DEHIDRASI PADA ILEUS OBSTRUKTIVUS

OBSTRUKSI USUS

AKUMULASI SISA MAKANAN PEMBUSUKAN H2S

TEKANAN INTRA LUMEN MENINGKAT HAMBATAN VENA & LYMFE EDEMA & SECRESI MENINGKAT

DEHIDRASI

TINGKAT DEHIDRASI
Ringan (4% TBW) Sedang (6% TBW) Berat (8% TBW) : kembung : turgor kurang, mata cekung : syok

MAINTENANCE
Volume (anak-anak)
Weight First 10 Kg Second 10 Kg Each Kg above 20 kg ml/kg BW/h 4 2 1 ml/kgBW/day 100 50 10

Dewasa-Tua: bertahap turun dari 40-25 cc/KgBB/Jam Electrolit

Na : 1-2 meq/kg BW/ day Cl : 1-2 meq/kg BW/ day K : 1 meq/kg BW/day

CAIRAN DAN ELEKTROLIT RUMATAN 14 TAHUN 50 KG UMUR 30 TAHUN

Volume 35 CC/KG BB X 50 KG 1750 CC Natrium 50 x (1-2) meq = 50-100 meq Chlorida 50 x (1-2) meq = 50-100 meq Kalium 50x (1) meq = 50 meq
Cairan Volume (1750 CC) Kalori Protein Natrium 50-150 meq Ch1orida 50-150 meq Kalium 50-100 meq Osmolari tas

R.L. D5

500 cc 1250 cc

-250

---

65 0

54 0

2 0

273 278

KCl

50 cc
1750 cc

0
250

0
0

0
65

50
104

50
52

VOLUME & COMPOSITION OF GI FLUID LOSESS

SOURCE STOMACH DUODENUM ILUEM COLON VOLUME 1000-4200 100-2000 1000-3000 500-1700 Na 20-120 110 80-150 120 Cl 130 115 60-100 90 K 10-15 15 10 25 HCO3 -10 30-50 45 H 30-100 ----

PLASMA

142

104

4,3

24

CAIRAN REHIDRASI
VOLUME:
DEFISIT (sesuai tingkat dehidrasi) + MAINTENANCE

COMPOSISI:
DEFISIT : sesuai dengan level obstruksi (lihat tabel diatas) MAINTENANCE: sesuai dengan rumus

CARA PEMBERIAN
6 JAM PERTAMA: 50% DIHARAPKAN PERFUSI ORGAN PENTING SUDAH TERCAPAI (PRODUKSI URINE) PASIEN SIAP OPERASI 18 JAM BERIKUTNYA: 50% SISA

OVERVIEW SEPSIS MANAGEMENT (CO-ASS BEDAH UNDIP)

MANAGEMENT SEPTIC SHOCK

Vital organ support:
Mechanical ventilation Early Goal Directed Therapy

Antibiotics Source control Nutrition support

Goal during first 6 hours: # CVP 8-12 mm Hg (Mechanically ventilated patients or Increase IAP 12-15 mmHg) # MAP 65 mm Hg # Urine output 0.5 ml/kg/hour # Central Venous (Superior Vena Cava) or mixed venous oxygen saturation 70% (ScvO2)

FLUID THERAPY
Target CVP 8 mm Hg ( 12 mm Hg if mechanically ventilated) (1 C) Fluid challenges in patients with suspected in adequate arterial circulation: 500-1000 cc crystalloid or 300-500 cc colloid over 30 minutes. More rapid and larger volume may be required in sepsis-induced tissue hypoperfusion (1 D)

VASOPRESSOR
1. Fluid challenge fails to restore adequate blood pressure and organ perfusion vasopressor (Grade E) 2. Maintain MAP 65 mm Hg (1C) 3. Norepinephrine and dopamine centrally administrated are the initial vasopressor ( 1C) 4. Epinephrine, phenylephrine or vasopressin should not be administrated as the initial vasopressor in septic shock (2C) 5. Use epinephrine as the first alternative agent in septic shock when blood pressure is poorly responsive to norepinephrine or dopamine (2B) 6. Do not use low-dose dopamine for renal protection (1 A) 7. Requiring vasopressor --> insert arterial catheter (1D)

