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04/11/2304/11/23 11
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
04/11/2304/11/23 2727
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
04/11/2304/11/23 2929
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
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