This document discusses enteral and parenteral nutrition. It begins by describing enteral nutrition, including types of enteral delivery such as oral diet or tube feeding. It then discusses indications, advantages, and effects of enteral nutrition on gut microbiota. Various techniques for enteral access like gastrostomy and jejunostomy are described. The document then discusses parenteral nutrition, including types like total or peripheral parenteral nutrition. Methods for calculating nutrient requirements and formulations for parenteral nutrition are provided. Complications of both enteral and parenteral nutrition are also summarized.

1. ENTERAL AND PARENTERAL
NUTRITION
DR KAVITA KUMARI

2. ENTERAL NUTRITION
• Delivery of nutrients into the gastrointestinal tract.
TYPES:
• Normal oral diet
• Tube feeding

3. INDICATIONS
• Inadequate oral intake >5-7days.
• Adaptive phase of short bowel syndrome
• Following severe trauma (Head and neck) and burns.
• Mechanical ventillation
• Dysphagia (Post stroke)
• Post operative cases for early gastrointestinal tract
rehabilitation.
• Metastatic Carcinoma esophagus

4. ADVANTAGES
• Preserves gut Integrity
• Decreases bacterial translocation
• Preserves immunological functions of the gut
• Few complications
• Safe and cost effective

5. EFFECT OF ENTERAL NUTRION ON GUT
MICROBIOTA

6. CONTRAINDICATIONS
• High output proximal fistula
• Intractable vomitting /Diarrhoea
• Paralytic ileus
• Intestinal obstruction
• Severe Gasrointestinal bleed (increase splanchnic
blood flow and variceal bleed)

7. ACCESS TECHNIQUES
• <4 Weeks : (i)Nasogastric tube- Gastric feed
(ii)Nasoenetric tube -Post pyloric feed
(Nasoduodenal,Nasojejunal)
• >4-6 Weeks: (i)Gastrostomy
(ii)Jejunostomy
Via Endoscopy
Radiologically
Open surgery

8. GASTRIC FEED
Advantages:
• More physiological
• Ease of placement
Disadvantages:
• Delayed Gastric emptying
• Gastroesophageal reflux and apsiration

9. POST PYLORIC FEED
Advantages:
• Minimizes risk of aspiration
Disadvantages :
• Difficulty with placement
• Feeding Intolerance

11. STAMM GASTROSTOMY
• Patient is laid supine with feet lower than head.
• Under LA and asepsis,a small incision is made high in the left
mid rectus region and the muscle is split.
• The mid anterior gastric wall is grasped with babcock forceps
and purse string sutures taken.
• A stab incision made in the abdominal wall and the tube is
passed .
• An incision is made in the stomach using electrocautery for
tube passage about which the wall is inverted using 2nd purse
string suture.
• The gastric wall is anchored to the peritoneum and closed
in layers.
• The tube is fixed to the abdominal skin with non
absorbable sutures.

12. STAMM GASTROSTOMY

13. JANEWAY GASTROSTOMY
• Under LA and asepsis,an upper midline incision
given and the abdomen opened in layers.
• Stomach is held with babcock forceps and a
horizontal flap of tissue is raised.
• The stomach is closed in layers and the flap is closed
in a tubular fashion which is further brought up by a
stab incision and the mucosa fixed to abdominal skin.
• Tube is inserted along the path and fixed to the
abdominal skin.

14. JANEWAY GASTROSTOMY

15. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY
• Under sedation, Gastroscope is passed into the stomach
which is inflated with air.
• After switching off the lights ,the area of transillumination
is marked.
• Under LA, 1cm skin incision is made and an intravenous
cannula is inserted into the abdominal and gastric wall.
• A guide wire is inserted through the cannula which is
puuled out through the mouth using polypectomy snare.
• A PEG catheter is inserted along the guide wire onto the
incision site.
• Tube is secured from outside using a stopper and fixed to
the skin with non absorbable sutures.

16. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

17. STAMM JEJUNOSTOMY
• Under GA , midline skin incision close to the umbilicus is
given.Abdomen opened up in layers.
• A loop of jejunum close to the ligament of Teritz is identified.
• A concentric purse string suture is taken over it.
• A stab incision is made while clamping the ends and a feeding
tube is passed which is tightened by the inner and outer purse
string suture.
• The jejunum is anchored to the peritoneum with non absorbable
sutures.
• The other end of the tube is taken out of the abdominal wall
through another incision.
• The tube is fixed to the abdominal wall with non absorbable
sutures.

18. STAMM JEJUNOSTOMY

19. WITZEL JEJUNOSTOMY
• Under GA, midline skin incision is given, a loop of
jejunum is identified.
• A concentric purse string suture is taken over the jejunum.
• A portion of the feeding tube is buried by interrupted
sutures, and then using a stab incision over the purse string
sutures, the tube is pushed inside.
• The tube is secured by tightening the knot.
• The jejunum is anchored to the peritoneum along the
direction of peristalsis.
• The other end of the tube is taken out through the
abdominal wall by a stab incision.
• The tube is fixed to the abdominal wall using non
absorbable sutures.

20. WITZEL JEJUNOSTOMY

21. ADMINISTRATION
Bolus
Continuous
Intermittent
cyclic

22. BOLUS FEEDING
Infusion of up to 500 ml of enteral
formula into the stomach over
5 to 20 minutes, usually by gravity
or with a large-bore syringe
Indications:
• Recommended for gastric
feedings
• Requires intact gag reflex
• Normal gastric function

23. CONTINUOUS FEEDING
Enteral formula administration into the gastrointestinal tract
via pump or gravity, usually over 8 to 24 hours per day
Indications:
• Initiation of feedings in acutely ill patients
• Promote tolerance
• Compromised gastric function
• Feeding into small bowel
• Intolerance to other feeding techniques

24. INTERMITTENT FEEDING
Enteral formula administered at specified times throughout the
day ; generally in smaller volume and at slower rate than a
bolus feeding but in larger volume and faster rate than
continuous drip feeding
• Typically 200-300 ml is given over 30-60 minutes q 4-6
hours
Precede and follow with 30-ml flush of tap water
Indications:
• Intolerance to bolus administration
• Initiation of support without pump
• Preparation of patient for rehab services or discharge to
home facility

25. CYCLIC FEEDING
Administration of enteral formula via continuous drip over a
defined period of 8 to 12 hours, usually at night.
Indications:
• Ensure optimal nutrient intake when:
• Transitioning from enteral support to oral nutrition
(enhance appetite during the day)
• Supplement inadequate oral intake
• Free patient from enteral feedings during the day

26. COMPLICATIONS
Tube related:
• Malposition
• Displacement
• Blockage
• Leakage
• Erosion of skin
Infective:
• Abscess
• Necrotising fascitis

27. Metabolic:
• Refeeding syndrome
• Electrolyte disorder
Gastrointestinal:
• Diarrhoea
• Constipation
• Aspiration
• Abdominal cramps
• Bloating
• Nausea, vomitting
• Persistent Gastric fistula

28. PARENTERAL NUTRITION
• Provision of all nutritional requirements by means of
intravenous route without the use of gastrointestinal tract.
TYPES:
• TPN-Total/central parenteral nutrition
• PPN-Partial/Peripheral parenteral nutrition
Routes:
• Central vein
• Peripheral vein

29. PERIPHERAL PARENTERAL
NUTRITION
• Peripheral veins
• Less than 2weeks.
• Osmolarity less than 900mosm/l, preferably
600mosm/l
• Easy and safe venous access
• Avoids morbidity associated with central parenteral
nutrition

30. INDICATIONS
• Post opeartive patients where requirement is 7-
10days.
• Central venous catheter not possible e.g,
Coagulopathy
• Sepsis or bacteremia

31. CONTRAINDICATIONS
• Patients of cardiac,renal hepatic failure
(provides larger fluid volume).
• Prexisting moderate to severe malnutrition.
• Critically ill patients.

