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Parenteral and
Enteral Nutrition (Tube feeding)
Introduction
What is Nutrition?
Nutrition is the process by which organisms obtain and utilize nutrients necessary
for growth, maintenance, and repair of tissues, as well as for sustaining vital
bodily functions. It encompasses the intake, absorption, assimilation, and
utilization of nutrients from food sources to support overall health and well-being.
According to WHO (World Health Organization), Nutrition is the intake of food,
considered in relation to the body's dietary needs. Adequate food is vital in
keeping people alive. Good nutrition is essential to good health.
 A balanced and adequate nutrition is crucial for maintaining optimal health
throughout the life span, from infancy to old age.
 Poor nutrition can lead to various health problems, including malnutrition,
obesity, cardiovascular diseases, diabetes, and certain cancers.
 Therefore, proper nutrition is fundamental for promoting overall health,
preventing diseases, and supporting physical and mental well-being.
Types of Nutrients
Nutrients can be broadly categorized into two main types:
Macronutrients: These are nutrients required in relatively large
amounts and provide the bulk of energy needed for daily
activities. The three primary macronutrients are:
 Carbohydrates: Serve as the body's main source of energy
and are found in foods like grains, fruits, and vegetables.
 Proteins: Essential for building and repairing tissues, as well
as for various physiological functions. Sources include
meat, fish, eggs, dairy, legumes, and nuts.
 Fats: Provide concentrated energy and play crucial roles in
cell structure, hormone production, and nutrient
absorption. Common sources include oils, butter, nuts, and
avocados.
Types of Nutrients
Micronutrients: These are nutrients required in smaller quantities
but are essential for maintaining health and preventing
deficiency diseases. Micronutrients include:
 Vitamins: Organic compounds necessary for various
metabolic processes, growth, and immunity. They are
found in fruits, vegetables, dairy, and fortified foods.
 Minerals: Inorganic elements crucial for bone health, fluid
balance, nerve function, and many other physiological
functions. Sources include fruits, vegetables, dairy, nuts,
seeds, and whole grains.
Routes of Providing Nutrition
Nutrition can be provided through various routes depending on
the individual's health status, ability to eat orally, and specific
medical needs.
The primary routes of providing nutrition include:
 Oral Nutrition: The most natural and preferred method of
nutrient intake, where individuals consume food and fluids
orally.
 Enteral Nutrition: Involves delivering liquid nutrients directly into
the gastrointestinal tract through a tube.
 Parenteral Nutrition: Parenteral nutrition bypasses the digestive
system altogether, providing essential nutrients directly into the
bloodstream. This method is typically reserved for individuals
who have conditions that prevent them from eating or
absorbing nutrients through the GI tract.
Enteral Nutrition
 Enteral Nutrition: Involves
delivering liquid nutrients
directly into the
gastrointestinal tract through a
tube.
 How It is given:
Enteral feeding can be
administered via different
routes, including:
 Orally taken
 Nasogastric Tube (NGT):
Inserted through the nose and
into the stomach. Nasogastric
(NG) tubes are used to
feed babies and children who
cannot take in enough
calories by mouth.
 Nasojejunal Tube (NJT):
Inserted through the nose
and into the jejunum (part of
the small intestine).
 A doctor might recommend
a nasojejunal tube (NJT)
feeding in
 a patient cannot empty their
stomach properly or
 has a blockage in the small
bowel, or
 has had pancreatic surgery.
Routes : Enteral Nutrition
 Gastrostomy Tube (G-tube): Surgically implanted directly into
the stomach through the abdominal wall.
 Gastrostomy tubes, also known as G-tubes, are used for
patients who have trouble swallowing, can't get enough
nutrition from their mouth, or have other health problems.
 Patients who may need a gastrostomy tube include:
 Babies with birth defects of the mouth, esophagus, or stomach
 Children with sucking and swallowing disorders
 Children who have difficulty taking medicine
 Patients with conditions that interfere with how their body
processes nutrition
 Patients in a coma or with neurological events
 Patients with severe facial trauma or oropharyngeal or
esophageal cancer
Routes : Enteral Nutrition
Routes : Enteral Nutrition
 Jejunostomy Tube (J-tube): Surgically implanted directly
into the jejunum. A J-tube is also known as a post-pyloric
or trans-pyloric feeding tube. It's used when:
 Artificial nutrition is required for more than six weeks
 The patient has had major gastrointestinal surgery with a
long recovery time such as
 The patient has gastric outlet obstruction
 The patient has Gastroparesis (stomach problems)
 The patient has Pancreatitis
 The patient has severe reflux with faltering growth
 The patient has known reflux with aspiration of gastric
contents.
Routes : Enteral Nutrition
Routes : Enteral Nutrition
Routes: Parenteral
 Parenteral nutrition : Parenteral nutrition (PN) is a method of
delivering nutrition directly into the bloodstream when a person is
unable to consume food orally or absorb nutrients through the
gastrointestinal (GI) tract.
It involves administering a nutritionally complete solution
containing proteins, carbohydrates, fats, vitamins, minerals, and
electrolytes intravenously.
How It is given:
Parenteral nutrition is administered through a central venous
catheter (CVC) or peripheral vein, which is a tube inserted into a
large vein/ peripheral vein, usually in the chest, neck, or arm.
