Enteral and Parenteral Nutrition, indications, complications

Enteral and Parenteral Nutrition: Indications, complications, how to calculate parenteral nutrition

1. Enteral and P arenteral Nutrition Nazia Asad 28 Dec 2020 Updated 15 th, 17 th October 2025

2. Learning Objectives Understand Basic concept of enteral and parenteral nutrition. Differentiate basic routs of Enteral and Parenteral Nutrition. Calculate the calories for parenteral nutrition. Identify the characteristics, nutritional composition and concentration of Formula feedings. Complications associated with enteral feeding and parenteral feeding.

3. What is parenteral nutrition? What is parenteral nutrition? Parenteral nutrition, or intravenous feeding, is a method of getting nutrition into your body through your veins. Depending on which vein is used, this procedure is often referred to as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN). This form of nutrition is used to help people who can’t or shouldn’t get their core nutrients from food. It’s often used for people with: Crohn’s disease cancer short bowel syndrome ischemic bowel disease

4. Enteral tube feeding Nutrition plays an important role in maintaining health as well as in the prevention and management of a variety of diseases. Nutritional support is therapy for people who cannot get enough nourishment by eating or drinking. Enteral tube feeding is the delivery of nutrients directly into the digestive tract via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route . It is used to feed patients who cannot obtain an adequate oral intake from food and/or oral nutritional supplements, or who cannot eat/drink safely. Enteral feeding is used commonly in patients with dysphagia – any impairment of eating, drinking and swallowing. 3

5. TPN (Total Parenteral Nutrition)

6. Gastrostomy feeding tubes are put in for different reasons. Gastrostomy feeding tubes are put in for different reasons . They may be needed for a short period of time or permanently. This procedure may be recommended for: People, potentially babies, with birth defects of the mouth, esophagus, or stomach (for example, esophageal atresia or tracheal esophageal fistula) Persons who cannot swallow correctly Persons who cannot take enough food by mouth to stay healthy

7. What is exclusive enteral nutrition? What is exclusive enteral nutrition? Children with  inflammatory bowel disease (IBD)  often have trouble gaining weight. Intestinal inflammation often makes it difficult for their bodies to absorb the nutrients needed to help them grow. In addition, impaired bone growth and delayed puberty may also occur in children managing IBD. Exclusive Enteral Nutrition (EEN) is the recommended first-line therapy to treat active  Crohn’s disease . The formula-based (no solid foods) diet is designed to induce remission in patients. It is a short-term program and may extend six to 12 weeks.

8. Total parenteral nutrition  (TPN) Parenteral nutrition is by definition given IV. Partial parenteral nutrition  supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method. Total parenteral nutrition  (TPN) supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required. Parenteral nutrition should not be used routinely in patients with an intact gastrointestinal (GI) tract. Compared with  enteral nutrition , it has the following disadvantages : It causes more complications. It does not preserve GI tract structure and function as well. It is more expensive . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition

9. Indications for TPN Indications TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following: Some stages of ulcerative colitis Bowel obstruction Certain pediatric GI disorders ( eg , congenital GI anomalies, prolonged diarrhea regardless of its cause) Short bowel syndrome due to surgery

10. Nutritional content Nutritional content TPN requires water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day, depending on energy expenditure; up to 45 kcal/kg/day for critically ill patients), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals  Children who need TPN may have different fluid requirements and need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).

