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Aries Budianto
Divisi Bedah Digestif
Departemen Bedah RSSA/FKUB
Ariesb.bdmlg@gmail.com
Perubahan Metabolisme ->
trauma/operatif
Perubahan fungsi
pencernaan
Optimalisasi nutrisi
perioperatif bedah digestif
Stressors in surgery
Pain
Hypoxemia
Anaesthesia
Overhydration
Systemic
inflammation Dehydration
Stressors
Immobilization
Starvation
Hypothermia
Tissue injury
i 30 Malnourished
20
e 10
0
Complication Rate Post-Operative
n Mortality
t
Meguid et al, Am J Surg 1988; 341-345
Perubahan Metabolisme
TRAUMA
NEURO
ENDOCRIN
IMMU
NOLO
GIC
Modified from: Samy et al. Critical Role of Hormones in Traumatic Injury and Outcome
In Vincent (ed) Yearbook of Intensive Care and Emergency Medicine 2003
EBB & FLOW PHASE
1930: Sir David Cuthberstson
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
EBB PHASE
Characteristic by:
Hypovolemia
Decrease BMR
Reduced cardiac output
Hypothermia
Lactic acidosis
Regulated by:
Catecholamine, cortisol & aldosterone
Purpose: Conserve both circulating volume & energy store for
recovery and repair
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
FLOW PHASE
Characterized by:
Tissue edema (vasodilatation & capillary leak)
Hypermetabolism
Increased cardiac output
Raise body temperature
Leukocytosis
Increased O2 consumption
Increased gluconeogenesis
Purpose: Mobilization of body energy stores for
recovery and repair. Replacement of lost or damage
tissue
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
FLOW PHASE
Anabolic phase
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
CATABOLIC PHASE OF FLOW
PHASE
Lasting approximately 3-10 days
Increase production of counter-regulatory hormones
(catecholamine, cortisol, insulin & glucagon)
Increase production of inflammatory cytokines (IL-1, IL-6 &
TNF)
Significant fat and protein mobilization
Significant weight loss and increased urinary nitrogen excretion
Insulin resistance
If aggravated by neuroendocrine & inflammatory stress
response vicious catabolic cycle.
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
INSULIN RESISTANCE
Pro-inflammatory cytokine & decreased responsiveness of
insulin-regulated glucose transporter protein:
Insulin resistance
Increased glucose production
Following routine upper abdominal surgery insulinHYPERGLYCEMIA
resistance
may persist for approximately 2 weeks
Maintenance normal glucose level using insulin reduce both
morbidity & mortality
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
CHANGES IN BODY COMPOSITION FOLLOWING
MAJOR SURGERY/CRITICALLY ILLNESS
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
Factors that exacerbate the metabolic response to surgical injury including
hypothermia, controlled pain, starvation, immobilization, sepsis and medical
complication
Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26thth ed, CRC Press 2013
Perubahan fungsi
Saluran Cerna
Optimalisasi nutrisi
perioperatif
Malnutrition
neumonia
septic complications
multiple organ dysfunction
length of hospital stay mortality
Goals of Nutritional Therapy
Acute/Short-term
Preserve function
Minimise complications
Avoid overload
Correct mineral, micronutrient and
electrolyte balance
Medium to Long-term
Restore function
Improve quality of life
Screening and Assessment
Severity of disease
Potential Causes of Pre-op
Malnutrition
neoplasm,
an inability to swallow,
a lack of access to nutrition,
gastrointestinal tract dysfunction
Methods of Nutritional Assessment
Aims:
Nutritional monitoring
and follow-up after
discharge
Nutritional Goals in
the Perioperative Period
The Ultimate Nutritional Goal
Pain
Lack of G.I. Function
Immobility
Multi-disciplinary team
Nurses
Dieticians
Physiotherapy
Occupational therapy
Pain team
Theatre staff
Anaesthetists
Surgeons
STRATEGIC PLAN
C
L Surgery H
I
N Preop D Ward Home
I Anesthesia U
C
PATIENTS JOURNEY
46 appendicectomy 60
patients double- 50
blindly randomised
40
to:
Time (hours) 30 *** Placebo
Laxative
Postoperative low-
20
dose bisacodyl 10 mg
BID (n=23) 10
0
Placebo (n=23) Gas Stool
Medians, *** P<0.001, Mann-Whitney U-test
Day 1 Day 2
Day 3
With integrated nutritional and
metabolic care (ERAS) in the
peri-op period, can we improve
clinical outcomes?
Total LOS with ERAS
9
8
7
6
Days post-op
5
4
3
2
1
0
Traditiona 2002- 2004 Denmar
l care 2003 Early k
Introducin ERAS
g
ERAS
RANDOMISED TRIALS?
www.erassociety.org