MNT For Digestive Surgery

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MNT For Digestive Surgery

Leny Budhi HartiJurusan Gizi

Fakultas Kedokteran Universitas Brawijaya

Malang28 Mei 2012

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Content

Nutritional Alteration1

Perioperative Nutrition Management2

Gastrectomy 3

Ileostomy & Colostomy 4

Nutrition Access5

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Nutritional Alterations in Perioperative Period

Preoperative :Reduce preoperative

intakePreoperative

malabsorbtionPreoperative nutrient

losses

Postoperative :Reduce postoperative

intakePostoperative nutrient

losses

PerioperativeMetabolic response hormonal & inflamatory responseEnergy and protein depletion

ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)

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Perioperative Nutritional Management

Nutritional Screening : PNI postoperativeSGA

Nutritional Assessment :anthropometribiochemical history and physical examination

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

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

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Perioperative

Preoperative

Intraoperative

Postoperative

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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

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Nutritional Support during Preoperative

Indications ;1. malnourished2. elective and safe to delay for 7 -10

daysAccess :

enteral or parenteral (TPN) nutrition

Nutrient :Energy : 25 – 35 kkal/kgBBProtein : 1,5 – 2 g/kgBB


Perioperative

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Nutrition Support during Postoperative

Nutritional Status

Well-nourished & mildly

malnourished

Moderately malnourished &

severe malnourished

Nutritional supportOral nutrition


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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

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Gastrectomy

Ileostomy

Colostomy

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Gastrectomy

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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, 2008

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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


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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.


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Syarat Diet GastrectomyPostoperative : 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


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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


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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

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EARLY DUMPING SYNDROME

This usually happen 10-60 minutes after eating. S/S :

o nauseao Vomitingo abdominal crampingo Bloatingo Diarrhoeao rapid pulseo Weaknesso fatigue

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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 levelSign and symptom :• light-headedness• weakness• sweating• rapid heart rate

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IleostomyEtiolo

gi

Sifat

Efek

Chorn’s disease, polyposis, dan cancer colon

Sementara atau permanen

↓ lemak, asam empedu, absorpsi vit. B12, kehilangan Na dan K


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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


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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


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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

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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.

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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

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Nutrition intervention SBS

Phase 3

Phase 2

Phase 1

EN ↓ + oral; 60% CHO, 20% P, 20% LNo colon : CHO 40 -50%, P : 20%, L : 30 - 40%

TPN ↓ + EN, E : 40-60 kkal/kgBB, P : 1,2 – 1,5 g/kgBB

TPN


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Colostomy

Etiologi

Sifat

Fungsi

Kanker, divertikulitis, perforasi usus, obstruksi, hirschsprung’s disease

Sementara atau permanen

Absorpsi cairan & Na, ekskresi K & bikarbonat


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Tujuan Diet

Mencegah komplikasi Mempercepat penyembuhan Mencegah kehilangan BB akibat malabsopsi

protein, anemia, perdarahan GI, steatorea Mencegah kehilangan air Mencegah infeksi


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Syarat Diet Individualized diet Makanan diberikan bertahap : cair lunakmakanan 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


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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

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Rute Enteral Feeding

Krause’s Food & Nutrition Therapy, 12 edition

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Metode Pemberian EF/EN

Continuous gravity feeding

(kontiniu)

Intermittent

Bolus

pemberian EN secara terus

menerus selama 24 jam

pemberian EN sebanyak 200 – 300 ml selama 30 – 60 menit setiap 4 – 6

jam

pemberian EN sebanyak 24o ml

setiap 3 jam


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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

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Monitoring Enteral Feeding

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/stoping feeding


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Transitional Feeding

Oral

Enteral

Parenteral

Intake 75% nutrient need

EN diberikan 30 – 40 ml/hr+ 25 – 30 ml/h> 75% nutrient need


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MNT For Digestive Surgery

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