Enteral nutrition (EN) and parenteral nutrition (TPN) are important nutritional support methods. EN is preferred when possible as it is more physiological and safer. TPN is indicated when EN is not feasible due to conditions like short bowel syndrome or high output fistulas. Both methods aim to meet caloric and protein needs but can have complications like refeeding syndrome, infections, and line issues that require monitoring.

1. Prof.dr.ir.Faisal Ali
• Enteral nutrition
• Parenteral nutrition

2. Hippocrates 400 B.C.

3. • Outline the indications & complications of
EN
• Outline the indications & complications of
TPN
• Illustrate with diagrams about Tube-
feeding

4. • Nutritional support is the
provision of nutrients to
patients who cannot
meet their nutritional
requirements by eating
standard diets.

5. • To meet the energy
requirement
for metabolic processes.
• To maintain a normal core
body

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. • 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

9. Severely Malnourished
Post – op complications
Trauma
Burns
Malignant disease
Renal & Liver failure
Short bowel syndrome

10. • 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

11. Duodenal Leak Gastro-duodeno-pancreatectomy

12. ESOPHAGECTOMY COLON REPLACEMENT
CAUSTIC INGESTION, ESOPHAGEAL STRICTURE

13. • 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

14. • 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)

15. 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

16. • Enteral nutrition
• Parenteral nutrition

18. • More physiological
(liver not bypassed)
• Lesser cardiac work
• Safer and more efficient
• Better tolerated by the
patient

19. • Sip feeding
• NGT/ NDT/ NJT
• Gastrostomy
• Jejunostomy
• PEG (percutaneous
endoscopic

21. • Hemodynamic instability
• Intestinal Obstruction / GI bleed /
Ileus
• Intractable vomiting / Diarrhoea
• High output proximal fistula
• Inability to gain access

22. Severity
Tube – related
Metabolic
Infective
 Malposition /
Displacement
 Block / Break / Leakage
 Local complications
Gastro-intestinal  N V D
 Aspiration
 Constipation
 Electrolyte disorders
 Vitamins / minerals Def.
 Drug interactions
> Exogenous / Endogenous

24. 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.

25. Patient not expected to
feed in 7 -10 days
Massive resection of small
bowel
High output fistulas
Prolonged intestinal failure
– some reasons

26. Central
Peripheral

27. • Central – Catheter is placed
using a needle & guide wire
via -
• Subclavian approach
• Internal jugular approach
• External jugular approach
Superior
Vena Cava

28. • Peripheral Parenteral Nutrition
*Through a peripherally inserted
central venous catheter. [PICC]
Catheter.
*Through a formal peripheral
venous line.

31. • Cardiac failure
• Blood dyscrasias
• Altered fat metabolism

32. Severity
Nutrition
Sepsis
Line
(refeeding syndrome)
 Hypoglycaemia/Ca/P/Mg
 Chronic deficiency syndromes
(EFA, Zn, mineral and trace
elements)
 Glucose- Hyperglycaemia,
Over - feeding
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

33. • 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

34. • 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.

35. • 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.

36. Overfeeding
1980s