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Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 28 Mei 2012 1.

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Presentasi berjudul: "Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 28 Mei 2012 1."— Transcript presentasi:

1 Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 28 Mei

2 Content 2 Nutritional Alteration 1 Perioperative Nutrition Management 2 Gastrectomy 3 Ileostomy & Colostomy 4 Nutrition Access 5

3 Nutritional Alterations in Perioperative Period 3 Preoperative : Reduce preoperative intake Preoperative malabsorbtion Preoperative nutrient losses Postoperative : Reduce postoperative intake Postoperative nutrient losses Perioperative Metabolic response  hormonal & inflamatory response Energy and protein depletion ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

4 Perioperative Nutritional Management  Nutritional Screening : PNI  postoperative SGA  Nutritional Assessment : anthropometri biochemical history and physical examination 4 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 NUMBER 4 APRIL 2004

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7 Perioperative Nutritional Management 7 Perioperative Preoperative Intraoperative Postoperative

8 Perioperative Nutritional Management 8 Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, may drink clear fluids until 2 h before anaesthesia. Solids are allowed until 6 h before anaesthesia Clinical Nutrition (2006) 25, 224–244

9 Nutritional Support during Preoperative Indications ; 1. malnourished 2. elective and safe to delay for days Access : enteral or parenteral (TPN) nutrition Nutrient : Energy : 25 – 35 kkal/kgBB Protein : 1,5 – 2 g/kgBB 9 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 NUMBER 4 APRIL 2004 Perioperative

10 Nutrition Support during Postoperative 10 Nutritional Status Well-nourished & mildly malnourished Moderately malnourished & severe malnourished Nutritional supportOral nutrition ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

11 Nutrition Protocol for Postoperative  Enteral nutrition is given 6 – 12 h after postoperative  Energy : 25 – 35 kkal/kg BB  Protein : 0,8 – 1,5 g/kgBB  Fluid : 30 – 35 ml/kgBB 11 Manual of Dietetic Practice 4 edition, 2007

12 Gastrectomy Ileostomy Colostomy 12

13 Gastrectomy 13

14 Intervention:Objectives Gastrectomy Pre-operative  Empty the stomach and upper intestines  Ensure high-calorie intake for glycogen stores and weight maintenance or weight gain if needed.  Ensure adequate nutrient storage to promote post- operative wound healing.  Maintain normal fluid and electrolyte balance Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

15 Post-operative :  Prevent distention and pain.  Compensate for loss of storage/holding space and lessen dumping of large amounts of chime into the doudenum/jejunum at one time.  Overcome negative N2 balance after surgery; restore healthy nutritional status.  Prevent or correct iron malabsorption; steatorrhea, Ca mal absorption, and Vit B12 of folacin anemias. Intervention:Objectives Gastrectomy Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

16 Nutrition Intervention Gastrectomy Preoperative  Use a soft diet that is high in calories with adequate protein and vitamin C and K  Regress to soft diet with full liquids and then NPO about 8 hours before surgery. Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

17 Syarat Diet Gastrectomy Postoperative :  Energi sesuai dengan kebutuhan dan keadaan pasien  Protein : 1,5 – 2 g/kgBB/hari  Karbohidrat kompleks : 50 – 60% dari total energi  Karbohidrat sederhana : 0 – 15%  Lemak cukup, diutamakan lemak MCT  mudah serap  Mengurangi BM sumber laktose, jika lactose intolerance Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

18 Nutrition Intervention Gastrectomy  Vitamin dan mineral cukup : kromium, Vit B12, D, riboflavin, Fe, Ca. Jika perlu diberikan suplemen  Na cukup  Cairan cukup, diberikan 1 jam sebelum makan atau sesudah makan.  Porsi kecil, frekuensi sering  EN via jejunustomi dan TPN  Ketika makan  posisi tegak Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

19 DUMPING SYNDROME  Dumping syndrome is the term for a group of symptoms caused by food moving too quickly through the digestive system. It can be a side effect after a gastrectomy because the stomach is much smaller and is less able to control the release of food into the intestines 19

20 EARLY DUMPING SYNDROME  This usually happen minutes after eating. S/S : o nausea o Vomiting o abdominal cramping o Bloating o Diarrhoea o rapid pulse o Weakness o fatigue 20

21 LATE DUMPING SYNDROME  Late dumping syndrome can occur anywhere between 1-4 hours after a meal. It is a consequence of sugar being rapidly absorbed into the blood stream causing a high blood sugar level Sign and symptom : light-headedness weakness sweating rapid heart rate 21

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23 Ileostomy Etiologi Sifat Efek Chorn’s disease, polyposis, dan cancer colon Sementara atau permanen ↓ lemak, asam empedu, absorpsi vit. B12, kehilangan Na dan K Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