MONITORING INITIAL RESUSCITATION

During the first 6 hrs of resuscitation if Scvo2 of 70% is not achieved with fluid resuscitation to a central venous pressure of 8-12 mm Hg, then transfuse PRBC to achieve a hematocrit of 30% and/or administer a dobutamin infusion to achieve this goal. (Grade 1 B)

INOTROPIC
Use dobutamine in patients with myocardial dysfunction as supported by elevated cardiac filling pressures and low cardiac output (1C) Do not increase cardiac index to predetermined supranormal level (1B)

Overview NURTRISI BEDAH (Co-Ass Bag. Bedah UNDIP)

Prof. Riwanto Sub.Bag. Bedah Digestif
BACAAN: NUTRITION ON SURGICAL PATIENTS

CEKLIST NUTRISI
Apakah ada indikasi untuk pemberian nutrisi? Apakah ada kontraindikasi pemberian nutrisi? Apakah pemberian perioperative atau hanya pasca bedah? Apakah jalur oral/ enteral bisa dimanfaatkan? Apakah hanya jalur parenteral saja atau kombinasi? Apakah volume sediaan sesuai dengan kebutuhan? Apakah elektrolit dasar sudah terpenuhi? Apakah dosis pemberian sudah menyesuaikan dengan kondisi metabolik pasien? Apakah pemberian karbohidrat sudah disesuaikan dengan kondisi metabolik pasien? Apakah pemberian lemak sudah disesuaikan dengan kebutuhan dan kondisi metabolik pasien? Apakah pemberian protein sudah disesuaikan dengan penyakit tertentu pada pasien dan kondisi metabolik? Apakah vitamin, mineral dan trace element sudah dipenuhi? Apakah jalur sudah menyesuaikan dengan osmolaritas? Apa yang perlu dimonitor selama pemberian nutrisi?

MALNUTRITION IN HOSPITAL
40% - 45% of hospitalized patients: malnutrition or potentially malnutrition. 50% of surgical patients are malnutrition 12% severe malnutrition. Complication 3 times higher Higher mortality Longer LOS Hospital cost increase by 35%-75%
Gallagher-Alfred, et al : J Am Diet Assoc 1996:96;361-369

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

Ability to consume and absorb adequate

nutrients orally or by enteral tube feeding

Hemodynamic instability

Who profits from nutrition support pre-operative?

Severely malnourished patients profit from enteral or parenteral nutrition support the most. About 10% of post operative complications can be reduced especially for severe malnourished patients
ASPEN 2002 and Metabolic Work Group 2004

TRAUMA

Modified from: Samy et al. Critical Role of Hormones in Traumatic Injury and Outcome In Vincent (ed) Yearbook of Intensive Care and Emergency Medicine 2003

POST OPERATIVE NUTRITION

START LOW and GO SLOW BIASA DIMULAI HARI PERTAMA DENGAN DOSIS AWAL MAKSIMAL 50% KEBUTUHAN HARI KE II BISA DINAIKKAN 75% HARI KE III BILA MEMUNGKINKAN SUDAH MENCAPAI MENDEKATI 100%

NUTRISI PASCA-BEDAH
LAKI-LAKI 30 TAHUN, LAPARATOMI KARENA PERFORASI LAMBUNG (TUKAK PEPTIK) MALNUTRISI, BB 50 KG, TB 160 CM, BMI=17.57, GENGGAMAN LEMAH, Hb 11 GR%, TOTAL PROTEIN 5,7 ALBUMIN 3,1 BUATLAN PROGRAM NUTRISI PASCA BEDAH

