Terapi Enteral Parenteral

7/21/2019 Terapi Enteral Parenteral

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TERAPI ENTERAL-PARENTERAL PASIEN PASCA

OPERASI

Clarissa Tertia 07120100009

Martha Riestiana 07120100026

Jan !inata "inna 0712010006#

Pe$%i$%in& '(r) "ita S*+$ara,

S.)


2/74

I(entitas

Na$a' Tn) S*%rt

/sia' #0 tah*n

R*an& raat' Par+it II


3/74

Ana$nesis

el*han *ta$a' ti(a+ %*an& an&in(an %*an& air %esar sea+ # hariSMRS)

el*han ta$%ahan' -


4/74

Ria3at Pen3a+it Se+aran&

Pasien (atan& (en&an +el*han ti(a+%isa %*an& an&in (an %*an& air %esarsea+ # hari SMRS) Se%el*$n3a

asien (aat .A. lan4ar setia harina$*n sea+ 1 $in&&* SMRSter(aat .A. %erarna +ehita$an)

N3eri er*t 5 (i %a&ian *sar sea+8 10 hari SMRS) N3eri (irasa+anhilan& ti$%*l)


5/74

Pasien (iraat (i RS P*s(i++es sea+ 1$in&&* SMRS (an (i (ia&nsis $en(eritaen3a+it $aa&, (an +el*ar (ari RS sea+

1 hari SMRS) Pasien $erasa er*tn3ati(a+ n3a$an sea+ +el*ar (ari RSP*s(i++es (an er*t terasa en*h (an+e$%*n& sea+ 11 a$ SMRS)

M*ntah 5 2 +ali, %erisi 4airan %enin&,(arah 5-

e$a$ 5- .A nr$al)


6/74

Ria3at Pen3a+it ah*l*

Men&i(a &eala seerti inise%el*$n3a 5-

Ria3at hiertensi 5- Ria3at M 5-

Ria3at aler&i 5-


7/74

Pe$eri+saan :isi+

Stat*s ;eneralis

ea(aan *$*$' ta$a+ sa+it se(an&

esa(aran ' 4$s $entisTe+anan (arah ' 120&

La* na(i ' 92?


8/74

eala ' nr$4ehali, (e@r$itas 5-Mata ' A-


9/74

A%($en'

I' ta$a+ 4e$%*n&, $assa 5-, (ar$+nt*r 5, (ar$ stei@*n& 5-

P' tera%a te&an& (i sel*r*h +*a(ran,n3eri te+an 5 (i R/, (e@ans$*s4*lair 5-

P' ti$ani (i sel*r*h +*a(ran a%($en

A' ./ 5 $ele$ah

E+stre$itas' a+ral han&at, CRT F2 (eti+


10/74


11/74

Re4tal t*4her

Tn*s shin4ter ani %ai+

A$*la re4ti +lasM*+sa li4in

n3eri te+an5-

$assa5-Pa(a han(s4n ter(aat @eses

+ehita$an)


12/74

Pe$eri+saan Pen*nan&


13/74

:t Pls A%($en 2 sisi


14/74

ia&nsis era

Ile*s %str*+ti@


15/74

Tatala+sana

ns*l (r) S*$i(i, S).

P*asa

I!: RL ' H 2 ' 2 2000 44


16/74

>asil N;T' +el*ar 4airan %erarna+ehia*an (en&an serihan-serihan+e4+latan

>asil *rin +ateter' +el*ar *rin +e+*nin&an


17/74

Intraeratie

E+slrasi ta$a+ (istensi siste$*s*s hal*s

Ter(aat ina&inasi ile4e4*$

Rese+si ile4e4*$


18/74

Pe$eri+saan La%ratri*$ as4aerasi 5 es 201


19/74

N*trisi Enteral

se&ala rses $a+an 3an&$en&&*na+an siste$ en4ernaan5&astrintestinal *nt*+

$en&antar+an se%a&ian ata* sel*r*hse%a&ai e$en*han +e%*t*han +alrit*%*h seseran&, 3an& $en4a+*

