nutrisi pada pasien bedah
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review nutrisi pada pasien bedahTRANSCRIPT
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Nutrisi Pada Pasien BedahDr. Suharjendro H., SpUSMF Bedah RSU Mataram
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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
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NUTRITIONAL ASSESSMENTHISTORY Actual weight X 100 Present Illness = ----------------------------- Ideal weight
Actual weight X 100 Percentage Usual Body Weight = ------------------------------------ Usual weight
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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
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Rectum : Stool color, perineal fistuleNeurologic : Peripheral neuropathy, dorsolateral column deficitExtremities : Muscle size & strength, pedal edema
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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
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Nutrient Requirements & SubstratesCaloriesProteinGlutamine AginineNucleotides Fatty AcidsVitamins
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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 + breakdownGlutamine : important in metabollicaly streessed patient ( injury, operations, sepsis etc.)Aginine : substrate for urea cycle, precursor nitric oxideNucleotides : precursor DNA & RNAFatty Acids : immunomodulators
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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
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NUTRITIONAL PATHOFISIOLOGYStarvationElective Operations or TraumaSepsis
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Starvation During Starvation lever muscles
Acut or chronic starvation alterations energy hormon fuelAdaptive change decreased energy expenditure
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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
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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
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PEMBERIAN NUTRISI PADA PASIEN BEDAH
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NUTRITIONAL SUPPORTENTERAL NUTRITION
PARENTERAL NUTRITIONPeripheral Parenteral Nutrition ( PPN )Total Parenteral Nutrition ( TPN )
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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
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Possible Contraindications For Enteral Feeding
Short BowelGastrointestinal ObstructionGastrointestinal BleedingProtected Vomiting & diarrheaFistulaIleusGastrointestinal Ischmia
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Complications Of Enteral FeedingTechnical Complications a. Perforation b. Feeding Aspiration
Functional Complications Nausea, Vomiting, Abdominal Distenstion, Constipation & Diarrhea
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PARENTERAL NUTRITION
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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
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Formulation :Dextrose : D20WProtein : 10% Amino acids : essentiale & non essentialeFat : Fat emolsion 20% 500 ml dailyRoute of Administration : Peripheral 18 gauge intravenous infusion
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Complications : TechnicalInfectiousMetobolic
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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
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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
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Complications : TechnicalInfectiousMetobolic
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Complication of Parenteral NutritionTECHNICAL
Air EmbolusArterial LacerationArteriovenous FistuleBrachial Plexus InjuryCatheter MalpositionVenous LacerationEtc.
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Complication of Parenteral NutritionB. INFECTIOUS
Catheter FeverCatheter Tip InfectionCatheter Exit Site infectionCatheter Tip Infection With Bacteriemia infection
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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