Prof . M.C. Bansal.
MBBS; MS. MICOG. FICOG.
Founder principal & Controller ;
Jhalawar Medical College And Hospital , Jhalawar.
Ex Principal & Controller ;
Mahatma Gandhi Medical College And Hospital ; Sitapur.,
We now need more attention to patient’s diet and
dietary habits; but more often we send him away with
quick Verbal advice and hastily written prescription .
Principles of Nutrition
Avoiding malnutrition is the main goal of nutrition
therapy; as mal nutrition is associated with increased
morbidity and mortality of any disease or operative
procedure done / to be done in near future.
Malnutrition increases chances of sepsis, poor
recovery , wound healing , increased respiratory
complications and decrease tolerance to many
drugs(chemotherapy) and radiotherapy.
Whenever possible GIT ( enteral ) route of nutrition
should be used ideally. If it is not possible than only
parenteral route is to be used.
Principles of Nutrition---
Over feeding should be avoided as it causes hyper
glycaemia, Hepatic steatosis , raised BUN and excessive
Timing and type is also equally important.
Properly planned nutritional therapy reduces protein
Immunomodulators like glutamin , arginin and mega3
fatty acids are also need supplementation. Glutamin is a
non essential amino acid synthesized in skeletal muscles. It
is necessary for cell proliferation during tissue repair .
Glutamin helps in GI mucosal proliferation , maintains
mucosal integrity . Improves immune function and prevent
translocation of bacteria.
Normal adult = 40 Kcal / KG / Day .
Adult with catabolism = 60Kcal / KG / Day.
It is given as ---
> Fat -30 – 40 % .
> Protein – 10 – 15 % .
Caloric Value ---
Carbohydrate—4 Kcal / gm.
Fat --- 9 Kcal / gm.
Protein --- 3 Kcal / gm.
1-1.5 ml / Kcal of energy required., in normal
physiological conditions ; to be increased in
cicustences like excessive sweating , fever , vomiting
, diuresis. Diarrhoea and diseases with water and
Calculation of normal water loss =50-100ml in feces +
500-1000ml in exhalation + 1000 ml by kidney
depending on solute load +Temperature ( add 100 ml
for each centigrade rise in temperature).
Indications for Nutritional Support
Preoperative nutritional depletion –to be corrected.
Post operative complications—sepsis, ileus , fistula.
Anorexia nervosa and intractable vomiting .
Patient with Renal / hepatic failure.
Post delivery .
Special attention to diabetics , hypertensive PIH
,Obese patients in OB –Gy Floors.
Body weight .
Mid arm circumference.
Triceps skin Thickness.
Serum Albumin level .
Lymphocyte count .
Carbohydrates, fats, proteins, vitamins, minerals
, anti oxidants and trace elements .
Water and plenty of fibers in diet .
Methods of Feeding
a. Gastro intestinal tract is the best route of feeding.
b. Enteral feeding can be given by bolus(oral semisolid/solid / liquid
food may need ingestion ,Chewing and deglutination ), By gravity or
using mechanical pump to push it down in GI.
c. By mouth : requires common sense , cleanliness and compassion .
d. By Nasogastric Tube : Nasogastric tube (ryle’s tube ) is put in and its
right introduction is confirmed by pushing 5ml of air and
auscultation of bubbling sound in stomach area. Feeding rate is 30-
50 ml / hour . %hours gap at night is given to let gastric Ph return to
normal . Problems with Tube feeding are Blockage , nausea and
vomiting –Aspiration, Hyperosmolality , Diarrhoea , tube discomfort
, Cholestasis , Pull out by patient .
e. By Enterostomy Gastrostomy, Jejunestomy., soluble fiber
containing diet with sufficiently required nutrients and calori a re
better to prevent diarrhoea.
Methods of feeding --Enteral
Complication of tube Feeding
> Aspiration, wound infection and leak—in cases of
gastrostomy and jejunostomy.
> Diarrhoea due to rapid feeding and Hypo -
> Hyperglycaemia , hypokalaemia.
> Refeeding syndrome due to hypokalaemia and
Advantages of Enteral Feeding
Enteral feeding preserves mucosal proteins , digestive
enzymes , IgA secretion ; prevents mucosal atrophy
and bacterial translocation.
