Leny Budhi Harti
Jurusan Gizi
Fakultas Kedokteran Universitas Brawijaya
Malang
28 Mei 2012
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Content
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Nutritional Alteration
Perioperative Nutrition Management
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Gastrectomy
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Ileostomy & Colostomy
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Nutrition Access
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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)
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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
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CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004
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CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 4 APRIL 2004
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Perioperative Nutritional Management
Preoperative
Perioperative
Intraoperative
Postoperative
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Perioperative Nutritional Management
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. 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
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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)
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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 postoperative wound healing.
 Maintain normal fluid and electrolyte balance
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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Intervention:Objectives Gastrectomy
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.
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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.
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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
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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
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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 nausea
o Vomiting
o abdominal cramping
o Bloating
o Diarrhoea
o rapid pulse
o Weakness
o 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
level
Sign and symptom :
• light-headedness
• weakness
• sweating
• rapid heart rate
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Ileostomy
Etiologi
Chorn’s disease,
polyposis, dan cancer
colon
Sifat
Sementara atau
permanen
Efek
↓ lemak, asam empedu,
absorpsi vit. B12,
kehilangan Na dan K
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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Syarat diet
 Energi dan protein tinggi  penyembuhan luka
 Rendah serat tak larut
 Mencegah makanan tinggi serat selama 4 minggu
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


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
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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
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
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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
Sylvia Escott-Stump, Nutrition and Diagnosis Related Care, 2008
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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
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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)
pemberian EN secara
terus menerus selama 24
jam
Intermittent
pemberian EN sebanyak
200 – 300 ml selama 30 –
60 menit setiap 4 – 6 jam
Bolus
pemberian EN sebanyak
24o ml setiap 3 jam
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
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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
Checking
residual :
prior to each
intermittent
feeding or 4
hours with
continous
feed
Residual < 200 ml, clear
EF
Residual >= 200 ml(NGT), or
>=100 ml (Gastrostomy tube
Intolerance
to be
assessed
Volume exceed twice the
hoursly infusion during
continous feeding or exceed
50% infusion volume during
bolus feeding
Slowing/stopi
ng feeding
ASPEN Nutrition Support Practice Manual 2 nd Ed, 2005)
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Transitional Feeding
Intake 75% nutrient need
Oral
EN diberikan 30 – 40 ml/hr
+ 25 – 30 ml/h
> 75% nutrient need
Enteral
Parenteral
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