NUTRISI PERIOPERATIVE

STASE DIGESTIV JANUARI 2019

Nutrition

 Nutrisi memungkinkan tubuh mendapatkan semua substrat nutrisi

dasar dan energi yang dibutuhkan untuk mempertahankan atau
memulihkan semua fungsi vital tubuh dari karbohidrat dan lemak
dan untuk membangun massa tubuh dari asam amino.
Malnutrition

 Malnutrisi — berasal dari asupan nutrisi yang tidak mencukupi atau

beban penyakit parah pada komposisi dan fungsi tubuh —
memengaruhi semua sistem tubuh
MALNUTRITION IN HOSPITAL

 40% - 45% dari pasien rawat inap: kekurangan gizi atau berpotensi
kekurangan gizi.
 50% dari pasien bedah adalah malnutrisi
 12% gizi buruk.
 Komplikasi 3 kali lebih tinggi  Kematian yang lebih tinggi, LOS lebih
lama, Biaya rumah sakit naik 35% -75%
Effects of malnutrition on recovery
process
 30 - 55% pasien; 25% pasien anak di rumah sakit mengalami
kekurangan gizi

Pasien yang kekurangan gizi memiliki:

 proses pemulihan lebih lama
 biaya medis yang lebih tinggi
 peningkatan mortalitas dan morbiditas
 peningkatan tingkat komplikasi, termasuk. kesulitan penyembuhan luka
(wound healing)

Terapi nutrisi agresif penting untuk pengobatan beberapa kondisi (mis.

Kanker, pankreatitis, transplantasi sumsum tulang)
Nutrition Support Guideline
Recommendations
 Skrining (Screening) untuk risiko gizi disarankan untuk pasien rawat
inap. E
 Penilaian nutrisi (assessment) disarankan untuk semua pasien yang
teridentifikasi berisiko gizi dengan penyaringan gizi. E
 Intervensi dukungan gizi (support intervention) direkomendasikan
untuk pasien yang diidentifikasi dengan penyaringan dan penilaian
sebagai risiko kekurangan gizi (malnutrition) atau kekurangan gizi
(malnourished). C

A.S.P.E.N. Clinical Guidelines : Nutrition Screening, Assessment, and Intervention in Adults

JPEN J Parenter Enteral Nutr 2011 35: 16

JPEN J Parenter Enteral Nutr 2011 35: 16
Skrining Malnutrisi

 Nutrition Risk Screening-2002 (NRS-2002)

 Malnutrition Universal Screening Tool (MUST)
 Mini Nutritional Assessment (MNA)
 Subjective Global Assessment (SGA)
Diagnosis malnutrisi

ESPEN 2015 ASPEN 2012

2 or more of the following 6 characteristics is

recommended for diagnosis:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation
that may sometimes mask weight loss
• Diminished functional status as measured by
handgrip strength
 Surgical patients at severe nutritional risk by the presence of
at least one of the following criteria
 weight loss >10-15% within 6 months
 BMI <18.5 kg/m2
 Subjective Global Assessment (SGA) Grade C or NRS >5
 preoperative serum albumin <30 g/l (with no evidence of hepatic or renal
dysfunction)
 In case of severe metabolic risk  10-14 days of nutritional therapy may be
beneficial, but without measurable change in body composition or serum
albumin concentration.

A. Weimann et al. / Clinical Nutrition 36 (2017) 623-650

Indication of nutritional therapy
(ESPEN 2017)
 Patient at nutritional risk
 Patient with malnutrition
 Unable to eat for more than 5 days perioperatively
 Expected to have low oral intake and cannot maintain >50% of
recommended intake for >7 days

ESPEN Guideline: Clinical nutrition in Surgery (2017)

SCHEDULE OF PERIOPERATIVE
NUTRITION
 Mulai 10-14 hari sebelum operasi untuk meningkatkan status gizi
 5-7 hari sebelum operasi untuk keganasan abdomianal diberikan
Immunonutrient untuk meningkatkan fungsi kekebalan tubuh
 Puasa 6 jam untuk makanan padat dan 2 jam untuk cairan
(pemberian minuman yang jelas mengandung karbohidrat sebelum
tengah malam dan 2 hingga 3 jam sebelum operasi kolon
memperbaiki status pasien sebelum dan sesudah operasi,
mempercepat, memulihkan dan mempersingkat masa tinggal di
rumah sakit)
 Nutrisi enteral harus dimulai dalam waktu 24 jam

Gastroenterology Research and Practice, 2011, Article ID 739347

ERAS
(Enhanced Recovery After Surgery)

 ERAS programme
 a multimodal approach that aims to optimize perioperative
management
 a package of evidence-based modifications in preoperative,
intraoperative, and postoperative elements of care to reduce surgical
stress and postoperative catabolism
Preoperative fasting