11. Nutritional content Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism , or other factors. Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/minute of dextrose is given. Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

12. Nutritional content Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories may help obese patients mobilize endogenous fat stores, increasing insulin sensitivity . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

13. TPN Solutions TPN Solutions Many TPN solutions are commonly used. Electrolytes can be added to meet the patient’s needs. TPN solutions vary depending on other disorders present and patient age, as for the following: For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein content and a high percentage of essential amino acids For heart or kidney failure: Limited volume (liquid) intake For respiratory failure: A lipid emulsion that provides most of nonprotein calories to minimize carbon dioxide production by carbohydrate metabolism For neonates: Lower dextrose concentrations (17 to 18%) https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

14. Beginning TPN administration Beginning TPN administration Because the central venous catheter needs to remain in place for a long time, strict sterile technique must be used during insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques. If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged. The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular insulin/L of TPN fluid . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

15. Calculating calories for Parenteral nutrition How much fluid the patient needs may also depend on sodium status and comorbidities. Fluid status is difficult to assess – but this is generally a decent first start to determine maintenance fluids. Most adult patients will tolerate a 1.5-2.5 L/day of PN . (https:// www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

16. Holliday- Segar method Weight Daily requirements 3-10 kg 100ml/kg 11-20 kg 1000ml + 50 ml/kg for each kg >10kg >20 kg 1500ml + 20 ml/kg for each kg >20kg The Holliday-Segar Method for estimating fluid requirements. For example, a 50 kg patient would require 2100 mL/day (1500 + 20*30). Let’s make it easy and say patient requires ~2 L/day. How much fluid the patient needs may also depend on sodium status and comorbidities. Fluid status is difficult to assess – but this is generally a decent first start to determine maintenance fluids. Most adult patients will tolerate a 1.5-2.5 L/day of PN.

17. Parentral N utrition solution Due to the risk of thrombophlebitis, these solutions are generally limited to an osmolarity of < 600-900 mOsm /l

18. An Example of Calculating Macronutrients for Parenteral Nutrition An Example of Calculating Macronutrients for Parenteral Nutrition Patient 1: 50 year old Female (50kg, 167cm) with ischemic bowel and history of physiologic short gut syndrome admitted for malnutrition. Patient has multiple decubitus ulcers/sacral wounds. We already determined her fluid needs are ~2000 mL/day and her metabolic needs are ~1500 kcal/day. Proteins: 1.5-2 g/kg (based on wounds) 1.5*(50 kg) – 2*(50 kg) = 75 - 100 g protein/day 75 - 100 g protein/day * (4 kcal/g) = 300-400 kcal/day from protein Fats: 250 mL bag of lipids/day * 2 kcal/mL = 500 kcal/day from fat Carbohydrates: 1500 kcal/day – kcal protein – kcal fats = kcal of dextrose needed 1500kcal – 400 kcal protein – 500 kcal fats = 600 kcal dextrose 600 kcal dextrose/(3.4 kcal/g dextrose) = 176 g dextrose needed 176 g dextrose/2000mL * Xg /100mL (cross multiply and solve for X) = 8.8% dextrose GUR ( G lucose utilization rate): [85 mL/ hr x 8.8%]/[50 kg x 6] = 2.5 mg/kg-min (which is less than the max of 4 for GUR) Note: You may need to start with lower glucose and work up to goal to prevent refeeding syndrome depending on how long patient has been without adequate nutrition . (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

19. Estimate Rate of Infusion for Parenteral Nutrition 5. Estimate Rate of Infusion for Parenteral Nutrition To determine rate of PN, use your fluid volume requirements from step 1, divide by 24 hours in a day, and now you have your PN rate in mL/hr. But you can’t just start with that. Sorry. When you determine a rate, start low and go slow. Initiate PN at 25mL/ hr for 8 hours, increase by 25mL/ hr every 8 hours to the final goal rate. Don’t mess this up, you’ll end up spending the next few days treating refeeding syndrome (significant, quick drops in K, Mg, and Phos ) and be really mad that you gave them too much sugar. Start your first PN bag with a low dextrose solution . (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

20. Calculating calories for Parenteral nutrition Hypometabolic Normometabolic Hypermetabolic Ischemic stroke Sepsis Wound healing/trauma Spinal cord injury Post-elective surgery Organ transplant Neuromuscular block COPD Burns Encephalopathy Renal failure/liver failure Traumatic brain injury

