This document provides an overview of the history and clinical applications of enteral and parenteral nutrition. It discusses how ancient Egyptians used enemas to deliver nutrients and how total parenteral nutrition was developed in the 1960s. The document outlines factors to consider in determining a patient's nutritional needs such as weight loss, albumin levels, and ability to eat. Guidelines are provided for initiating and advancing enteral and parenteral nutrition based on a patient's condition and nutritional status. Potential complications of each method are also reviewed.
Anuman- An inference for helpful in diagnosis and treatment
Topics on Surgical Nutrition
1. Kristopher R. Maday, MS, PA-C, CNSC
University of Alabama at Birmingham
Department of Nutritional Sciences
Surgical Physician Assistant Program
2. 3500 BC
• Ancient egyptians would infuse wine, milk, whey,
wheat or barley broths, eggs, and brandy through
rectal enemas to preserve health, protect inflamed
bowel, and treat diarrhea
1598
• Capivacceus reported infusing liquids through a
hollow tube placed into the esophagus
3. 1930s
• Protein hydrolysate formulas and automatic
feeding pumps were developed
1968
• Dr. Stanley Dudrick - UPenn
Invented Total Parenteral Nutrition (TPN)
4. 1936 – Studley et al.
• Malnourished patients with the same diseases as
nourished patients had poorer outcomes
1962 – Keys et al.
• Healthy individuals who are deprived of adequate
nutrients for a long enough period of time will
develop adverse clinical events due to
malnutrition
5. NPO after surgery until bowel function
resumes
• Prevent nausea and vomiting
• Protect surgical anastomosis before being
stressed by food
6. Length of starvation
• Well-nourished person has a 7-10 day energy and
protein store
• Healthy individual can tolerate up to 12-14 days
without adverse effects
Major surgery or critical illness can shorten to 5-7 days
Nutritional State
• Identifying malnutrition
7. > 10% loss of usual body weight
< 85% of Ideal Body Weight
• ***Obese patients can be malnourished***
Serum Albumin
• 2003 - Kudsk et al
Pre-op Albumin < 3.25 g/dl saw a marked rise in complications and
mortality in GI surgery patients
Inability to eat for > 7 days
Nutritional Risk Index
• (1.519×serum albumin)+(41.7×(present weight/usual weight))
No Risk - > 100
Mild – 97.5-100
Moderate – 83.5-97.5
Severe - < 83.5
8. Acute Phase Proteins
• Albumin and Prealbumin
Energy Needs
• Harris Benedict, Ireton-Jones, Indirect Calorimetry,
22-25kcal/kg
• Permissive Underfeeding
50-70% of caloric goals
***only need 400kcal to needing for “protein sparing”***
Indirect Calorimetry
Protein Needs
• 0.5-2 g/kg
• 24hr Urine Urea Nitrogen collection
Nitrogen Balance
9. Provide support consistent with the
patients medical condition and nutritional
status
Prevent or treat macronutrient and
micronutrient deficiencies
Provide doses of nutrients compatible with
existing metabolism
Avoid complications related to dietary
delivery
Improve patient outcome
10. Feeding via the GI
tract
Types of Access
• Bedside
NG, Dobhoff
• Surgical
G-tube, J-tube, G-J Tube
11. “If the gut works….use it”
Prevent translocation of
bacteria
Maintains gut integrity
Sustains closure of the
paracellular channels between
the intraepithelial cells
Stimulate immunoglobulin A and
bile salts which coat enteric
bacteria
Stimulates peristalsis
13. Lewis SJ, Egger M, Sylvester PA, Thomas S
BMJ 2001;323:775
Mortality - 7% in early feeding group and 13% in control
14. Abdominal Distension
Aspiration
• Gastric vs Transpyloric Feeding
Significant reduction if tube is past the Ligament of
Trietz
Diarrhea
• Hyperosmolar enteral feedings
Elemental formula helps prevent
Iatrogenic Injury
15. Johnson MD, Walsh RM
Cleveland Clinic Journal of Medicine 2009;76(11):642
16.
17.
18. Developed in 1968 as a
“bridging” modality for
patients whom the oral
route is not feasable
Admixture of amino
acids, dextrose, lipids,
vitamins, minerals, and
electrolytes
• Not as nutritional
complete as enteral
formulas
20. Non-stressed patient undergoing surgery
who has severe protein-calorie malnutrition
Patient who has a nonfunctional GI tract
• Short gut Syndrome, High output fistulae,
obstruction, chronic mesenteric ischemia
Patient who fails oral/enteral intake
• Intractable vomiting or diarrhea
• +/- Pancreatitis
21.
