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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiogenic shock is associated with hemodynamic unstable and elevated arterial lactate as one indicator for anaerobic metabolism due to low perfusion in tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;2</span></a> Evaluation of hemodynamic condition can be used to determine a plan of nutritional therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Nutritional therapy consists of macronutrients and micronutrients requirements&#46; In the critically ill patient with hypercatabolic state&#44; nitrogen losses can reach 16&#8211;20<span class="elsevierStyleHsp" style=""></span>g&#47;day and&#44; in some cases&#44; up to 24<span class="elsevierStyleHsp" style=""></span>g&#47;day compared to those without catabolic stress which generally loses only 10&#8211;12<span class="elsevierStyleHsp" style=""></span>g of nitrogen&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Loss of body mass around 30&#8211;40&#37; will increase the mortality rate due to starvation or protein malnutrition&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> High protein diet and adequate micronutrients intervention can improve the outcome of the patient&#46; Delayed nutritional therapy will worsen negative nitrogen balance&#44; nutritional status&#44; and hypercatabolic state&#46; On the other hand&#44; too early nutritional intervention can worsen anaerobic metabolism in a hemodynamically unstable patient&#46; Therefore&#44; the nutritional goal can be planned by evaluating hemodynamic changes to determine the time for postponing nutritional therapy or increasing the nutritional target&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is a case report of a patient who was treated in September 2018 at the Wahidin Sudirohusodo Hospital&#46; This case report has fulfilled the requirement of the Ethics Committee of Hasanuddin University School of Medicine&#46; The patient and the family were given informed consent and agreed to be reported as a case report without mentioning the name and private information&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 44-years-old female patient with severe protein-energy malnutrition with the marasmic type &#40;<span class="elsevierStyleItalic">Subjective Global Assessment</span> Score-C&#59; MUAC 15<span class="elsevierStyleHsp" style=""></span>cm&#41; was consulted from Pulmonology Departement with hemodynamic unstability due to cardiogenic shock and infected bronchiectasis since one day ago at the infection center of Wahidin Sudirohusodo Hospital&#44; Makassar&#46; She had a history of low dietary intake since 3 months ago due to decreased appetite and shortness of breath&#46; Unintentional weight loss of about 4<span class="elsevierStyleHsp" style=""></span>kg was present 3 months ago&#46; Intake was postponed due to mean arterial pressure 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support and oxygen saturation below 93&#37;&#46; Physical examinations showed loss of subcutaneous fat&#44; lung crackles and wheezing&#44; muscle wasting&#44; and pretibial edema&#46; Laboratory assessments showed elevated arterial lactate &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; hypoalbuminemia &#40;2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; lymphocytopenia &#40;650&#47;&#956;L&#41;&#44; elevated liver enzymes &#40;SGOT 780<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; SGPT 868<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#44; and urine urea nitrogen &#40;UUN 5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Echocardiography showed the left and right ventricle &#40;ejection fraction 64&#37;&#41; with mild diastolic dysfunction of the left ventricle&#46; Abdominal ultrasonography showed congestive liver signs&#46; Thoracal MSCT showed dilated bronchiectasis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Basal metabolic rate &#40;BMR&#41; by Harris-Benedict Formula was 983<span class="elsevierStyleHsp" style=""></span>kcal&#44; and total energy expenditure &#40;TEE&#41; was 1500<span class="elsevierStyleHsp" style=""></span>kcal&#46; Nutritional therapy was started after mean arterial pressure &#8805;65<span class="elsevierStyleHsp" style=""></span>mmHg with a stable dosage of the vasopressor drug for 6<span class="elsevierStyleHsp" style=""></span>h and arterial lactate 2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L with 30&#8211;40&#37; of TEE on 2&#8211;3 days after stable hemodynamic&#46; Macronutrients were given for patients with protein 0&#46;8&#8211;1&#46;3<span class="elsevierStyleHsp" style=""></span>g&#47;ideal body weight &#40;IBW&#41;&#47;day&#44; carbohydrates 45&#8211;50&#37;&#44; and lipid 30&#37; for seven days after hemodynamic unstability onset&#46; Protein was gradually increased to 1&#46;5&#8211;1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;IBW&#47;day using a high protein diet and high branched-chain amino acid formula to create a positive nitrogen balance based on the UUN result&#46; The positive nitrogen balance target was &#43;4&#46; In addition&#44; routine arterial lactate and blood gas analyses were assessed to control hemodynamic tolerance&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Result</span><p id="par0025" class="elsevierStylePara elsevierViewall">After arterial lactate