MANAJEMEN NUTRISI PADA ENTEROSTOMA

NURHAYAT USMAN
KSM ILMU BEDAH/ DIVISI BEDAH DIGESTIF
RSUP. Dr. HASAN SADIKIN BANDUNG
UNIVERSITAS PADJADJARAN
2020

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 Introduction

● Ostomy surgery is a life-saving procedure that allows

bodily waste (urine or stool) to pass through a surgically
created opening on the abdomen called a stoma. The waste
passes into a prosthetic known as an ostomy “pouch”
worn on the outside of the body over the stoma.
PERTIMBANGAN PEMBERIAN NUTRISI PADA ENTEROSTOMA

• Keadaan malnutrisi pre operatif dan

derajatnya.
• Rute pemberian nutrisi ( Enteral/Parenteral)
• Waktu yang paling optimal untuk re-start
feeding.
• Permasalahan balance Cairan dan Elektrolit.
• Permasalahan absorpsi nutrisi dan proses
pencernaan (sisa usus yang fungsional,
aktivitas enzim).
• Adanya penyakit kronis (IBD, CHF, DM,
cirrhosis, obesity)
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PERJALANAN KLINIK
Apa yang terjadi pada pasien?

PRE-OPERATIF:
INTRA-OPERATIF POST-OPERATIF
PENYAKIT/KELAINAN
BEDAH + MALNUTRISI STRESS METABOLIK
PEMULIHAN LUKA
PENYAKIT
PENYAKIT PENYERTA TERAPI NUTRSI
+ POST-OPERATIF
PENYAKIT BEDAH STRESS PERAWATAN KOMPLIKASI
BERISIKO
BEDAH
MALNUTRISI

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 FAKTOR PENYEBAB STRESS
METABOLIK PADA PEMBEDAHAN
Anaesthesia Nyeri Hipoksemia

Overhidrasi
Inflamasi
Sistemik Dehidrasi

Immobilisasi
Stressors Starvasi

Hipotermia Trauma jaringan

Opioids Hipoperfusi
jaringan
Transfusi darah Kehilangan darah

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PATOFISIOLOGI PEMBEDAHAN
Prosedur Bedah

INFLAMASI

LEUKOSIT + ENERGI ↑

Multiplikasi sel & Kebutuhan nutrisi ↑

PENYEMBUHAN LUKA

TIDAK ADA MALNUTRISI MALNUTRISI

NORMAL BURUK + KOMPLIKASI

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 DAMPAK MALNUTRISI THD
HASIL PEMBEDAHAN
Sistem Immun
Komplikasi sepsis
MODS

Penyembuhan luka Kekuatan Otot

Insisi
masalah respirasi
Anastomosis
Pneumonia

Lama Rawat RS/ICU bertambah

Meningkatkan morbiditas/mortalitas

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 SKRINING DAN ASESMEN
BAGIAN RUTIN EVALUASI PRE OPERATIF

IMT < 18.5 kg/m2

BB turun > 10 -15 %
dalam 6 bulan
Subjective global
assessment (SGA) C
Serum albumin < 30 g/l
(tanpa penyakit hati & ginjal)*

Clin Nutr 36 (April 2017) 623-650

doi: 10.1016/j.clnu.2017.02.013.

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9
Subjective Global Assessment
 TERAPI NUTRISI PERIOPERATIF PADA
PASIEN BEDAH DENGAN MALNUTRISI DAN RISIKO MALNUTRISI

ESPEN Guidelines in Surgery1:

 Perioperative nutritional therapy should be initiated in the following
circumstances:
- It is anticipated that the patient will be unable to eat for >5 days or
- The patient is expected to have low oral intake and cannot maintain
>50% of recommended intake for >7 days
 Patients with severe nutritional risk shall receive nutritional therapy prior to
major surgery even if operations including those for cancer have to be
delayed. A period of 7-14 days may be appropriate.
 Whenever feasible, the oral/enteral route shall be preferred.
 Postoperatively, early tube feeding (within 24 h) shall be initiated in patients in
whom early oral nutrition cannot be started, and in whom oral intake will be
inadequate (<50%) for more than 7 days.
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1. Weimann et al. Clin Nutr 2017;36:623‒50.

 TERAPI NUTRISI PERIOPERATIF PADA
PASIEN BEDAH DENGAN MALNUTRISI DAN RISIKO MALNUTRISI

Preoperative PN Postoperative PN
Indicated in patients at risk of malnutrition who Indicated in malnourished patients for whom
cannot be adequately fed orally or enterally 1‒4 EN is infeasible, intolerable, or insufficient 1

For severely malnourished patients, PN should
be initiated as soon as metabolically possible
and continued for ≥ 5‒7 days. 4
PN initiated preoperatively should be continued
in the postoperative period.4
In patients who require postoperative nutrition
therapy, enteral nutrition or a combination of
enteral and supplemental parenteral nutrition
is the first choice.1

ESPEN Guidelines on PN: Surgery

Combined administration of EN and PN should be considered for surgical patients with an indication
for nutritional support for whom <60% of energy needs can be met via the enteral route. 1,3
1. Braga et al. Clin Nutr 2009;28:378–86. 3. Weimann et al. Clin Nutr 2017;36:623‒50.
2. McClave et al. J Parenter Enteral Nutr 2013;37:73S–82S. 4. Rosenthal et al. Curr Probl Surg 2015;52:147–182.