The catheter is connected to an infusion pump that delivers the
nutrition solution continuously over a specified period, typically 24
hours a day.
Routes: Parenteral
Enteral (Tube) feeding is provided
Enteral (tube feeding) and parenteral (intravenous) nutrition therapies.
According to the Enteral Nutrition Practice Guidelines published by the
American Society for Parenteral and Enteral Nutrition (ASPEN),
“The principal indication for enteral nutrition is a functional GI tract with
sufficient length and absorptive capacity and the INABILITY to take
nutrients through the oral route either totally or in part.
Enteral (Tube Feeding) Therapy:
 Inability to Eat Orally:
 Enteral nutrition is indicated when a person cannot consume
adequate nutrition orally due to conditions such as dysphagia
(difficulty swallowing), severe oral-motor dysfunction, or impaired
consciousness.
Enteral (Tube) feeding is provided
 Neurological Disorders:
 Patients with neurological conditions like stroke, Parkinson's
disease, or advanced dementia may have difficulty eating or
swallowing safely, will require tube feeding
 Cancer or Critical Illness:
 Enteral nutrition may be used in patients with cancer, severe
burns, trauma, or critical illness who are unable to eat
sufficiently.
 Preoperative and Postoperative Nutrition:
 Enteral feeding can be used to patients before surgery
(preoperative nutrition) and support after surgery
(postoperative nutrition) in patients at risk of malnutrition or
prolonged fasting.
Common conditions where
Enteral (Tube) feeding is given
 Impaired food ingestion:
 Dysphagia
 Unconscious
 Fracture of facial bone (mandible)
 Respiratory failure,
 Inability to suck (premature infants)
 Impaired digestion of whole intact foods :
 Chronic Pancreatitis
 Other GUT abnormalities
 Cannot meet nutritional requirements:
 Major Burn
 Trauma
 Anorexia Nervosa
Parenteral (Intravenous) Nutrition Therapy:
 GI Dysfunction or Failure:
 Parenteral nutrition is used when the gastrointestinal tract is
unable to absorb nutrients adequately, such as in cases of severe
malabsorption, extensive bowel surgery, intestinal fistulas, or
intestinal obstruction.
 Short Bowel Syndrome:
 Patients with short bowel syndrome, a condition characterized by
a significant portion of the small intestine being surgically
removed or nonfunctional.
 Intestinal Obstruction:
 In cases of mechanical intestinal obstruction where enteral
feeding is not feasible, parenteral nutrition may be used
temporarily until the disease is cured or surgery is performed.
When Parenteral feeding is given
Parenteral (Intravenous) Nutrition Therapy:
 Severe Malnutrition:
 Parenteral nutrition may be necessary in cases of severe
malnutrition or protein-energy malnutrition when enteral
feeding is contraindicated or insufficient to meet nutritional
needs.
 Gastrointestinal Rest:
 Parenteral nutrition can be utilized to rest the
gastrointestinal tract in certain medical conditions or
during specific treatments, such as pancreatitis, severe
gastrointestinal bleeding, or bowel rest in inflammatory
bowel disease.
When Parenteral feeding is given
 Short term:
 Severe pancreatitis
 Post-chemo with intolerance of enteral nutrition
 Gut failure
 Prolonged nil by mouth (NBM) after major surgery
 High output or enterocutaneous fistula
 Intractable vomiting
 Severe Malnourished with inability to enteral nutrition
 Long term:
 Inflammatory bowel disease
 Radiation enteritis
 Extreme short bowel syndrome
 Chronic malabsorption
Common conditions where
Parenteral Nutrition is given
Nutrition in special situations
General ill patient (ward admitted):
 A variety of condition presents at general hospital ward for
treatment, which requires special care to patient including
extra attention to diet.
 Usually ward patient are fed by normal enteral (oral) feeding
 Special concern regarding background illness requires
attention
 Patient in general ward who requires special attention:
 Pregnant and post birth patients
 Patient with Acute / Chronic Kidney Disease
 Patient with Acute/ Chronic Liver Disease
 Patient with Recent cardiac intervention
 Malabsorption syndrome patients
Ward patient with increased nutritional support
 A group of patients usually treated in ward/ general
care but requires increased nutritional supports
 Usually their background condition utilizes more energy
than normal patients or basal nutrient deficiencies are
prominent
 In order to balance such condition, increase supply is
required
 Conditions where increased nutritional support is required
 Pancreatitis (More metabolism occurs)
 Over controlled diabetes (More glucose is broken)
 Nutritional Anaemia (Iron deficiency/ Vit B12 deficiency)
 Severe infection (sepsis)
Nutrition in special situations
Critically ill patient (ICU Admitted)
 Apart from general patients, critically ill patients requires more
sophisticated nutritional care irrespective of background illness.
 As well specific nutrients to aid the neural condition are required
 Critical patients may develop condition related to nutritional
imbalance in ICU
 Nutrition in Critically ill patients are:
 More than the calorie requirement
 Small and frequent feeding
 Parenteral nutrition is mostly practiced
 Calculated fluid and electrolytes are provided to maintain fluid
balance
Nutrition in special situations
Available Formulation (Oral)
 Protein:
 Sources: Whey protein, casein, soy protein, pea protein,
hydrolyzed protein.
 Carbohydrates:
 Sources: Corn syrup solids, maltodextrin, cornstarch.
