DUKUNGAN NUTRISIPADA BEDAH ANAK

TERMINOLOGI

NUTRISI=NUTRITION=NUTRIENTERAPI NUTRISI:ORAL, ENTERAL, PARENTERALMALNUTRISIPEM ( MARASMIK, MARASMIK -KWASHIORKOR, KWASHIORKOR ): Skoring Sistem Mc Laren

PENDAHULUANDASAR TERAPI NUTRISI:STRESS METABOLIK: TRAUMA, LUKA BAKAR, PEMBEDAHAN, RADIO/ KHEMO TERAPISISA GLUKOSE: HABIS 2 4 JAMGLIKOGEN DI HATI&OTOT: HABIS DALAM BEBERAPA JAM, NORMAL UNTUK MENGISI SELA WAKTU ANTARA MAKANCADANGAN LEMAK, 24 JAM KEMUDIAN VIA GLUKONEOGENESIS DARI PROTEIN

PENDAHULUANSTARVASI:NUTRISI TERHENTI >24JAMKEBUTUHAN ENERGI BASAL: 20 -25KCAL/KGBB/HARI TERJADI GLUKONEOGENESIS (PROTEOLISIS T.U. ALANIN) 125 -150 GRAM/HARISETARA 200 300 GRAM JAR.OTOT YANG HILANGDALAM 3 5 HARI CADANGAN PROTEIN MENCAPAI TITIK KRITIS (BILA TETAP TAK ADA MASUKAN ASAM AMINO)

WHY IS NUTRITION IMPORTANT ?ENERGY OF DAILY LIVINGMAINTENANCE OF ALL BODY FUNCTIONSVITAL TO GROWTH AND DEVELOPMENT ( INFANT&CHILDREN)THERAPEUTIC BENEFITS - HEALING - PREVENTION : IMMUN

PROBLEM PERIOPERATIF DAN MALNUTRISISTRESS METABOLIK (STARVASI, INFEKSI, TRAUMA, FEBRIS & BEDAH), LUKA BAKARDIPUASAKAN : HIPOGLIKEMIA, DEHIDRASIKONDISI KLINIS PENYAKIT (underlying disease):ABDOMEN AKUT : ILEUS, STRANGULASI, PERITONITIS DAN PERDARAHAN ILEUS : KOMPRESI, DEHIDRASI, INFEKSITUMOR : cancer cachexia-anorexia PEM (Protein Energi malnutrisi)

AKUT ABDOMENILEUSSTRANGULASIPERITONITISPERDARAHANKOMBINASI-TRAUMA

ILEUS: PROBLEM KOMPRESI-DEHIDRASI DAN INFEKSI

MEGACOLON CONGENITAL(HIRSCHSPRUNG DISEASE)

HOW TO SOLVE THE PROBLEM ?TO ORGANIZE NUTRITION CARE TEAM: - PHYSICIAN - NURSE - DIETITIAN - PHARMACIST

HOW TO SOLVE THE PR0BLEM ?TO PERFORM NUTRITION CARE ACTIVITIESNUTRITIONAL ASSESSMENTNUTRITIONAL REQUIREMENTSROUTES OF DELIVERYFORMULA / IVF SELECTIONMONITORING

INDIKASI TERAPI NUTRISI PARENTERAL (TNPE )TIDAK MAU MAKANTIDAK CUKUP MAKAN

TIDAK BISA MAKANTIDAK BOLEH MAKAN

Parenteral NutritionPeripheral (PPN)Short term parenteral support (up to 2 weeks)Hypertonic solutions (> 900 mOsm/L) may cause phlebitis; thus must limit PPN solutions osmolarityEnergy and protein provided by PPN are limited because dextrose and amino acids contribute significantly to osmolarityElectrolytes also contribute to osmolarity

Central or Total (TPN)For long term use, catheters are surgically placedMay have surgically implanted catheters which lie beneath the skin and are accessed by special needle to decrease risk of infectionCan add solution of higher osmolarity into central vein (larger lumen)

KONTRA INDIKASI TNPEKRISIS HEMODINAMIK: SYOK, DEHIDRASI ( k/I MUTLAK)GAGAL NAFAS TANPA RESPIRATOR DAN PASIEN KEGANASAN TUMOR PADA FASE TERMINAL (k/I RELA- TIF)

Nasogatric tubeAH, boy, 16 monthsW 3.6 kg L 65 cm 9 monthslaterW 10.7 kgs

Gastrostomy

When children need tube feeding & how to choose route of delivery ? Children with acute conditions and increased requirements. E.g. Burns Severe trauma, Major surgery and Sepsis. Children unable to eat due to mental/physical disability. E.g. mental retardation, Cerebral palsy and congenital anomalies.