21. Calculating calories for Parenteral nutrition Normometabolic patients usually require 25-30 kcal/kg/day. For hypometabolic patients, consider decreasing your weight-based caloric need estimate to 20-25 kcal/kg. For hypermetabolic patients, increase to 30-35 kcal/kg . However, the magic comes in when a patient is obese or malnourished. Permissive underfeeding in critically ill obese patients is defined in the 2016 ASPEN guidelines. Implement a high protein, hypocaloric feeding to preserve the lean body mass and minimize overfeeding. Patients with a BMI of 30-50 should receive 11-14 kcal/kg/day of Actual Body Weight, and people with BMI >50 should receive 22-25 kcal/kg/day of Ideal Body Weight. In this case, comparing weight-based dosing to the other equations would help to find common ground between the patient’s energy requirements and calorie restriction needs. The more protein you can use to make up those calories, the better . (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

22. Macronutrients requirement in Parenteral nutrition Nutrition is broken down into the three main macronutrients: protein, fats, and carbohydrates. PROTEIN (provides 4 kcal/gram) – “Do you even lift, Bro?” There are 20 amino acids necessary for…basically everything. These can be broken down into essential amino acids and then further into branch chain amino acids (leucine, isoleucine, valine, aka The Girls - Lucy, IsoLucy , and Val - as my mentor likes to call them) and aromatic amino acids (phenylalanine, tryptophan, and tyrosine). Proteins are hydrolyzed to smaller fragments and larger fragments require digestion. On the other hand, di- and tri- peptides are absorbed directly. The type of protein becomes important when you have a patient with absorption or digestion issues. While this is more of an issue in enteral nutrition, it is important to recognize how the type of protein could be a barrier to successful enteral nutrition. It is also important to remember that protein is needed for wound healing. Give as much protein as you can -> give them all the “GAINZ.” The following are some ideas of how to estimate daily protein requirements : Maintenance, Unstressed: 0.8 - 1 g/kg Mild stress: 1 - 1.2 g/kg Infection, Major surgery, Cancer, Critically ill: 1.3 - 1.6 g/kg Multiple trauma or CHI: 1.4 - 1.6 g/kg Large wounds, Protein-losing enteropathy: 1.5 - 2 g/kg >20% Total Body Surface Area burns: 2 - 3 g/kg (https ://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

23. Macronutrients requirement in Parenteral nutrition FATS (provide 9 kcal/gram; or easier to remember, 20% IV Fat Emulsion provides 2 kcal/ml) – IV lipids are easy! They come in a bag, so just give the (affectionately dubbed) Fat Bubbles! Fats are important to maintain integrity of cellular membranes and provide 30-40% of calories needed. Intravenous fat emulsions are long chain triglycerides derived from safflower or soybean oil with purified egg yolk phospholipids. Which means if a patient has an egg allergy, no Fat Bubbles for them . (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

24. Clinical Pearls about Fats: Clinical Pearls about Fats: Compatible with the other components of PN but have to be infused with a filter (usually 1.2 micron). Check triglycerides (goal TG <200 mg/ dL ). Patients on propofol may not need many/any lipids since propofol = 1.1 kcal/mL of fats ! (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

25. Macronutrients requirement in Parenteral nutrition CARBOHYDRATES (provide 3.4 kcal/gram) - Make up the difference with sugar! Carbohydrates are the preferred fuel for the brain and blood cells. So they are the original “brain food”, which is even more reason to eat that pasta you have been craving. If a patient is diabetic, insulin regimens will need to be adjusted to keep the patient’s glucose under control. You can add insulin to the bag, but if a patient becomes hypoglycemic – you’ve wasted an entire PN bag. Bottom line, just give insulin outside of the PN (regular insulin that is!). If the patient is not diabetic, decrease the dextrose when the glucose is >180 mg/ dL . Studies have shown that patients can easily be overfed if glucose concentrations are too high based on initial clinical assessment. Some clinicians will calculate a Glucose Utilization Rate (GUR or GIR) to determine how quickly a patient is storing/depleting the dextrose. GUR should not exceed 4 mg/kg-min, because fats providing 40 to 60 percent of calories will meet the energy requirements of most critically ill patients. GUR = [(Rate of PN x % dextrose) / (kg weight x 6 )] (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