was below 2&#46;0<span class="elsevierStyleHsp" style=""></span>mmol&#47;L with tappering-off vasopressor dosage&#44; nutritional therapy was planned for 100&#37; TEE on day 8 &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; In addition&#44; supplementations of Snakehead fish extract&#44; zinc 20<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin B complex&#44; thiamine 300<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin A 6000<span class="elsevierStyleHsp" style=""></span>IU&#44; vitamin C 500<span class="elsevierStyleHsp" style=""></span>mg&#44; and vitamin D3 400<span class="elsevierStyleHsp" style=""></span>IU were given to improve immune and metabolic function&#46; After 15 days of nutritional therapy&#44; the patient was discharged from the hospital with stable hemodynamic without vasopressor support&#44; adequate oral intake &#40;90&#8211;95&#37; of TEE&#41;&#44; improvement of anthropometric parameters&#44; and laboratory test results &#40;arterial lactate 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; albumin 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; lymphocyte 1&#46;871&#47;&#956;L&#44; SGOT 34<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; SGPT 41<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; UUN 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted to the emergency department with diagnosis of cardiogenic shock &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; She had mean arterial pressure of 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support&#44; oxygen saturation below 93&#37;&#44; and elevated arterial lactate level to 3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#46; Hyperlactatemia in this patient was hyperlactatemia type A that occurred due to impaired tissue perfusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">6&#44;7</span></a> Furthermore&#44; periodic control of arterial lactate level was carried out to assess the hemodynamic status to determine nutritional therapy target&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> Cuthberson&#44; the first person who described the metabolic changes that occurred after major trauma in 1942&#44; divided metabolic response to trauma into Ebb and Flow Phases&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> The Ebb phase begins within the first hour after trauma and can last up to 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; characterized by a decrease in total energy requirements and a decrease in urinary nitrogen excretion&#46; Targets in this phase are hemodynamic adaptation and stable tissue perfusion&#46; The flow phase is also known as the catabolic phase&#46; The metabolic response in this phase is mediated by catabolic hormones &#40;such as glucagon&#44; catecholamines&#44; and corticosteroids&#41; and accompanied by insulin resistance&#46; Acute phase protein synthesis in liver&#44; pro-inflammatory cytokines and free radicals are also increase in this phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> Hyperlactatemia in critically ill patients and particularly those in shock is generally interpreted as a marker of secondary anaerobic metabolism due to inadequate oxygen supply inducing cellular distress&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> In this case&#44; arterial lactate test was performed 18<span class="elsevierStyleHsp" style=""></span>h &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; after the onset of shock&#44; then re-assessed 24<span class="elsevierStyleHsp" style=""></span>h later &#40;2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; and controlled every day till lactate level 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L to plan 100&#37; nutritional target&#46; Mizuki et al&#46; reported lactate clearance as one of the most important predictors of in-hospital mortality in patient treated with extracorporeal cardiopulmonary resuscitation after cardiac arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the critical phase&#44; the priority of protein synthesis in liver is to form acute-phase proteins&#44; such as C-reactive protein&#44; &#945;1-acid glycoprotein&#44; &#945;1-protease inhibitor&#44; fibrinogen&#44; and haptoglobin&#44; than constitutive proteins&#44; such as albumin&#44; prealbumin&#44; and retinol-binding protein&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Albumin level in this patient was 2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL at admission and gradually increased up to 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; which was correlated with the decrement of UUN from 5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h to 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Loss of lean mass about 30&#8211;40&#37; due to negative nitrogen balance and undernourishment are correlated with high mortality rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">5&#44;12</span></a> Data from an observational study showed that protein intake of 1&#46;2&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg IBW&#47;day was associated with a better outcome&#46; Ishibasi et al&#46; showed that protein intake of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg BW&#47;day was associated with a minimal negative nitrogen balance&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> Negative nitrogen balance &#40;&#8722;2&#46;89&#41; in this patient was calculated from UUN &#40;5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; by using a nitrogen balance correction formula in critical patients &#40;nitrogen balance<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;protein intake&#47;6&#46;25&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#40;UUN&#47;0&#46;85&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> Therefore&#44; the protein target was increased to 1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg IBW&#47;day to achieve positive nitrogen balance &#40;&#43;0&#46;5&#41; using high protein formula&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> After 15 days of nutritional therapy&#44; UUN was 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h with a higher estimated positive nitrogen balance &#40;&#43;4&#46;72&#41;&#46; Positive nitrogen balance &#40;around &#43;4<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; can support protein synthesis by 25<span class="elsevierStyleHsp" style=""></span>g&#47;day and increase body mass up to 100<span class="elsevierStyleHsp" style=""></span>g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Elevated liver enzymes can be caused by acute liver injury due to hepatic hypoperfusion or due to acute cardiogenic liver injury&#46; This condition is commonly seen in a patient with decreased cardiac output&#44; cor pulmonale disease&#44; and acute decompensated heart failure&#46; In acute circulation disruption&#44; blood flow to the liver decreases about 10&#37; for every 10<span class="elsevierStyleHsp" style=""></span>mmHg decrease in arterial pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> The role of Branched Chain Amino Acids &#40;BCAAs&#41; in acute liver injury is still controversial&#46; There is no recommendation about it&#46; However&#44; several animal studies have shown the role of BCAAs in animals experiencing an acute liver injury&#46; Kitagawa et al&#46; reported that BCAAs play a role in improving the liver condition in mice that experience acute liver injury due to the ischemic&#8211;reperfusion phase through improved microcirculation&#44; inflammatory response&#44; and leukocyte adhesion&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> Daily Snakeheadfish extract&#44; zinc 20<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin B complex&#44; Thiamine 300<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin C 500<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin A 6000<span class="elsevierStyleHsp" style=""></span>IU&#44; vitamin D3 600<span class="elsevierStyleHsp" style=""></span>IU&#44; and Curcumin 1&#46;200<span class="elsevierStyleHsp" style=""></span>mg were given&#46; Vitamin D has a role in modulating innate and adaptive immune responses&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> Snakehead fish extract contains high protein&#44; albumin&#44; and several micronutrients&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">17&#44;18</span></a> This extract increases albumin levels in hypoalbuminemia patients and modulates the immune response by molecular and immunological mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a> Zinc plays a role in boosting the immune system by optimizing A20mRNA upregulation and decreasing NF-&#954;B activation&#44; suppressing activation of TNF-&#945;&#44; IL-1&#946;&#44; and IL-8&#46; Zinc supplementation can reduce oxidative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> Parikh et al&#46; reported that vitamin C 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day in children or 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day in adults could optimize mitochondrial function and reduce arterial lactate level&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleItalic">In vitro</span> studies demonstrate that T cell development requires vitamin C&#44; while vitamin C also enhances T cell proliferation and may influence T cell function&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Adequate medical nutrition therapy&#44; which is planned by evaluating hemodynamic tolerance&#44; can improve clinical outcomes and positive nitrogen balance in hemodynamically unstable patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiogenic shock is defined as tissue hypoperfusion due to cardiac dysfunction&#46; It is associated with hemodynamic unstability and elevated arterial lactate as one indicator for anaerobic metabolism&#46; Hypercatabolic state in this condition leads to increasing nutritional requirement and negative nitrogen balance&#46; Therefore&#44; medical nutrition therapy by considering metabolic tolerance can prevent further metabolic deterioration and loss of lean mass and improve the patient&#39;s clinical outcome&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 44-years-old female patient with severe protein-energy malnutrition &#40;<span class="elsevierStyleItalic">Subjective Global Assessment</span> Score C&#59; MUAC 15<span class="elsevierStyleHsp" style=""></span>cm&#41; suffered from hemodynamic unstability due to cardiogenic shock and infected bronchiectasis at the infection center of Wahidin Sudirohusodo Hospital&#46; Intake was postponed due to mean arterial pressure 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support and oxygen saturation below 93&#37;&#46; Physical examinations