MAINTENANCE
Volume (anak-anak)
Weight First 10 Kg Second 10 Kg Each Kg above 20 kg ml/kg BW/h 4 2 1 ml/kgBW/day 100 50 10

Dewasa-Tua: bertahap turun dari 40-25 cc/KgBB/Jam Electrolit

Na : 1-2 meq/kg BW/ day Cl : 1-2 meq/kg BW/ day K : 1 meq/kg BW/day

CAIRAN DAN ELEKTROLIT RUMATAN 30 TAHUN 50 KG

Volume 50 Kg 1750 cc Natrium 50 x (1-2) meq = 50-100 meq Chlorida 50 x (1-2) meq = 50-100 meq Kalium 50x (1) meq = 50-meq
Cairan Volume (1750 CC) Kalori Protein Natrium 50-150 meq

FASE EBB (H0 PASCA BEDAH BISA? MENGEMBANGKANNYA MENJADI NUTRISI PARENTERAL?
Ch1orida 50-150 meq Kalium 50-100 meq Osmolari tas

CAIRAN DAN ELEKTROLIT RUMATAN 30 TAHUN 50 KG

Volume 50 1750 cc Natrium 50 x (1-2) meq = 50-100 meq Chlorida 50 x (1-2) meq = 50-100 meq Kalium 50x (1) meq = 50 meq
Cairan Volume (1750 CC) Kalori Protein Natrium 50-150 meq

FASE EBB (H0 PASCA BEDAH BISA? MENGEMBANGKANNYA MENJADI NUTRISI PARENTERAL?
Ch1orida 50-150 meq Kalium 50-100 meq Osmolari tas

R.L. D5

500 cc 1250 cc

-250

---

65 0

54 0

2 0

273 278

KCl

50 cc
1750 cc

0
250

0
0

0
65

50
104

50
52

Calculation energy requirements

RULE OF THUMB

Calorie requirement= 25-30 kcal/kg/day

NUTRIENT
Protein 4 kcal/g Carbohydrates - enteral 4 kcal/g - parenteral 3.4 kcal/g Lipids 9 kcal/g Water Vitamins - water soluble (Bc, C, folic acid, biotin, pantothenic) - fat soluble (A,D,E,K) Minerals - electolytes (K,Na,Cl) - trace elements (Cu Zn, Mn) - ultra trace elements ( I, Cr, Mo, Se)

NUTRITIONAL REQUIRREMENT - Calory 25 - 30 kcal/kg/day - Protein 1.2 - 2.0/kg/day - Non protein calory: Nitrogen 100 - 150 : 1 (100 - 150 calories / gram nitrogen) Stress patients need more protein

- Non protein calory 70 - 80% dextrose Lipid (MCT/LCT lipid emulsion) * Essential polyunsaturated fatty acids - Vitamin & minerals - Water & electrolyte

Macronutrients during stress

Carbohydrate At least 100g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30-40% of total calories Glucosa intake should not exceed 5 mg/kg/min
TNT version 2, 2003

Macronutrients during stress

Fat Provide 20-35% of total calories Maximum recommendation for intravenous lipid infusion: 1,0-1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance
TNT version 2, 2003

Macronutrients during stress

Protein Requirement range from 1.2-2.0 g/kg/day during stress Comprise 20-30% of total calories during stress

TNT version 2, 2003

KEBUTUHAN NUTRIEN KASUS DIATAS BERAT BADAN 50 KG KALORI: 50X 30 = 1500 KCAL PROTEIN 50X (1,2-2) = 60-100 GR
HARI KALORI PROTEIN

I (50%)
II (75%) III (100%)

750 kcal
1125 kcal 1500 kcal

30-50 gr
45-75 gr 60-100 mg

Rasio KH: Fat 60-70 : 40-30 %

PROGRAM NUTRISI HARI I

Cairan Volume (1750 CC) Kalori 750 Protein 30-50 Natrium 50-150 meq Ch1orida 50-150 meq Kalium 50-100 meq Osmolarit as MOS/L