26. Estimate the Patient’s Micronutrient Needs 4. Estimate the Patient’s Micronutrient Needs Calcium/Phosphate precipitation 25 mMol /L of phos + Calcium 10mEq/L + 6% amino acids is the maximum. Less than 6% amino acids will increase risk of precipitation. Sodium 90% of sodium acetate is converted to sodium bicarbonate 70 mEq /L of sodium chloride will generally keep patients normonatremic if they are at goal when initiated on PN Recommended Maximum Electrolytes Sodium (Na): 130 mEq /L (that’s pretty salty) Potassium (K): 80 mEq /L (watch your heart) Magnesium (Mg): 12-16 mEq /L Calcium (Ca): 10 mEq /L Phosphorus ( Phos ): 25 mMol /L (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

27. Estimate the Patient’s Micronutrient Needs When to add thiamine, folate, and vitamins? How about every day? Most are water soluble, and there’s really no such thing as an overdose. Vitamin K (Hold for patients on warfarin…) Vitamins: Be Oprah - You get a vitamin! You get a vitamin! Most institutions have a standard multivitamin (MVI), of which 10 mL generally goes into each bag of PN. What about the trace elements? Zinc, manganese ,selenium, copper, and chromium Manganese and copper are metabolized by the liver and trace elements should be omitted if liver function tests are more than twice the upper limit of normal. Manganese toxicity: Parkinson’s symptoms Copper deficiency: anemia Chromium deficiency: glucose intolerance Selenium deficiency: cardiomyopathy and other muscle pain Zinc deficiency: alopecia, dermatitis, poor wound healing. Add extra for wound healing or excessive GI losses . (https://www.tldrpharmacy.com/content/the-total-rundown-on-total-parenteral-nutrition)

28. Harris Benedict equation BMR of Women: 655 + (9.6 x kg weight) + (1.8 x cm height) – (4.7 x age years) BMR of Men: 66 + (13.7 x kg weight) + (5 x cm height) – (6.8 x age yrs )

29. Monitoring Monitoring Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often ( eg , daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often. Liver tests should be done. Plasma proteins ( eg , serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured twice/week. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion. Full nutritional assessment (including  BMI calculation  and  anthropometric measurements ) should be repeated at 2-week intervals. https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

30. Characteristics, nutritional composition and concentration of formula feeding Formula selection Enteral formulas vary in caloric content from 1.0-2.0 kcal/ mL. Formulas are composed of different sources of carbohydrates, protein, fats, and micronutrients. 4 Carbohydrates The majority of energy in enteral formulas generally comes from carbohydrates, with standard/polymeric formulas providing 30-60% of energy from carbohydrates. Carbohydrates can come in the form of sucrose, fructose, corn syrup solids, or sugar alcohols. Carbohydrates in enteral formulas provide 4 kcal/gm. Protein Standard/Polymeric enteral formulas provide 10-25% of energy from protein sources, including milk protein, whey protein, casein, caseinates , or soy protein. Protein in enteral formulas provides 4 kcal/gm . ( https ://dietitiansondemand.com/enteral-nutrition-overview-formula-selection-considerations /)

31. Characteristics, nutritional composition and concentration of formula feeding Fats Standard/Polymeric enteral formulas provide 10-45% of energy from fat sources, including canola oil, corn oil, soy lecithin, safflower oil, and/or medium-chained triglycerides. Fats in enteral formulas provide 9 kcal/gm. Micronutrients Enteral formulas will meet 100% of the adult Dietary Reference Intakes (DRIs) in a volume designated on the nutrition label, which is generally 1,000-1,500 mL of formula . (https://dietitiansondemand.com/enteral-nutrition-overview-formula-selection-considerations/)