Exceptions  patients “at special risk”, undergoing emergency

surgery, and those with known delayed gastric emptying for any
reason or gastro-oesophageal reflux

ESPEN Guideline: Clinical nutrition in Surgery (2017)

Preoperative metabolic preparation

CHO loading
800 ml CHO drinks (12,5%) evening before surgery
400 ml CHO drinks (12,5%) 2 hours before anesthesia

ESPEN Guideline: Clinical nutrition in Surgery (2017)

WHAT IS THE ROUTE OF
PERIOPERATIVE NUTRITION?
 Enteral adalah preferensi pertama
 Parenteral adalah pilihan kedua jika pemberian makanan enteral
dikontraindikasikan
 Gabungkan rute jika enteral tidak memadai
Enteral Nutrition

The enteral route should always be preferred except for the following
contraindications:
 Intestinal obstructions or ileus,
 Severe shock
 Intestinal ischaemia
 High output fistula
 Severe intestinal haemorrhage

 If the energy and nutrient requirements cannot be met by oral and

enteral intake alone (<50% of caloric requirement) for more than
seven days, a combination of enteral and parenteral nutrition is
recommended
Indications:
Parenteral Nutrition

• Non-functional gastrointestinal tract

• Inability to use the gastrointestinal tract
 intestinal obstruction
 peritonitis
 intractable vomiting
 severe diarrhea
 high-output enterocutaneous fistula
 short bowel syndrome
 severe malabsorption.
• Need for bowel rest

Palliative use in terminal patients is controversial.

ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA
Contraindications:
Parenteral Nutrition
 Kemampuan untuk mengkonsumsi dan menyerap nutrisi yang
cukup secara oral atau dengan pemberian makanan enteral
 Ketidakstabilan hemodinamik
WHEN IS POST-OPERATIVE
PARENTERAL NUTRITION INDICATED
 Pasien kurang gizi yang nutrisi enteralnya tidak layak atau tidak dapat
ditoleransi (A),
 Komplikasi pasca operasi yang mengganggu fungsi gastrointestinal
yang tidak dapat menerima dan menyerap jumlah makanan oral /
enteral yang adekuat setidaknya 7 hari (A)
 Kombinasi EN-PN harus dipertimbangkan jika diindikasikan untuk
dukungan nutrisi tetapi> 60% kebutuhan energi tidak dapat dipenuhi
melalui rute enteral: (entero-cutan fistula berkecepatan tinggi) (C),
atau obstruksi gastrointestinal parsial (C)
 Gagal gastrointestinal yang berkepanjangan

ESPEN Guidelines on Parenteral Nutrition: Surgery

Clinical nutrition 28 (2009): 378-386
Administration
Parenteral Nutrition

Central Nutrition Peripheral nutrition

 Subclavian line  Peripheral line
 Long period  Short period < 14days
 Hyperosmolar solution  Low osmolality
 Full requirement < 900 mOsm/L
 Minimum volume  Min. requirement
 Expensive  Large volume
 More side effect  Thrombophlebitis
Routes of TPN
Central TPN
(usual osmolarity = 2000 mosmol/L)
Advantages:
 Can provide full nutritional support (No
 limits in concentration of dextrose and amino acids)
 No risk of thrombophlebitis, No pain.
Disadvantages:
 Requires surgery
 More risk of sepsis than peripheral TPN
 High risk of mechanical complications
Routes of TPN
Peripheral TPN
maximum osmolarity;
neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L

Advantages:
 Does not require surgery
 Less risk of sepsis than central TPN
 No risk of mechanical complications

Disadvantages:
 High risk of thrombophlebitis
 Painful
 Does not provide full nutrition support. Needs more
 fluids to provide more nutrition. (maximum dextrose
 = 7.5% and AA = 2.5%).
Monitoring
Monitoring

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 Avoid overfeeding
 Avoid respiratory problem
 Promote nitrogen retention
 Triglyceride clearance
 Fluid and electrolyte
 Weight
 Liver function
Monitoring for Complications

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 Malnourished patients at risk for refeeding syndrome should
have serum phosphorus, magnesium, potassium, and glucose
levels monitored closely

 In patients with diabetes or risk factors for glucose intolerance,

insulin infusion should be initiated with a low dextrose infusion
rate and blood and urine glucose monitored closely.

 Blood glucose should be monitored frequently upon initiation,

any change in insulin dose, and until measurements are stable.
Monitoring for Complications

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 Serum electrolytes (sodium, potassium, chloride, and
bicarbonate) should be monitored frequently until
measurements are stable.

 Patients receiving intravenous fat emulsions should have

serum triglyceride levels monitored until stable and when
changes are made in the amount of fat administered.

 Liver function tests should be monitored periodically in

patients receiving PN.
Complications of TPN