showed loss of subcutaneous fat&#44; lung crackles and wheezing&#44; muscle wasting&#44; and pretibial edema&#46; Laboratory assessments showed elevated arterial lactate &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; hypoalbuminemia &#40;2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; lymphocytopenia &#40;650&#47;&#956;L&#41;&#44; elevated liver enzymes &#40;SGOT 780<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; SGPT 868<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#44; and urine urea nitrogen &#40;5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Nutritional therapy was started after mean arterial pressure &#8805;65<span class="elsevierStyleHsp" style=""></span>mmHg with a stable dosage of the vasopressor drug and decreased arterial lactate level to 2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L then given gradually with a target calorie of 1500<span class="elsevierStyleHsp" style=""></span>kcal and protein 1&#46;5&#8211;1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg ideal body weight&#47;day using high protein diet&#46; Arterial lactate and blood gass analyses were controlled every day to determine the target of nutritional therapy day by the day&#46; Snakehead fish extract&#44; zinc&#44; vitamin B complex&#44; Thiamine&#44; vitamin C&#44; vitamin A&#44; vitamin D3&#44; and Curcumin were supplied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Result</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After 15 days of nutritional therapy&#44; the patient was discharged from the hospital with stable hemodynamic without vasopressor support&#44; adequate nutritional intake&#44; improvement of anthropometric parameters&#44; and laboratory test results &#40;arterial lactate 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; albumin 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; lymphocyte 1&#46;871&#47;&#956;L&#44; SGOT 34<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; SGPT 41<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; urine urea nitrogen 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adequate nutritional therapy&#44; which is planned by evaluating hemodynamic tolerance&#44; can improve patient clinical outcomes and positive nitrogen balance in the hemodynamically unstable patient&#46;</p></span>"
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Medical nutrition therapy in hemodynamically unstable patients due to cardiogenic shock with infected bronchiectasis and severe protein-energy malnutrition
Caroline Prisilia Marsellaa,
Autor para correspondencia
, Nurpudji Astuti Taslimb, Nurbaya Syamb, Andi Yasmin Syaukib
a Clinical Nutrition Specialist Program, Department of Nutrition, Hasanuddin University School of Medicine, Makassar, Indonesia
b Department of Nutrition, Hasanuddin University School of Medicine, Makassar, Indonesia
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Improvements of liver enzymes&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiogenic shock is associated with hemodynamic unstable and elevated arterial lactate as one indicator for anaerobic metabolism due to low perfusion in tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;2</span></a> Evaluation of hemodynamic condition can be used to determine a plan of nutritional therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Nutritional therapy consists of macronutrients and micronutrients requirements&#46; In the critically ill patient with hypercatabolic state&#44; nitrogen losses can reach 16&#8211;20<span class="elsevierStyleHsp" style=""></span>g&#47;day and&#44; in some cases&#44; up to 24<span class="elsevierStyleHsp" style=""></span>g&#47;day compared to those without catabolic stress which generally loses only 10&#8211;12<span class="elsevierStyleHsp" style=""></span>g of nitrogen&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Loss of body mass around 30&#8211;40&#37; will increase the mortality rate due to starvation or protein malnutrition&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> High protein diet and adequate micronutrients intervention can improve the outcome of the patient&#46; Delayed nutritional therapy will worsen negative nitrogen balance&#44; nutritional status&#44; and hypercatabolic state&#46; On the other hand&#44; too early nutritional intervention can worsen anaerobic metabolism in a hemodynamically unstable patient&#46; Therefore&#44; the nutritional goal can be planned by evaluating hemodynamic changes to determine the time for postponing nutritional therapy or increasing the nutritional target&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is a case report of a patient who was treated in September 2018 at the Wahidin Sudirohusodo Hospital&#46; This case report has fulfilled the requirement of the Ethics Committee of Hasanuddin University School of Medicine&#46; The patient and the family were given informed consent and agreed to be reported as a case report without mentioning the name and private information&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 44-years-old female patient with severe protein-energy malnutrition with the marasmic type &#40;<span class="elsevierStyleItalic">Subjective Global Assessment</span> Score-C&#59; MUAC 15<span class="elsevierStyleHsp" style=""></span>cm&#41; was consulted from Pulmonology Departement with hemodynamic unstability