This medical file is concerned with medical dental sciences and similar fields

2. Components
 Fluid
 Electrolytes
 Carbohydrates
 Proteins
 Lipids
 Vitamins
 Trace menirals

3. FLUID AND ELECTROLYTES:
Fluid intake either:
- Exogenous ( liquids consuming).
- Endogenous ( Oxidation of solid food stuffs ).

4. Fluid losses:
 Urine: The normal urine output is approximately 1500 mL/
day and provided that the kidneys are healthy
 Skin: In a temperate climate, skin (i.e. sweat) losses are
between 600 and 1000 mL/day.
 Lungs: About 400 ml of water is lost in expired air each 24 hours.
 Stool: Between 60 and 150 mL of water are lost daily in
patients with normal bowel function.
A minimum urine output of 400 mL/day is required to excrete the end
products of protein metabolism.
24 mL/kg/day is daily requirements of fluid

6. Daily Requirement of Electrolytes :
 Sodium ( Na ) = 1500 mg/day.
 Potassium ( K ) = 1 mEq/kg/day … 70 mEq/day
 Calcium ( Ca ) = 1000 mg /day
 Magnesium (Mg )= 320 mg /day for men and 420 mg /day for female
Macronutrient requirements:
Energy: Total energy requirement is 25-30 Kcal/Kg/Day.
Carbohydrate: The daily glucose requirement is 2 gm/Kg/day.
Fat: 20-35 % of total calories intake, 44-77 gm per day
Protein : The basic requirement of nitrogen is 1gm/kg/day.
Vitamins, Minerals, Trace elements: Vitamin B, C, A, D, E, K.

7. ARTIFICIAL NUTRITIONAL SUPPORT:
Indications:
 Inadequate absorption resulting from short bowel syndrome
 Gastrointestinal fistula
 Bowel obstruction (NPO)(NBM)
 Prolonged bowel rest (post operative)
 Severe malnutrition, significant weight loss and/or
hypoproteinemia when enteral therapy is not possible
 Other disease states or conditions in which oral or enteral
feeding are not an option example severe maxillofacial injury

8. Enteral nutrition :
Delivery of nutrients into G.I.T.
Alimentary tract should be used whenever possible.
Achieved by:
- Oral supplement ( Sip feeding ).
- tube-feeding techniques delivering food into the
stomach, duodenum or jejunum e.g. N/G tube,
percutaneous endoscopic gastrostomy( PEG).

11. Parenteral nutrition (TPN):
It is the provision of all nutritional requirements by means of the
intravenous route and without the use of the gastrointestinal tract.
Indications:
It is indicated when energy and protein needs cannot be met by the
enteral administration of these substrates, e.g.:
• Patients who have undergone massive resection of the small Intestine.
• Who have intestinal fistula.
• Who have prolonged intestinal failure for other reasons.

12. Peripheral Feeding :
It is appropriate for short-term feeding of up to 2 wks.
Insertion: either
• Peripherally inserted central venous catheter (PICC) line. It has the
advantage of minimizing inconvenience to the patient and clinician.
• PICC lines have a mean duration of survival of 7days.
• The disadvantage is thrombophlebitis occurs.
Short cannula in the wrist veins. It is for 12 hrs. then removed and re-
sited in the contralateral arm.

13. Central Feeding:
• The catheter can be inserted via the
• Subclavian vein
• Internal jugular vein
• external jugular vein
• The most favor is cannulation of internal or external jugular
veins as these vessels are easily accessible.
• The disadvantage is the site where situated on the side of the
neck with repeated movements result in disruption of the
dressing and the attendant risk of sepsis.
• The subclavian approach is more suitable for feeding as the
catheter then lies flat on the chest wall which optimizes
nursing care.

15. Recommendations :
Post-insertion chest x-ray is essential before feeding is commenced to
confirm the absence of pneumothorax.
The catheter tip lies in the distal part of superior vena cava to
minimize the risk of central venous or cardiac thrombosis.
The advantages: are
Minimizes the risks of insertion.
Ensures distance between the site of skin entry and the tip of the
catheter.

16. Disadvantages: are
1. Requires placement of central venous catheter:
 Cost.
 Immediate morbidities: pneumothorax, haemothorax.
 Delayed morbidities: central venous catheter infection (2-10%).
2. Metabolic abnormalities: e.g. hyperglycaemia, metabolic acidosis.
3. Intestinal mucosal atrophy: probably increases bacteraemia and
infections.