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 Guidelines ESPEN
• Rekomendasi :
• Nutrisi enteral tinggi protein dengan bentuk
protein utuh (polimerik).
• Nutrisi parenteral preoperatif diindikasikan pada
pasien malnutrisi berat yang tidak mendapatkan
nutrisi per oral atau enteral secara adekuat.
• Nutrisi parenteral postoperatif bermanfaat :
• Pasien malnutrisi yang tidak mampu atau tidak
dapat menoleransi nutrisi enteral.
• Komplikasi saluran cerna  tidak dapat
mencerna/menyerap nutrisi enteral selama
minimal 7 hari.

Weimann A, et al. ESPEN guideline: Clinical nutrition in surgery. Clinical Nutrition 2017;36:623-50.
 Kebutuhan Nutrisi pada Perioperatif

• Kalori :
• Fase akut/inisial  20-25 Kkal/kgBB/hari
• Fase flow/anabolik  25-30 Kkal/kgBB/hari
• Protein :
• Pembedahan mayor  1-2 g/kgBB/hari
• Trauma/luka bakar  1,5 – 3 g/kgBB/hari
• Karbohidrat  40-60% dari total kalori
• Lemak  25-40% dari total kalori sehari

Weimann A, et al. ESPEN guideline: Clinical nutrition in surgery. Clinical Nutrition 2017;36:623-50.
KEBUTUHAN ENERGI PADA KONDISI STRES METABOLIK

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RESPON METABOLIK PADA STRES BERAT

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Preiser JC, et al. Metabolic response to the stress of critical illness. British Journal of Anaesthesia 2014;113 (6):945–54
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 Re-START FEEDING
• Feeding pada pasien dengan enterostoma dapat dimulai sesegera
mungkin saat kondisi umum baik dan stoma tampak sudah produktif
• Jumlah kalori yang dibutuhkan :
• Perhatikan permasalahan- permasalahan nutrisi pada enterostoma

ESPEN Guidelines:
Energy: Protein:
- Surg: 25-30 kcal/kg/d - 1.3 - 1.5 g/kg/d
- ICU: 20-25 kcal/kg/d - 1.3g/kg/d 19
PERMASALAHAN PADA ENTEROSTOMA

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 EXPECTED OUTPUT OSTOMY LEVEL
 
• Jejunum: 3500 to 8000 mL/day
 
• Ileum: 1500 to 3000 mL/day PERHATIKAN BALANCE CAIRAN
  DAN ELEKTROLIT
• Colon: up to 1500 mL/day

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PERMASALAHAN PADA ENTEROSTOMA

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PERMASALAHAN PADA ENTEROSTOMA

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 LONG-TERM HYDRATION OUTCOME RELATED TO BOWEL REMNANT
Jejunum Ileum Colon Hydration
Intact TI Resected Intact Not Needed
Resected Intact Intact or Resected Not Needed

60-100 cm present Absent Intact ORT

60-100 cm present Absent Absent ORT; may need IV

30-60 cm present Absent Intact IV; ORT may be possible

30-60 cm present Absent Absent IV

< 30 cm present Absent Intact or Absent IV

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IV = Intravenous fluids ORT = Oral Rehydration Therapy
 LONG-TERM NUTRITION OUTCOME RELATED TO BOWEL REMNANT

Jejunum Ileum Colon Diet & Vitamins

Intact TI Resected Intact Regular; B12
Resected Intact Intact or Resected Regular or low fat
60-100 cm present Absent Intact Diet as tolerated; B12, Ca,
Cholestyramine

60-100 cm present Absent Absent High Na Diet as tolerated; B12

30-60 cm present Absent Intact PN usually needed
30-60 cm present Absent Absent TPN
< 30 cm present Absent Intact or Absent TPN
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FOOD REFERENCE CHART FOR OSTOMY

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FOOD REFERENCE CHART FOR OSTOMY

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 PRESENCE OF CHRONIC DISEASE
DISORDER
• In cirrhosis or heart failure, minimize Na in diet & fluids (80 mEq/day
+ ostomy/fistula losses). Avoid TPN in cirrhosis.
• In Diabetes Mellitus, avoid hyperglycemia (do not overfeed, use
enteral diabetic formula, ADA diet, insulin in TPN)
• Obesity: moderate caloric restriction (500 kcal deficit/day)
• IBD: if in tube feeds, consider Modulen; replace Zn & B12 as
appropriate

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 SIMPULAN
• Managemen nutrisi pada pasien bedah sangat penting khususnya
pada operasi mayor atau pasien enterostoma
• Pemberian nutrisi pada pasien dengan enterostoma tidak berbeda
dengan non enterostoma
• Food reference perlu jadi perhatian dalam pasien enterostoma
• Permasalahan usus yang tersisa harus jadi perhatian untuk pemberian
nutrisi.

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HATUR NUHUN

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