22. Central Line
• Good for short term, inpatient
TPN
Tunneled, Cuffed Catheters
• Hickman, Groshong
• Good for long term, home TPN
PICC Line
• Good for long-term, home TPN
Ports
• Mediport, Port-a-Cath
• Good for long term, hom TPN
Peripheral IV
• ***For PPN, not TPN***
Osmolarity issues
25. Diabetic patients
Obese patients
Trauma/Burn
• EEN, hypermetabolic
demands
Renal Disease
• Limit protein 2o elevated
BUN
• Increased protein
requirements for dialysis
Liver Disease
• TPN can worsen liver
function
Pregnancy
HIV/AIDS
• Increased energy demands
• Drugs, oral lesions
Cancer
• Site of cancer, mucositis
Transplant patients
• Pancreas, small bowel
• Post-transplant obesity
26. Avoid
over/underfeeding
• More ≠ Better
Promote nitrogen
retention
• Avoid protein overload
Calorie Counts
Actual amount infused
ABG
Nitrogen Balance
• 24hr Urine Urea
Nitrogen
• Laboratory Studies
•Albumin, Pre-albumin, BMP, Mg, Ca, PO4,LFT
• Intake vs Output
27. TPN
• Weaned until 60% of energy needs are met by
oral intake
Reduced oral intake can be expected if >25% of caloric
needs are met via TPN
Enteral Nutrition
• Transition from continuous to nocturnal feeding or
bolus feeding
• Weaned until 75% of energy needs are met by
oral intake
28. Obtaining nutritional assessment as part of
pre-op workup
• Identifying at risk patients prior to surgery
Nutritionally optimize patients before elective surgery
Delay inpatient cases to outpatient
Add procedures to case while in OR
• Estimate nutritional needs for post-op management
Allow for early identification of potential problems
29. Early PO Intake
• Post-op ileus resolve earlier than commonly practiced
Gastric Ileus – 24-48 hours
Small Bowel Ileus – 4-8 hours
Colonic Ileus – 3-5 days
• Helps prevent anastomotic dehisence
Nutrient intake associated with significant collagen deposition
and reversal of mucosal atrophy at anastomosis
• Decrease mortality, infectious complications, and
hospital length of stay
30. 9505 Patient Name
Age 57 Gender Male BEE Protein Requirement
Height 168 SCI or TBI No Ireton-Jones 1955 97
Weight 63 25kCal/Kg 1575
IBW 64.9 Harris-Benedict 2120 kCal : N2 Ratio
BMI 22.3 126
TEN
Formula kCal/cc kCal Rate Protein/cc Total Protein In Carbohydrate/cc Fat/cc Osmolarity % Water
Osmolite 1.5 55 0.0627 83 0.2036 0.0491 525 76.2
Oxepa 1.5 55 0.0627 83 0.1053 0.0938 535 78.5
Pulmocare 1.5 55 0.0626 83 0.1057 0.0933 475 78.5
Glucerna 1.5 1.5 55 0.0825 109 0.1331 0.075 875 76
Peptamen 1.2 70 0.0756 127 0.107 0.0548 390 81.1
Nepro 1.8 45 0.081 87 0.1668 0.096 585 72.5
Pivot 1.5 1.5 55 0.094 124 0.172 0.051 595 76
Promote 1 80 0.063 121 0.138 0.028 380 83
Date Albumin Pre-Albumin UUN Total cc of TEN N2 Balance Changes
31. 9501 Patient Name
Age 57 Gender Male BEE Protein Requirement
Height 168 Injury Trauma Ireton-Jones 1955 97
Weight 63 % TBSA 25kCal/Kg 1575
IBW 64.9 Head Injury No Harris-Benedict 2120
BMI 22.3 SCI No Curreri NA
Carbohydrates Protein Fat
Requirement 316 Requirement 97 kCal needed 550
cc of D70 451 cc of AA 970 cc of Lipid 306
Total kCal 1075 Total kCal 330
Electrolytes Guidelines Volume Last Labs Last Dose Dose Needed Adjusted Dose Total Volume
Sodium 60-120 mEq
NaCl 4 mEq/cc 80 43 11
Potassium 40-120 mEq
KCl 2 mEq/cc 60 21 11
Acetate 10-40 mEq
NaOAc 2 mEq/cc 10 5
KOAc 2 mEq/cc 10 5
Phosphate 10-40 mEq
NaPO4 3 mMol/cc 20 7
KPO4 3 mMol/cc 20 7
Electrolytes
MgSO4 10-20 mEq 4.06 mEq/cc 16 4
Ca Gluc 5-15 mg 0.465 mEq/cc 5 11
ZnSO4 1-15 mg 1mg/cc 15 15
Vitamin C 1000 mg 50mg/cc 1000 20
Folate 1mg 5mg/cc 1 1
g/kg % Total TPN Volume 1837
4.9 Carbohydrates 55 kCal : N2 Ratio 24hr Fluid Requirement 2360
1.5 Protein 17 126 Sterile Water Addition 523
0.9 Fat 28
32. American Society for Parenteral and
Enteral Nutrition (ASPEN)
• 2009 Clinical Guidelines
Charney P, Malone A, ADA Pocket Guide
to Nutrition Assessment. Published by:
American Dietetic Association (2004)
33. Kristopher R. Maday, MS, PA-C, CNSC
Assistant Professor
University of Alabama at Birmingham
Surgical Physician Assistant Program
1530 3rd Ave South, SHPB 466
Birmingham, AL 35294-1212
Telephone: 205-996-2656
maday@uab.edu
Editor's Notes
Presdient Garfield was treated this way in 1882 q4 x 79d - Continued through 1940s
Starvation reduces the collagen content in anastomotic scar tissue diminishes the quality of healing
Prior to this patients were essentially condemned to die of malnutrition
Diabetes – treat malnutrition, gastroparesis
HIV – increased energy requirement, drugs alter metabolism, oral lesions and PO intake
Cancer – mucositis from radiation/chemo
Trasnplant – pancreas 3-5 days, SB 1-2 weeks, post-transplant obesity – steroids,