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PEMBEDAHAN


Surgery

Fernando Soares Vannucci Braz*
Angelo Bustani Loss*
Ricardo Miguel Japiass�*
*Fourth year medicine students – The Federal University of Rio de Janeiro

Nutrition & Surgery – Part I

Introduction

Nutritional support has been available for approximately two decades. It has proved its value as one of the most important therapeutic modalities in this century and perhaps in the history of medicine. The gut has been a major focus on nutritional support over the past decade, and this is likely to continue.

The importance of a satisfactory nutritional status in surgical patients

It is known that nutritional status is a very important factor in the recovery process from all kind of surgical interventions. The concept of nutritional status in surgery evolves all the perioperative nutrition period, including both preoperative and postoperative aspects. Many studies show that preoperative acceptable nutritional conditions help to prevent early and late postoperative complications. Klein et. al. published in 1996 a study that compared 2 groups of patients: a previously malnourished one and another in agreeable nutritional conditions. Both groups undergone in elective lumbar spinal surgery. Of 26 postoperative complications, 24 were in the malnourished group. The authors recommend that close attention be paid to the perioperative nutritional status of patients undergoing in this surgical procedure and also say that individuals with suboptimal nutritional parameters should be supplemented and replenished before elective surgery. Based in many other studies, we can say that these conclusions can be taken as true not only for spinal surgeries but for all kind of operations, always with special and particular considerations. In midline laparotomies, malnutrition is one of the well known risk factors determining wound dehiscences.

As we can see, there is a highly significant correlation between preoperative denutrition and postoperative morbidity. Di Costanzo et. al. say that this correlation also exists for postoperative mortality and it does not depend on whether the operation is performed in gastrointestinal tract or not, whether the primary disease is cancer or not. This study shows that the more important the denutrition, the more frequent the postoperative complications and deaths, with morbidity and mortality rates linearly correlated to denutrition. An important information included in this study is that obesity had the same prognostic value as denutrition. In the same way that preoperative nutritional status is important, postoperative nutrition must be considered. Successful recovering from a surgical intervention depends on many factors and postoperative nutritional support is one of these important factors. Postoperative nutrition should be initiated as soon as possible. The nutrients implemented will help in wound closure, in improving immune responses, in preventing infections or sepsis and in many other processes that play a role in the recovering period. Delaying this support may impair all this period, thus putting in risk patient’s life in addition to increase hospital stay time and costs.

Protein and caloric requirements

In a 70 kg man there are about 10 to 11 kg of protein. Daily protein turnover is 250 to 300 g. After digestion, all amino acids are absorbed, save 1 g of nitrogen which is excreted in the stool. Proteolysis accounts for another 50 to 70 g of amino acids. In total, ingested amino acids contribute only 25 g to the free amino acid pool, whereas 250 g is provided by endogenous breakdown. If adequate energy is present, most of these amino acids are resynthesized. Protein turnover decreases with age, but as lean body mass increases, total body turnover remains approximately the same.

Caloric supply is important. Carbohydrate increases muscle protein synthesis under the influence of insulin; fat increases hepatic and other visceral protein synthesis. The average normal requirement of a patient is 0.8 g of protein / kg / day. Any kind of trauma, including surgical one, increases this requirement (see Figure 1).

Figure 1. The increases in resting energy expenditure that have been shown to occur during catabolic phase of trauma situations (injury and infection), when compared with the decreases that develop during partial starvation. (From Sabiston Textbook of Surgery, 15th edition)

Alternative or nonconventional fuels

Glutamine as a fuel for enterocytes has received much attention, with several recent clinical trials. Small insignificant changes in nitrogen balance result from a dipeptide glutamine ester. However, in severe stress, such as bone marrow transplant, a beneficial effect of glutamine in decreasing hospital stay, increasing nitrogen balance and decreasing infection rates has been demonstrated. These effects have been attributed to improved gut barrier function, but improved gut and hepatic protein synthesis are equally possible.

Nutritive solutions enriched with arginine, RNA and omega-3 fatty acids are also important fuels that influence positively the postoperative recovering of many plasma parameters which reflect patient’s recovering from surgery. These “enriched solutions” are a better choice than standard diets in improving parameters such as prealbumin concentration, retinol binding protein concentration, delayed hypersensivity responses, phagocytic ability of monocytes and concentration of IL-2 receptors. People who receive the enriched solution has the same risk of developing postoperative infections if compared with people who receive the standard diet, but the infections in the latter group tend to be much more severe and difficult to treat.