due to cardiogenic shock and infected bronchiectasis since one day ago at the infection center of Wahidin Sudirohusodo Hospital&#44; Makassar&#46; She had a history of low dietary intake since 3 months ago due to decreased appetite and shortness of breath&#46; Unintentional weight loss of about 4<span class="elsevierStyleHsp" style=""></span>kg was present 3 months ago&#46; Intake was postponed due to mean arterial pressure 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support and oxygen saturation below 93&#37;&#46; Physical examinations showed loss of subcutaneous fat&#44; lung crackles and wheezing&#44; muscle wasting&#44; and pretibial edema&#46; Laboratory assessments showed elevated arterial lactate &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; hypoalbuminemia &#40;2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; lymphocytopenia &#40;650&#47;&#956;L&#41;&#44; elevated liver enzymes &#40;SGOT 780<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; SGPT 868<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#44; and urine urea nitrogen &#40;UUN 5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Echocardiography showed the left and right ventricle &#40;ejection fraction 64&#37;&#41; with mild diastolic dysfunction of the left ventricle&#46; Abdominal ultrasonography showed congestive liver signs&#46; Thoracal MSCT showed dilated bronchiectasis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Basal metabolic rate &#40;BMR&#41; by Harris-Benedict Formula was 983<span class="elsevierStyleHsp" style=""></span>kcal&#44; and total energy expenditure &#40;TEE&#41; was 1500<span class="elsevierStyleHsp" style=""></span>kcal&#46; Nutritional therapy was started after mean arterial pressure &#8805;65<span class="elsevierStyleHsp" style=""></span>mmHg with a stable dosage of the vasopressor drug for 6<span class="elsevierStyleHsp" style=""></span>h and arterial lactate 2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L with 30&#8211;40&#37; of TEE on 2&#8211;3 days after stable hemodynamic&#46; Macronutrients were given for patients with protein 0&#46;8&#8211;1&#46;3<span class="elsevierStyleHsp" style=""></span>g&#47;ideal body weight &#40;IBW&#41;&#47;day&#44; carbohydrates 45&#8211;50&#37;&#44; and lipid 30&#37; for seven days after hemodynamic unstability onset&#46; Protein was gradually increased to 1&#46;5&#8211;1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;IBW&#47;day using a high protein diet and high branched-chain amino acid formula to create a positive nitrogen balance based on the UUN result&#46; The positive nitrogen balance target was &#43;4&#46; In addition&#44; routine arterial lactate and blood gas analyses were assessed to control hemodynamic tolerance&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Result</span><p id="par0025" class="elsevierStylePara elsevierViewall">After arterial lactate was below 2&#46;0<span class="elsevierStyleHsp" style=""></span>mmol&#47;L with tappering-off vasopressor dosage&#44; nutritional therapy was planned for 100&#37; TEE on day 8 &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; In addition&#44; supplementations of Snakehead fish extract&#44; zinc 20<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin B complex&#44; thiamine 300<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin A 6000<span class="elsevierStyleHsp" style=""></span>IU&#44; vitamin C 500<span class="elsevierStyleHsp" style=""></span>mg&#44; and vitamin D3 400<span class="elsevierStyleHsp" style=""></span>IU were given to improve immune and metabolic function&#46; After 15 days of nutritional therapy&#44; the patient was discharged from the hospital with stable hemodynamic without vasopressor support&#44; adequate oral intake &#40;90&#8211;95&#37; of TEE&#41;&#44; improvement of anthropometric parameters&#44; and laboratory test results &#40;arterial lactate 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; albumin 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; lymphocyte 1&#46;871&#47;&#956;L&#44; SGOT 34<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; SGPT 41<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; UUN 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted to the emergency department with diagnosis of cardiogenic shock &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; She had mean arterial pressure of 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support&#44; oxygen saturation below 93&#37;&#44; and elevated arterial lactate level to 3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#46; Hyperlactatemia in this patient was hyperlactatemia type A that occurred due to impaired tissue perfusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">6&#44;7</span></a> Furthermore&#44; periodic control of arterial lactate level was carried out to assess the hemodynamic status to determine nutritional therapy target&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> Cuthberson&#44; the first person who described the metabolic changes that occurred after major trauma in 1942&#44; divided metabolic response to trauma into Ebb and Flow Phases&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> The Ebb phase begins within the first hour after trauma and can last up to 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; characterized by a decrease in total energy requirements