 Fats:
 Sources: Soybean oil, medium-chain triglycerides (MCT oil),
safflower oil, coconut oil.
Available Formulation (Oral)
 Fiber:
 Sources: Soluble and insoluble fibers such as cellulose, inulin,
soy fiber, oat fiber.
 Vitamins and Minerals
 Sources: Chemical formulation in the form of tablet/liquids
 Tube feeding formulations may also include additional
components such as
 prebiotics,
 probiotics,
 symbiotics and
 specialized nutrients
tailored to specific medical conditions
Available Formulation (Tube)
 Enteral formulas vary in caloric content from 1.0-2.0 kcal/mL. Formulas are
composed of different sources of carbohydrates, protein, fats, and
micronutrients.
 Carbohydrates
The standard/polymeric formulas providing 30-60% of energy from
carbohydrates. Carbohydrates can come in the form of sucrose,
fructose, corn syrup solids, or sugar alcohols. Carbohydrates in enteral
formulas provide 4 kcal/gm.
 Protein
Standard/Polymeric enteral formulas provide 10-25% of energy from
protein sources, including milk protein, whey protein, casein, caseinates,
or soy protein. Protein in enteral formulas provides 4 kcal/gm.
 Fats
Standard/Polymeric enteral formulas provide 10-45% of energy from fat
sources, including canola oil, corn oil, soy lecithin, safflower oil, and/or
medium-chained triglycerides. Fats in enteral formulas provide 9
kcal/gm.
Available Formulation (Tube)
 Micronutrients
Enteral formulas will meet 100% of the adult Dietary Reference
Intakes (DRIs) in a volume designated on the nutrition label, which
is generally 1,000-1,500 mL of formula.
Specialty enteral nutrition formulas
There are also specialty enteral formulas to meet specific nutritional
needs. Some examples are listed below.
 Semi-elemental formula: partially hydrolyzed; used for individuals
with dysfunction in the GI tract preventing standard enteral
formulas to be digested or tolerated.
 Elemental formula: fully hydrolyzed; used only for individuals who
cannot tolerate semi-elemental formula
Available Formulation (Tube)
 Disease-specific enteral formula: specialty formulas are
available for medical conditions including
 Diabetes,
 COPD,
 acute respiratory distress syndrome (ARDS),
 wound healing,
 chronic kidney disease (on and off dialysis),
 liver failure,
 compromised immune system.
These products have varying differences in macronutrient and
micronutrient content based on specific disease states (e.g., very
high protein for wound healing).
Available Formulation (Tube)
 Ready-to-use liquid formulas
 Powdered formulas that require reconstitution with water
 Concentrated formulas that can be diluted to achieve
the desired caloric density
 It's essential to select the appropriate formulation based on
the patient's nutritional needs, medical condition,
gastrointestinal tolerance, and dietary preferences.
 Regular monitoring and adjustments to the formulation may
be necessary based on the patient's response and ongoing
nutritional requirements.
Available Formulation (Tube)
Common Tube feeding formulations
Available formulation (PN)
 Modern parenteral nutrition (PN) solutions are referred to as All-in-
One (AIO) or multi-chamber bags (MCB) containing all the required
nutritional components.
 Standardized fixed feeding regimens or individually
compounded mixtures are available.
 Vitamins, trace elements, minerals and water may be added to
both regimens but must only be done under controlled aseptic
pharmaceutical conditions.
 The volume will vary widely depending on oral intake, excess
losses, and other medical conditions such as cardiac or renal
failure.
 Although the basal requirement for water is quoted as
25-35ml/kg/day, the above factors lead to wide variations in
the total volume and electrolyte content of PN.
Available formulation (PN)
Common Parenteral Nutrition combo pack
Available Formulation (PN)
Macronutrients in parenteral nutrition
 Carbohydrate
 Carbohydrate in PN is provided by glucose,
 Available in a range of concentrations (5-70%).
 Generally provided in amounts up to 60% of total energy provided per
day.
 The maximum glucose oxidation rate (4-7 mg/kg /min/day) should not
be exceeded as this may result in hyperglycaemia.
 Nitrogen
 Nitrogen requirements are generally provided in a range of 0.17-
0.3g/kg/day
 Amino acid solutions are available with a range of nitrogen content
(e.g. 6-20g).
 In addition, solutions enriched with certain amino acids have become
available e.g. glutamine.
Available Formulation (PN)
Lipid
 Lipid in PN solutions provides a concentrated form of energy
 Reduces the need large amounts of glucose
 Minimizes respiratory and metabolic stress,
 Prevents essential fatty acid deficiency and allows peripheral
infusion of nutrients.
 It is available in 10%, 20% and 30% concentrations and generally
used to provide 20-30% of daily energy requirements.
 It is recommended that lipid content of PN should not exceed 1-
1.5g/kg/day.
Available Formulation (PN)
Micronutrients in Parenteral Nutrition
 Commercially prepared mixtures are available that provide
well-balanced amounts of all essential vitamins and trace
elements.
 Requirements for parenteral vitamins, trace elements and
minerals will vary among patients depending on clinical and
metabolic status
 Further supplements may be appropriate in certain
circumstances. For example, starved patients may require
additional thiamine as reserves would be expected to be low.
 Electrolytes may be added according to patient requirements.
