ASPEK MEDIS BEDAH

(PERIOPERATIF)
DAN ENTERAL - PARENTERAL
NUTRISI

Dr. dr. AKHMAD MAKHMUDI SpB,SpBA

Pediatric Surgery Dept.Dr.Sardjito-Hospital /
Medicine School of Gadjah Mada University
YOGYAKARTA
 PENDAHULUAN

 PADA UMUMNYA KELAINAN – KELAINAN DIBAGI ATAS :

(1) RADANG/ INFEKSI, (2) CACAT BAWAAN / KONGENITAL
(3) NEOPLASMA (4) TRAUMA (5) DEGENERATIF

 PERKEMBANGAN TEKNOLOGI MUTAKHIR :

NUTRISI KLINIK - ENTERAL, PARENTERAL NUTRISI

 HUBUNGAN MORBIDITAS DAN MORTALITAS DENGAN

DIAGNOSIS DINI SERTA PENANGANAN SEGERA SECARA
BENAR DARI DOKTER, FARMASIS, PARAMEDIS, DIETETIS
 ASPEK UMUM
 MEDICAL PROBLEM

 SURGICAL PROBLEM:

- ELEKTIF
- ACUTE
/ EMERGENCY
 ASPEK BEDAH
 DIGESTIF PROBLEM
(Saluran cerna – Bedah Digestif)
 NON DIGESTIVE PROBLEM:
- Bedah Onkologi
- Bedah Urologi
- Bedah Pulmo dan Jantung
- Bedah Anak
- Bedah Saraf
- Bedah Plastik
 ANATOMI
GASTRO INTESTINALIS TRACT

Gastric outlet

Ampulla of Vater

Peyery patchs of lymphoid

 ASPEK UMUM

 ENTERAL NUTRISI
 PARENTERAL NUTRISI
 SURGICAL PROBLEM:
GASTROSTOMY
ILEOSTOMY
COLOSTOMY
SHORT BOWEL SYNDROME
 LUKA BAKAR (COMBUSTIO)
 Wound healing
 General Hospital

Nutrition Support Team

President

ＮＳＴ Supervisor
Chairman
Exective director
Director
Assistant directors

Members
 NST(Nutrition Support Team) Hospital

NST
Doctor ４
（ Surgeon ２ , Int Med １ , Rehabili １）
Nurse ３ Nutrition Committee
（ Head Nurses ）
Dietitian ２
Pharmacist ３ NST
Technician ２
Therapist １ Chairman
+ Team members
Support members
Ward nurses, Home care nurses
Inpatients Home care
Office worker
Selection of NST Patients

Subjective Global Assessment

A, History
1, Weight loss ( past 6M, past 2W)
2, Change of oral intake
3, Digestive symptom
4, Functional status
5, Disease & Stress
B, Physical Findings
Loss of subcutaneous fat
Loss of muscle volume
Edema
NST
Severe malnutrition
Control
 Main Tasks of NST

Case Conference
 After NST Round
 Oral Intake &
Swallowing
 Energy Balance
 Nutritional Therapy
 New information
 Screening list
 Effects of NST
Improvement Control of
of nutrition Appropriate TPN
Complication

Reduction
Hospital stay
Nosocomial infection Decreased Enteral Nutrition
Albumin solution Sepsis TPN reduction
Antibiotics
Etc.

Cost Effectiveness
 PROBLEM PERIOPERATIF

 UNDERLYING DISEASE :
- EMERGENSI KASUS BEDAH DIGESTIF,
KANKER, NEONATUS, ORANG TUA DG DM,
HIPERTENSI,PENYAKIT HATI DAN GINJAL

 MALNUTRISI : MARASMIK, MARASMIK-KWA

SHIORKOR, KWASHIORKOR
 RESPON METABOLIK

 RESPON METABOLIK ADANYA TRAUMA, LUKA BAKAR,ATA

SEPSIS SEPERTI HIPERMETABOLISME, PROTEOLISIS,
INSULIN RESISTANCE PENYEBAB MALNUTRISI KALORI-
PROTEIN YANG PROGRESIF

 PREOPERASI:
- PENURUNAN BB > 20% MORTALITAS OPERASI 33%
- BILA PENURUNAN BB< 20% MORTALITAS OPERASI 3,5
INTERKONVERSI
METABOLIK