and a decrease in urinary nitrogen excretion&#46; Targets in this phase are hemodynamic adaptation and stable tissue perfusion&#46; The flow phase is also known as the catabolic phase&#46; The metabolic response in this phase is mediated by catabolic hormones &#40;such as glucagon&#44; catecholamines&#44; and corticosteroids&#41; and accompanied by insulin resistance&#46; Acute phase protein synthesis in liver&#44; pro-inflammatory cytokines and free radicals are also increase in this phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> Hyperlactatemia in critically ill patients and particularly those in shock is generally interpreted as a marker of secondary anaerobic metabolism due to inadequate oxygen supply inducing cellular distress&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> In this case&#44; arterial lactate test was performed 18<span class="elsevierStyleHsp" style=""></span>h &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; after the onset of shock&#44; then re-assessed 24<span class="elsevierStyleHsp" style=""></span>h later &#40;2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; and controlled every day till lactate level 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L to plan 100&#37; nutritional target&#46; Mizuki et al&#46; reported lactate clearance as one of the most important predictors of in-hospital mortality in patient treated with extracorporeal cardiopulmonary resuscitation after cardiac arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the critical phase&#44; the priority of protein synthesis in liver is to form acute-phase proteins&#44; such as C-reactive protein&#44; &#945;1-acid glycoprotein&#44; &#945;1-protease inhibitor&#44; fibrinogen&#44; and haptoglobin&#44; than constitutive proteins&#44; such as albumin&#44; prealbumin&#44; and retinol-binding protein&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Albumin level in this patient was 2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL at admission and gradually increased up to 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; which was correlated with the decrement of UUN from 5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h to 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Loss of lean mass about 30&#8211;40&#37; due to negative nitrogen balance and undernourishment are correlated with high mortality rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">5&#44;12</span></a> Data from an observational study showed that protein intake of 1&#46;2&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg IBW&#47;day was associated with a better outcome&#46; Ishibasi et al&#46; showed that protein intake of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg BW&#47;day was associated with a minimal negative nitrogen balance&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> Negative nitrogen balance &#40;&#8722;2&#46;89&#41; in this patient was calculated from UUN &#40;5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; by using a nitrogen balance correction formula in critical patients &#40;nitrogen balance<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;protein intake&#47;6&#46;25&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#40;UUN&#47;0&#46;85&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> Therefore&#44; the protein target was increased to 1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg IBW&#47;day to achieve positive nitrogen balance &#40;&#43;0&#46;5&#41; using high protein formula&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> After 15 days of nutritional therapy&#44; UUN was 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h with a higher estimated positive nitrogen balance &#40;&#43;4&#46;72&#41;&#46; Positive nitrogen balance &#40;around &#43;4<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; can support protein synthesis by 25<span class="elsevierStyleHsp" style=""></span>g&#47;day and increase body mass up to 100<span class="elsevierStyleHsp" style=""></span>g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Elevated liver enzymes can be caused by acute liver injury due to hepatic hypoperfusion or due to acute cardiogenic liver injury&#46; This condition is commonly seen in a patient with decreased cardiac output&#44; cor pulmonale disease&#44; and acute decompensated heart failure&#46; In acute circulation disruption&#44; blood flow to the liver decreases about 10&#37; for every 10<span class="elsevierStyleHsp" style=""></span>mmHg decrease in arterial pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> The role of Branched Chain Amino Acids &#40;BCAAs&#41; in acute liver injury is still controversial&#46; There is no recommendation about it&#46; However&#44; several animal studies have shown the role of BCAAs in animals experiencing an acute liver injury&#46; Kitagawa et al&#46; reported that BCAAs play a role in improving the liver condition in mice that experience acute liver injury due to the ischemic&#8211;reperfusion phase through improved microcirculation&#44; inflammatory response&#44; and leukocyte adhesion&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> Daily Snakeheadfish extract&#44; zinc 20<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin B complex&#44; Thiamine 300<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin C 500<span class="elsevierStyleHsp" style=""></span>mg&#44; vitamin