combust 2011
TRANSCRIPT
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COMBUSTIONFajar Ari Nugroho
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LUKA BAKAR
Merupakan luka yang disebabkan oleh panas,listrik, maupun bahan kimia Panas =
- benda panas: padat, cair, udara (uap)- api- sengatan matahari atau sinar panas
Listrik = aliran listrik tegangan tinggi Kimia = asam kuat, basa kuat
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DIAGNOSIS LUKA BAKAR
Berdasar :1. Luas luka bakar2. Derajat (kedalaman) luka bakar3. Lokalisasi4. Penyebab
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Penetapan Luas Luka Bakar
1. Rumus – 9 (Rule of Nine)2. Telapak tangan = 1%
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Rumus – 9 (Rule of Nine)
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Derajat Luka Bakar
Derajat IMengenai epidermis, lapisan basal masih baik, eritema, oedematus, nyeri
Derajat IIEpidermis dan dermis, bagian dasar kulit masih baik (IIa) superfisial (dangkal) : bulla, oedema, erithema, nyeri (IIb) deep (dalam) : hampir mengenai seluruh lapisan kulit
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Derajat Luka Bakar
Derajat IIIseluruh lapisan kulit, tidak nyeri, jaringan putih, abu-abu, kecoklatan (nekrosis)
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Fase Luka Bakar
Ebb-phase responsehypovolemic shock:
1. tissue perfusion2. metabolic rate3. oxygen consumption4. blood pressure5. body temperature
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Fase Luka Bakar
Flow-phaseacute responses :
1. glucocorticoid2. glucagon3. catecholamin4. Release of cytokines, lipid mediators5. Production of acute-phase proteins6. excretion of nitrogen7. metabolic rate8. oxygen consumption9. Impaired use of fuels
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Fase Luka Bakar
Flow-phase adaptive response
1. Hormonal response gradually disminishes2. hyper metabolic rate3. Associated with recovery4. Potential with restoration of body protein5. Wound healing depends in part on njutrient intake
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MNT principal
1. Because of difficulty in conducting a nutritional assessment in a critically ill patients (combust) the ability to predict, will resume adequate oral food intake
2. Must focus on laboratory data not to define nutritional status, but for design the nutritional prescription
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MNT principal
3. Should review indices of organ system function, blood glucose, laboratory abnormalities, specially electrolytes & acid-base balance may impact enteral & parenteral formulation/diet order
4. Urine Urea Nitrogen (UUN) excretion in grams/day has been evaluate the degree of hyper metabolism : 5=no stress, 5-10=mild hyper metabolism (level 1 stress), 10-15=moderate hyper metabolism (level 2), >15=severe hyper metabolism (level 3)
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Factor to consider
1. Pre injury nutritional status2. Type of trauma3. Extent of injury4. Surgical finding5. Gastrointestinal function6. Enteral access option
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Fluid & electrolyte repletion
The first 24-48 hour treatment fluid & electrolyte replacement; the calculate volume for first 24-h given in first 8-h (the period of greatest intravascular loss); the volume of fluid needed age & weight, extent of the burn
Early adequate fluid preventing ischemia, maintaining circulatory volume
Encourage fluid intake = juice (stump) To determined fluid & electrolyte needs:1. Lund & border chart2. Baxter/parkland
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calculation
Lund & browder2.0-3.1 mL/kg body weight per 24-h per %TBSA = fluid volume
Baxter/parkland4 cc x BB x % TBSA = RL volume
Ket: TBSA the percentage body surface area (luas permukaan luka bakar); RL ringer laktat
NB: <15%+grade 2 oral, infus >15%; ½ hasil perhit 8 jam pertama, sisa ½ nya 16 jam berikutnya
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Energy
Adult 1. Harris benedict
kebut energi (p) = 66+(13,7 x BB)+(5 x TB)–(6,8 x U) x AF x FSkebut energi (w) = 665 + (9,6 x BB) + (1,8 x TB)–(4,7 x U) x AF x FS
Note: meningkatkan resiko morbiditas dan mortalitas, terutama pada fase akut LB berat (overfeeding)
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Energy
2. The curreri formula kebut energi = 24 Kcal x BBI + 40 Kcal x % TBSA burned (max 50% TBSA)
Note: bila TBSA >50%-60% minimal increases in energy expenditure occur; ketika formula ini digunakan hrs dipastikan penambahan kalori max 100% (2xREE); biasanya menghasilkan perhitungan > actual energy expenditure
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Energy
3. Rule of thumbKebut energi = 25 – 30 Kal/KgBB
Note: merupakan metode perhitungan yang praktis
dan dapat menghindari overfeeding
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Energy
Pediatric 1. Galveston formula
Kebut energi = 1800 Kcal/m2 BSA+ 2200 Kcal/m2 BSA
2. Polk formulaKebut energi = (60 Kcal x kg body weight) x (35 Kcal x % burn)
Note: polk children less then 3 yrsBSA = weight (kg)0,5378 x height (cm)0,3964 x 0,024265