(iet nr$al er ral, s*le$en liK*i(


20/74

Enteral T*%e @ee(in&

Pe$%erian n*trisi (en&an$en&&*na+an selan& 3an&(i$as*++an $en** la$%*n&,

(*(en*$ ata**n een*$)


21/74

N*trisi Parenteral

Pen3al*ran +alri (an n*trisi +e (ala$t*%*h se4ara intraena seerti rtein,+ar%hi(rat, le$a+, $ineral (an

ele+trlit, ita$in ele$en ta$%ahanlain %a&i asien-asien 3an& ti(a+(aat $a+an ata* $en3era $a+anan

$elal*i tube feeding formula *nt*+$e$ertahan+an stat*s n*trisi 3an&%ai+)


22/74

N*trisi enteral (an arenteral ter&a%*n&(ala$ specialized nutrition support 5SNS3an& $e$ili+i t**an '

1) Me$%eri+an as*an n*trisi 3an& a(e+*ata(a asien (en&an @ase en3e$%*han sa+itata* tra*$a, saat asien $asih %el*$$a$* *nt*+ $enelan ata* @*n&si a%srsin*trisi ter&an&&*

2) /nt*+ $en*nan& asien se%a&ai resnssela$a $en&ala$i +era(an&an, tra*$a,rses in@e+si a(a sa+it +ritis (ala$ a+t*3an& la$a)


23/74

Man@aat n*trisi Pas+aOerasi

.er+*ran& an&+a $r%i(itas +arenasesis

e$a$*an $e$ertahan+ansiste$ i$*nitas

Me$er4eat en3e$%*han l*+a


24/74

Per*%ahan Pa(a PasienPas4aerasi

Per*%ahan sil&is

Per$ea%ilitas (in(in& *s*s 2-?as4aerasi 58 hari en3eraan

n*trisi (an @*n&si %arrier *s*s *nt*+$en&el*ar+an %a+teri (an t+sin en(&en

Per*%ahan $eta%lis$e

Resn t*%*h terha(a l*+a ' $eta%lis$e$enin&+at, se+resi &l*++rti+i( (an+ate+la$in, r(*+si sit+in, retensi *rin


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Enhan4e( re4er3 @ atients a@ters*r&er3 5ERAS

Men&hin(ari *asa 3an& la$a ra-erasi

Penetaan +e$%ali $a+an erral se(ini$*n&+in setelah erasiB

Men&inte&rasi+an n*trisi +e (ala$ en&ellaan+esel*r*han (ari asienB

ntrl $eta%li+, $isaln3a &l*+sa (arah

Men&*ran&i @a+tr 3an& $e$er%*r*+ stres 3an&

%erh*%*n&an (en&an +ata%lis$e ata* 3an&$er*sa+ @*n&si en4ernaan

M%ilisasi aal


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Earl3 enteral @ee(in&

Early enteral feeding(i%eri+an (ala$= a$ setelah eristia +linis $a3r,seerti ' tra*$a $*ltiel, l*+a %a+ar %erat,

tra*$a ta+, sesis %erat, (an +n(isiina$asi %erat lainn3a a(a tin&+at+earahan tertin&&i %er(asar+an s4rin&5$isaln3a APAC>E, ersentase l*as l*+a

%a+ar t*%*h, ata* ;CS e*nt*n&an ' $e$er4eat

en3e$%*han, $en&*ran&i +ea(ianin@e+si sesis, (an $en&*ran&i an&+a

+e$atian)

N/TRISI.


27/74

N/TRISIENTERAL

Hasil yang lebih baik daripada parenteralproses berlangsung faali

nutrisi enteral lebih disukaibiaya lebih murah dan risiko ier&li+e$ia - a(a asien (en&an

