• Enteral nutrition
• Parenteral nutrition Prof.dr.ir.Faisal
Hippocrates 400 B.C.
•
Outline the indications & complications
of EN
•
Outline the indications & complications
of TPN
•
Illustrate with diagrams about
Tube- feeding
• Nutritional support is the
provision of nutrients to
patients who cannot
meet their nutritional
requirements by eating
standard diets.
• To meet the energy
Requirement for metabolic
processes.
• To maintain a normal core
body temperature.
• Avoiding of malnutrition
• Enteral nutrition – Ideal one
• Overfeeding to be avoided
• Timing & Type of nutrition
• Nutrition therapy protein
wasting
• Immunomodulators – glutamine,
arginine, omega 3 fatty acids – very
• No single “ Gold Standard ”
• Body wt.loss > 10% - 6mths – prognostic index
Body mass index : weight (kg)/ height (m2)
[ <18 .5 – nutritional impairment ]
• Anthropometric measures – Indirect
measures
- TSF / MAC – muscle & fat mass
• Transport proteins –
(Sr.alb.-30mg/dl, prealb.-12g/dl,transferrin-
150mmol/L)
• Immune incompetence –
TLC / Delayed Hypersensitivity
Severely Malnourished
Post – op complications
Trauma
Burns
Malignant disease
Renal & Liver failure
Short bowel syndrome
• Patient not expected to feed in 7
days
Prolonged ileus or intestinal
obstruction
Entero - cutaneous fistulas
Pancreatitis, U C, Pyloric
stenosis
Major bowel surgery
• Esophageal replacement
• Gastric or colon surgery
Duodenal Leak Gastro-duodeno-pancreatectomy
ESOPHAGECTOMYCOLON REPLACEMENT CAUSTIC INGESTION,
ESOPHAGEAL STRICTURE
• Basic Needs
* 25-30 kcal/kg/day
• Hospitalized patients - TER
* 1300 - 1800 kcal/day – rough
• Basic Nutritional
Requirements
*Carbohydrates, fat,
proteins, vitamins minerals &
trace elements
• Feeding regimen – planned
* Standard tables - available
• For Carbohydrates - Glucose [40-
50%]
* 100-200 g/day
• For Fat - EFA [30-40%]
* 100-200 g/week
• For Protein – N2 [10-15%]
* 0.10-0.15g/kg/day (1.25g/kg/day)
Body wt. / Temp
Daily
CBC / RBS / BUN
I-O / electrolytes
Nutrition Plasma proteins
LFT/ Acid-base status
Weekly
Ca / Mg / Zn / Po4
U & P osmolality
Sr-Vit B12 / Iron / Folate
Sr-Lactate
Fortnightly
Trace elements
• Enteral nutrition
• Parenteral nutrition
• More physiological
(liver not bypassed)
• Lesser cardiac work
• Safer and more
efficient
• Better tolerated by the
patient
• Sip feeding
• NGT/ NDT/ NJT
• Gastrostomy
• Jejunostomy
• PEG (percutaneous
endoscopic
• Hemodynamic instability
• Intestinal Obstruction / GI bleed /
Ileus
• Intractable vomiting / Diarrhoea
• High output proximal fistula
• Inability to gain access
Malposition /
Tube – related Displacement
Block / Break
/ Leakage
Local
complication
Severity Gastro-intestinal N V D
s
Aspiration
Constipation
Metabolic Electrolyte disorders
Vitamins / minerals Def.
Drug interactions
Infective
> Exogenous / Endogenous
Total parenteral nutrition
(TPN) is defined as the
provision of all nutritional
requirements by means
of the I.V route & without
the use of GIT.
Patient not expected to
feed in 7 -10 days
Massive resection of small
bowel
High output fistulas
Prolonged intestinal failure
– some reasons
Central
Peripheral
• Central – Catheter is placed
using a needle & guide wire
via -
• Subclavian approach
• Internal jugular approach
• External jugular approach
Superior
Vena Cava
• Peripheral Parenteral Nutrition
*Through a peripherally inserted
central venous catheter. [PICC]
Catheter.
*Through a formal peripheral
venous line.
• Cardiac failure
• Blood dyscrasias
• Altered fat metabolism
Hypoglycaemia/Ca/P/Mg
Nutrition (refeeding syndrome)
Chronic deficiency syndromes
(EFA, Zn, mineral and trace
elements)
Glucose- Hyperglycaemia,
fluid retention, electrolyte abn.
Severity Over - feeding
Fat- Hypertriglyceridemia
A.A- Aminoacidaemia,
uraemia, metabolic acidosis
Catheter related
Sepsis Systemic sepsis
Drug interactions
Line > On insertion – PT / AE /
bleeding
> Long-term use - occlusion, VT
• Preserves gut integrity
• Possibly decreases bacterial translocation
• Preserves immunological function of gut
• Reduces costs
• Fewer infectious complications in critically ill
patients
• Safer and more cost effective in many settings
• Is occurrence of severe fluid & electrolyte imbalance in
severely malnourished pts. while starting {RE-FEEDING}
EN/TPN. More common in TPN.
• Causes -
* ↓ Mg, ↓ Ca, & ↓ Po4 → myocardial dysfn.,
resp.changes, altered liver fns, convulsions & death.
• Commonly seen → chronic starvation, severe anorexia &
alcoholic pts.
• Gradual feeding & correction of Mg, Po4 & ca. & other
electrolytes & vitamins is important.
• It is becoming popular in Western countries.
• Indicated in Pts. who require nutrients for long term –
extensive Crohn’s, mesenteric infarction etc.
• Pt. uses the TPN fluids as advised at home. A
indweling Silastic catheter is designed for long term
use.
• Pt. should attend TPN clinic weekly – follow-up or any
complications.
• Pt. is psychologically comfortable & can attend his job
also.
Overfeeding
1980s