Assessment and calculations
of demand of Enteral Feeding
GENERAL CALCULATION
 Formulas are composed of different sources of carbohydrates,
protein, fats, and micronutrients.
 The majority of energy in enteral formulas generally comes
from carbohydrates, with standard/polymeric formulas
providing 30-60% of energy from carbohydrates.
 Nutritional needs are very situational . It depends on medical
conditions and patient acceptation.
Assessment and calculations
of demand of Enteral Feeding
Assessment and calculations
of demand of Enteral Feeding
Step 1 : Estimate the nutritional need of the patient
 Calories : 25-30 Kcal/kg
 Protein : 1.2-1.5 g/kg
 Fluid : 1 ml/Kcal
For example , a 85kg patient’s requirement of
 Calories : (25X85) = 2100 Kcal to (30X85) = 2520 Kcal
 Protein:(1.2X85) = 100gm to (1.5X85) =126gm
 Fluid:2100 ml to 2520 ml
Assessment and calculations
of demand of Enteral Feeding
 The more complications the patient gets, the more these
ranges may change.
 For example, if patient has heart failure or renal disease we
may restrict the fluid to 1 L per day.
 If the patient has injury or large surgical would , it may
consider providing more calories and protein for healing.
Caloric Density
 Patients may be very much sensitive to fluid.
 In such patient dense formulation are provided
 Densities of 1 kcal/mL, 1.5 kcal/mL, and 2 kcal/mL are
available
Assessment and calculations
of demand of Enteral Feeding
 Step 2 : Selecting feeding formula
The four categories of tube feeding formula
Feeding
formula
Standard
Pre
digested
Disease
specific
Blenderized
Assessment and calculations
of demand of Enteral Feeding
Standard
Also known as polymeric
Contain intact
micronutrients that the body
needs to break down to be
absorbed
Pre digested
Contain macronutrients that
are already broken down to
maximize absorption
Disease specific
Also known as specialized
Have a nutrient profile that
address a metabolic
condition / organ
dysfunction
Blenderized
Contain a mixture of whole
foods that have been
pulverized into liquid
Assessment and calculations
of demand of Enteral Feeding
Step 3 : Calculate the energy , protein and fluid load
 We divide the formula by 24 hours.
 To determine the desired infusion rate for feeding,
 Next, divide the feeding volume (L/hr) by the number of hours
each day that the feeding formula will be infused.
Assessment and calculations of
demand of Enteral Feeding
 Step 4. Adjust the protein intake, if necessary.
 The final step in the process is to determine if the feeding regimen will
provide enough protein to satisfy the daily protein requirement (from
step 1).
 The projected protein intake is simply the daily feeding volume
multiplied by the protein concentration in the feeding formula.
 If the projected protein intake is less than the desired protein intake,
powdered protein is added to the tube feedings to correct the
discrepancy.
Pros & Cons - Enteral Feeding
Advantages Enteral Nutrition
 Cheaper
 Simpler
 Fewer complications
 For efficient use of nutrients
 Stimulates intestinal blood flow
 Protects GUT health
 Reduces infective complications compared with TPN
 Avoids catheter related complications
 Avoids TPN induced immunosuppression (lipid load)
Pros & Cons - Enteral Feeding
Disadvantages Enteral Nutrition
 Difficult to measure amount and volume of nutrient
 Independent risk factor for Pneumonia in Ventilated patients (VAP)
 Sinusitis (N/G)
 Misplacement into trachea – aspiration pneumonia
 Perforation of esophagus, pharynx, stomach or bowel
 Gut infection, bowel obstruction
 Metabolic derangement: electrolytes, hyperglycemia, re-feeding
syndrome
 Intolerance: vomiting, excessive load (200-500mL), abdominal
distension
 Constipation or diarrhea
Pros & Cons – PN
Advantages of Parenteral Nutrition
 Bypasses the Gastrointestinal Tract: For patients with issues
related to the gastrointestinal tract
 Parenteral feeding can provide essential nutrients directly,
bypassing the need for digestion.
 Complete Nutrition: Parenteral feeding can be tailored to
provide all the necessary nutrients, ensuring that patients
receive a balanced diet according to their specific needs.
 Life-Saving: For patients who are severely malnourished and
cannot eat or absorb nutrients through their gastrointestinal
tract, parenteral nutrition can be life-saving.
 Control and Flexibility: Very much calculated, It allows for
precise control over the intake of nutrients, which is particularly
beneficial for patients with specific nutritional needs or
metabolic complications.
Pros & Cons – PN
Demerits of Parenteral Nutrition
 Risk of Infection: One of the most significant risks of parenteral
feeding is the risk of infection, particularly bloodstream
infections, because it requires a central venous catheter.
 Liver Complications: Long-term parenteral nutrition can lead
to liver problems, including fatty liver, cholestasis, and liver
failure.
 Metabolic Complications: Parenteral feeding can lead to
metabolic imbalances, including issues with blood sugar
levels, electrolyte levels, and fluid balance.
 High Cost: The costs associated with parenteral nutrition can
be significantly higher than enteral nutrition due to the need
for specialized formulations, equipment, and monitoring.
Pros & Cons – PN
Demerits of Parenteral Nutrition
 Dependency: Long-term use can lead to dependency on
parenteral nutrition, making it challenging to transition back to
normal eating.