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25 Tujuan Diet  Modifikasi diet untuk menangani malabsorpsi zat gizi sepeti protein, kehilangan cairan, keseimbangan N negatif  Koreksi anemia akibat intake yang tidak adekuat dan kehilangan zat gizi  Menangani lemah dan kram otot akibat kehilangan K  Menangani peningkatan kebutuhan energi akibat demam  Mencegah kehilangan Ca akibat steatorea Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

26 Syarat diet  Energi dan protein tinggi  penyembuhan luka  Rendah serat tak larut  Mencegah makanan tinggi serat selama 4 minggu preoperative  Vitamin dan mineral sesuai kebutuhan Pasien  Cairan sesuai kebutuhan Pasien  Porsi kecil, frekuensi sering  Hindari makanan yang bergas Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

27 Short Bowel Syndrome  SBS is inadequate functional bowel to support nutrient and fluid requirements for that individual, regardless of the length of the GI tract in the setting of normal fluid and nutrient intake 27

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29 GOALS OF MANAGEMENT  The primary goal in managing SBS is to maximize the utilization of the existing gut while assuring that patients are provided with adequate nutrients, water and electrolytes to maintain health and/or growth  Clinicians must focus on reducing the severity of intestinal failure while treating and preventing complications when they arise. 29

30 GOALS OF MANAGEMENT  weaning from TPN or IV fluids, it is essential to increase nutrient and fluid retention by slowing intestinal transit time, controlling gastric acid hypersecretion and by enhanced mixing of pancreatic enzymes and bile salts 30

31 Nutrition intervention SBS 31 Phase 3 Phase 2 Phase 1 EN ↓ + oral; 60% CHO, 20% P, 20% L No colon : CHO %, P : 20%, L : % TPN ↓ + EN, E : kkal/kgBB, P : 1,2 – 1,5 g/kgBB TPN Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

32 Colostomy Etiologi Sifat Fungsi Kanker, divertikulitis, perforasi usus, obstruksi, hirschsprung’s disease Sementara atau permanen Absorpsi cairan & Na, ekskresi K & bikarbonat Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

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34 Tujuan Diet  Mencegah komplikasi  Mempercepat penyembuhan  Mencegah kehilangan BB akibat malabsopsi protein, anemia, perdarahan GI, steatorea  Mencegah kehilangan air  Mencegah infeksi Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

35 Syarat Diet  Individualized diet  Makanan diberikan bertahap : cair  lunak  makanan biasa  Tinggi energi, protein,vitamin dan mineral  Garam diberikan cukup hingga tinggi sesuai dengan keadaan pasien  Hindari makanan yang bergas dan menyebabkan diare  Serat diberikan bertahap : rendah  tinggi. Hindari BM mentah seperti fresh fruit & vegetables  Jika terjadi batu ginjal : cairan diberikan tinggi, minghandari BM sumber oksalat Sylvia Escott-Stump, Nutrition and Diagnosis Related Care,

36 Nutrition Access : Pemberian Enteral Nutrition  24 jam setelah pascabedah digestive  menurunkan risiko infeksi dan lama rawat  Pasien laparotomi dengan reseksi  EN diberikan setelah 23 jam pascabedah  Pasien laparotomi dengan lower gastrointestinal surgery  EN diberikan 4 jam pascabedah  Pasien bedah digestive mayor  EN diberikan 12 jam pascabedah Working Group on Metabolism and Clinical Nutrition,

37 Rute Enteral Feeding 37 Krause’s Food & Nutrition Therapy, 12 edition

38 38 Metode Pemberian EF/EN ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

39 39 Feeding Protocol Sesegera mungkin setelah operasi antara 24 – 48 jam Awal : Awal : 10 – 50 ml/jam, dengan cara tetesan  Toleransi baik  pemberian ditingkatkan secara bertahap 10 – 20 ml tiap 4 – 8 jam sampai kebutuhan kalori tercapai Working Group on Metabolism and Clinical Nutrition, 2003

40 Monitoring Enteral Feeding 40 Residual < 200 ml, clear Residual >= 200 ml(NGT), or >=100 ml (Gastrostomy tube Volume exceed twice the hoursly infusion during continous feeding or exceed 50% infusion volume during bolus feeding Checking residual : prior to each intermittent feeding or 4 hours with continous feed EF Intolerance to be assessed Slowing/stopi ng feeding ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

41 Transitional Feeding 41 Oral Enteral Parenteral Intake 75% nutrient need EN diberikan 30 – 40 ml/hr + 25 – 30 ml/h > 75% nutrient need Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

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