Nutrisi Pada Pasien BedahDr. Suharjendro H., SpUSMF Bedah RSU Mataram

SURGICAL METABOLISM & NUTRITIONINTRODUCTIONSEffect of DiseasePCM on surgicals patients Lean muscles massAltered respiratory mechanicsImpaired immune functionIntestinal atrophyBody weight lost > 10% delay wound healing & complications

BW lost > 20% increased morbiditas & mortalitas

NUTRITIONAL ASSESSMENTHISTORY Actual weight X 100 Present Illness = ----------------------------- Ideal weight

Actual weight X 100 Percentage Usual Body Weight = ------------------------------------ Usual weight

Physical ExaminationSkin : quality, texture, rash, folllicles, hyperkeratosis & nail deformitiesHair : quality, texture & recent lostEyes : Keratoconjunctivitis, night blindnessMouth : Cheilosis, glositis, mucosal atrophy & dentitionHeart : Chamber enlargement, murmursAbdomen : Hepatomegali, abdominal mass, fistula

Rectum : Stool color, perineal fistuleNeurologic : Peripheral neuropathy, dorsolateral column deficitExtremities : Muscle size & strength, pedal edema

Laboratory TestsCBC : Hb, Hmt, red cell, white count & diffferential, lymphocyte & plateletElectrolyte : K, Na, Cl, Ca, Phosphate, MgLFT : SGOT, SGPT, Alkali Phosphatase, Albumin, Bilirubin etc.Miscellaneous : BUN-SC, triglycerides, cholesterol, free fatty acids, uric acid

Nutrient Requirements & SubstratesCaloriesProteinGlutamine AginineNucleotides Fatty AcidsVitamins

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 %

Protein : balance sum of protein synthesis + breakdownGlutamine : important in metabollicaly streessed patient ( injury, operations, sepsis etc.)Aginine : substrate for urea cycle, precursor nitric oxideNucleotides : precursor DNA & RNAFatty Acids : immunomodulators

Vitamins Fat Soluble VitaminsA, D, E, KImmune function & wound healing

Water Soluble VitaminsB1, B2, B6, B12, Vit C, Naicin, folate, etcCofactors generations & transfers energyAmino acid & nucleic acid metabolism

NUTRITIONAL PATHOFISIOLOGYStarvationElective Operations or TraumaSepsis

Starvation During Starvation lever muscles

Acut or chronic starvation alterations energy hormon fuelAdaptive change decreased energy expenditure

Elective Operation or TraumaDiffer from starvation activation of neural & endocrine system acceleration loss of lean tissue & inhibits adaptationsNeuro-endocrine scretion :Peripheral lipolysisAccelerated catabolismDecreased peripheral glucose

Sepsis Increase more : plasma glucose, amino acid, FFA levelIncrease muscle protein catabolismAbnormal plasma amino patern : AAAs BCAAs -------- lever failureTerminal sepsis further increase plasma amino acid & fall glucose concentration

PEMBERIAN NUTRISI PADA PASIEN BEDAH

NUTRITIONAL SUPPORTENTERAL NUTRITION

PARENTERAL NUTRITIONPeripheral Parenteral Nutrition ( PPN )Total Parenteral Nutrition ( TPN )

ENTERAL NUTRITIONBenefits Of Enteral FeedingPhysiologic And Metabolic BenefitsImmunologic BenefitsSafety BenefitsCost Benefits

Indications For Enteral FeedingUnable & Unwilling Eat for 2/3 3/4 DaylneedsFunctional Gut Who Are Unable To Eat

Possible Contraindications For Enteral Feeding

Short BowelGastrointestinal ObstructionGastrointestinal BleedingProtected Vomiting & diarrheaFistulaIleusGastrointestinal Ischmia

Complications Of Enteral FeedingTechnical Complications a. Perforation b. Feeding Aspiration

Functional Complications Nausea, Vomiting, Abdominal Distenstion, Constipation & Diarrhea

PARENTERAL NUTRITION

PERIPHERAL PARENTERAL NUTRITION ( PPN )

Indications : - Compromised Gut Function - short- term nutrition ( < 10 days ) - unable ingest adequat nutrition

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

Formulation :Dextrose : D20WProtein : 10% Amino acids : essentiale & non essentialeFat : Fat emolsion 20% 500 ml dailyRoute of Administration : Peripheral 18 gauge intravenous infusion

Complications : TechnicalInfectiousMetobolic

TOTAL PARENTERAL NUTRITION ( TPN )

Indications : - Patients cannot be nourished - Long-term ( > 10 days ) nutritional support

2. Contraindications:Able to consume daily needs nutritionRequire short-term ( < 10 days ) gut disfunction

Formulation :Dextrose : D50WProtein : 8,5% Amino Acids : ( essentiale & non essentiale )Fat : Fat emolsion 20% 500 ml Monday, Wednesday & Friday Route of Administration : Central intravenous infusion catheter

Complications : TechnicalInfectiousMetobolic

Complication of Parenteral NutritionTECHNICAL

Air EmbolusArterial LacerationArteriovenous FistuleBrachial Plexus InjuryCatheter MalpositionVenous LacerationEtc.

Complication of Parenteral NutritionB. INFECTIOUS

Catheter FeverCatheter Tip InfectionCatheter Exit Site infectionCatheter Tip Infection With Bacteriemia infection

Complication of Parenteral NutritionMETABOLIC

AzotemiaFluid OverloadHyperkalemia HypercalcemiaHypernatremiaHypervitaminosis A / DLFT ElevationEtc.

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TugasKelompok A : Protocol for Nasogastric FeedingKelompok B : Formula for Enteral NutritionsKelompok C : Nutritional Pathophysiology During StarvationKelompok D : Nutritional Pathophysiology During Elective Operation or TraumaKelompok E : Nutritional Pathophysiology During Sepsis