 STARVASI
 TRAUMA BEDAH
 FEBRIS
 SEPSIS
 PROBLEM PERIOPERATIF DAN
MALNUTRISI

 STRESS METABOLIK (STARVASI, INFEKSI,

TRAUMA, FEBRIS & BEDAH), LUKA BAKAR
 DIPUASAKAN : HIPOGLIKEMIA, DEHIDRASI
 KONDISI KLINIS PENYAKIT (underlying
disease):
 ABDOMEN AKUT : ILEUS, STRANGULASI,
PERITONITIS DAN PERDARAHAN
ILEUS : KOMPRESI, DEHIDRASI, INFEKSI
 TUMOR : cancer cachexia-anorexia
 PEM (Protein Energi malnutrisi)
INTERKONVERSI METABOLIK
TRAUMA BEDAH MAYOR
 ALGORITME PERENCANAAN
TERAPI NUTRISI
MENILAI STASUS GIZI DAN KONDISI KLINIK PENDERITA
I
HITUNG KEBUTUHAN NUTRISI
(energi, protein, lemak, elektrolit dll)
I
MEMILIH KOMPOSISI TERAPI NUTRISI
I
MENENTUKAN TEKNIK & SKEMA
PEMBERIANTERAPI NUTRISI
I
MONITOR:
EFEK TERAPI NUTRISI
KOMPLIKASI
INDIKASI TERAPI NUTRISI
PARENTERAL (TNPE )

 TIDAK MAU MAKAN

 TIDAK CUKUP MAKAN
 TIDAK BISA MAKAN
 TIDAK BOLEH MAKAN
Nasogatric tube

9 months
later

AH, boy, 16 months

W 3.6 kg L 65 cm W 10.7 kgs
 When children need tube feeding
& how to choose route of
delivery ?
 Children with acute conditions
and increased requirements. E.g.
Burns Severe trauma, Major
surgery and Sepsis.
 Children unable to eat due to
mental/physical disability. E.g.
mental retardation, Cerebral palsy
and congenital anomalies.
 Children with chronic illnesses
who require long term nutritional
support. E.g. Cancer, Inflammatory
bowel disease, Cystic fibrosis and
congenital heart disease.
 Nasogastric (NG) and
Orogastric (OG) - usually for
short term (< 3 months)
 Gastrostomy (Surgical or
Percutaneous Endoscopic
Gastrostomy)- for long term
 Transpyloric Feedings
 those who are at high risk for
aspiration;
 in pancreatitis patients best
to feed nasojejunally beyond
the ligament of Treitz
Monitoring Indicators
 Body weight  Serum phosphorus
 Liver function tests
 Intake/output  Serum calcium and
 Bowel function magnesium
 Blood glucose  Serum transferrin
 24 hour urinary
 Serum electrolytes nitrogen
 Blood urea  Serum albumin
nitrogen, creatinine
 KOMPLIKASI PARENTERAL
NUTRISI
 HIPERGLIKEMI
 HIPOGLIKEMI
 UREMI PRERENAL
 GANGGUAN FUNGSI HATI
 GANGGUAN CAIRAN&ELECTROLIT
 DEFISIENSI TRACE ELEMEN/VITAMIN
 HIPERCAPNI : CO2 >
KONTRA INDIKASI TNPE

 KRISIS HEMODINAMIK: SYOK,

DEHIDRASI ( k/I MUTLAK)
 GAGAL NAFAS TANPA RESPIRATOR
DAN PASIEN KEGANASAN TUMOR
PADA FASE TERMINAL (k/I RELA-
TIF)
AKUT ABDOMEN
 ILEUS
 STRANGULASI
 PERITONITIS
 PERDARAHAN
 KOMBINASI-TRAUMA