 Specific disease: Refeeding syndrome, Zinc deficiency, Metabolic
bone disease
While parenteral feeding is a critical medical tool for those who need
it, generally considered only when enteral feeding is not possible or
adequate.
The decision to start parenteral nutrition involves careful consideration
of the benefits and risks, ideally involving a multidisciplinary team of
healthcare professionals.
Thank You All

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Parental and enteral nutrition Final.pdf

  • 2. Introduction What is Nutrition? Nutrition is the process by which organisms obtain and utilize nutrients necessary for growth, maintenance, and repair of tissues, as well as for sustaining vital bodily functions. It encompasses the intake, absorption, assimilation, and utilization of nutrients from food sources to support overall health and well-being. According to WHO (World Health Organization), Nutrition is the intake of food, considered in relation to the body's dietary needs. Adequate food is vital in keeping people alive. Good nutrition is essential to good health.  A balanced and adequate nutrition is crucial for maintaining optimal health throughout the life span, from infancy to old age.  Poor nutrition can lead to various health problems, including malnutrition, obesity, cardiovascular diseases, diabetes, and certain cancers.  Therefore, proper nutrition is fundamental for promoting overall health, preventing diseases, and supporting physical and mental well-being.
  • 3. Types of Nutrients Nutrients can be broadly categorized into two main types: Macronutrients: These are nutrients required in relatively large amounts and provide the bulk of energy needed for daily activities. The three primary macronutrients are:  Carbohydrates: Serve as the body's main source of energy and are found in foods like grains, fruits, and vegetables.  Proteins: Essential for building and repairing tissues, as well as for various physiological functions. Sources include meat, fish, eggs, dairy, legumes, and nuts.  Fats: Provide concentrated energy and play crucial roles in cell structure, hormone production, and nutrient absorption. Common sources include oils, butter, nuts, and avocados.
  • 4. Types of Nutrients Micronutrients: These are nutrients required in smaller quantities but are essential for maintaining health and preventing deficiency diseases. Micronutrients include:  Vitamins: Organic compounds necessary for various metabolic processes, growth, and immunity. They are found in fruits, vegetables, dairy, and fortified foods.  Minerals: Inorganic elements crucial for bone health, fluid balance, nerve function, and many other physiological functions. Sources include fruits, vegetables, dairy, nuts, seeds, and whole grains.
  • 5. Routes of Providing Nutrition Nutrition can be provided through various routes depending on the individual's health status, ability to eat orally, and specific medical needs. The primary routes of providing nutrition include:  Oral Nutrition: The most natural and preferred method of nutrient intake, where individuals consume food and fluids orally.  Enteral Nutrition: Involves delivering liquid nutrients directly into the gastrointestinal tract through a tube.  Parenteral Nutrition: Parenteral nutrition bypasses the digestive system altogether, providing essential nutrients directly into the bloodstream. This method is typically reserved for individuals who have conditions that prevent them from eating or absorbing nutrients through the GI tract.
  • 6. Enteral Nutrition  Enteral Nutrition: Involves delivering liquid nutrients directly into the gastrointestinal tract through a tube.  How It is given: Enteral feeding can be administered via different routes, including:  Orally taken  Nasogastric Tube (NGT): Inserted through the nose and into the stomach. Nasogastric (NG) tubes are used to feed babies and children who cannot take in enough calories by mouth.
  • 7.  Nasojejunal Tube (NJT): Inserted through the nose and into the jejunum (part of the small intestine).  A doctor might recommend a nasojejunal tube (NJT) feeding in  a patient cannot empty their stomach properly or  has a blockage in the small bowel, or  has had pancreatic surgery. Routes : Enteral Nutrition
  • 8.  Gastrostomy Tube (G-tube): Surgically implanted directly into the stomach through the abdominal wall.  Gastrostomy tubes, also known as G-tubes, are used for patients who have trouble swallowing, can't get enough nutrition from their mouth, or have other health problems.  Patients who may need a gastrostomy tube include:  Babies with birth defects of the mouth, esophagus, or stomach  Children with sucking and swallowing disorders  Children who have difficulty taking medicine  Patients with conditions that interfere with how their body processes nutrition  Patients in a coma or with neurological events  Patients with severe facial trauma or oropharyngeal or esophageal cancer Routes : Enteral Nutrition
  • 9. Routes : Enteral Nutrition
  • 10.  Jejunostomy Tube (J-tube): Surgically implanted directly into the jejunum. A J-tube is also known as a post-pyloric or trans-pyloric feeding tube. It's used when:  Artificial nutrition is required for more than six weeks  The patient has had major gastrointestinal surgery with a long recovery time such as  The patient has gastric outlet obstruction  The patient has Gastroparesis (stomach problems)  The patient has Pancreatitis  The patient has severe reflux with faltering growth  The patient has known reflux with aspiration of gastric contents. Routes : Enteral Nutrition
  • 11. Routes : Enteral Nutrition
  • 12. Routes: Parenteral  Parenteral nutrition : Parenteral nutrition (PN) is a method of delivering nutrition directly into the bloodstream when a person is unable to consume food orally or absorb nutrients through the gastrointestinal (GI) tract. It involves administering a nutritionally complete solution containing proteins, carbohydrates, fats, vitamins, minerals, and electrolytes intravenously. How It is given: Parenteral nutrition is administered through a central venous catheter (CVC) or peripheral vein, which is a tube inserted into a large vein/ peripheral vein, usually in the chest, neck, or arm. The catheter is connected to an infusion pump that delivers the nutrition solution continuously over a specified period, typically 24 hours a day.