It is also important to say that all the other nutrients must be remembered. Vitamins and minerals are necessary and must be administrated within the nutritional support plan.

Causes of inadequate nutrition or increased protein loss

Lack of food is a cause of malnutrition in urban poor populations, especially in alcoholics. However, the most common causes of in-hospital malnutrition are poor food unappetizingly serve, with timing for the benefit of personnel rather than patients. Patients are given nothing by mouth for the most trivial reasons (chest or abdominal films; other radiological exams). Diets are not advanced rapdly after trivial operations.

The hospital administration regards food as an area which to save money.
Proteolysis occurs in response to starvation, stress and sepsis; and it is mediated by glucagon, cathecols and steroids, with a considerably smaller increase in insulin and (in trauma or sepsis) cytokines. With normal protein and caloric intake and without strenuous exercise, only minuscule daily accrual of nitrogen occurs.

There is rapid adaptation to resting starvation, and proteolysis is minimal after as little as four days. The metabolic tragedy of sepsis is that this adaptation to starvation does not occur, and breakdown of protein continues, to supply amino acids either for hepatic protein synthesis for host defenses or for gluconeogenesis for the energy needs of the organism.

Methods of assessment of nutritional status

Accumulation of lean body mass is the principal objective of nutritional support; thus determination of lean body mass is the most appropriate means of nutritional assessment. The methods used are:
# HISTORY AND PHYSICAL EXAMINATION
Weight loss, anorexia or a disease process that interferes with intake (such as esophageal carcinoma) should alert the examiner to the possibility of malnutrition. On physical examination, muscle wasting; loss of thenar eminence muscles; loose flabby skin; edema of hypoproteinemia; weakness; loss of body fat and pallor are the key signs that confirm the malnutrition.
# NITROGEN BALANCE
# INDIRECT CALORIMETRY
# DELAYED CUTANEOUS HYPERSENSIVITY OR ANERGY
# FUNCTIONAL STUDIES OF MUSCLES FUNCTION
# DISPLACEMENT OF WATER VOLUME
# NEURON ACTIVATION ANALYSIS
# MAGNETIC RESONANCE IMAGING

In 1996, Butters et. al. proposed that only simple and inexpensive anamnestic and anthropometric measurements (as weight development abdominal complaints and fat tissue measurements) are necessary for the evaluation of nutritional status. After, from these data, body mass index and ideal body weight can be calculated. Concentrations of albumin, prealbumin, retinol binding protein and creatinine height index can be obtained by simple biochemical laboratory tests. The author defines these parameters to be enough to determine a patient’s nutritional status.

The patient at predicted risk for surgery can be recognized as follows:
1- Recent weight loss of greater than 10% body weight and/or body weight of 80 to 85% ideal body weight.
2- Serum albumin in a stable, hydrated patient of less than 3 g / 100 ml
3- Anergy to injected skin recall antigens
4- True transferrin of less than 200 mg / 100 ml
5- A history of functional impairment
6- Significant deficits in hand dynamometry or muscle response to nerve stimulation

Indications for nutritional support

The indications for nutritional support should consider the following:
1- The premorbid state (healthy or otherwise);
2- The current nutritional status;
3- Age of the patient;
4- Duration of starvation;
5- Degree of the anticipated insult;
6- The likelihood of resuming normal intake soon;
7- Weight loss of 15% and
8- A serum albumin value less than 3 g / 100 ml.

This is the first part of “Nutrition & Surgery” topic. The second part is in another article and will discuss the enteral and parenteral routes of administration; their concepts, advantages and eventual complications.