 ILEUS: PROBLEM
KOMPRESI-DEHIDRASI DAN
INFEKSI
 ANATOMI
GASTRO INTESTINALIS TRACT

Gastric outlet

Ampulla of Vater

Peyery patchs of lymphoid

 SYNOPSIS
Malformations
Disruptions Hollow viscus obstruction: G I Tract
Deformations Ileus simple -mild : anorexia Ureter
Syndrome -Moderate : nausea Billiary Tract
Colicky pain
-Severe : vomiting Pancreatic Tract
(intermittent) Tuba Fallopii
Congenital
anomaly
Upper ileus:
Hypo volumic shock -vomiting> Pylorus (Gastric outlet)
-mild distention Duodenum Obstructions
Morbus Obstipation (epigastric)
HIrschsprung Distention
Ileus Vomiting
Lower Ileus: Mechanical Ileus
Gold standart: 6 hours -vomiting<
- significant
whole distention Functional Ileus
Contiuous pain Ileus Strangulation
/Ischemic pain (Vascular compromise)
(anoksia)

HAEC Peritonitis Acute Abdomen

(toxic Megacolon)
(Emergencies)

Septic shock
Anal Bleeding
(melena,hematozesia, fresh)
MEGACOLON CONGENITAL
(HIRSCHSPRUNG DISEASE)
 Ileus
illustrations

Vasa:
lymph,venous,artery

Normal
Ileus

Complications:
I.Third space syndrome
(Venous Obstruction)
Dehydrations – mild (5%deficit)
- moderate (10%) Tx/ Fluid resucitations
- severe (15%)
II.Abdomen compartment syndrome Tx/Naso Gastirc Tube(NGT), rectal
(distended abdomen- venous return disrturb) tube
III.Sepsis Decompressions operative
(fecal retentions-bactreial overgrowth-mucous Tx/ Antibiotic Drugs
barrier damage)
HIGH GIT OBSTRUCTION
 GASTRIC OUTLET OBSTRUCTION
- HPS ( HYPERTROPHIC PYLORIC STENOSIS )
- ANTHRAL WEB

- PYLORIC MUCOSA PROLAPS

 DUODENAL OBSTRUCTION
- ATRESIA/STENOSIS DUODENUM
- PANCREAS ANNULARE
- LADD`S MEMBRANE
MECHANICAL LOWER GIT
OBSTRUCTION

 MECONIUM ILEUS
 MECONIUM PLUG SYNDROME
 NEONATAL SMALL LEFT COLON SYN DROME
 MALROTATION WITH VOLVULUS
 INCARCERATED HERNIA
 JEJUNOILEAL ATRESIA
 COLONIC ATRESIA
 INTESTINAL DUPLICATION
 INTUSSUSCEPTION
 NEC
 OMPHALOCELE
 GASTROSCHIZIS
Gangguan Cairan, Elektrolit dan
Asam-Basa Perioperatif
 Preoperatif
 Puasa terlalu lama
 Kehilangan cairan/elektrolit
 Asam-basa (Asidosis/alkalosis metabolik)
 Durante operatif
 Kehilangan cairan/elektrolit
 Asam-basa (Respiratorik & Metabolik)
 Postoperatif
 Kehilangan cairan (NGT,drain)
 Iatrogenik
 TIGA STABILITAS :