KENMG3 TRIFLUID

500 500

200 210

0 0

25 17,5

25 17,5

10 10

695 800

AMINO VEL 600

500
250 25

200
100 0

25
0 0

17,5
0 0

19
0 25

12,5
0 25

1145
278

D5 Kcl 7.46%

1775

710

25

55

86,5

57,5

JALUR: VENA PERIFIR AMINOVEL DICAMPUR KAENMG3

PROGRAM NUTRISI HARI II

Cairan Volume (1750 CC) Kalori 1125 Protein 45-75 Natrium 50-150 meq Ch1orida 50-150 meq Kalium 50-100 meq Osmolarit as MOS/L TRIPARE N1 KENMG3

500 500 500 250 12,5

466 200 0 225 0

0 0 50 0 0

2,5 25 1 0 42,5

7,5 25 0 0 42,5

22,5 10 0 0 0

1458 695 911

AMIPAR EN

IVELIP 10% NaCl 20%

KCl 7,46%

25
1800

0
891

0
50

0
70

25
100

25
57,5

JALUR VENA SENTRAL

PROGRAM NUTRISI HARI III

Cairan Volume (1750 CC) Kalori 1500 Protein 60-100 Natrium 50-150 meq Ch1orida 50-150 meq Kalium 50-100 meq Osmolarit as MOS/L TRIPARE N2 AMINOV EL 600

500 500 500 250 12,5

584 200 0 450 0

0 25 50 0 0

29 17,5 1 0 42,5

36,5 19 0 0 42,5

22,5 12,5 0 0 0

1889 1145 911

AMIPAR EN

IVELIP 20% NaCl 20%

KCl 7,46%

25 1782,5

0 1234

0 75

0 89

25 123

25 60

JALUR VENA SENTRAL

ABDOMINAL COMPARTMENT SYNDROME

(overview untuk coass bangian bedah FK Undip)

Normal ventilation with effective diaphragm

Abdominal content pushing upward

Abdominal Compartment Syndrome (ACS)

Alterations in cardiovascular hemodynamics, respiratory mechanics and renal function that occur as a result of a sustained increase in intraabdominal pressure.

Awareness of the ACS has increased:

1. Laparoscopy 2. Planned repeat laparotomy for trauma
(Nathens et al. CJS Vol 40, 1997)

Adverse physiologic effects of IAH A. Respiratory

Elevated diaphragm: decrease thoracic volume increased thoracic pressure and decreased dynamic compliance Increased Peak Respiratory Pressure: ventilation-perfusion abnormality Increased Pulmonary Vascular resistance - Intrapulmonary shunt Hypoxemia, hypercarbia, respiratory acidosis

Adverse physiologic effects of IAH B. Cardiovascular

False increases in CVP, PCWP, SVR Decrease in Venous Return due to - retroperitoneal vein compression pooling blood caudally, - narrowing IVC at the diaphragm due to elevated diaphragm. Decrease in Cardiac output Tachycardia, Blood pressure usually unaffected Pooling blood in the extremities: bilateral deep vein thrombosis

Adverse physiologic effects of IAH C. Renal

Increased renal vascular resistance Direct compression (renal compartment syndrome) Increased plasma renin and aldosteron Decrease RBF Reduce urine output Oliguria Anuria. Oliguria is often in earliest sign of ACS (IAH 15-20 mmHg)

INCREASE IAP 20 mm Hg - GFR = 21% of normal - RBF = 23% of normal - Reno vascular resistance 55%

Adverse physiologic effects of IAH D. Abdominal Wall

Decreased Abdominal Wall Blood Flow (IAP 10 mm Hg: blood flow reduce 60%) Pressure-volume curve is not linear (the IAP rises, stiffness of abdominal wall increases) so progressively smaller volume increments are required to further elevate IAP. Increased wound infection & fascial dehiscence

