Total Parenteral Nutrition and its use in ICU about introduction , management, preparation, types and administration and complications and limitations

1. TOTAL PARENTERAL
NUTRITION
Guide : Dr Chandrashekar K
Student : Dr Chetan K G

2. HISTORY
• Early 1960s, the use of intravenous nutrition
was restricted to high concentrations of
dextrose and electrolytes.
• 1962, Wretlind and colleagues developed lipid
infusions as the principle source of calories for
parenteral feeding.

3. •1966, Dudrick and Rhoads developed parenteral
nutrition (PN) for patients who had lost their small
bowel.
•1976, Solassol and Joyeux developed the three-in-
one mixture by putting sugars, lipids and amino
acids in a single bag.
• 1978, Shils and colleagues and Jeejeebhoy and
colleagues developed ‘home based’ PN to reduce
costs.

4. Human nutrition is the provision to obtain the
essential nutrients necessary to support life
and health
Nutrients are the substances that are not
synthesized in sufficient quantity in the body
and therefore must be supplied from diet

5. • Protein (Amino acids)
• Fat
• Carbohydrate
• Dietary fiber
• Water and electrolytes
• Vitamins
• Minerals
• Trace elements

6. • Patients should be assessed for PEMas well as specific
nutrient deficiencies
• Evidence of malabsorption
• Symptoms of specific nutrient deficiencies
• Look for factors which may increase metabolic stress
(infection, inflammation, malignancy)
• Functional status (bed ridden, suboptimally active,
fully active)

7. Look for tissue depletion(loss of body fat and
skeletal muscle wasting)
Assess muscle function (strength testing of
individual muscle groups)
Fluid status: dehydration or fluid overload
Look for sources of protein or nutrient losses:
large wounds, burns, nephrotic syndrome,
chronic diseases, GI losses of nutrients,
surgical drains.
Lab parameters: plasma albumin, electrolytes,
vitamins and minerals

9. ENERGY PARAMETERS
• 1 Cal (1 kcal) = 4.128 KJ
• Carbohydrates : 4 kcal/g
• Fats : 9 kcal/g
• Proteins : 4 kcal/g
• Alcohol : 7 kcal /g

10. UTILIZATION OF ENERGY IN MAN
• Basal metabolic rate
• Specific dynamic action
• Physical activity.

11. BMR
• BMR is defined as the minimum amount of energy required by the
body to maintain life at complete physical and mental rest in the
post absorptive state (12 hr after last meal)
• REE (resting energy expenditure) : doesn’t require post absorptive
fasting state as BMR assessment
Normal values of BMR :
• For an adult man :
35–38 kcal/sq.m/hr; 1600kcal/day
• For an adult woman :
32-35 kcal/sq.m/hr. 1400kcal/day

12. ESTIMATING ENERGY REQUIREMENTS
Harris-Benedict equations :
• Men: BEE = 66.47 + 13.75W + 5.00H − 6.76A
• Women: BEE = 655.10 + 9.56W + 1.85H − 4.68A
Where ,
• W is weight in kilograms,
• H is height in centimeters,
• A is age in years.

13. REE formula
• Males, REE = 900 + 10m,
• Females, REE = 700 + 7m,
where is m mass in kilograms.
REE is then adjusted for physical activity level by
multiplying by
• 1.2 for sedentary,
• 1.4 for moderately active,
• 1.8 for very active individuals.

14. TEE= REE+ Stress Factor + Activity Factor
1.1 = without evidence of significant physiologic stress
1.4 = marked stress such as sepsis or trauma
Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
Obese or Super obese Add 15-20 kcal/kg
ESTIMATING ENERGY REQUIREMENTS

15. Factors affecting BMR
• Surface area : directly proportional
• Sex : males 5% more than females
• Age : infants highest
• Physical activity : directly proportional
• Hormones : thyroid
• Climate and temperature : inversely proportional
• Starvation : reduces in starvation
• Fever : increases
• Diseases : increases
• Race : eskimos have high BMR

16. Significance of BMR
• Calculate the calorie requirement of an
individual
• Planning of diets

17. SPECIFIC DYNAMIC ACTION
• Proteins possess the highest SDA while
carbohydrates have the lowest
• For a regularly consumed mixed diet, the SDA
is around 10%.
• Therefore, essential that an additional 10%
calories should be added to the total energy
needs (of the body) towards SDA

