients showed improvement, in both subjective and objective parameter. Total energy requirement was achieved in preoperative periode and seven until nine days postoperative in all of this patients. Length of stay of this patients were 12-20 days. Improvement of nutritional status were not found in this patients, but there were significant improvement of functional capacity and wound healing happened in them. Perioperative nutritional management applied to the patients were expected could increase or maintain the patiens’ nutritional status, improve prognosis post surgery functional capacity, and eventually leads to improvement of overall quality of life of the patients."