(ia%etes ata* stres 3an& $ensti$*lasiins*lin resisten - treat (en&an sli(in&

s4ale is@*n&si hear - aran& - le%ih serin&

a+i%at sesis ata**n %at

N*trisi a(a ran& 3an& ti(a+


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N*trisi a(a ran& 3an& ti(a+$en&ala$i tra*$a %erat ata**n

resi+ re@ee(in& s3n(r$e

Ttal ener&i' 2# +4al


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N*trisi arenteral as4a erasi (ian*r+an a(a

asien 3an& ti(a+ (aat $e$en*hi +e%*t*han +alri $ere+a(ala$ 7-10 hari se4ara ral ata* enteral)

asien 3an& $e$erl*+an n*trisi ta$%ahan as4a erasi $a+anan enteral ata* +$%inasi enteral (an ta$%ahan arenteral

a(alah ilihan erta$a

le$a+ (an +ar%hi(rat (ala$ n*trisi arenteral ti(a+ *nt*+$e$%eri+an $a+anan %erle%ih a(a asien, kebutuhan dasar '25 kkal / kgBB/ hari, (ala$kondisi stres : 30 kkal/ kgBB/

hari

+n(isi stres +e%*t*han nitr&en sehari setara (en&an as*anrtein 1, & < +& %erat %a(an 3an& i(eal 5ata* se+itar 20H (ari

+e%*t*han ener&i ttal *$*$n3a e@e+ti@ *nt*+ $en&*ran&i+er*&ian nitr&en


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N*trisi a(a Pasien Resi+ tin&&iRe@ee(in& s3n(r$e

*+*n&an n*trisi aal' $a? 10 +4al


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PROTEIN

e%*t*han rtein $en*r*tRe4$$en(e( ietar3 Allan4e5RA a(alah 0,= &


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;*i(elines @r Prtein Inta+e inA(*lts

Kondisi klinis Recommended intake(g/kg/da!

>ealt3 a(*lt, nr$al r&an@*n4tin

0,=

"ost operati#e $,0%$,5

Sesis 1,2-1,

M*ltile tra*$a 1,#-1,7

Mar %*rn 1,=-2,


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Ji+a as*an rtein $enin&+at *nt*+

+e%*t*han $eta%li+, +n(isi ini har*s

(ii$%an&i (en&an e$%erian +alri 3an&

a(e+*at *nt*+ $ena$in rtein (aat

(i&*na+an e@e+ti@

Re+$en(asi ara ahli - e$%erian 10 ++al

*nt*+ setia &ra$ nitr&en sela$a en3a+it%erat 56,2 &r setara (en&an 1 &r nitr&en


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I$%an& Nitr&en

In(i+asi terha(a +e4*+*an as*an rtein(en&an $e$%an(in&+an as*an nitr&en(en&an e+s+resi nitr&en

&enghitung 'mbang itrogenNitr&en %alan4e 5N. nitr&en inta+e nitr&en lsses

Nitr&en inta+e rtein inta+e


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I$%an& nitr&en

Psiti@

As*an nitr&en $ele%ihi e+s+resinitr&en as*an n*trisi 4*+* *nt*+

tera(in3a ana%lis$e (an (aat$e$ertahan+an lean body massU

Ne&ati@

E+s+resi nitr&en $ele%ihi as*an %er+*ran&n3a arin&an tt)


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Ele+trlit

Mer*a+an Dat 3an& ter(issiasi(ala$ 4airan (an $en&hantar+anar*s listri+)

Ele+trlit (i%e(a+an $ena(i insiti@ 5+atin (an in ne&ati@ 5anin)

J*$lah +atin (an anin (ala$ lar*tan

a(alah selal* sa$a 5(i*+*r (ala$$ilie+*ialen)


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atin

atin *ta$a (ala$ 4airane+strasel*lar a(alah s(i*$ 5Na

Se(an&+an +atin *ta$a (ala$4airan intrasel*lar a(alah tassi*$5 )

S*at* siste$ $a ter(aat (i

(in(in& sel t*%*h 3an& $e$$a+el*ar s(i*$ (an tassi*$ ini


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Anin

Anin *ta$a (ala$ 4airane+strasel*lar a(alah +lri(a 5Cl- (an%i+ar%nat 5>CO #-, se(an&+an

anin *ta$a (ala$ 4airanintrasel*lar a(alah in @s@at 5PO#-


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arena +an(*n&an ele+trlit (ala$las$a (an 4airan interstitial a(aintin3a sa$a $a+a nilai ele+trlit

las$a $en4er$in+an +$sisi(ari 4airan e+strasel*ler tetai ti(a+$en4er$in+an +$sisi 4airan

intrasel*ler)


