Nutrisi Pada Pasien

Bedah
Dr. Suharjendro H., SpU
SMF Bedah RSU Mataram

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 SURGICAL METABOLISM &
NUTRITION
INTRODUCTIONS
• Effect of Disease
• PCM on surgicals patients ≈
1. Lean muscles mass
2. Altered respiratory mechanics
3. Impaired immune function
4. Intestinal atrophy
• Body weight lost > 10% → delay wound
healing & complications ↑

• BW lost > 20% → increased morbiditas &

mortalitas
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NUTRITIONAL 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 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 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 &
Substrates
• 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
a. Fat Soluble Vitamins
 A, D, E, K
 Immune function & wound healing

b. Water Soluble Vitamins

o B1, B2, B6, B12, Vit C, Naicin, folate, etc
o Cofactors generations & transfers energy
o Amino acid & nucleic acid metabolism

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NUTRITIONAL PATHOFISIOLOGY

• Starvation
• Elective Operations or Trauma
• Sepsis

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 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 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
• 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
PASIEN BEDAH

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 NUTRITIONAL SUPPORT

1. ENTERAL NUTRITION

2. PARENTERAL NUTRITION
a) Peripheral Parenteral Nutrition ( PPN )
b) Total Parenteral Nutrition ( TPN )

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 ENTERAL NUTRITION
• Benefits Of Enteral Feeding
1) Physiologic And Metabolic Benefits
2) Immunologic Benefits
3) Safety Benefits
4) Cost Benefits

• Indications For Enteral Feeding

1. 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 Feeding

1. Technical Complications
a. Perforation
b. Feeding Aspiration

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

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 PARENTERAL NUTRITION

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 PERIPHERAL PARENTERAL
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 :
Dextrose : D20W
Protein : 10% Amino acids : essentiale &
non essentiale
Fat : 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
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 :
Dextrose : D50W
Protein : 8,5% Amino Acids :
( essentiale & non essentiale )
Fat : Fat emolsion 20% 500 ml
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 Nutrition

A. TECHNICAL

1. Air Embolus
2. Arterial Laceration
3. Arteriovenous Fistule
4. Brachial Plexus Injury
5. Catheter Malposition
6. Venous Laceration
7. Etc.

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 Complication 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 Nutrition

C. METABOLIC

a. Azotemia
b. Fluid Overload
c. Hyperkalemia
d. Hypercalcemia
e. Hypernatremia
f. Hypervitaminosis A / D
g. LFT Elevation
h. Etc.

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• .

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 Tugas
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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