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Considerable energy needs
Weight gain (severely underweight patient) not feasible until after the acute illness
Weight maintenance should be the goal overweight patient
For obese patient more than calculation when using ideal body weight, less than calculation when using actual body weight; indirect calorimetry is the most accurate methods of determining the energy needs
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Energy sources
Carbohydrate are excellent for protein-sparing (60%, stump) recommended as the chief of energy source excess : lipogenesis causes oxygen consumption, CO2 production, hyperglicemia, osmotic diuresis, respiratory difficulty
Although lipids are a concentrate source of energy excess: deleterious immunologic response, susceptibility to infection
Diet high -3 increase immune response & tube feeding tolerance by: inhibit prostaglandin E2 & leucotrienes (immunosuppressive); a reasonable approach 15%-20% (krause), 20% fat (2-4% essential amino acid, slight in omega 3) (stump)
MCT & structured lipids under investigation
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Protein
Losses trough urine & wound, increased use in gluconeogenesis & wound healing
20-25% recommended for adult (krause)or 1.5-3 g/kg BW (stump), 2.5- 3.0 g/kg BW for pediatric (pediatric: depend on renal function & fluid balance)
BCAAs seem to have no beneficial effect, the conditional essential amino acids: arginine may improve cell mediated immunity & wound healing, anabolic hormone production, (up to 2% of kcal) (stump); glutamine ability of neutrophils (krause);
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Assessment of Energy & Protein Adequacy The best evaluated by: 1) wound healing, 2) graft
take, 3) basic nutritional assessment parameter Weight change trends can be identified after fluid
gained during resuscitation period in 2 weeks Nitrogen balance is frequently used to evaluated the
efficacy of nutrient regimen, but it can’t considered accurate without accounting for wound losses, the first 4 weeks may be the most reflective measure in nutritional monitoring
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Assessment of Energy & Protein Adequacy Formulas for predicting nitrogen losses:1. <10% open wound = 0.02 g nitrogen/kg/day2. 11-30% open wound = 0.05 g nitrogen/kg/day3. >31 open wound = 0.12 g nitrogen/kg/day Note: albumin levels remain depressed until major
burn are healed; prealbumin, RBP, transferin helping to assess protein status of patient
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Vitamin & mineral
Vitamin needs increased, but exact requirement have not been establish
Recommended:1. Vitamin C = 500 mg twice daily (krause); 5-10 x RDA
(stump)2. Vitamin A = 5000 IU/1000 calories of enteral nutrition
(krause); 2 x RDA (stump)3. Sodium/potassium are corrected by adjusting fluid
therapy restriction sodium free water : correct hyponatremia; resuscitation & protein synthesis : hypokalemia (slightly : inadequate rehydration )
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Vitamin & mineral
4. Depression of calcium levels may be seen in patient more than 30% TBSA (hypocalcemia : hypoalbuminemia) = supplement may necessary
5. Hypophospathemia large volume of resuscitation & large antacid = supplement via parenterally (prevent gastric irritation)
6. Magnesium levels loss from wound = supplement via parenterally (prevent gastric irritation)
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Vitamin & mineral
7. Depressed zinc levels unclear : total body zinc nutriture or an artifact of hypoalbuminemia = supplementation 220 mg zinc sulfate is appropriate (krause); 2 x RDA zinc sulfate (stump)
8. Anemia usually unrelated to iron deficiency (no history) = packed red blood cell
9. Vitamin B-com 2-3 x RDA (stump)10. Vitamin B12 & K diberikan mingguan (stump)
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Others
11. Use high calorie, high protein diet with 5-6 small meals & snack
12. Avoid excesses of linoleic acid depress immunocompetence
13. Be careful iron & zinc excess in patient with sepsis
14. Do not alter nutritional support because watery diarrhea is likely occur for reason other than carbohydrate intolerance
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Beware Clinical indicator
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Beware Clinical indicator
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DNI
Analgesic = GI function & appetite Antacid = change digestion process Antibiotic = leaching of sodium,
potassium, magnesium, calcium & B-com Insulin = use for stress induce
hyperglicemia Interferon gamma or alpha-2b = dry
mouth, stomatitis, nausea & vomiting, diarrhea, abdominal pain
Supportive therapy = no interaction
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Refference
Stump, S.E., (2008),Nutrition and Diagnosis-Related Care, sixth edition, Philedelpia : lippincott
Mahan, K., (2000), Krause’s Food nutrition & Diet Therapy, USA: Saunders company
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Terimakasih