Children with chronic illnesses who require long term nutritional support. E.g. Cancer, Inflammatory bowel disease, Cystic fibrosis and congenital heart disease. Nasogastric (NG) and Orogastric (OG) - usually for short term (< 3 months)

Gastrostomy (Surgical or Percutaneous Endoscopic Gastrostomy)- for long term Transpyloric Feedingsthose who are at high risk for aspiration;in pancreatitis patients best to feed nasojejunally beyond the ligament of Treitz

Benefits of enteral nutrition in pediatric patientsPhysiological presentation of nutrients Trophic effects on the GI tract Stimulation and maintenance of the gut mucosa Reduced metabolic and infectious complications Improved hepatic function versus parenteral nutrition Simplified fluid and electrolyte management More "complete" nutrition May reduce the incidence of pathogen entry or bacterial translocation into the peritoneal cavity or circulation Less expensive

KOMPLIKASI PARENTERAL NUTRISIHIPERGLIKEMIHIPOGLIKEMIUREMI PRERENALGANGGUAN FUNGSI HATIGANGGUAN CAIRAN&ELECTROLITDEFISIENSI TRACE ELEMEN/VITAMIN HIPERCAPNI : CO2 >

Pediatric parenteral amino acid solutionInfantPrimene 5% (Baxter)Aminosteril Infant (Fresenius)PediatricAminofusin Paed (Baxter)Aminosteril (Fresenius)]

Parenteral AccessPeripheral Access Access by placing catheter into a peripheral veinPeripheral Parenteral Nutrition (PPN)

Central AccessAccess by catheter into vein feeding into the superior vena cavaTotal Parenteral Nutrition (TPN)

Monitoring IndicatorsBody weightIntake/outputBowel functionBlood glucoseSerum electrolytesBlood urea nitrogen, creatinine

Serum phosphorusLiver function testsSerum calcium and magnesiumSerum transferrin24 hour urinary nitrogenSerum albumin

ALGORITME PERENCANAANTERAPI NUTRISI

MENILAI STASUS GIZI DAN KONDISI KLINIK PENDERITAIHITUNG KEBUTUHAN NUTRISI(energi, protein, lemak, elektrolit dll)IMEMILIH KOMPOSISI TERAPI NUTRISIIMENENTUKAN TEKNIK & SKEMA PEMBERIANTERAPI NUTRISIIMONITOR:EFEK TERAPI NUTRISIKOMPLIKASI

TERAPI NUTRISI PARENTERALEBB PHASE : CAIRAN RESUSITASI RL/ ASERINGFLOW PHASE : CAIRAN NUTRISI KH : D5, D10PROTEIN : ASAM AMINO 2,5%, 5%,10%LEMAK : LIPID 20%ELEKTROLIT

DASAR PEMBERIAN NUTRISI PARENTERALIMBANG PROTEIN POSITIPPERHITUNGAN ENERGI: RUMUS HARRIS BENEDICT: (kcal/hari) BEE Pria =66,5+13,8xBB(kg)+T(cm)-6,8xU(th)BEEWanita=65.5+9,5xBB(kg)+1.8xT(cm)-4,7xU(th)MALNUTRISI : AEE = 1,2 X BEESTRESS FAKTOR : PUASA = 0,85-1.00 AEE = BEE X STRESS FAKTOR X1,25

BEE=Basic Energy ExpenditureAEE=Actual Energy Expenditure

PROGRAM CAIRAN :

JUMLAH CAIRANJENIS CAIRANCARA PEMBERIANMONITORING

TOTAL BODY WATER ( ASHCRAFT )UMUR%

Gestasional 12 minggu9412 minggu 32 minggu80Aterm3-5 hari78 -3 5Neonatus 75 - 80Children 65 - 75Young Man60Young Woman50Over 60 years man50Over 60 years women45