  • 14. Enteral (Tube) feeding is provided Enteral (tube feeding) and parenteral (intravenous) nutrition therapies. According to the Enteral Nutrition Practice Guidelines published by the American Society for Parenteral and Enteral Nutrition (ASPEN), “The principal indication for enteral nutrition is a functional GI tract with sufficient length and absorptive capacity and the INABILITY to take nutrients through the oral route either totally or in part. Enteral (Tube Feeding) Therapy:  Inability to Eat Orally:  Enteral nutrition is indicated when a person cannot consume adequate nutrition orally due to conditions such as dysphagia (difficulty swallowing), severe oral-motor dysfunction, or impaired consciousness.
  • 15. Enteral (Tube) feeding is provided  Neurological Disorders:  Patients with neurological conditions like stroke, Parkinson's disease, or advanced dementia may have difficulty eating or swallowing safely, will require tube feeding  Cancer or Critical Illness:  Enteral nutrition may be used in patients with cancer, severe burns, trauma, or critical illness who are unable to eat sufficiently.  Preoperative and Postoperative Nutrition:  Enteral feeding can be used to patients before surgery (preoperative nutrition) and support after surgery (postoperative nutrition) in patients at risk of malnutrition or prolonged fasting.
  • 16. Common conditions where Enteral (Tube) feeding is given  Impaired food ingestion:  Dysphagia  Unconscious  Fracture of facial bone (mandible)  Respiratory failure,  Inability to suck (premature infants)  Impaired digestion of whole intact foods :  Chronic Pancreatitis  Other GUT abnormalities  Cannot meet nutritional requirements:  Major Burn  Trauma  Anorexia Nervosa
  • 17. Parenteral (Intravenous) Nutrition Therapy:  GI Dysfunction or Failure:  Parenteral nutrition is used when the gastrointestinal tract is unable to absorb nutrients adequately, such as in cases of severe malabsorption, extensive bowel surgery, intestinal fistulas, or intestinal obstruction.  Short Bowel Syndrome:  Patients with short bowel syndrome, a condition characterized by a significant portion of the small intestine being surgically removed or nonfunctional.  Intestinal Obstruction:  In cases of mechanical intestinal obstruction where enteral feeding is not feasible, parenteral nutrition may be used temporarily until the disease is cured or surgery is performed. When Parenteral feeding is given
  • 18. Parenteral (Intravenous) Nutrition Therapy:  Severe Malnutrition:  Parenteral nutrition may be necessary in cases of severe malnutrition or protein-energy malnutrition when enteral feeding is contraindicated or insufficient to meet nutritional needs.  Gastrointestinal Rest:  Parenteral nutrition can be utilized to rest the gastrointestinal tract in certain medical conditions or during specific treatments, such as pancreatitis, severe gastrointestinal bleeding, or bowel rest in inflammatory bowel disease. When Parenteral feeding is given
  • 19.  Short term:  Severe pancreatitis  Post-chemo with intolerance of enteral nutrition  Gut failure  Prolonged nil by mouth (NBM) after major surgery  High output or enterocutaneous fistula  Intractable vomiting  Severe Malnourished with inability to enteral nutrition  Long term:  Inflammatory bowel disease  Radiation enteritis  Extreme short bowel syndrome  Chronic malabsorption Common conditions where Parenteral Nutrition is given
  • 20. Nutrition in special situations General ill patient (ward admitted):  A variety of condition presents at general hospital ward for treatment, which requires special care to patient including extra attention to diet.  Usually ward patient are fed by normal enteral (oral) feeding  Special concern regarding background illness requires attention  Patient in general ward who requires special attention:  Pregnant and post birth patients  Patient with Acute / Chronic Kidney Disease  Patient with Acute/ Chronic Liver Disease  Patient with Recent cardiac intervention  Malabsorption syndrome patients
  • 21. Ward patient with increased nutritional support  A group of patients usually treated in ward/ general care but requires increased nutritional supports  Usually their background condition utilizes more energy than normal patients or basal nutrient deficiencies are prominent  In order to balance such condition, increase supply is required  Conditions where increased nutritional support is required  Pancreatitis (More metabolism occurs)  Over controlled diabetes (More glucose is broken)  Nutritional Anaemia (Iron deficiency/ Vit B12 deficiency)  Severe infection (sepsis) Nutrition in special situations
  • 22. Critically ill patient (ICU Admitted)  Apart from general patients, critically ill patients requires more sophisticated nutritional care irrespective of background illness.  As well specific nutrients to aid the neural condition are required  Critical patients may develop condition related to nutritional imbalance in ICU  Nutrition in Critically ill patients are:  More than the calorie requirement  Small and frequent feeding  Parenteral nutrition is mostly practiced  Calculated fluid and electrolytes are provided to maintain fluid balance Nutrition in special situations
  • 23. Available Formulation (Oral)  Protein:  Sources: Whey protein, casein, soy protein, pea protein, hydrolyzed protein.  Carbohydrates:  Sources: Corn syrup solids, maltodextrin, cornstarch.  Fats:  Sources: Soybean oil, medium-chain triglycerides (MCT oil), safflower oil, coconut oil.