Adverse physiologic effects of IAH E. Splanchnic Blood

Decreased Hepatic Blood Flow decreased hepatocyte mitochondrial function Decreased Mesenterial Blood Flow Promote gut mucosal ischaemia acidosis, bowel edema and production of oxygen free radicals IAP possible bacterial translocation

Adverse physiologic effects of IAH F. Neurological

Intra thoracic pressure CVP Jugular venous pressure cerebral venous outflow

cerebral perfusion pressure, may potentially aggravate neuronal disease. Intracranial pressure

Grading system for ACS

Grade Bladder pressure (Cm H2O) mmHg

I II III IV

10-15 15-25 25-35 >35

7- 11 11-18 18-26 >26

Burch JM et al. Surg. Clin North Am 1996;76:838, Hiat JR.Trauma Secret 2nd ed, 2003.

Percentage of patients with respective organ dysfunction per grade of ACS

Grade UO<0.5 ml/kg/hr 0% 0% 65% 100% PAP>45
(Cm H2O)

SVR>1000
(dyne/sec/cm2)

DO2I <600
(mlO2/min/m2)

I II III IV

0% 40% 78% 100%

0% 20% 65% 100%

0% 20% 57% 100%

PAP=Peak Airway Pressure);DO2I=Oxygen Delivery Index; SVR= Systemic Vascular Resistance; UO= Urine output
Meldrum DR et al Am J Surg 1997;174:667

Diagnosis of ACS
High index of suspicion Clinical syndrome
Abdominal distention Peak inspiratory pressure CVP (if patients euvolumic) Oliguria Hypercarbia

Diagnosis of ACS
Measuring IAP IAP> 25 mmHg correlates with renal dysfunction IAP> 25 mmHg in postoperative patients with adequate blood volume and oliguria indication for decompression laparotomy

Prophylaxis and Treatment of IAH

Temporary closure of fascia to patients at high risk for IAH ICU/SICU management Monitoring gastric mucosal pH and use this variable as end-point of resuscitation IAP is measured every 4-6 hours / more frequently Persistent evaluation>20-25 mm Hg is an indication for re-exploration

Temporary closure of abdominal wall

(Sherck et al, The Am. Surgeon Vol 64, 1998)

Response to abdominal decompression

et al. CJS Vol 40, 1997)

(Nathens

HERNIA ABDOMINALIS (OVERVIEW COAS BEDAH FK. UNDIP)

BENJOLAN INGUIAL

TESTIS

APA BEDA TORSIO TESTIS (GAMBAR KIRI) DAN HERNIA SCROTALIS (GAMBAR KANAN)?

GAMBARAN & GERAKAN PERISTALTIK

GAMBAR SAMPING Apa locus minoris resistensiae? Bagaimana bentuk kantong? Bisa mencapai scrotum? Bisa inkarserata? Bisa stangulata? Beda dengan torsio testis? Beda dengan hydrocele (lihatgambar bawah)

Semi circular bulging

RM

Funiculus spermaticus

Hernial sac

PERHATIKAN GAMBAR Apa HT? IL? IE? RM? Hernia apa? Apa bedanya dengan kasus didepan? Apa bisa inkarserata? Apa bisa strangulata? Apa bisa masuk ke skrotum?

KASUS II

SIAS
Pubic Tubercle

bulging

Wanita 65 tahun, agak kurus, benjolan selakang kanan tdk bisa masuk, perut kembung, muntah bau tinja. Dimana Lig Inguinale? Apa diagnosis? Apa lokus minorisnya? Bagaimana batas-batasnya? Apa bentuk kantongnya? Apa faktor risiko terjadinya? Apa diagnosa banding? Mengapa mudah inkarserata? Apa persiapan pra-bedah? Bagaimana prinsip operasinya? Apa beda dengan kasus didepan?

PERHATIKAN GAMBAR DIATAS

Apa hernioraphy? Kapan dilakukan? Apa herniotomy? Kapan dilakukan? Apa Hernioplastic? Apa saja macamnya? Hernioplastic mana yang saat ini menjadi standard ? Mengapa?