18. RDA (recommended dietary allowance)
• For adults, RDA for protein is 0.6 g/kg
desirable body mass per day
• Fat intake should total no more than 30% of
calories
• Saturated fat and trans fat should be limited
to <10% of calories and
• Polyunsaturated fats to <10% of calories, with
monounsaturated fats accounting for the
remainder of fat intake

19. RDA
Nutrient Male Female
Water (litre/day) 3.7 2.7
Carbohydrate (g/day) 130 130
Fibre (g/day) 38 25
Protein (g/d) 56 46
Calcium (mg/d) 1000 1000
Iodine (μg/d) 150 150
Iron (mg/d) 8 18
Magnesium (mg/d) 400-420 310-320
Phosphorus (mg/d) 700 700
Zinc (mg/d) 11 8
Sodium (g/d) 1.5 1.5
Potassium (g/d) 4.7 4.7
Chloride (g/d) 2.3 2.3
Harrisons Principles of Internal medicine , 19th E , chapter nutrition

20. RDA
Nutrient Male Female
Vitamin A (μg/d) 900 700
Vitamin C (mg/d) 90 75
Vitamin D (μg/d) 15 15
Vitamin E (mg/d) 15 15
Vitamin K (μg/d) 120 90
Thiamin (mg/d) 1.2 1.1
Riboflavin (mg/d) 1.3 1.1
Niacin (mg/d) 16 14
Vitamin B6 (mg/d) 1.3 1.3
Folate (μg/d) 400 400
Vitamin B12 (μg/d) 2.4 2.4
Pantothenic Acid (mg/d) 5 5
Biotin (μg/d) 30 30
Harrisons Principles of Internal medicine , 19th E , chapter nutrition

21. Supplementary Nutritional Support
• Enteral SNS is the provision of liquid formula
meals through a tube placed into the gut
• Parenteral SNS is the direct infusion of
complete mixtures of crystalline amino acids,
dextrose, triglyceride emulsions, and
micronutrients into the bloodstream through
a central venous catheter or via a peripheral
vein

22. INDICATIONS FOR SPECIALIZED
NUTRITIONAL SUPPORT
• PEM is already present at the time of hospital
admission and remains unimproved or worsens
during the ensuing hospital stay
• INANITION (exhaustion caused by lack of
nourishment)
• INFLAMMATION
• INACTIVITY

23. Common reasons for PEM worsening
• Refusal of food because of anorexia, nausea,
pain, or delirium,
• Communication barriers,
• An unmet need for hand-feeding of patients
with physical or sensory impairment,
• Disordered or ineffective chewing or
swallowing,
• Prolonged periods of physician-ordered fasting

24. Metabolic states
• Hypometabolic state : relatively less stressed but
mildly catabolic and chronically starved individual
who, with time, will develop cachexia/marasmus.
• Hypermetabolic state : stressed from injury or
infection is catabolic (experiencing rapid
breakdown of body mass) and is at high risk for
developing acute malnutrition/ kwashiorkor if
nutritional needs are not met and/or the illness
does not resolve quickly

26. Total protein loss and protein balance
• Protein catabolic rate (g/d) =
[24-h UUN (g) + 4] × 6.25
• 4 g added to the UUN(urinary urea nitrogen)
represents a liberal estimate of the
unmeasured nitrogen lost in the urine (e.g.,
creatinine and uric acid), sweat, hair, skin, and
feces

28. Nitrogen Balance = N input - Noutput
N input
N output
= (protein in g / 6.25)
= 24h urinary urea nitrogen + non-urinary
N losses
+4 to + 6 : Net anabolism
+1 to - 1 : Homeostasis
- 2 to - 1 : Net catabolism

29. ENTERAL
NUTRITION
PARENTERAL
NUTRITION

30. Does the patient has PEM ? Or is at the risk of PEM ?

32. Enteral Nutrition (Definition)
• Nutritional support via placement through
the nose, esophagus, stomach, or
intestines (duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT !
—Exhaust all oral diet methods first.