Bibliography

1. Beier-holgersen, R.; Boesby, S.; Influence of postoperative enteral nutrition on surgical infections; Gut ; 1996, 39:96, 833-5
2. Braga, M.; et. al.; Immune and nutritional effects of early enteral nutrition after major abdominal operations; Eur. J. Surg.; 1996, 162:2, 105-12
3. Butters, M.; Straub M.; Kraft, K.; Bittner, R.; Studies on nutritional status in general surgery patients by clinical, anthropometric and laboratory parameters; Nutrition; 1996, 12:6, 405-10
4. Current Surgical diagnosis and treatment; 10th ed.; ch. 10; 143-74
5. Di Costanzo, J.; Role of preoperative nutritional status on postoperative morbidity; Ann. Fr. Anesth. Reanim.; 1995, 14:suppl. 2, 33-8
6. Klein, J.D.; et. al.; Perioperative nutrition and postoperative complications in patients undergoing spinal surgery; Spine; 1996; Nov 15; 21:22; 2676-82
7. M�kel�, J.T., MD, PhD; et. al.; Factors influencing wound dehiscence after midline laparotomy; Am. J. surg.; 1995; 170: 387-90
8. Fischer, J.E. MD; Metabolism in surgical patients – Protein, Carbohydrate, and Fat Utilization by Oral and Parenteral Routes; in Sabiston Textbook of Surgery; 15th ed.; ch.9; 137-76
9. Wachtler, P.; et. al.; Influence of a total parenteral nutrition enriched with w-3 fatty acids on leukotriene synthesis of peripheral leukocytes and systemic cytokine levels in patients with major surgery; J. Trauma; 1997; 42:2; 191-7

PENAMBAHAN NUTRISI
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Journal Article Printable view
Clinical effects of enteral and parenteral nutrition preceding cancer surgery
Clinical effects of enteral and parenteral nutrition preceding cancer surgery
Journal Medical Oncology
Publisher Humana Press Inc.
ISSN 1357-0560 (Print) 1559-131X (Online)
Issue Volume 2, Number 3 / September, 1985
Category Nutritional Support of Cancer Patients
DOI 10.1007/BF02934552
Pages 225-229
Subject Collection Medicine
SpringerLink Date Thursday, July 31, 2008

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Nutritional Support of Cancer Patients
Clinical effects of enteral and parenteral nutrition preceding cancer surgery

Stanley Jensen1 Contact Information
(1) Department of Anaesthesiology, University Hospital of Aarhus, Aarhus Kommunehospital, DK-8000 Aarhus, Denmark

Received: 22 April 1985
Abstract Parenteral and enteral nutrition have become major tools in the nutritional management of cancer patients perioperatively. The purpose of this article is to see if there is evidence from prospective controlled trials that parenteral and enteral nutrition preceding cancer surgery are of clinical benefit. From our investigation and from 8 other controlled, randomized clinical investigations the following conclusions can be drawn: (1) Parenteral and enteral nutrition preceding cancer surgery improve nutritional parameters; (2) Parenteral and enteral nutrition preceding cancer surgery may decrease postoperative morbidity and mortality, but this beneficial effect may not be limited to malnourished patients; (3) If enteral nutrition can provide the same amount of proteins and calories as parenteral nutrition can, parenteral and enteral nutrition are equal with regard to clinical effects.

Key words Parenteral nutrition – Enteral nutrition – Clinical effects – Perioperatively – Cancer surgery

Essential fatty acid deficiency during total parenteral nutrition.
Barr, L H
Dunn, G D
Brennan, M F
Location: http://www.pubmedcentral.gov/articlerender.fcgi?artid=1345066

Essential fatty acid (EFA) deficiency has become a clinical problem since the advent of fat-free total parenteral nutrition (TPN). The following study was done to determine the minimum fat requirements for patients receiving continuous TPN solution. Seventy-seven patients who had 97 courses of TPN of at least 14 days duration were prospectively studied. The following fat supplementation was given: a) none, b) 10% soybean oil emulsion intravenously at fixed dosage, c) fat from an oral diet, or d) intravenous and oral fat. No patient was EFA deficient before the onset of TPN. EFA deficiency was prevented when at least 3.2% of total calories were given as intravenous fat or at least 15% as oral fat. Lesser amounts of fat decreased the rate of EFA deficiency development but did not prevent it from occurring. The 7.7 g/day of linoleic acid provided in 1000 ml per week of 10% soybean oil emulsion provides adequate fat to prevent EFA deficiency.

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TOP > J-EAST > List of Journal Titles (I) > Intern Med(2003) > Selenium Deficiency in a Patient with Crohn’s Disease Receiving Long-term Total Parenteral Nutrition.
# Selenium Deficiency in a Patient with Crohn’s Disease Receiving Long-term Total Parenteral Nutrition.