MAINTENANCE ( ASHCRAFT ) * Daily Fluid RequirementsWeight Volume

Premature (< 2kg )150 ml / kgNeonatus & infant (2-10 kg )100ml/kg for first 10kg Infant & children (10-20kg )1000ml+50ml/kg over 10 kgChildren ( > 20 kg )1500ml+20ml/kg over 20 kg

Jumlah cairan :1. Defisit cairan / dehidrasi a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )* Tonisitas darah:Hipotonis,isotonis,hipertonis2. Maintenance Neonatus: 24 jam post operatif dikurangi 30%3. Perkiraan cairan hilang dalam 24 jam ( on going loss )

2&3 modification to Fluid intake ( see table )

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TABLE :MODIFICATION TO FLUID INTAKE

DecreaseAdjustment

Humidified Inspired airX 0.75

Basal state (eg pa ralysed )X 0.7

High ADH (IPPV,brain injury )X 0.7

Hypothermia- 12 % per C

High room humidityx 0.7

Renal failurex 0.3 (+urine output )

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TABLE :MODIFICATION TO FLUID INTAKE

DecreaseAdjustment

Humidified Inspired airX 0.75

Basal state (eg pa ralysed )X 0.7

High ADH (IPPV,brain injury )X 0.7

Hypothermia- 12 % per C

High room humidityx 0.7

Renal failurex 0.3 (+urine output )

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STANDART PAEDIATRIC

MAINTENANCE SOLUTION

UMURLAR.KRISTALOID

1-2 hariD10% ( tak boleh elektrolit )

3-7 hariD5% NaCl 0,18 % *

< 1 thD5% NaCl 0,225 % *

< 10 thD5% NaCl 0,45 % *

* Tambahkan Maintenance KCl 7,5 %

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Useful Intravenous Solutions Commercially

Available

SolutionDextroseNaClKLactateCa

gm/lmEq/l

D5 %50-----

D10 %100-----

N/1-D550154154---

N/2-D5507777---

N/4-D55038.538.5---

N/5-D5503131---

R L-130108.74282.7

Aminofusin Paed-301025-10

Intra Lipid 10 %------

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TERAPI CAIRAN & NUTRISI

NAMA PRODUKElektrolit ( Meq / L )KALORIA AOsm

Na +K +Ca ++Cl -( Kkal )( gr / L )( mOsm / L )

ASERING13043109--273

KA-EN 3 B502050108-290

KA-EN MG3 ( 500 ml in 1000 ml )5020-50400-695

AMIPAREN2----100888

PAN ENTERAL 1 sachet----40030278

ANJURAN PEMBERIAN TERAPI :

HARI 1HARI 2HARI 3 - dst

2 btl ASE + 2 btl KAEN 3 B4 btl KAEN 3 B2 btl KAEN 3B + SOLUMIX

2 sachet PAN ENTERAL ( pagi & sore )2 sachet PAN ENTERAL ( pagi & sore )( AMI + KN MG3 )

908 Kcal1016 Kcal3 sachet PAN ENT (pagi,siang,sore )

1508 Kcal

Penggunaan OTSU NS/OTSU D5 (100 ml) utk. pemberian dgn int. IV drip :- ANTIBIOTIK

- ANALGESIK

- VITAMIN

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KOMPOSISI LARUTAN ELEKTROLIT DAN NUTRISI YANG RASIONAL

PRODUKElektrolit ( mEq / L )DextroseSorbitolProteinBCAAVitKaloriKemasanOsmotikKeterangan

Na +K +Ca++Mg++Cl -MaleatLaktatAsetatgr/Lgr/Lgr/L%Kcal/LmlmOsm/L

Ka En 1 B38.5---38.5---37.5----150500285Rasional

Ka En 3 A6010--50-20-27.0----108500290Rasional

Ka En 3 B5020--50-20-27.0----108500290Rasional

Ka En MG35020--50-20-100----400500695Rasional

500/1000

ASERING13043-109--28------500273Rasional

PAN AMIN G----52----5027.27.9-308500507ASKES

AMINOVEL 6003525-53822-35-100508.8+6005001320ASKES

AMIPAREN2------120--10030-400500888ASKES

NON RASIONALRASIONALKASUS PENYAKIT DALAM :