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Natri*$ Natri*$ se%a&ai +atin *ta$a (i(ala$ 4airan e+strasel*ler

(an alin& %ereran (i (ala$ $en&at*r +esei$%an&an 4airan)

a(ar natri*$ las$a' 1#-1$EK


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ali*$

ali*$ $er*a+an +atin *ta$a 599H (i (ala$ 4airane+strasel*ler %ereran entin& (i (ala$ terai &an&&*an+esei$%an&an air (an ele+trlit)

J*$lah +ali*$ (ala$ t*%*h se+itar # $EK


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>inatre$ia

Ji+a F 120 $&, li(isi si+&eni+,

hile$ia 5(is@*n&si t*%*li &inal, (iare,$*ntah, third space losses, (i*reti+a,

hierle$ia 5sirsis, ne@rsis)


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ea(aan ini (aat (iterai (en&an

restri+si 4airan 5Na6V 12 $&


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N/TRISI

e%*t*han Meta%lis$e .asal < Basal Metabolic Rate

Perhit*n&an +alri %er(asar+an R*$*s >arris-.ene(i4t

La+i-la+i ' 66, 51#,7 ? .. 5 ? T. 56,76 ? /

"anita ' 6,1 59,6 ? .. 51,= ? T. 5,6= ? /

.. (ala$ il&ra$T. (ala$ 4enti$eter

/ (ala$ tah*n

R*$*s Rle @ Th*$%

#0 ++al < +& ..

oreksi katabolisme yang tinggi seperti pada pasca trauma" pasca bedah" infeksi


59/74

Status "asien "eningkatan terhadapR))

Tra*$a t*lan& #0 H

Oerasi ele+ti@ 10H

Sesis intra a%($en #0 0 H

Ce(era eala 60 H

Sesis < Ce(era (i IC/ 0 60 H

L*+a %a+ar l*as < %erat 100 H

i+*ti ' >ill ;L

oreksi katabolisme yang tinggi seperti pada pasca trauma" pasca bedah" infeksi

atau sepsis harus ditambahkan &'% atau lebih dari (M)" tetapi tidak melebihi

*&'% (M).


60/74

e%*t*han +alri asien '

La+i-la+i

66, 51#,7 ? .. 5 ? T. 56,76 ? /

66, 51#,7 ? 5 ? 16 56,76 ? #066, 76,2 =2 20,2= 1627,7 ++al

Pas4a %e(ah ' .MR 10H .MR 1790,217

++al

e%*t*han nr$al 4airan (an


61/74

e%*t*han nr$al 4airan (anele+trlit harian

P*asa ra-%e(ah sela$a 12 a$ ata*le%ih (aat $eni$%*l+an (esit4airan 5air (an ele+trlit se%an3a+ 1

liter a(a asien ran& (easa) Oran& (easa rata-rata

$e$%*t*h+an 4airan8 #0-#

$l


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e+*ran&an ata* +ele%ihan siste$ +ar(ias+*ler (an $eta%lis$et*%*h)

ELETROLIT

Setia hari a+an +ehilan&an se+itar 0-100 $eK< l (ala$ *rine, @ae4es, +erin&at)

.&.R Kebutuhan airan

16 2 tah*n 0 44< +&..< hari

2 tah*n # 44< +&..< hari

6 tah*n #0 44< +&..< hari

6 tah*n 2 44< +&..< hari

atrium $%3 me*/kgBB/hari

Chlri(a 1-# $eK


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e%*t*han 4airan asien '

#0 ? 160 44


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E./T/>AN ASAR PROTEIN


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e%*t*han rtein asien '

e%*t*han nr$al 1,2-1, &r


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Al%*$in Mer*a+an +li( ala$i (en&an rtein las$a

H (an al%*$in $an*sia (an 2,H

aat (i&*na+an a(a +as*s'