Accession number;03A0176769
Title;Selenium Deficiency in a Patient with Crohn’s Disease Receiving Long-term Total Parenteral Nutrition.
Author;ISHIDA T(Oita Medical Univ., Oita) HIMENO K(Oita Medical Univ., Oita) TORIGOE Y(Oita Medical Univ., Oita) INOUE M(Oita Medical Univ., Oita) WAKISAKA O(Oita Medical Univ., Oita) TABUKI T(Oita Medical Univ., Oita) ONO H(Oita Medical Univ., Oita) HONDA K(Oita Medical Univ., Oita) SAKATA T(Oita Medical Univ., Oita)
Journal Title;Intern Med
Journal Code:Z0157B
ISSN:0918-2918
VOL.42;NO.2;PAGE.154-157(2003)
Figure&Table&Reference;FIG.2, TBL.1, REF.17
Pub. Country;Japan
Language;English
Abstract;We report a case of selenium deficiency in a patient with Crohn’s disease on long-term total parenteral nutrition (TPN). She manifested lassitude of the legs, discoloration of the nail beds, and macrocytosis. Since her plasma selenium level was found to be below the measurable level, we diagnosed this case as selenium deficiency. After intravenous administration of sodium selenite, her symptoms were reversed. Careful attention should be paid to selenium deficiency when a patient receives long-term TPN; supplementary administration of selenium via TPN may be required because selenium is often not routinely added to TPN formulations. (author abst.)

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ournal of the American College of Nutrition, Vol. 27, No. 3, 428-433 (2008)
Published by the American College of Nutrition
# Vitamin C Deficiency in a University Teaching Hospital

Runye Gan, Shaun Eintracht, MD and L. John Hoffer, MD, PhD

Lady Davis Institute for Medical Research, McGill University (R.G., L.J.H.)
Department of Diagnostic Medicine (S.E.), Jewish General Hospital, Montreal, CANADA

Address reprint requests to: Dr. L. John Hoffer, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Cote-Ste.-Catherine Road, Montreal, Quebec, Canada H3T 1E2. E-mail: l.hoffer@mcgill.ca

Objectives: There is almost no information regarding the vitamin C status of patients treated in Canadian and American hospitals. We determined the prevalence and predictors of vitamin C deficiency in patients hospitalized on the acute-care wards of a Canadian teaching hospital, and tracked their plasma vitamin C concentrations while they were there.

Methods: This was a population-based cross-sectional and time course survey of 149 medical patients shortly after admission to a university teaching hospital. The procedure for sample handling, storage and analysis was validated by measuring the vitamin C concentrations of a reference sample of 141 presumably well nourished people and comparing the results with published norms.

Results: In keeping with published norms, 13% of people in the reference group had a subnormal vitamin C concentration (<28.4 µmol/L) and 3% were vitamin C deficient (<11.4 µmol/L). By contrast, 60% of hospitalized patients had a subnormal vitamin C concentration and 19% were deficient. A history of inadequate nutrition or failure to use a vitamin supplement prior to admission, low serum albumin, and male sex predicted plasma vitamin C deficiency, whereas use of a vitamin supplement prior to admission was associated with adequate vitamin C status in hospital. In a second measurement, obtained in 52 patients after an average of 17 days in hospital, vitamin C status had not improved.

Conclusions: Vitamin C deficiency is prevalent and sustained in patients in a Canadian teaching hospital. The abnormality can be prevented by providing a diet sufficient in vitamin C or by prescribing a multiple vitamin tablet.

Key words: ascorbic acid, vitamins, supplementation, scurvy
# Health Care Industry

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Vitamin D Deficiency In Hospital Patients
# Nutrition Research Newsletter , April, 1998