A 6000<span class="elsevierStyleHsp" style=""></span>IU&#44; vitamin D3 600<span class="elsevierStyleHsp" style=""></span>IU&#44; and Curcumin 1&#46;200<span class="elsevierStyleHsp" style=""></span>mg were given&#46; Vitamin D has a role in modulating innate and adaptive immune responses&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> Snakehead fish extract contains high protein&#44; albumin&#44; and several micronutrients&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">17&#44;18</span></a> This extract increases albumin levels in hypoalbuminemia patients and modulates the immune response by molecular and immunological mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a> Zinc plays a role in boosting the immune system by optimizing A20mRNA upregulation and decreasing NF-&#954;B activation&#44; suppressing activation of TNF-&#945;&#44; IL-1&#946;&#44; and IL-8&#46; Zinc supplementation can reduce oxidative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> Parikh et al&#46; reported that vitamin C 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day in children or 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day in adults could optimize mitochondrial function and reduce arterial lactate level&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleItalic">In vitro</span> studies demonstrate that T cell development requires vitamin C&#44; while vitamin C also enhances T cell proliferation and may influence T cell function&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Adequate medical nutrition therapy&#44; which is planned by evaluating hemodynamic tolerance&#44; can improve clinical outcomes and positive nitrogen balance in hemodynamically unstable patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiogenic shock is defined as tissue hypoperfusion due to cardiac dysfunction&#46; It is associated with hemodynamic unstability and elevated arterial lactate as one indicator for anaerobic metabolism&#46; Hypercatabolic state in this condition leads to increasing nutritional requirement and negative nitrogen balance&#46; Therefore&#44; medical nutrition therapy by considering metabolic tolerance can prevent further metabolic deterioration and loss of lean mass and improve the patient&#39;s clinical outcome&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 44-years-old female patient with severe protein-energy malnutrition &#40;<span class="elsevierStyleItalic">Subjective Global Assessment</span> Score C&#59; MUAC 15<span class="elsevierStyleHsp" style=""></span>cm&#41; suffered from hemodynamic unstability due to cardiogenic shock and infected bronchiectasis at the infection center of Wahidin Sudirohusodo Hospital&#46; Intake was postponed due to mean arterial pressure 56<span class="elsevierStyleHsp" style=""></span>mmHg on vasopressor support and oxygen saturation below 93&#37;&#46; Physical examinations showed loss of subcutaneous fat&#44; lung crackles and wheezing&#44; muscle wasting&#44; and pretibial edema&#46; Laboratory assessments showed elevated arterial lactate &#40;3&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; hypoalbuminemia &#40;2&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; lymphocytopenia &#40;650&#47;&#956;L&#41;&#44; elevated liver enzymes &#40;SGOT 780<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; SGPT 868<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#44; and urine urea nitrogen &#40;5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Nutritional therapy was started after mean arterial pressure &#8805;65<span class="elsevierStyleHsp" style=""></span>mmHg with a stable dosage of the vasopressor drug and decreased arterial lactate level to 2&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L then given gradually with a target calorie of 1500<span class="elsevierStyleHsp" style=""></span>kcal and protein 1&#46;5&#8211;1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg ideal body weight&#47;day using high protein diet&#46; Arterial lactate and blood gass analyses were controlled every day to determine the target of nutritional therapy day by the day&#46; Snakehead fish extract&#44; zinc&#44; vitamin B complex&#44; Thiamine&#44; vitamin C&#44; vitamin A&#44; vitamin D3&#44; and Curcumin were supplied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Result</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After 15 days of nutritional therapy&#44; the patient was discharged from the hospital with stable hemodynamic without vasopressor support&#44; adequate nutritional intake&#44; improvement of anthropometric parameters&#44; and laboratory test results &#40;arterial lactate 1&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; albumin 3&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; lymphocyte 1&#46;871&#47;&#956;L&#44; SGOT 34<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; SGPT 41<span class="elsevierStyleHsp" style=""></span>U&#47;L&#44; urine urea nitrogen 0&#46;72<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adequate nutritional therapy&#44; which is planned by evaluating hemodynamic tolerance&#44; can improve patient clinical outcomes and positive nitrogen balance in the hemodynamically unstable patient&#46;</p></span>"
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ISSN: 02139111
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