32. CENTRAL PARENTERAL
NUTRITION
• Central venous catheter positioned into superior or
inferior vena cava.
• Osmolarity 1000-1900mosm/l(hypertonic).
• Moderate to severe malnutrition

33. SITES OF INSERTION:
1.Short term central access:
• Subclavian vein(infraclavicular approach)
• Internal jugular vein
2.Long term central access
• Tunneled catheter and implanted subcutaneous ports
via subclavian or internal jugular vein into SVC.
3.Percutaneous inserted central catheter(PICC):
• Antecubital vein into SVC

36. Delivery system
Multiple bottle system:
Advantages:
• Ease of adjustment
Disadvantages:
• Needs monitoring (risk of hyperglycemia)
• Risk of incompatibility (improper mixing)

37. DELIVERY SYSTEM
Three in one system:
Advantages:
• Convenient and time saving
• Cost saving
• Less chance of infection
• Better nutrient assimilation(slow infusion)
Disadvantages
• Lack of flexibility
• Less stability due to lipids

38. DURATION OF DELIVERY
CONTINUOUS INFUSION:
• slow infusion throughout the day in critically ill
patients.
CYCLIC INFUSION:
• 8-12hrs at night
• Safe and stable patients
• Home parenteral nutrition

39. INDICATIONS
• Inadequate oral or enteral nutrition for 7-10days
• Short bowel syndrome
• High output enetrocutaneous fistula
• Anastomotic leak
• Paralytic ileus
• Intestinal obstruction
• Motility disorders
• Sepsis with multiorgan failure
• Severe acute pancreatitis
• Hyperemesis gravidarum

40. CONTRAINDICATIONS
• Coagulopathy
• Fluid overload
• Electrolyte disturbance
• Severe liver failure,cardiac failure

41. ADVANTAGES
• Provides bowel rest in case of anastomotic leak.
• Prevents malnutrition
• Prevents catabolic state of body
• Prevents muscle wasting
• Improves wound healing

42. METHODS FOR ESTIMATING
ENERGY REQUIREMENTS (kcal)
1. Simple body weight based calculation:
REE(kcal /day) = 25 x weight
2. Harris - Benedict Equation:
REE(Man) = 66+(13.7xW) + (5.0 x H) – (6.7 X A)
REE(Woman) = 655+(9.6xW) + (1.8 x H) – (4.7 X A)
3. Indirect calorimetry :
REE(Man) = (39 x VO2) + (1.1 x VCO2) – 61

43. CALCULATION OF DAILY
REQUIREMENTS
• Fluid requirement: 35ml/kg
• Calorie requirement: 25kcal/kg
• Protein requirement: 1gm/kg body weight
• Fat requirement: 30% of total calories
• Carbohydrate requirement: 50-70% of total calorie

44. CALCULATION OF
REQUIREMENTS OF PARENTERAL
NUTRITION
1. Fluid requirement: 35ml/kg x60 (60kg man) = 2100ml/day.
2. Calorie requirements: 25kcal/kg x60 = 1500kcal
3. Protein requirements: 1gm/kg x60 = 60gmx4 =240 kcal =
600ml of 10% amino acid.
4. Fat requirement : 30% of total calories= 30% of 1500 =
450kcal = 500ml of 10% lipid emulsion.
5. Carbohydrate requirement: 1500-(240+450)kcal = 810 kcal
=202.5gm dextrose= 1000ml of D20.

45. CALCULATION OF TPN

46. CALCULATION OF TPN
So, for 60kg man,
• 1TPN + 1 CELEMINE + 6D25=
(1000+500+600ML)=2100ml
• Calorie = 320kcal(TPN GLUCOSE)+200KCAL(Lipid
TPN)+600KCAL)=1120kcal
• Protein = 22g(TPN)+40gm (CELEMINE)= 62gm
• Carbohydrate =80gm(TPN)+150gm(D25)=230gm

47. INITIATION OF PARENTERAL
NUTRITION
• Slow infusion (pancreatic beta cells to adapt)
• Goal: 50% on 1st day
• 75% on 2nd day
• 100% on 3rd and 4th day.