  • 24. Available Formulation (Oral)  Fiber:  Sources: Soluble and insoluble fibers such as cellulose, inulin, soy fiber, oat fiber.  Vitamins and Minerals  Sources: Chemical formulation in the form of tablet/liquids  Tube feeding formulations may also include additional components such as  prebiotics,  probiotics,  symbiotics and  specialized nutrients tailored to specific medical conditions
  • 25. Available Formulation (Tube)  Enteral formulas vary in caloric content from 1.0-2.0 kcal/mL. Formulas are composed of different sources of carbohydrates, protein, fats, and micronutrients.  Carbohydrates The standard/polymeric formulas providing 30-60% of energy from carbohydrates. Carbohydrates can come in the form of sucrose, fructose, corn syrup solids, or sugar alcohols. Carbohydrates in enteral formulas provide 4 kcal/gm.  Protein Standard/Polymeric enteral formulas provide 10-25% of energy from protein sources, including milk protein, whey protein, casein, caseinates, or soy protein. Protein in enteral formulas provides 4 kcal/gm.  Fats Standard/Polymeric enteral formulas provide 10-45% of energy from fat sources, including canola oil, corn oil, soy lecithin, safflower oil, and/or medium-chained triglycerides. Fats in enteral formulas provide 9 kcal/gm.
  • 26. Available Formulation (Tube)  Micronutrients Enteral formulas will meet 100% of the adult Dietary Reference Intakes (DRIs) in a volume designated on the nutrition label, which is generally 1,000-1,500 mL of formula. Specialty enteral nutrition formulas There are also specialty enteral formulas to meet specific nutritional needs. Some examples are listed below.  Semi-elemental formula: partially hydrolyzed; used for individuals with dysfunction in the GI tract preventing standard enteral formulas to be digested or tolerated.  Elemental formula: fully hydrolyzed; used only for individuals who cannot tolerate semi-elemental formula
  • 27. Available Formulation (Tube)  Disease-specific enteral formula: specialty formulas are available for medical conditions including  Diabetes,  COPD,  acute respiratory distress syndrome (ARDS),  wound healing,  chronic kidney disease (on and off dialysis),  liver failure,  compromised immune system. These products have varying differences in macronutrient and micronutrient content based on specific disease states (e.g., very high protein for wound healing).
  • 28. Available Formulation (Tube)  Ready-to-use liquid formulas  Powdered formulas that require reconstitution with water  Concentrated formulas that can be diluted to achieve the desired caloric density  It's essential to select the appropriate formulation based on the patient's nutritional needs, medical condition, gastrointestinal tolerance, and dietary preferences.  Regular monitoring and adjustments to the formulation may be necessary based on the patient's response and ongoing nutritional requirements.
  • 29. Available Formulation (Tube) Common Tube feeding formulations
  • 30. Available formulation (PN)  Modern parenteral nutrition (PN) solutions are referred to as All-in- One (AIO) or multi-chamber bags (MCB) containing all the required nutritional components.  Standardized fixed feeding regimens or individually compounded mixtures are available.  Vitamins, trace elements, minerals and water may be added to both regimens but must only be done under controlled aseptic pharmaceutical conditions.  The volume will vary widely depending on oral intake, excess losses, and other medical conditions such as cardiac or renal failure.  Although the basal requirement for water is quoted as 25-35ml/kg/day, the above factors lead to wide variations in the total volume and electrolyte content of PN.
  • 31. Available formulation (PN) Common Parenteral Nutrition combo pack
  • 32. Available Formulation (PN) Macronutrients in parenteral nutrition  Carbohydrate  Carbohydrate in PN is provided by glucose,  Available in a range of concentrations (5-70%).  Generally provided in amounts up to 60% of total energy provided per day.  The maximum glucose oxidation rate (4-7 mg/kg /min/day) should not be exceeded as this may result in hyperglycaemia.  Nitrogen  Nitrogen requirements are generally provided in a range of 0.17- 0.3g/kg/day  Amino acid solutions are available with a range of nitrogen content (e.g. 6-20g).  In addition, solutions enriched with certain amino acids have become available e.g. glutamine.
  • 33. Available Formulation (PN) Lipid  Lipid in PN solutions provides a concentrated form of energy  Reduces the need large amounts of glucose  Minimizes respiratory and metabolic stress,  Prevents essential fatty acid deficiency and allows peripheral infusion of nutrients.  It is available in 10%, 20% and 30% concentrations and generally used to provide 20-30% of daily energy requirements.  It is recommended that lipid content of PN should not exceed 1- 1.5g/kg/day.
  • 34. Available Formulation (PN) Micronutrients in Parenteral Nutrition  Commercially prepared mixtures are available that provide well-balanced amounts of all essential vitamins and trace elements.  Requirements for parenteral vitamins, trace elements and minerals will vary among patients depending on clinical and metabolic status  Further supplements may be appropriate in certain circumstances. For example, starved patients may require additional thiamine as reserves would be expected to be low.  Electrolytes may be added according to patient requirements.