N/4 - D5 ( D5 - 1/4 NS )Ka En 1 BHARI IASERING 4 BTL

N/2 - D2.5 , N/2 - D5 ( D5 - 1/2 NS )Ka En 3 AHARI II + IIIKN 3B 2 BTL + PAN AMIN 2 BTL

RD5, RL + D5Ka En 3 BHARI IV dstKN MG3 2 BTL+PAN AMIN / AMINOVEL / AMIPAREN

RL + D-10Ka En MG3( SESUAI KEBUTUHAN ) 2 BTL

RLASERING ( RA )

KASUS BEDAH ( POST OP ) :

HARI IKN 3 B / KN MG3 4 BTL

HARI II + IIIKN MG3 2 BTL + PAN AMIN G / AMIPAREN 2 BTL

HARI IV dstKN MG3 2 BTL + AMIPAREN 2 BTL

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KOMPOSISI LARUTAN KA EN DAN ASERING

KOMPOSISI ELEKTROLIT ( mEq/L )

NAMA PRODUKOSMOLARITASNa+Cl-K+Ca++AsetateLactate-GlukosaKaloriKEMASAN

mOsm/LKcal/L

KaeN 1 B28238.538.537.5150500

KaeN 3 A2906050102027108500

KaeN 3 B2905050202027108500

KaeN MG369550502020100400500

500/1000

Asering273.4130108.742.728500

CONTOH KASUSSeorang laki-laki, usia 50 tahun BB 40 kg, tinggi badan 150 cm. Penderita dirawat karena luka bakar 20%Dengan rumus Harris Benedict: BEE = 66.5 + (13.8x40)+(5x150) (6.8x50)=1028.5 kcal/hari Stress factor(luka bakar 20%)= 1.5 AEE= 1028.5x 1.5x1.25= 1928 kcal/hari

SUMBER ENERGIKARBO HIDRAT 25 30 KCAL/KGBB/HARI (ASPEN 1993)GLUKOSE/DEXTROSE FISIOLOGIS: 6 -7,5 GRAM/KGBB/HARI, BILA BERLEBIHAN MERUGIKAN SEBAB RESPIRATORY QU0TIENT DAN PRODUKSI CO2 NAIKRASIO ENERGI : KH : LEMAK = 70:30 ( 60:40)

KEBUTUHAN PROTEINKEBUTUHAN PROTEIN= KONSUMSI NITROGEN X 6.25KONSUMSI NITROGEN (MG/24 JAM= UREUM URIN/24 JAM X 28 + 4000MG MMOL/LTANPA STRESS METABOLIK:PROTEIN(AA)= 1 GR/KGBB/HARIKALORI = 30 KCAL/KGBB/HARIDENGAN STRESS METABOLIK:KALORI = 40 KCAL/KGBB/HARIPROTEIN (AA) = 2 GR/KGBB/HARI

Berat badan pasien 50 kgTanpa stress metabolik: kalori = 50x30 kcal= 1500 kcal keb. Asam Amino = 50x1 gram /hari Dg stress metabolik: Kalori = 50x40 kcal= 2000 kcal/hari Asm Amino= 50x2= 100 gram/hari

Kebutuhan lemakUntuk memenuhi kebutuhan kalori, cairan emulsi lemak diberikan 1-3 gram/kgbb atau proporsi 25%-40% dari total kalori perhari. Pemberian lebih dari 60% dari kalori total dapat menyebab kan ketoasidosisLipid tidak diberikan pada kadar trigliserid lebih dari 400 mg/dl

KASUS ANAKLaki-laki umur 1 tahun BB 6 kg, TB 60cm Dx: Ileus dengan Dehidrasi berat, febris 40oC dan malnutrisi berat. Perhitungan: (1) Gangguan 3 stabilitas: ebb phase (RL/ ASERING) Program cairan 6 jam: 1kcal = 1ml kebutuhan cairan - Jumlah cairan: maintenens = 150 ml dehidrasi 15% = (150x6x70%) = 630 ml febris 40oC = 216 ml - Total resusitasi cairan = 996 ml (2) Bila kondisi stabil (flow phase): cairan nutrisi kenaikan bertahap - KH : KAEN 3A = ml - PROTEIN : AMINOFUSIN 5% = ml - LEMAK : LIPID 20% = ml (3) Malnutrisi berat : 2 x BEE = 500 kcal/hari

*