48. NUTRITION REQUIREMENTS
IN SPECIAL CASES
ENERGY
REQUIREME
NTS
PROTIEN
REQUIREME
NTS
CARBOHYD
RATE
REQUIREME
NTS
LIPID
REQUIREME
NTS
NORMAL
INDIVIDUAL
25kcal/kg/day 0.8-1gm/kg/day 3-4gm/kg/day
(50-70 % of
total calories)
1gm/kg/day
(30% of total
calories)
Severe acute
pancreatitis
25-
35kcal/kg/day
1.2-
1.5gm/kg/day
4-6gm/kg/day 2gm/kg/day
Compensated
cirrhosis
25-
35kcal/kg/day
1gm/kg/day 50% 25-35%
Cirrhosis with
encephalopathy
35-
45kcal/kg/day
0.5gm/kg/day 50-70% 30-40%
Uncomlicated
ARF
25kcal/kg/day 0.8g/kg/day 50-70% 30%

49. NUTRITION REQUIREMENTS
IN SPECIAL CASES
ENERGY
REQUIREME
NTS
PROTIEN
REQUIREME
NTS
CARBOHYD
RATE
REQUIREME
NTS
LIPID
REQUIREME
NTS
Compliated
ARF
25kcal/kg/day 1.5-
1.8gm/kg/day
(50-70 % of
total calories)
(30% of total
calories)
Pulmonary
disease
25-
35kcal/kg/day
1gm/kg/day 70% 30%
Weaning from
mechanical
ventillation
25-
35kcal/kg/day
1gm/kg/day 50% 50%
Cardiac disease EN Deferred untill patient is hemodynamically stable(risk of volume
overload ,electrolyte abnormalities and uremia)

50. Monitoring of parenteral nutrition
• Chest x ray
• Vitals 4hrly
• Daily Weight
• Dressing thrice/week or if wet
• Blood sugars 6hrly till patient is stable then once daily
• Serum electrolytes,LFT,KFT,serum albumin daily then
twice weekly
• INR and clotting factors baseline then weekly
• Hgm,hct and tlc baseline then weekly

51. COMPLICATIONS
Mechanical:
• Malposition
• Hemothorax/Pneumothorax/Air embolism/subclavian
artery puncture
• Catheter displacement/thrombosis/occlusion/tear

52. COMPLICATIONS
Metabolic:
• Fluid overload
• Hyperglycemia
• Electrolyte disturbances e.g., hypophosphatemia,
hypokalemia,hypomagnesemia
• Essential fatty acid defeciency
• Vitamin defeciency
• Refeeding syndrome

53. COMPLICATIONS
INFECTIONS:
• Catheter induced sepsis
• Exit site infection

54. CASE REPORT
• A 68 year old woman diagnosed with Metastatic
nasopharyngeal carcinoma was referred to the surgery OPD
i/v/o nasogastric tube palcement.
• Nasogastric tube could not be placed i/v/o obstruction and
the patient was further planned for feeding jejunostomy.
• Calculated BMI found to be 16.5

55. PATIENTS AT HIGH RISK OF
REFEEDING SYNDROME
• Post operative patients
• Inflammatory bowel disease
• chronic pancreatitis
• Short bowel syndrome
• Prolong starvation (Anorexia nervosa , oncology patients
• Long term users of antacids and diuretics(electrolyte
imbalance)
• Elder patients with comorbidities and decresaed
physiological reserve
• Chronic alcoholic patients

56. NICE GUIDELINES ON HIGH RISK
PATIENTS FOR REFEEDING
SYNDROME

57. MANAGEMENT

58. THANK YOU