32. Characteristics, nutritional composition and concentration of formula feeding Specialty enteral nutrition formulas There are also specialty enteral formulas to meet specific nutritional needs. Some examples are listed below. Semi-elemental formula:  partially hydrolyzed; used for individuals with dysfunction in the GI tract preventing standard enteral formulas to be digested or tolerated. Elemental formula:  fully hydrolyzed; used only for individuals who cannot tolerate semi-elemental formula Disease-specific enteral formula:  specialty formulas are available for medical conditions including diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), wound healing, chronic kidney disease (on and off dialysis), liver failure, and compromised immune system. These products have varying differences in macronutrient and micronutrient content based on specific disease states (e.g., very high protein for wound healing ). (https://dietitiansondemand.com/enteral-nutrition-overview-formula-selection-considerations/)

33. Complications Complications About 5 to 10% of patients with a TPN line have  complications related to central venous access . Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skin care around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

34. Complications Glucose abnormalities  are common. Hyperglycemia can be avoided by monitoring plasma glucose often, adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged hypoglycemia may require infusion of 5 or 10% dextrose for 24 hours before resuming TPN via the central venous catheter. Hepatic complications  include liver dysfunction, painful hepatomegaly, and hyperammonemia . They can develop at any age but are most common among infants, particularly premature ones (whose liver is immature). Liver dysfunction  may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result from excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive fibrosis occasionally develops. Reducing protein delivery may help. Painful hepatomegaly  suggests fat accumulation; carbohydrate delivery should be reduced. Hyperammonemia  can develop in infants, causing lethargy, twitching, and generalized seizures. Arginine supplementation at 0.5 to 1.0 mmol /kg/day can correct it . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

35. Complications If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be necessary. Abnormalities of serum electrolytes and minerals  should be corrected by modifying subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated blood urea nitrogen may reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein. Volume overload  (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy requirements and thus require large fluid volumes. Metabolic bone disease , or bone demineralization (osteoporosis or osteomalacia ), develops in some patients given TPN for > 3 months. The mechanism is unknown. Advanced disease can cause severe periarticular , lower-extremity, and back pain. https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

36. Complications Adverse reactions to lipid emulsions  ( eg , dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/kg/hour. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions. Gallbladder complications  include cholelithiasis , gallbladder sludge, and cholecystitis . These complications can be caused or worsened by prolonged gallbladder stasis. Stimulating contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is helpful. Oral or enteral intake also helps. Treatment with metronidazole, ursodeoxycholic acid, phenobarbital, or cholecystokinin helps some patients with cholestasis . https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

37. Key Points Key Points Consider parenteral nutrition for patients who do not have a functioning gastrointestinal tract or who have disorders requiring complete bowel rest. Calculate requirements for water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day, depending on energy expenditure; up to 45 kcal/kg/day for critically ill patients), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals. Choose a solution based on patient age and organ function status; different solutions are required for neonates and for patients who have compromised heart, kidney, or lung function. Use a central venous catheter, with strict sterile technique for insertion and maintenance. Monitor patients closely for complications ( eg , related to central venous access; abnormal glucose, electrolyte, mineral levels; hepatic or gallbladder effects; reactions to lipid emulsions, and volume overload or dehydration). https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~:text=TPN%20

38. References https://www.healthline.com/health/parenteral-nutrition https://www.bostonscientific.com/en-US/patients/health-conditions/enteral-feeding.html https://www.childrenshospital.org/conditions-and-treatments/treatments/een https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn#:~: text=TPN%20 https://www.google.com/search?sca_esv=552fb68e3d08662a&sxsrf=AE3TifNCCjPsLi4UfD06AbxSukEHJTkGGg:1760512843341&udm

39. ACKNOWLEDGEMENT Allah Almighty

40. Thank you

41. Questions