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Enteral & Parenteral nutrition

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

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Enteral & Parenteral nutrition

  1. 1. Dr. Murali. U. M.S; M.B.A. Asso. Prof. of Surgery IMS / MSU / Malaysia.
  2. 2. Hippocrates 400 B.C.
  3. 3. • Outline the indications & complications of EN • Outline the indications & complications of TPN • Illustrate with diagrams about Tube- feeding
  4. 4. • Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets.
  5. 5. • To meet the energy requirement for metabolic processes. • To maintain a normal core body
  6. 6. • 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. 7. • 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. 8. Severely Malnourished Post – op complications Trauma Burns Malignant disease Renal & Liver failure Short bowel syndrome
  9. 9. • 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. 10. Duodenal Leak Gastro-duodeno-pancreatectomy
  11. 11. ESOPHAGECTOMY COLON REPLACEMENT CAUSTIC INGESTION, ESOPHAGEAL STRICTURE
  12. 12. • 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. 13. • 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)
  14. 14. 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. 15. • Enteral nutrition • Parenteral nutrition
  16. 16. • More physiological (liver not bypassed) • Lesser cardiac work • Safer and more efficient • Better tolerated by the patient
  17. 17. • Sip feeding • NGT/ NDT/ NJT • Gastrostomy • Jejunostomy • PEG (percutaneous endoscopic
  18. 18. • Hemodynamic instability • Intestinal Obstruction / GI bleed / Ileus • Intractable vomiting / Diarrhoea • High output proximal fistula • Inability to gain access
  19. 19. 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
  20. 20. 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.
  21. 21. Patient not expected to feed in 7 -10 days Massive resection of small bowel High output fistulas Prolonged intestinal failure – some reasons
  22. 22. Central Peripheral
  23. 23. • Central – Catheter is placed using a needle & guide wire via - • Subclavian approach • Internal jugular approach • External jugular approach Superior Vena Cava
  24. 24. • Peripheral Parenteral Nutrition * Through a peripherally inserted central venous catheter. [PICC] Catheter. * Through a formal peripheral venous line.
  25. 25. • Cardiac failure • Blood dyscrasias • Altered fat metabolism
  26. 26. 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
  27. 27. • 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
  28. 28. • 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.
  29. 29. • 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.
  30. 30. Overfeeding 1980s

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