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High rates of vitamin D deficiency have been reported in certain high-risk population subgroups, such as nursing home residents and homebound elderly people. Less is known about the prevalence of hypovitaminosis D in more diverse populations. This study, from Massachusetts General Hospital, Boston, evaluated the vitamin D status of patients hospitalized on a general medical ward.
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Among 150 patients admitted in March 1994 and 140 admitted in September 1994, 164 (57%)were found to be vitamin D-deficient (serum 25-hydroxyvitamin D less than or equal to 15 ng/mL), of whom 65 (22%) were severely deficient (serum 25-hydroxyvitamin D less than 8 ng/mL). Univariate predictors of vitamin D deficiency included lower vitamin D intake, less exposure to ultraviolet light, anticonvulsant drag therapy, renal dialysis, nephrotic syndrome, hypertension, diabetes mellitus, winter season, higher serum parathyroid hormone and alkaline phosphatase, and lower serum ionized calcium and albumin. Sixty-six percent of patients who consumed less than the recommended amount of vitamin D (the 1997 recommendations were used as the standard) and 37% who met the recommendations were vitamin D-deficient. Sixty percent of patients who reported not taking multivitamins and 46% of those who reported taking them were vitamin D-deficient.

These findings indicate that vitamin D deficiency is common among hospital patients, at least in the northern part of the United States. “Because of the potential adverse effects of vitamin D deficiency on the skeleton and other organ systems, widespread screening for vitamin D deficiency or routine vitamin D supplementation should be considered.”

An editorial accompanying this study notes that many individuals do not ingest the recommended amount of vitamin D, and even the new adequate intake values [200 IU for adults aged 19-50 years, 400 IU for those aged 51-70 years, and 600 IU for those aged 71 years and over] may be too low. There is increasing evidence of widespread vitamin D deficiency in old and sick people. The editorial writer states, “On the basis of what we know about vitamin D, sick adults, older adults, and perhaps all adults probably need 800 to 1000 IU daily, substantially more than the newly established levels of adequate intake…. The amount of vitamin D in supplemental multivitamins or calcium supplements should be increased substantially, and all adults should be advised to take them. A widespread increase in vitamin D intake is likely to have a greater effect on osteoporosis and fractures than many other interventions.”

Melissa K. Thomas, Donald M. Lloyd-Jones, Ravi I. Thadhani et al, Hypovitaminosis D in Medical Inpatients, New England J Medicine 338(12):777-783 (Mar 19, 1998) [Reprints: Joel S. Finkelstein, MD, Endocrine Unit, Bulfinch 327, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114]

Robert D. Utiger, The Need for More Vitamin D [Editorial], New England J Medicine 338
duardo Brambila1 , Jose Luis Muñoz-Sánchez2, Arnulfo Albores3 and Michael Waalkes4
(1)
Laboratorio de Investigaciones Químico Clínicas de la Facultad de Ciencias Químicas, Universidad Autónoma de Puebla, Puebla, México
(2)
Departamento de Bioquímica, Escuela Nacional de Cs. Biologicas-IPN, México

(3)
Sección de Toxicología Ambiental, CINVESTAV-IPN, México

(4)
Zinc

National Cancer Institute at NIEHS, Research Triangle Park, NC

Received: 9 December 1998 Revised: 1 March 1999 Accepted: 9 March 1999
Abstract Time-response effects of experimental surgery on zinc (Zn) and metallothionein (MT) homeostasis were investigated in female rats up to 24 h. Hepatic Zn content increased at 20 and 24 h postsurgery, whereas serum Zn levels decreased. Hepatic MT increased significantly by 9 h postsurgery and peaked at up to twofold of control at 12 h after surgery. Following the peak at 12 h, hepatic MT content decreased with time but did not reach control levels at the end of this study. When MT isoforms were evaluated, MT-II levels were elevated to the highest extent by 12 h after surgery, whereas MT-I levels started to decrease after 3 h postsurgery but then increased by 20 h. The early increases in MT content are probably mediated by nonmetallic mediators released during the postsurgical inflammatory process, favoring the plasma/tissue mobilization of Zn. This process might be part of the overall mechanisms occurring in the inflammation.
Index Entries Zinc – metallothionein – metallothionein isoforms – inflammation – experimental surgery

zinc

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1: Surg Today. 1999;29(1):34-41.Click here to read Links
The importance of total parenteral nutrition-associated tissue zinc distribution in wound healing.
Nezu R, Takagi Y, Ito T, Matsuda H, Okada A.

First Department of Surgery, Osaka University Medical School, Suita, Japan.