 CAIRAN DAN ELEKTROLIT

 ASAM – BASA
 SUHU
Dehidrasi
 Kekurangan cairan akibat puasa
 Kebutuhan cairan perjam x lama puasa
 Rehidrasi
 Tanda syok (atasi syok segera)
 Sisa cairan rehidrasi diberikan
 Isotonik : cepat (<8 jam)
 Hipertonik : lambat (48 jam)
 Kalium diberikan bila perfusi ginjal baik
Dehidrasi
 Derajat dehidrasi
 Ringan 5%
 Sedang 10%
 Berat 15%
 Jenis dehidrasi
 Isotonik (Na 130 – 150 mEq/L)
 Hipotonik (Na <130 mEq/L0
 Hipertonik (Na >150mEq/L)
 Tabel : Sign and symptoms of dehydration
Assessment Mild (5%) Moderate (10%) Severe( 15%)
Vital sign
Heart rate Normal Increased Tachycardia>130/min
Respiratory rate Normal Increased tachypnea
Blood pressure Normal Normal Hypotensive systolic <80
Capillary refill Normal 2 – 3 second >3 seconds
Mental Status Alert Irritable Lethargic
Skin
Color Pale Ashen Mottled
Turgor Normal Poor Tenting
Temperature Warm Cool Cool,clammy
Texture Normal Dry Doughy
Fontanelle Flat Depressed Sunken
Mucous membrane Dry Very dry Parched
± tears no tears
Eyes Normal Darkened Sunken
sunken Soft
Thirst Increased Intense Intense if conscious
Urine Output Normal Decreased Minimal
(N:1-2ml/kgbb/jam) concentrated very concentrated
NUTRISI ENTERAL
NUTRISI PARENTERAL
TERAPI NUTRISI PARENTERAL
 EBB PHASE :-HIPOVOLEMIA
- CAIRAN RESUSITASI RL/ ASERING
 FLOW PHASE : NORMOVOLEMIA
CAIRAN NUTRISI:
 KH : D5, D10
 PROTEIN : ASAM AMINO 2,5%, 5%,10%
 LEMAK : LIPID 20%
 ELEKTROLIT: KAEN I B, 3A, 3B
 MINERAL
Replacement therapy
 NGT atau drain
 Third-Space Loss
 The Quadrant Scheme (“educated guesses”)
 Setiap kuadran abdomen = + ¼ maintenance
 Disesuaikan dengan pantauan keluaran urin.
 Trauma bedah
 Ringan : + 1 – 2 ml/kg/jam
 Sedang : + 4 ml/kg/jam
 Berat : + 6 ml/kg/jam
 Kehilangan cairan diganti dengan komposisi
hampir sama
 DASAR PEMBERIAN NUTRISI
PARENTERAL

 IMBANG PROTEIN POSITIP

 PERHITUNGAN ENERGI:
RUMUS HARRIS BENEDICT: (kcal/hari)
BEE Pria =66,5+13,8xBB(kg)+T(cm)-6,8xU(th)
BEEWanita=65.5+9,5xBB(kg)+1.8xT(cm)-4,7xU(th)
 MALNUTRISI : AEE = 1,2 X BEE
 STRESS FAKTOR : PUASA = 0,85-1.00
AEE = BEE X STRESS FAKTOR X1,25

BEE=Basic Energy Expenditure

AEE=Actual Energy Expenditure
PROGRAM CAIRAN-TERAPI
PARENTERAL
( 6 JAM )

 JUMLAH CAIRAN
 JENIS CAIRAN
 CARA PEMBERIAN CAIRAN
 EVALUASI-MONITORING
 JUMLAH CAIRAN:
1. Defisit cairan / dehidrasi
a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )
b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )
c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )
* Tonisitas darah:Hipotonis,isotonis,hipertonis
2. Maintenance
Neonatus: 24 jam post operatif dikurangi 30%
3. Perkiraan cairan hilang dalam 24 jam
( on going loss )

2&3 modification to Fluid intake ( see table )

KOMPOSISI KIMIA TUBUH
PRIA UMUR 40 TAHUN
LEMAK(TG):15 Kg
Subkutan
Intermuskular LEMAK
Intraabdomen
Intratorakal

PROTEIN:12,8 Kg

MINERAL & GLIKOGEN

4,2 Kg MASSA TUBUH
NON LEMAK
73 % AIR
AIR 42,1 KG

(Data dari Beddoe

dkk 1984)
TOTAL BODY WATER ( ASHCRAFT )

