Fasilitator :

Kiki Lukman, dr., Sp.B-KBD

Presentan :
Danny, dr
Yhoga, dr
Ferry, dr
Syakuran, drg
PERI OPERATIVE
MANAGEMENT
 Pre Operative
 Intra Operative
 Post Operative

Fluid Problem?
Kriteria inisiasi nutrisi perioperatif
 Surgical patients with suboptimal nutritional support
have impaired wound healing, altered immune
responses, accelerated catabolism, increased organ
dysfunction, delayed recovery, and increased
morbidity and mortality
 Patients who are inadequately fed after surgery become
critically undernourished within 10 days and have a
markedly increased risk of death
 The ultimate goal of perioperative nutritional
management
 meet caloric and nutrient-specifc requirements safely to
promote wound healing,
 diminish risk of infection, and
 prevent loss of muscle protein
 Nonmalnourished

Pre Operatif

Malnourished
Nonmalnourished
 The duration of starvation can be curtailed by
minimizing the “NPO” window.
 Clear liquid intake can safely be allowed 2 hours before
surgery and can signifcantly dampen the metabolic
insult of surgery
Nonmalnourished
 Multiple studies have shown that oral ingestion of
adequate volumes of carbohydrate-rich solution in the
24-hour preoperative period leads to
 decreased muscle wasting,
 insulin resistance, and
 tissue glycolyzation postoperatively
Principles Guiding Routes of Nutrition: Enteral,
Parenteral, or Both

 supplemental PN is used to augment nutrition in

patients who are able to tolerate signifcant amounts of
EN, but not in quantities sufcient to meet their
calculated protein-caloric requirements
Enteral nutrition
 Mucosal exposure to feeds provides direct high
concentration nutrients, stimulates enteric blood flow,
maintains barrier function by preserving tightjunction
integrity, and induces production and release of
mucosal immunoglobulin and critical endogenous
growth factors.
 These functions are not replaced with PN
 early intestinal feeding minimizes ileus by facilitating
gut motility
•Swallowing function must be sufcient to
avoid food aspiration
•Indicators of compromised swallow
function include neurologic
impairment
•coughing or choking with
feeds, or symptoms indicating a possible
aspiration-associated
pathology (e.g., chronic cough, recurrent
pneumonia).
•Assessment
of swallow function can range from bedside
observation to formal
speech pathology consultation and imaging-
based swallow studies
 EN Feeding Routes
 In patients incapable
of oral feeding,
administration of EN
can be accomplished
via various routes
 Early (24 to 48 hours) institution of EN after major surgery
minimizes the risk of undernutrition and can abate the
hypermetabolic response seen after surgery.
 In a critically ill patient, EN should be initiated within 48
hours of injury or admission;
 average daily intake delivered within the ifrst week should be at least
60% to 70% of the total estimated energy requirements
 Nasogastric and
nasojejunal tube positions.
 PEG, percutaneous
endoscopic gastrostomy
EN Formula
 Standard formulas are sterile,nutritionally complete,
and intended for patients with a normal GI tract
 Immune-enhancing formulas consist of nutritional
components enriched with arginine, glutamine,
nucleotides, and omega-3 fatty acids
EN Complication
Parenteral nutrition
 Allowing for nutrition in and survival of patients with a
nonfunctioning GI tract
 PN involves IV infusion of nutrients in an elemental form,
bypassing the usual processes of digestion
 To promote gut integrity and motility in patients receiving PN
alone, one should use small volumes of EN, when possible.
 Before receiving PN, patients should be
hemodynamically stable and able to tolerate the fluid
volume and nutrient content of parenteral
formulations
 used with caution in patients with congestive heart
failure, pulmonary disease, diabetes mellitus, and other
metabolic disorders
PN Formula
 In the United States, PN formulations are traditionally
composed of 60% to 70% dextrose and 10% to 20%
amino acids, administered daily, and combined as two-
in-one solutions
 Formulations also may include 10% to 30% lipid
emulsion
Ordering Parenteral Nutrition
 Minimal fluid requirements in the absence of GI or
other losses are 25 to 35 mL/kg/day
 Total kilocalories (25 to 35 kcal/kg/day)
 Protein (1.5 g/kg/day)
Pasien dengan bb 70 kg
 Pasien dengan berat badan 70 kg
 Total kilokalori : 30 kcal/kg/day x 70 kg = 2100 kcal
 Protein : 1.5 g/kg/day x 70 kg = 105 g protein
TPN tanpa lipid
 Total kalori = 2100 kcal
 Total protein = 105 g
 Kalori dari asam amino : 105 g x 4 kcal/g = 420 kcal
 Kalori yg tersisa : 2100 kcal – 420 kcal = 1680 kcal
 Total Dextrose : 1680 kcal/(3.4 kcal/g) = 494 g dextrose
 TPN
 Dextrose 70% : 70% x 496 g dextrose = 705 cc
 Asam amino 20% : 20% x 105 g asam amino = 525 cc
TPN dengan lipid
 Total kalori = 2100 kcal
 Alokasi 20% dari total kalori pada lipid : 20% x 2100 kcal
= 420 kcal
 Kebutuhan lipid : 420 kcal/(9 kcal/g) = 47 g lipid
 Kalori dari protein : 105 x 4 kcal/g = 420 kcal
 Kalori yg tersisa : 2100-420 kcal-420 kcal = 1260 kcal
 Total dextrose : 1260 kcal/(3.4 kcal/g) = 370 g dextrose
 TPN
 Dextrose 70% : 70% x 370 g dextrose = 705 cc
 Asam amino 20% : 20% x 105 g asam amino = 525 cc
 Lipid 20% : 20% x 47 g lipid = 235 cc
 Total volume tpn = 1465 cc
Complication