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Nutrisi Pada Pasien Nutrisi Pada Pasien BedahBedah

Dr. Suharjendro H., SpUDr. Suharjendro H., SpU

SMF Bedah RSU MataramSMF Bedah RSU Mataram

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SURGICAL METABOLISM & SURGICAL METABOLISM & NUTRITIONNUTRITION

INTRODUCTIONS• Effect of Disease• PCM on surgicals patients ≈

1. Lean muscles mass2. Altered respiratory mechanics3. Impaired immune function4. Intestinal atrophy

• Body weight lost > 10% → delay wound healing & complications ↑

• BW lost > 20% → increased morbiditas & mortalitas

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NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT

• HISTORY Actual weight X 100

Present Illness = ----------------------------- Ideal weight

Actual weight X 100

Percentage Usual Body Weight = ------------------------------------

Usual weight

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Physical ExaminationPhysical Examination

• Skin : quality, texture, rash, folllicles, hyperkeratosis & nail deformities• Hair : quality, texture & recent lost• Eyes : Keratoconjunctivitis, night blindness• Mouth : Cheilosis, glositis, mucosal atrophy & dentition• Heart : Chamber enlargement, murmurs• Abdomen : Hepatomegali, abdominal mass, fistula

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• Rectum : Stool color, perineal fistule

• Neurologic : Peripheral neuropathy,

dorsolateral column deficit

• Extremities : Muscle size & strength,

pedal edema

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Laboratory TestsLaboratory Tests

• CBC : Hb, Hmt, red cell, white count &

diffferential, lymphocyte & platelet

• Electrolyte : K, Na, Cl, Ca, Phosphate, Mg

• LFT : SGOT, SGPT, Alkali Phosphatase,

Albumin, Bilirubin etc.

• Miscellaneous : BUN-SC, triglycerides,

cholesterol, free fatty acids, uric acid

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Nutrient Requirements & Nutrient Requirements & SubstratesSubstrates

• Calories

• Protein

• Glutamine

• Aginine

• Nucleotides

• Fatty Acids

• Vitamins

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• Calories

Energy consumed :– physical activity : 10 - 50 % of total– hospitalized patient : 10 - 20 %– elective operations : 10 %– trauma : 10 - 30 %– sepsis : 50 - 80 %– burns : 100 - 200 %

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• Protein : balance ≈ sum of protein

synthesis + breakdown

• Glutamine : important in metabollicaly

streessed patient ( injury,

operations, sepsis etc.)

• Aginine : substrate for urea cycle,

precursor nitric oxide

• Nucleotides : precursor DNA & RNA

• Fatty Acids : → immunomodulators

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Vitamins Vitamins

a. Fat Soluble Vitamins A, D, E, K Immune function & wound healing

b. Water Soluble Vitaminso B1, B2, B6, B12, Vit C, Naicin, folate, etco Cofactors generations & transfers energyo Amino acid & nucleic acid metabolism

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NUTRITIONAL PATHOFISIOLOGYNUTRITIONAL PATHOFISIOLOGY

• Starvation

• Elective Operations or Trauma

• Sepsis

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Starvation Starvation

• During Starvation → lever

muscles

• Acut or chronic starvation → alterations

→ energy

hormon

fuel• Adaptive change → decreased energy expenditure

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Elective Operation or TraumaElective Operation or Trauma

• Differ from starvation

→ activation of neural & endocrine system

→ acceleration loss of lean tissue & inhibits

adaptations

• Neuro-endocrine scretion :1. Peripheral lipolysis

2. Accelerated catabolism

3. Decreased peripheral glucose

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Sepsis Sepsis

• Increase more : plasma glucose, amino

acid, FFA level• Increase muscle protein catabolism• Abnormal plasma amino patern :

– AAAs ↑– BCAAs ↓

-------- lever failure

• Terminal sepsis further increase plasma amino acid & fall glucose concentration

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PEMBERIAN NUTRISI PADA PEMBERIAN NUTRISI PADA PASIEN BEDAHPASIEN BEDAH

