The Role of Amino Acids in Elderly Patients

Pedoman Terapi Cairan

Tatalaksana Syok Hipovolemik

Perioperative Fluid and Nutrition Management

Update on BCAA (Branched-Chain Amino Acids)

Update on BCAA.pdf 

PERIOPERATIVE FLUID THERAPY.pdf 

Update on Maintenance Fluid Therapy

See my slideshare

INTRODUCTION

Maintenance fluid therapy is one important component of comprehensive management of inpatients.Patients with severely deficient oral intake of fluid and nutrients due to  various reasons need attention, although the main focus of clinicians is the diagnosis and management of exact causal therapy.  Giving proper maintenance fluids can help a patient's recovery  faster and patient can return to physical activity earlier.

Definition of Maintenance Fluid Therapy

Maintenance fluid therapy can be defined as giving IV fluids to hospitalized patients with the following criteria: 

•        In moderate dehydration but cannot be adequately treated orally

•        No hemodynamic disturbances (eg MAP > 65-70 mmHg, without signs of peripheral vasoconstriction, tachycardia and prolonged capillary refill time)

•        No severe electrolyte disorders

•        Fulfil the daily  basal requirement of fluid, electrolyte and nutrients 

Normal saline (0.9% NaCl) and Lactated Ringer’s or Acetated Ringer’s are not suitable as maintenance solutions

Normal saline (NaCl 0,9%), Lactated Ringer’s and A cetated Ringer’s are replacement solutions NOT maintenance solutions because  of the two reasons:

•     Sodium content is above 100 mEq/L, as isotonic solutions are more suitable as resuscitation fluid to replace acute abnormal or massive fluid loss.

•     0.9% NaCl does not contain potassium, whereas Lactated Ringer’s and acetated Ringer’s contain only 4 mEg/L. They cannot meet the minimum requirement of potassium, ie 10-20 mEq per day Table 1. Resuscitation Solutions

	Glu (g/dl)	Electrolytes (mEq/L)
PRODUCTS		Na+	K+	Ca++	Cl-	Lactate-	Acetate-	mOsm/L	Vol(ml)
OTSU-NS (0.9% NaCl)	-	154	-	-	154	-	-	308	500
Ringer Solution	-	147	4	4.5	155.5	-	-	310	500
OTSU-RL (Lactated Ringer’s)		130	4	3	109	28	-	272.5	500
ASERING (Acetated Ringer’s)		130	4	3	109	-	28	272.5	500
ASERING-5 (Acetated Ringer’s +D5W)	50	130	4	3	109	-	28	272.5	500
RL-D5	50	130	4	3	109	28	-	272.5	500
RD-5	50	147	4	4.5	155.5	-	-	310	500

What about D5W ? Can it be considered as maintenance fluid?

D5W in small volume (eg 50 ml,100 ml) are usually used as drug diluent for intermittent IV drip. However, when used as maintenance fluid, the calorie content is too small, 200 kcal/L (glucose anhydrate) or 170 kcal/L (glucose monohydrate), and associated with high risk of hyponatremia and hypokalemia if given in maintenance requirement (eg 30 ml/kg/day). Nowadays, even fluid containing glucose and low sodium (eg 0.18% saline + D5W) have been reported to cause hyponatremia in pediatric patients ⁽¹⁾.

Are KAEN 3B and KAEN 4A  ideal maintenance soluitions ?

KAEN 3B and KAEN 3 A are basic maintenance solutions suitable for patients with moderate dehydration with risk of hypokalemia owing to insufficient oral intake or after acute fluid loss (severe diarrhea) has been replaced with isotonic fluids (Latated Ringer and ASERING®). Therefore the use of KAEN3B and KAEN3A helps restore potassium homeostasis.Clinically, the effect of KAEN3B and KAEN3A is obvious with the absence of abdominal distention. Hypokalemia in hospitalized patients have been recorded by three investigators in Indonesia, as shown in the following table:

Principal Investigator	Centre	Number of patients	% of Hypokalemia on admission	% of Hypokalemia on discharge`
Untung Sudomo (2)	RSPAD Gatot Subroto	100	28	45
Djoko Widodo (3)	RSCiptomangunkusumo	100	22,9	52,4
Nasronudin (4)	RS Dr SUtomo	110	36,36	50,91

Nevertheless, very often that patients are admitted in poor condition with systemic symptoms, such as fatigue, weakness and loss of appeti te, so provision of simple electrolyte and glucose solutions is not enough.

Lack of oral intake may be attributable to the following: 

•        Patients with moderate dehydration may have dry and bitter tongue. Dry tongue can also be caused by medication (antihistamines, anticholinergics).

•        Anxiety, depression and fear 

•        The same hospital food for different types of patients.

•        Too weak to chew and swallow food

•        Gastrointestinal symptoms due to effects of illness or side effects of medication

•        Reduced consciousness

•    Poor dentition in elderly etc 

In the above circumstances, the response will be better if patients receive a practical and complete maintenance solution. Thus, on top of glucose and basic electrolytes (sodium, potassium), patients also need glucose, amino acids, microminerals to facilitate the metabolic processes and prevent protein catabolism. 

