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

1. Dr. Murali. U. M.S;
M.B.A.
Asso. Prof. of Surgery
IMS / MSU / Malaysia.

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
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

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
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

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