It is more physiological as nutrients absorbed in
jejunum and ileum pass through liver first before
processing / storage. Gallstone formation is prevented
as gall bladder maintains its contractility.
It is cost effective with minimal problems and
complications even after long term feeding.
It supplies glutamine and short chain fatty acids to gut
Contra Indication of Entreat
Intestinal obstruction , GI bleed, paralytic ileums , severe
diarrhea and high out put fistula.
Low cardiac out put / aerodynamically unstable patient.
If safe assess to entreat feeding is not available .
Complications are anticipitated.
Total Pareteral Nutrition ( TPN)
All nutrition requirements are given through
About 5% hospitalized patient need TPN.
Central venous catheter ---Put in Subclavian
, internal jugular where tip of venous catheter reaches
at distal part of superior vena cava.
It can be peripheralPerenteral nutrition ---Through
a peripherally inserted venous catheter / canula/
butter fly or vene section
Technique Of TNP
Using a needle or guide wire a subclavian vein catheter
is passed just below clavicle and fixed to skin with
micropore adhesive tap .
TPN is better given through central vein and not
through peripheral vein( butterfly , small canola/
needle of 22/ 24 gaze ) . Peripherally inserted central
vein catheter(as in Femoral Vein—inferior vena cava)
can also be used .
Indication Of TPN
Failure or any contra indication for enteral nutrition for 7-
High out put abdominal fistula, duodenal , biliary /
Major abdominal surgery .
peritonitis , paralytic Ileus.
Massive GI bleed / unstable haemodynamics.
High risk of aspiration .
Hyper emesis Gravidorum .
MODS , head injury , coma. Severe burns.
Goal Factors For TPN
To decrease adverse effects of catabolism.
To increase protein synthesis, to reduce protein break
down and to prevent weight loss.
To support on going metabolism .
To improve immune function.
To improve cardiac and respiratory function.
To maintain glycogen reserve in cardiac and skeletal
To maintain acid –base and electrolyte metabolism .
Assessment in TPN
Age, morbid state, muscle mass and weight should be noted.
Underlying disease, its severity, therapies given / continued till date , GI function is to be
> serum albumin level , Serum electrolytes, p02.pco2. ph , Blood sugar , Blood
urea, serum retaining , SGOT and SGPT other enzyme study as per individual case.
> CBP, Platelet count , BT, CT and clot retraction time and coagulation / fibrinolysis as
per need of case.
> urine analysis –Ph , Na+ , urea , Protein ,casts and hourly output.
(a) Assessment of fluid requirement
1500 ml for 20 kg body weight + 20 ml / kg for additional weight.
(b) Energy requirement assessment
Resting Energy expenditure ( REE) .1. by simple calculation : REE in Kcal /day = 25 X
Wt in KG.
2. Herris Benedict equation : REE in woman =655+ (9.6 X weight ) + (1.8 X ht)- ( 4.7X
Physical activity / disease / body temperature are also added.
3. Indirect Calorimettry : it is more accurate method. , done by using special instrument .
REE =(3.9 X Vo2 ) + (1.1 X Vco2 ) – 61.
Note VCo2 means---
Vo2 Means ------
Component Used in TPN
Amino acids ---
Trace Elements ---
Fluids– as vehicle and to meet its daily requirement as
Components in TPN----Carbohydrates
Dextrose is less costly and provide 3.4 Kcal / gm , can be
used in 50-70% concentration through central venous
catheter/ per oral .
It supplies 50- 60 % of require calories, stimulate insulin
release and aerobic oxidation of glucose, prevents neo
glucogenesis, there by prevents muscle protein breakdown
and thus has nitrogen sparing ability and prevention of
1. low caloric value as compared to fats.
2.Require large fluid volume to infuse .
3. Hyperglycemia if develops causes more CO2 production
4. High osmolality in High concentration( > 10% solution )
5.Rate of dextrose infusion is 5mg / kg / min.
Components In TPN –Fats
Fats give high calorie (1gm = 9 Kcal.)
Essential fatty acids – given as emulsion containing Triglycerides---Emulsion is
prepared from Sunflower/soybean oil with egg phospholipids (emulsifying
factor) and Glycerin (isotonic ).