Pen&&anti l*$e las$a (an rtein a(a

+ea(aan s3+ hile$ia, hial%*$ine$ia,hirteine$ia, erasi, tra*$a,

4ar(i*l$nar3 %3 ass, hier%ilir*%ine$ia,

&a&al &inal a+*t, an4reatitis, $e(iasinitis,

sel*litis l*as (an l*+a %a+ar, ARS,Pe$%erian :*rse$i(e a$ *nt*+ $en&hin(ari

eni$%*nan Al%*$in (ala$ t*%*h)


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Pe$%erian al%*$in

a Kecepatan inus

1 Pa(a in@*s al%*$in 20H +e4eatan$a+si$al a(alah 1 $l


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Men&hit*n& +e%*t*han Al%*$interha(a asien '

4 (lbumin target % lbumin sekarang ! BB

(kg! 60 2 7 / $00

Nilai nr$al Al%*$in ' #, - , &r


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Pe$%erian N*trisi Pasien

e%*t*han +alri ' 1=00 ++al

e%*t*han 4airan ' 160 44

>1 st- 2H +e%*t*han +alri0 ++al A$in*i( 500 ++al ' RL 50044 1' 1

>2 st- 0H +e%*t*han +alri

900 ++al aen M 500 ++al 2 liter aen M 500 ++al ' A$in*i(

500 ++al 2 ' 1

anE!AL/ASI


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E!AL/ASI Status cairansetiap hari pada pasien sakit kritis

8ormulasi nutrisi parenteral harus terkonsentrasi dan natrium harus

dikurangi saat berat badan tiba%tiba meningkat $%2 kg dalam 26 9am

Kadar glukosa, natrium, kalium, status asam basa dan ungsi gin9alsetiap hari, Kadar kalsium, osor dan magnesium tiga kali dalamsatu minggu

1rigliserida, tes ungsi hati, hitung darah lengkap, aktu prothrombindan aktu tromboplastin dinilai mingguan selama ase akut cedera

Keseimbangan nitrogen dapat dihitung setelah pengumpulan urin 269am, #olume dan urea nitrogen digunakan untuk menentukanberatna katabolisme

Keseimbangan nitrogen adalah perbedaan antara asupan nitrogendan ekskresi nitrogen, keseimbangan nol nitrogen dapat ter9adi padapasien stres, sehat sebelumna dan pasien bedah ang masih muda


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SIMP/LANN*trisi enteral le%ih (ire+$en(asi+an sela$a ti(a+ a(a &an&&*an a(a

&astrintestinal)

N*trisi arenteral (i%eri+an i+a (ala$ a+t* - hari , (en&an e$%erian

n*trisi enteral ti(a+ %isa $e$en*hi +e%*t*han, +$%inasi e$%eriann*trisi enteral (an arenteral (it**+an s*a3a (aat $en4aai tar&et

+e%*t*han tra4e ele$ent $en4e&ah tera(in3a (esiensi

n(isi $eta%li+ se4ara ti$al (aat ter4aai, serta (ala$ ran&+a+re+si &an&&*an sil&i serta *nt*+ er%ai+an stat*s n*trisi,(ierl*+an +e4*+*an ener&i (ari +ar%hi(rat (an le$a+, +e4*+*an

rtein, ele+trlit, ita$in (an $ineral serta tra4e ele$ent)

Tra4e ele$en (an ita$in A, C, (an E --) @*n&si anti +si(ati@ *nt*+$en&i+at ra(i+al %e%as, $enin&+at+an @*n&si i$*nitas, (an er%ai+an

arin&an)

Xin4 $e$er%ai+i siste$ i$*n (an en3e$%*han l*+a)


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(g/


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;enis

"rod

K

(

e?tr

saNa Ca Cl La+

=5> 0 - - - - - 2

=$0> 100 - - - - -

=20> 200 - - - - - =al 0,?> - 1 - - 1 - -

al 3> - 1# - - 1# - -

$=5 0 1 - - 1 - 2

2=2,5 2 77 - - 77 - 1

2=5 0 77 - - 77 - 2

6=5 0 #= - - #= - 2

en s

"rod54al< 5$Ose?tr Na Ca Cl La+


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"rodL $

Terapi Enteral Parenteral

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