UMUR %

Gestasional – 12 minggu 94
12 minggu – 32 minggu 80
Aterm
3-5 hari 78
-3 – 5
Neonatus 75 -
80
Children 65 -
75
Young Man 60
Young Woman 50
Over 60 years man 50
Over 60 years women 45
 MAINTENANCE ( ASHCRAFT )

* Daily Fluid Requirements

Weight Volume

Premature (< 2kg ) 150 ml / kg

Neonatus & infant (2-10 kg ) 100ml/kg for first 10kg
Infant & children (10-20kg ) 1000ml+50ml/kg over 10 kg
Children ( > 20 kg ) 1500ml+20ml/kg over 20 kg
Maintenance therapy
 Jumlah cairan menurut Holliday – Segar
 100/50/20 ml/Kg/hari atau
 4/2/1 ml/kg/jam
 Elektrolit
 Na : 3 – 4 mEq/kg/hari
 K : 2 – 3 mEq/kg/hari
 Cl : 3 – 4 mEq/kg/hari
TABLE : MODIFICATION TO FLUID INTAKE

Decrease Adjustment

Humidified Inspired air X 0.75

Basal state (eg pa ralysed ) X 0.7
High ADH (IPPV,brain injury ) X 0.7
Hypothermia - 12 % per C
High room humidity x 0.7
Renal failure x 0.3 (+urine output )
 Increase
Full activity + oral feeds X 1.5
Fever + 12 % per C
Room temperature > 31 C + 30 % per C
Hyperventilation X 1.2
Neonate - preterm (1-1.5 kg ) X 1.2
- radiant heater X 1.5
- photo terapy X 1.5
Burn - first day + 4% per 1%
area burn
- Subsequently + 2% per 1%
area burn
Useful Intravenous Solutions Commercially
Available

Solution Dextrose Na Cl K Lactate Ca

gm/l mEq/l
D5 % 50 - - - - -
D10 % 100 - - - - -
N/1-D5 50 154 154 - - -
N/2-D5 50 77 77 - - -
N/4-D5 50 38.5 38.5 - - -
N/5-D5 50 31 31 - - -
RL - 130 108.7 4 28 2.7
Aminofusin Paed - 30 10 25 - 10
Intra Lipid 10 % - - - - - -
 KOMPOSISI LARUTAN KA EN DAN ASERING

KOMPOSISI ELEKTROLIT ( mEq/L )

NAMA PRODUK OSMOLARITAS Na+ Cl- K+ Ca++ Asetate Lactate- Glukosa Kalori KEMASAN
mOsm/L Kcal/L
KaeN 1 B 282 38.5 38.5 37.5 150 500
KaeN 3 A 290 60 50 10 20 27 108 500
KaeN 3 B 290 50 50 20 20 27 108 500
KaeN MG3 695 50 50 20 20 100 400 500
500/1000
Asering 273.4 130 108.7 4 2.7 28 500
 KASUS :
 PASIEN ANAK USIA 1 tahun(BB 10 KG) DENGAN ILEUS
DISERTAI DEHIDRASI BERAT DAN FEBRIS SUHU 400C,
ASIDOSIS METABOLIK DAN ANEMIA. HASIL LAB.HB 8G%,
ALBUMIN 2 G/DL, K+ 2 MEQ/L, NA+ 160 MEQ/L,
TROMBOSIT 50000 MM2/DL.( TBW 70%, t normal 36,5C)

TERANGKAN PENATALAKSANAAN LENGKAP dalam 6 jam?

 JUMLAH CAIRAN
1. MAINTENANCE = 1000ML:4= 250ML
2. KOREKSI DEHIDRASI =150X10X70% = 1050 ML
3. KOREKSI SUHU ( SUHU NORMAL 36,5OC)
= 3,5X12%X1000ML = 420 ML
4. TOTAL FLUIDS REQUIREMENT= 1720 ML/6 JAM
= 1720/360 = 4,8 ml/second
= 96 drops/menit

INFUS MAKRO = 20 drops/Menit

INFUS MIKRO = 60 drops/Menit