Fat has low osmolality (260m mol /L); It is available as 10%, 20% ,30% emulsion
Advantage of fat in TPN : high calorie input , prevents hyperglycemia, Lees
CO2 and insulin production , prevents essential Fatty acid’s deficiency ; if given
3times a week and reduces thrombophlebitis i.e. prevention of problems which
may develop with high concentration dextrose therapy.
Problems with Fats IN TPN : Hypertrigyceraemia, sepsis , fat embolism , fat
over load , hepatic dysfunction, delayed gastric emptying and Pancreatitis,
Lipid emulsion is good culture media for bacteria and fungi -- > chances of
development of sepsis.
Triglyceride levels should be monitored weekly ; if > than 400mg% , infusion
should be discontinued .
Mixture of long and medium chain fatty acids is better tolerated and more
Lipid emulsions are avoided in in hyperlipidaemia, obesity , anaemia and
Components In TPN--- Amino acids
They are source of proteins.
Caloric Value 1gm=3-4 Kcal ; ^.25 gm protein contains 1 gm
IN TPN 20% calories are provided by proteins ; daily need
is 0.8 -1.5 gm/ Kg .
Less protein is given in cases of chronic live and renal
disease as blood urea and serum creatinin levels are high .
It is used in more ratio in cases of burns
, trauma, sepsis, enteropathy.
Protein supplement should not exceed 1.7 gm/ Kg/day, if so
it will cause raise blood urea .
Uses of amino acids in TPN ---in protein anabolism
, prevents catabolism .
Monitoring --- by doing BUN / ammonia level .
Vitamins,electrolyts minerals trace
Electrolytes like Na+, K=, Cl-, Mg++, Ca++, HCO3
Fat soluble Vitamins: Vitamin A , D , E, K.
Water soluble vitamins : B 1, 2,6,12,Methyl
cholamin,Folic acid and C.
Trace elements : iodine , zinc , Copper , chromium ,
iron, manganese and selenium.
Anti Oxidants : Vat: C,A, Zinc, selenium etc.
Monitoring The Patient On TPN
Body weight recording .
Fluid balance ( input and out put recording ).
Biochemical tests done on alternate day or twice awake
: blood sugar , urea, Electrolytes(Na, K, Magma and
Phosphates ),Triglycerides , serum creatinin , Total
proteins and AG ratio , LFT.
Weight gain > 1 KG / day signifies Fluid over load ; to
Complication Of TPN
A. Technical Air embolism , pneumothorax , bleeding
, Venous Catheter (displacement , sepsis
, block)., infection and thrombosis.
B. Biochemical electrolyte imbalance , hyper / hypo
osmolality , hyperglycaesmia, dehydration / fluid over
loading . Altered immunological and reticulo-
endothelial function., azotaemia.
C . Others Dermatitis , anaemia, increased capillary
permeability , Cholestatic Jaundice; severe hepatic
statuses, metabolic acidosis, candidasis, staphylo cocal
infection ( 10-15% cases ).
Contra Indications For TPN
Cardiac Failure .
Altered fat metabolism.
Anabolic steroid Durabolin( 25mg) Injection is
given weekly to improve nitrogen balance.
Home Parenteral TPN
It is becoming popular .
It is common in western countries.
It is indicate in short bowel syndrome or any condition
where enteral therapy is not feasible .
Pt himself uses the TPN fluid as advise at his home; he is
permitted to go home with TPN catheter. Patient should
attend TPN clinic weekly for follow-up , monitoring and
admission if any problem / complication is suspected.
Patient will have better psychology, comfortable and can
attend his job.
It decreases hospital bed load .
It is cost effective.
Re Feeding Syndrome
Re feeding syndrome is occurrence of severe fluid and
electrolyte imbalance in severely malnourished patient
while starting the proper feeding enteral or parenteral
It is more common in TPN .
It causes hypomagnesaemia, hypocalcaemia and hypo
phosphataemia leading to cardiac dysfunction, altered
level of consciousness, convulsion and often death.
Gradual feeding and correction of Mg ,Ca, phosphorus
deficiency and other electrolyte imbalance.
Condition is more common in chronic starvation
, severe anorexia and chronic alcoholics. s