It is well known that zinc (Zn), an essential trace element, plays a role in wound healing. Although the importance of Zn supplementation in total parenteral nutrition (TPN) has been recognized, the difference in tissue Zn distribution induced by TPN and whether this difference influences local wound healing remains uncertain. Thus, we conducted a study using 30 Sprague-Dawley rats to investigate the influence of TPN-induced changes in tissue Zn distribution on wound healing at sites of intestinal anastomosis, muscle, and skin sutures. In the ordinary diet group, no significant differences were observed between subgroups with and without supplemental Zn in tissue Zn distribution or in the healing of intestinal, muscular, and cutaneous wounds. In the subgroup given a low-protein diet without supplemental Zn, a gross change in tissue Zn distribution was noted to occur with a concomitant marked decrease in Zn concentration and the tensile strength of wounded skin. These results indicate an association between wound healing and Zn concentration in the respective tissues in TPN-induced Zn deficiency with alternations in tissue Zn distribution. They also provide evidence of the local action of Zn in wound healing.

PMID: 9934829 [PubMed – indexed for MEDLINE]

Related Articles

* The early influence of albumin administration on protein metabolism and wound healing in burned rats. [Wound Repair Regen. 2004]
* Influence of zinc deficiency on breaking strength of 3-week-old skin incisions in the rat. [Acta Chir Scand. 1990]
* [Effects of supplement Zn on levels of Zn in serum, growth hormone and hydroxyproline] [Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi. 1998]
* ReviewZinc in clinical surgery–a research review. [Jpn J Surg. 1990]
* ReviewTrace metal abnormalities in adults during hyperalimentation. [JPEN J Parenter Enteral Nutr. 1981]

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Total Parenteral Nutrition Your doctor has ordered total parenteral nutrition (TPN) for you. TPN will drip through a needle or catheter placed in your vein for 10-12 hours, once a day or five times a week.
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Journal Article Printable view
Zinc in clinical surgery —A research review—
Zinc in clinical surgery —A research review—
Journal Surgery Today
Publisher Springer Japan
ISSN 0941-1291 (Print) 1436-2813 (Online)
Issue Volume 20, Number 6 / November, 1990
Category Review Articles
DOI 10.1007/BF02471026
Pages 635-644
Subject Collection Medicine
SpringerLink Date Thursday, July 20, 2006

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Review Articles
Zinc in clinical surgery —A research review—

Akira Okada 1 Contact Information, Yoji Takagi 1, Riichiro Nezu 1 and Shoko Lee 1
(1) The Department of Pediatric Surgery, Osaka University Medical School, 1-1-50, Fukushima, Fukushima-ku, 553 Osaka, Japan

Received: 30 October 1989
Abstract Among the essential trace elements in mammals, zinc is somewhat unique in that it is a constituent of numerous metallo-enzymes having biologic significance in many respects. The discovery of zinc deficiency in man induced the remarkable progress of studies on its physiology and it is now recognized that zinc deficiency manifests itself differently in different areas of clinical medicine. It also appears reasonable to say that no trace elements have been more closely related to surgery than zinc. We discuss herein, its significance, implications and role in such areas as; (1) wound healing: where the usefulness of zinc for promoting wound healing in the presence of low plasma zinc levels has been firmly established; (2) total parenteral nutrition (TPN): zinc free TPN may cause skin eruptions associated with abdominal symptoms presenting a picture closely resembling that of acrodermatitis enteropathica; (3) specific pathological conditions: patients with Crohn’s disease and other benign diseases accompanied by mal-digestion or-absorbtion are often predisposed to zinc deficiency, similar to those manifesting clinical signs in the early stage of TPN; and (4) surgical stress: which triggers the release of various mediators, possibly increasing hepatic zinc deposition and decreasing plasma and skin zinc levels.

Key Words zinc – zinc deficiency – total parenteral nutrition – acroder-matitis enteropathica

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3 thoughts on “PEMBEDAHAN

  1. Saya mencari Journal Gizi di blog ini untuk bantu kakak yang nyelesain Masternya tentang Vit C dan Zn untuk penyembuhan luka. Carinya yaa di Googling saja

    Posted by tri | April 27, 2009, 3:16 am
  2. saya seneng skali bisa ktmu blog ini, kbtulan sy lg nyari yg sama, bhub sy sdg rencana penelitian gizi, bgm caranya tuk akses jurnal2 tsb?

    Posted by amelia | April 26, 2009, 10:01 pm

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