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MNT For Digestive Surgery

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  1. MNT For Digestive Surgery Leny Budhi Harti Jurusan Gizi Fakultas Kedokteran Universitas Brawijaya Malang 28 Mei2012

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

  3. Nutritional Alterations in Perioperative Period 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 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004

  5. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004

  6. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004

  7. Perioperative Nutritional Management Preoperative Perioperative Intraoperative Postoperative

  8. Perioperative Nutritional Management Preoperative fasting from midnight is unnecessaryin most patients.Patients undergoingsurgery, who are considered to have no specificrisk of aspiration, may drink clear fluids until 2 hbefore 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 7 -10 days Access : enteral or parenteral (TPN) nutrition Nutrient : Energy : 25 – 35 kkal/kgBB Protein : 1,5 – 2 g/kgBB Perioperative CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004

  10. Nutrition Support during Postoperative Nutritional Status Well-nourished & mildly malnourished Moderately malnourished & severe malnourished Oral nutrition Nutritional support 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 Manual of Dietetic Practice 4 edition, 2007

  12. Gastrectomy Ileostomy Colostomy

  13. Gastrectomy

  14. Intervention:ObjectivesGastrectomy 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, 2008

  15. Intervention:ObjectivesGastrectomy 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 folacinanemias. Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

  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, 2008

  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, 2008

  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, 2008

  19. DUMPING SYNDROME • Dumping syndrome is the term for a group ofsymptoms caused by food moving too quicklythrough the digestive system. It can be a sideeffect after a gastrectomy because the stomachis much smaller and is less able to control therelease of food into the intestines

  20. EARLY DUMPING SYNDROME • This usually happen 10-60 minutes after eating. S/S : • nausea • Vomiting • abdominal cramping • Bloating • Diarrhoea • rapid pulse • Weakness • fatigue

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

  22. Ileostomy Chorn’s disease, polyposis, dan cancer colon Etiologi Sementara atau permanen Sifat ↓ lemak, asam empedu, absorpsi vit. B12, kehilangan Na dan K Efek Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

  23. 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, 2008

  24. 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, 2008

  25. Short Bowel Syndrome • SBS is inadequate functional bowel to support nutrient and fluid requirements forthat individual, regardless of the length of the GI tractin the setting of normal fluid and nutrient intake

  26. GOALS OF MANAGEMENT • The primary goal in managing SBS is to maximize theutilization of the existing gut while assuring thatpatients are provided with adequate nutrients, waterand electrolytes to maintain health and/or growth • Clinicians must focus on reducing the severity of intestinalfailure while treating and preventing complications when they arise.

  27. GOALS OF MANAGEMENT • weaning from TPN or IV fluids, it is essential toincrease nutrient and fluid retention by slowing intestinaltransit time, controlling gastric acid hypersecretionand by enhanced mixing of pancreatic enzymes and bile salts

  28. EN ↓ + oral; 60% CHO, 20% P, 20% L No colon : CHO 40 -50%, P : 20%, L : 30 - 40% Phase 3 TPN ↓ + EN, E : 40-60 kkal/kgBB, P : 1,2 – 1,5 g/kgBB Phase 2 TPN Phase 1 Nutrition intervention SBS Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

  29. Colostomy Kanker, divertikulitis, perforasi usus, obstruksi, hirschsprung’s disease Etiologi Sifat Sementara atau permanen Absorpsi cairan & Na, ekskresi K & bikarbonat Fungsi Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008

  30. 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, 2008

  31. 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, 2008

  32. 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, 2003

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

  34. Metode Pemberian EF/EN pemberian EN secara terus menerus selama 24 jam Continuous gravity feeding (kontiniu) pemberian EN sebanyak 200 – 300 ml selama 30 – 60 menit setiap 4 – 6 jam Intermittent pemberian EN sebanyak 24o ml setiap 3 jam Bolus ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

  35. Feeding Protocol Sesegera mungkin setelah operasi antara 24 – 48 jam 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

  36. Monitoring Enteral Feeding Residual < 200 ml, clear EF Checking residual : prior to each intermittent feeding or 4 hours with continous feed Intolerance to be assessed 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 Slowing/stoping feeding ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

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

  38. Terima Kasih