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NUTRITIONAL SUPPORTNUTRITIONAL SUPPORT

1. ENTERAL NUTRITION

2. PARENTERAL NUTRITIONa) Peripheral Parenteral Nutrition ( PPN )

b) Total Parenteral Nutrition ( TPN )

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ENTERAL NUTRITIONENTERAL NUTRITION

• Benefits Of Enteral Feeding1) Physiologic And Metabolic Benefits

2) Immunologic Benefits

3) Safety Benefits

4) Cost Benefits

• Indications For Enteral Feeding1. Unable & Unwilling Eat for 2/3 – 3/4 Daylneeds

2. Functional Gut Who Are Unable To Eat

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• Possible Contraindications For Enteral Feeding

1. Short Bowel

2. Gastrointestinal Obstruction

3. Gastrointestinal Bleeding

4. Protected Vomiting & diarrhea

5. Fistula

6. Ileus

7. Gastrointestinal Ischmia

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Complications Of Enteral FeedingComplications Of Enteral Feeding

1. Technical Complications

a. Perforation b. Feeding Aspiration

2. Functional Complications

Nausea, Vomiting, Abdominal Distenstion, Constipation & Diarrhea

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PARENTERAL NUTRITIONPARENTERAL NUTRITION

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PERIPHERAL PARENTERAL PERIPHERAL PARENTERAL NUTRITION ( PPN )NUTRITION ( PPN )

1. Indications : - Compromised Gut Function ≈

- short- term nutrition ( < 10 days )

- unable ingest adequat nutrition

2. Contraindications:- Able to consume daily needs nutrition- Require long-term ( > 10 days ) → gut disfunction

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Formulation :Formulation :Dextrose : DDextrose : D2020WW

Protein : 10% Amino acids : essentiale & Protein : 10% Amino acids : essentiale & non essentiale non essentialeFat : Fat emolsion 20% 500 ml dailyFat : Fat emolsion 20% 500 ml daily

Route of Administration : Peripheral 18 gauge intravenous infusion

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• Complications : – Technical– Infectious– Metobolic

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TOTAL PARENTERAL TOTAL PARENTERAL NUTRITION ( TPN )NUTRITION ( TPN )

1. Indications :

- Patients cannot be nourished

- Long-term ( > 10 days ) nutritional support

2. Contraindications:- Able to consume daily needs nutrition- Require short-term ( < 10 days ) → gut

disfunction

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Formulation :Formulation :Dextrose : DDextrose : D5050WW

Protein : 8,5% Amino Acids : Protein : 8,5% Amino Acids : ( essentiale & non essentiale ) ( essentiale & non essentiale )Fat : Fat emolsion 20% 500 ml Fat : Fat emolsion 20% 500 ml Monday, Wednesday & Friday Monday, Wednesday & Friday

Route of Administration : Central intravenous infusion catheter

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• Complications : – Technical– Infectious– Metobolic

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Complication of Parenteral NutritionComplication of Parenteral Nutrition

A. TECHNICAL

1. Air Embolus2. Arterial Laceration3. Arteriovenous Fistule4. Brachial Plexus Injury5. Catheter Malposition6. Venous Laceration7. Etc.

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Complication of Parenteral NutritionComplication of Parenteral Nutrition

B. INFECTIOUS

1. Catheter Fever

2. Catheter Tip Infection

3. Catheter Exit Site infection

4. Catheter Tip Infection With Bacteriemia infection

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Complication of Parenteral NutritionComplication of Parenteral Nutrition

C. METABOLIC

a. Azotemiab. Fluid Overloadc. Hyperkalemia d. Hypercalcemiae. Hypernatremiaf. Hypervitaminosis A / Dg. LFT Elevationh. Etc.

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• .

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TugasTugas

Kelompok A : Protocol for Nasogastric Feeding

Kelompok B : Formula for Enteral Nutritions

Kelompok C : Nutritional Pathophysiology

During Starvation

Kelompok D : Nutritional Pathophysiology

During Elective Operation or Trauma

Kelompok E : Nutritional Pathophysiology

During Sepsis