Enteral & Parenteral nutrition

This PPT - is based on the chapter in Bailey & Love. Mostly for MBBS - Students. Mainly for nutritional assessment and feeding techniques.

1. Nutrition in Surgery Dr. Murali . U. M.S ; M.B.A. Asso . Prof. of Surgery IMS / MSU / Malaysia.

2. ‘ A slender and restricted diet is always dangerous in chronic and in acute diseases ’ Hippocrates 400 B.C.

3. Learning Outcomes Outline the indications & complications of EN Outline the indications & complications of TPN Illustrate with diagrams about Tube-feeding techniques

4. Definition Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets.

5. Nutritional Support – Fundamental Goals To meet the energy requirement for metabolic processes. To maintain a normal core body temperature. For tissue repair.

6. Principles of Nutrition 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 useful

7. Nutritional Assessment 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 MUST - Tool

8. Indications for Nutritional Support  Severely Malnourished  Post – op complications  Trauma  Burns  Malignant disease  Renal & Liver failure  Short bowel syndrome

9. Indications for Nutritional Support 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 Whipple’s procedure

10. Indications for Nutritional Support Duodenal Leak Gastro- duodeno - pancreatectomy

11. Indications for Nutritional Support ESOPHAGECTOMY COLON REPLACEMENT CAUSTIC INGESTION, ESOPHAGEAL STRICTURE

12. Nutritional Requirements 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

13. Nutritional Requirements 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) Vitamins / Minerals & Trace elements

14. Monitoring Feeding Regimes Nutrition Daily Weekly Fortnightly Body wt. / Temp CBC / RBS / BUN I-O / electrolytes Plasma proteins LFT/ Acid-base status Ca / Mg / Zn / Po4 U & P osmolality Sr-Vit B12 / Iron / Folate Sr -Lactate Trace elements

15. Routes of nutrition support Enteral nutrition Parenteral nutrition

16. Enteral Nutrition

17. Enteral Nutrition-Advantages More physiological ( liver not bypassed) Lesser cardiac work Safer and more efficient B etter tolerated by the patient More economical

18. Enteral Nutrition-Access Sip feeding NGT / NDT/ NJT Gastrostomy Jejunostomy PEG (percutaneous endoscopic gastrostomy)

19. Contraindications of EN Hemodynamic instability Intestinal Obstruction / GI bleed / Ileus Intractable vomiting / Diarrhoea High output proximal fistula Inability to gain access Anticipating complications

20. Complications Severity Tube – related Gastro-intestinal Metabolic Infective Malposition / Displacement Block / Break / Leakage Local complications N V D Aspiration Constipation Electrolyte disorders Vitamins / minerals Def. Drug interactions > Exogenous / Endogenous

21. Parenteral Nutrition

22. Definition 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.

23. Indications for TPN  Patient not expected to feed in 7 -10 days  Massive resection of small bowel  High output fistulas  Prolonged intestinal failure – some reasons

24. TPN - Access  Central  Peripheral

25. Central Access Central – Catheter is placed using a needle & guide wire via - Subclavian approach Internal jugular approach External jugular approach Superior Vena Cava

26. Peripheral Access Peripheral Parenteral Nutrition * Through a peripherally inserted central venous catheter. [PICC] Catheter. * Through a formal peripheral venous line.

27. Contraindications of TPN Cardiac failure Blood dyscrasias Altered fat metabolism

28. Complications Severity Nutrition Over - feeding Sepsis Line Hypoglycaemia / Ca /P/Mg ( refeeding syndrome) Chronic deficiency syndromes (EFA, Zn, mineral and trace elements) Glucose- Hyperglycaemia , fluid retention, electrolyte abn . Fat- Hypertriglyceridemia A.A- Aminoacidaemia , uraemia , metabolic acidosis Catheter related Systemic sepsis Drug interactions > On insertion – PT / AE / bleeding > Long-term use - occlusion, VT

29. Advantages - Enteral v/s PN 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

30. Refeeding Syndrome 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.

31. Home Parenteral Nutrition 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.

32. ICU Nutrition through the ages Overfeeding 1980s

33. References

34. “ Less you eat, you are malnourished More you eat, more you are diseased ”