Discussion about nutrition in surgical patients.

1. Enteral and
Parenteral
Nutrition Support
Dr Ashish Tripathi
Gen Surgery PGT,
RTIICS, Kolkata.

3. Enteral Nutrition Definition
Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.

4. Conditions That Require Other
Nutrition Support
Enteral
—Impaired ingestion
—Inability to consume adequate nutrition
orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth
Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral
tolerance or accessibility

5. Considerations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance

6. Formula Selection
The suitability of a feeding formula should be
evaluated based on
Functional status of GI tract
Physical characteristics of formula (osmolality,
fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte
needs or restriction
Cost effectiveness

7. Enteral Access: Clinical Considerations
Duration of tube feeding
—Nasogastric or nasoenteric tube for short term
—Gastrostomy and jejunostomy tubes for
long term
Placement of tube
—Gastric
—Small bowel

8. Placement Site
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning

10. Enteral Tube Placement

12. Advantages—Enteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not
possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with
disease state

13. More Advantages—
Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial
translocation
Preserves immunologic function of gut
Increased compliance with intake

14. Disadvantages—Enteral Nutrition
GI, metabolic, and mechanical complications
—tube migration; increased risk of bacterial
contamination; tube obstruction;
pneumothorax
Costs more than oral diets
Less “palatable/normal”
Labor-intensive assessment, administration,
tube patency and site care, monitoring

15. Complications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)

17. Aspiration Pneumonia
Can result from enteral feeds
High-risk patients
—Poor gag reflex
—Depressed mental status

18. Reducing Risk of Aspiration
Check gastric residuals if receiving gastric
feeds
Elevate head of the bed >30 degrees during
feedings
Postpyloric feeding
—Nasoenteric tube placement may require
fluoroscopic visualization or endoscopic
guidance
—Transgastric jejunostomy tube

19. Rate and Method of Delivery*
Bolus—300 to 400 ml rapid delivery via
syringe several times daily
Intermittent─300 to 400 ml, 20 to 30 minutes,
several times/day via gravity drip or syringe
Cyclic—via pump usually at night
Continuous—via gravity drip or infusion pump
*Determined by medical status, feeding route and
volume, and nutritional goals

20. Lower Osmolality
Large (intact) proteins
Large starch molecules

21. Higher Osmolality
Hydrolyzed protein or amino acids
Disaccharides

22. Tolerance
Signs and symptoms:
—Consciousness
—Respiratory distress
—Nausea, vomiting, diarrhea
—Constipation, cramps
—Aspiration
—Abdominal distention

23. Tolerance—cont’d
Other signs and symptoms
—Hydration
—Labs
—Weight change
—Esophageal reflux
—Lactose/gluten intolerances
—Glucose fluctuations

24. How to Determine Energy and
Protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
Example: Patient drinks 200 cc of a 15.3%
protein product that has 1 kcal/ml
1 kcal/ml x 200 ml = 200 kcal
0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal= 7.65 g protein

25. Energy in Formulas
1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration

26. Protein
From 4% to 26% of kcal is possible
14% to 16% of kcal is usual
18% to 26% of kcal—considered to be
high-protein solution

27. Recommended Water
Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to
85% water
Elderly: consider 25 ml/kg with renal, liver,
or cardiac failure; or consider 35 ml/kg if
history of dehydration

28. Sources of Fluid (“Free Water”)
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with
water about 3 times daily—include this
amount in estimated needs
—Example: “flush with 200 cc tid”

29. Administration: Feeding Rate
Continuous method = slow rate of 50 to 150
ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of
feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml
several time a day (“push” is not desired)

30. French Units—Tube Size
Diameter of feeding tube is measured in
French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types
and administration techniques.

31. Enteral Nutrition Monitoring

32. Routes of Parenteral Nutrition
Central access
—TPN both long- and short-term placement
Peripheral or PPN
—New catheters allow longer support via
this method limited to 800 to 900 mOsm/kg
due to thrombophlebitis
<2000 kcal required or <10 days

33. PPN vs. TPN
Kcal required
(10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated

34. Venous Sites from Which the Superior Vena Cava
May Be Accessed

35. Advantages—Parenteral Nutrition
Provides nutrients when less than
2 to 3 feet of small intestine remains
Allows nutrition support when GI
intolerance prevents oral or enteral
support

36. Indications for Total
Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food

37. Contraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)

38. Calculating Nutrient Needs
Avoid excess kcal (> 40 kcal/kg)
Adults
kcal/kg BW
Obese—use desired BMI range or an
adjusted factor

39. Adjusted Body Weight
Adjusted IBW for obesity
Female:
([actual weight – IBW] x 0.32) + IBW
Male:
([actual weight – IBW] x 0.38) + IBW

40. Parenteral Components
Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml

41. Protein Requirements
1.2 to 1.5 g protein/kg IBW
mild or moderate stress
2.5 g protein/kg IBW
burns or severe trauma

42. Carbohydrate Requirements
Max. 0.36 g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems

43. Lipid Requirements
4% to 10% kcals given as lipid meets
EFA requirements; or 2% to 4% kcals
given as lineoleic acid
Usual range 25% to 35% max. 60% of
kcal or 2.5 g fat/kg

45. Other Requirements
Fluid—30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements

46. Calculating the Osmolarity of a
Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5.
Example: 50 g of dextrose x 5 = 250 mOsm/L
2. Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L
3. Fat is isotonic and does not contribute to
osmolarity.
4. Electrolytes further add to osmolarity.
Total osmolarity = 250 + 300 = 500 mOsm/L

47. Compounding Methods
Total nutrient admixture of amino acids,
glucose, additives
3-in-1 solution of lipid, amino acids,
glucose, additives

48. Administration
Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs
or switch to dextrose IV)
Cyclic give 12 to 18 hours per day

49. Monitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome

52. Refeeding Syndrome
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest

53. Monitor
Weight
(daily)
Blood
Daily
Electrolytes (Na+
, K+
, Cl-
)
Glucose
Acid-base status
3 times/week
BUN
Ca+,
P
Plasma transaminases

54. Monitor—cont’d
Blood
Twice/week
Ammonia
Mg
Plasma transaminases
Weekly
Hgb
Prothrombin time
Zn
Cu
Triglycerides

55. Monitor—cont’d
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration (daily)
WBC and differential (as needed)
Cultures (as needed)

56. Problems
PPN
Site irritation
TPN
1. Catheter sepsis
2. Placement problems
3. Metabolic

57. Document in Chart
Type of feeding formula and tube
Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and
corrective actions
Patient education

60. Now the onus is on you.