  • 35. Assessment and calculations of demand of Enteral Feeding GENERAL CALCULATION  Formulas are composed of different sources of carbohydrates, protein, fats, and micronutrients.  The majority of energy in enteral formulas generally comes from carbohydrates, with standard/polymeric formulas providing 30-60% of energy from carbohydrates.  Nutritional needs are very situational . It depends on medical conditions and patient acceptation.
  • 36. Assessment and calculations of demand of Enteral Feeding
  • 37. Assessment and calculations of demand of Enteral Feeding Step 1 : Estimate the nutritional need of the patient  Calories : 25-30 Kcal/kg  Protein : 1.2-1.5 g/kg  Fluid : 1 ml/Kcal For example , a 85kg patient’s requirement of  Calories : (25X85) = 2100 Kcal to (30X85) = 2520 Kcal  Protein:(1.2X85) = 100gm to (1.5X85) =126gm  Fluid:2100 ml to 2520 ml
  • 38. Assessment and calculations of demand of Enteral Feeding  The more complications the patient gets, the more these ranges may change.  For example, if patient has heart failure or renal disease we may restrict the fluid to 1 L per day.  If the patient has injury or large surgical would , it may consider providing more calories and protein for healing. Caloric Density  Patients may be very much sensitive to fluid.  In such patient dense formulation are provided  Densities of 1 kcal/mL, 1.5 kcal/mL, and 2 kcal/mL are available
  • 39. Assessment and calculations of demand of Enteral Feeding  Step 2 : Selecting feeding formula The four categories of tube feeding formula Feeding formula Standard Pre digested Disease specific Blenderized
  • 40. Assessment and calculations of demand of Enteral Feeding Standard Also known as polymeric Contain intact micronutrients that the body needs to break down to be absorbed Pre digested Contain macronutrients that are already broken down to maximize absorption Disease specific Also known as specialized Have a nutrient profile that address a metabolic condition / organ dysfunction Blenderized Contain a mixture of whole foods that have been pulverized into liquid
  • 41. Assessment and calculations of demand of Enteral Feeding Step 3 : Calculate the energy , protein and fluid load  We divide the formula by 24 hours.  To determine the desired infusion rate for feeding,  Next, divide the feeding volume (L/hr) by the number of hours each day that the feeding formula will be infused.
  • 42. Assessment and calculations of demand of Enteral Feeding  Step 4. Adjust the protein intake, if necessary.  The final step in the process is to determine if the feeding regimen will provide enough protein to satisfy the daily protein requirement (from step 1).  The projected protein intake is simply the daily feeding volume multiplied by the protein concentration in the feeding formula.  If the projected protein intake is less than the desired protein intake, powdered protein is added to the tube feedings to correct the discrepancy.
  • 43. Pros & Cons - Enteral Feeding Advantages Enteral Nutrition  Cheaper  Simpler  Fewer complications  For efficient use of nutrients  Stimulates intestinal blood flow  Protects GUT health  Reduces infective complications compared with TPN  Avoids catheter related complications  Avoids TPN induced immunosuppression (lipid load)
  • 44. Pros & Cons - Enteral Feeding Disadvantages Enteral Nutrition  Difficult to measure amount and volume of nutrient  Independent risk factor for Pneumonia in Ventilated patients (VAP)  Sinusitis (N/G)  Misplacement into trachea – aspiration pneumonia  Perforation of esophagus, pharynx, stomach or bowel  Gut infection, bowel obstruction  Metabolic derangement: electrolytes, hyperglycemia, re-feeding syndrome  Intolerance: vomiting, excessive load (200-500mL), abdominal distension  Constipation or diarrhea
  • 45. Pros & Cons – PN Advantages of Parenteral Nutrition  Bypasses the Gastrointestinal Tract: For patients with issues related to the gastrointestinal tract  Parenteral feeding can provide essential nutrients directly, bypassing the need for digestion.  Complete Nutrition: Parenteral feeding can be tailored to provide all the necessary nutrients, ensuring that patients receive a balanced diet according to their specific needs.  Life-Saving: For patients who are severely malnourished and cannot eat or absorb nutrients through their gastrointestinal tract, parenteral nutrition can be life-saving.  Control and Flexibility: Very much calculated, It allows for precise control over the intake of nutrients, which is particularly beneficial for patients with specific nutritional needs or metabolic complications.
  • 46. Pros & Cons – PN Demerits of Parenteral Nutrition  Risk of Infection: One of the most significant risks of parenteral feeding is the risk of infection, particularly bloodstream infections, because it requires a central venous catheter.  Liver Complications: Long-term parenteral nutrition can lead to liver problems, including fatty liver, cholestasis, and liver failure.  Metabolic Complications: Parenteral feeding can lead to metabolic imbalances, including issues with blood sugar levels, electrolyte levels, and fluid balance.  High Cost: The costs associated with parenteral nutrition can be significantly higher than enteral nutrition due to the need for specialized formulations, equipment, and monitoring.
  • 47. Pros & Cons – PN Demerits of Parenteral Nutrition  Dependency: Long-term use can lead to dependency on parenteral nutrition, making it challenging to transition back to normal eating.  Specific disease: Refeeding syndrome, Zinc deficiency, Metabolic bone disease While parenteral feeding is a critical medical tool for those who need it, generally considered only when enteral feeding is not possible or adequate. The decision to start parenteral nutrition involves careful consideration of the benefits and risks, ideally involving a multidisciplinary team of healthcare professionals.