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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 )
Sheet1
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 )
Sheet2
Sheet3
Sheet1
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 )
Sheet2
Sheet3
Sheet1
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 %
Sheet2
Sheet3
Sheet1
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 %------
Sheet2
Sheet3
Sheet1
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
Sheet2
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
Sheet3
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
*