What are the indication of  Aminofluid ?

Aminofluid  is a PPN solution produced by Otsuka Pharmaceutical , which can generally be given to all inpatients except renal failure because its potassium content of 20 mEq/L can increase the risk of hyperkalemia.

Best response to administration of  Aminofluid  can be observed in the following conditions:

•        Febrile illnesses followed by excessive loss of IWL (insensible water loss) and hyperventilation.  Normally fever is a symptom of acute infections such as pneumonia, hepatitis A, Dengue hemorrhagic fever etc.

•        Gastrointestinal disorders 

•        Pre and postoperative Nutritional supplemention

•        Acute exacerbation of COPD.

Table Maintenance Solutions

	Glu (g/dl)	Electrolytes (mEq/L)
PRODUCTS		Na+	K+	Ca++	Cl-	Lactate-	Acetate-	mOsm/L	Vol(ml)
KAEN 3A	27	60	10	-	50	20	-	290	500
KAEN 3B	27	50	20	-	50	20	-	290	500
DG2A (Half-strength Darrow)	25	61	17.5	-	52	26.5	-	296	500
KAEN MG3	100	50	20	-	50	20	-	695	500
AMINOFLUID	75	35	20	5	50	20	13	817	500 & 1000

In addition to electrolytes and glucose,Aminofluid contains 30 g amino Acids, P,Mg and Zinc

Is there strong rationale of giving Aminofluid  to patients with acute infection?

Three important factor which justify the administration of Aminofluid to patients with acute infections:

1.     Despite thirst due to hypertonic dehydration, many  patients may not be able to ingest enough water and nutrient owing to abdominal discomfort/pain, hepatomegaly. 

2.     Elevated levels of cytokines, such as interferons (IFNs), interleukin-2 (IL-2), IL-8, and tumor necrosis factor alpha, have been reported in DHF⁽⁵⁾ One of their pleiotrophic effects is delaying gastric emptying

3.     Patients might experience loss of appetite because of dry mouth (dehydration), malaise and fatigue besides other systemic symptoms⁽⁶⁾  

QUESTION

1.     Does patient have dehydration?

2.     Are there any electrolyte imbalances? 3. How do you handle the   hyperglycemia in this patient? Can we give Aminofluid  this time?

Case Illustration:

Patient was admitted 24 hours ago with diagnosis of typhoid fever   PE : stupor, BP 100/70, 39^oC, HR 100, RR 12 shallow 
Electrolyte & Metabolic Panel (Na⁺ 145, K⁺ 3,Cl^- 102,HCO₃- 22,  BUN 22,Glu 240,Creatinine 0.8) 

QUESTIONS:

1. Does patient have dehydration? 
2. Are there any electrolyte imbalances? 
3. How do you handle the hyperglycemia in this patient? Can we give Aminofluid now? 

ANSWERS:

1.    Correct. The patient has some degree of dehydration.  How do we know it? Firstly, the BUN to cratinine ratio is 20 indicating the presence of dehydration. Secondly, the plasma osmolarity in this patient is high, i.e.  2 x [Na⁺] + glu/18  = 2 x 145 +  240/18 = 290 + 13.33 =303.33. Hyperosmolarity is defined as plasma osmolarity above 296 mOsm/L.  

2.    Patient has mild hypokalemia which does not require correction but can be prevented from worsening by giving maintenance solution. .

3.   Hyperglycemia  need to be corrected with insulin until the blood sugar level reaches 150 mg/dl. Parenteral glucose may be administered when the blood sugar reaches 150 mg/dl but require addition of regular insulin, 1 U/10 g glucose.  When 1 L Aminofluid (75 g glucose)is administered  7.5 unit regular insulin (drip) is added, if possible separately using syringe pump ^(7,8)

References:

1. Friedman JN. Risk of acute hyponatremia in hospitalized children and youth receiving maintenance intravenous fluids. Paediatr Child Health 2013;18(2):102-104 
2. Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy vol.5. Ed: Dec 2004. Page: 115-120 
3. Widodo D, Setiawan B, Khie Chen. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at Ciptomangun-kusumo HospitalJakarta. Acta Med Indones, 2006;38(4):202-5 
4. Nasronudin et al. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Medika 2006 Vol XXXII,No 12, p 732-734 
5. Anon Srikiatkhachorn, Chuanpis Ajariyakhajorn, Timothy P. Endy, Siripen Kalayanarooj, Daniel H. Libraty, Sharone Green, Francis A. Ennis, and Alan L. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 1592–1600. 
6. Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435 
7.  Perkeni 2007 Petunjuk Praktis Terapi Insulin pada Pasien Diabetes Mellitus 
8. Campbell KB, Braithwaite. Hospital management of hyperglycemia CLINICAL DIABETES • Volume 22, Number 2, 2004.