33. GOLDEN RULE
THE GUT SHOULD ALWAYS BE THE PREFERRED
ROUTE FOR NUTRIENT ADMINISTRATION
Enteral feeding also supports gut function by :
• Stimulating splanchnic blood flow,
• Neuronal activity,
• IgA antibody release, and
• Secretion of gastrointestinal hormones that stimulate gut trophic
activity.
• These factors support the gut as an immunologic barrier against
enteric pathogens.

40. Enteral nutrition is associated with fewer complications than
parenteral nutrition and is less expensive to administer
However, the use of enteral nutrition alone often does not
achieve caloric targets.
In addition, underfeeding is associated with weakness,
infection, increased duration of mechanical ventilation,
increased duration of hospital stay and death.
Combining parenteral nutrition with enteral nutrition
constitutes a strategy to prevent nutritional deficit but
may risk overfeeding which has been associated with liver
dysfunction, infection, and prolonged ventilatory support.

42. Parenteral Nutrition (Definition)
• Components are in elemental or “pre-digested” form
–PROTEIN as AMINO ACIDS
–CARBOHYDRATES as DEXTROSE
–FAT as LIPID EMULSION
–ELECTROLYTES, VITAMINS AND
MINERALS

43. •Parenteral nutrition should be considered if energy
intake has been inadequate for more than 7-10 days and
enteral feeding is not feasible
•It involves the continuous infusion of a hyperosmolar
solution containing carbohydrates, proteins, fat and
other necessary electrolytes through an indwelling
catheter
•Solutions that contain more than 3% amino acid and 5%
glucose are poorly tolerated peripherally

44. Macronutrients: Carbohydrate
• Source:
• Properties:
Monohydrous Dextrose
Nitrogen sparing
Energy source
3.4 Kcal/g
Hyperosmolar
• Recommended intake:
2 – 5 mg/kg/min
50-65% of total calories

45. Macronutrients: Carbohydrate
Potential Adverse Effects:
• Increased minute ventilation
• Increased CO2 production
• Increased RQ
• Increased O2 consumption
• Lipogenesis
• Hyperglycemia

46. Clinical condition Requirement (g/kg)
Normal 0.6 - 0.8
SNS 1.0
Metabolic stress (illness, injury, PEM) 1.0-1.5
Acute renal failure (undialyzed) 0.8-1.0
Hemodialysis 1.2-1.4
Peritoneal dialysis 1.3-1.5
Additional protein intake :
burn injuries, open wounds,
protein losing Enteropathy / Nephropathy.
A lower protein intake :
chronic renal insufficiency who are not treated by dialysis
hepatic encephalopathy
Each gram of nitrogen lost or gained represents : 30 g of lean tissue.

47. Macronutrients: AminoAcids
• Source:
• Properties:
Crystalline amino acids—
standard or specialty
4.0 Kcal/g
EAA 40–50%,
NEAA50-60%
• Recommended intake:
0.8 g/kg/day
15-20% of total calories
Potential Adverse Effects:
•Increased renal solute load
•Azotemia

48. •Requirement 3 g/kg/day
•30-40 percent of nutrition
•Liver can synthesize most fatty acids, but cant produce
omega-3 and omega-6 fatty acid series.
•Linoleic acid least 2% and
•Linolenic acid at least 0.5%
of daily caloric intake to prevent essential fatty acid
deficiency

49. Parenteral Fats
• Parenteral fat : 20% and 30% emulsions
• All-in-one mixture
• Max. 60% of kcal or 2 g fat/kg
• 500 mL of 20% lipids given once weekly will
prevent EFAD

50. Macronutrients: Lipids
Potential Adverse Effects:
• Egg allergy
• Hypertriglyceridemia
• Decreased cell-mediated immunity (limit to <1
g/kg/day in critically ill immunosuppressed
patients)
• Abnormal LFTs

51. By caloric intake : 1ml/calorie
Example: 1800 calorie diet = 1800 calories x
1ml= 1800ml
By body weight and age : average requirement is
30 ml/kg/d
•16-55 years 35 ml/kg/d
•56-65 years 30 ml/kg/d
•> 65 years 25 ml/kg/d

52. Parenteral Nutrition (Types)
• Delivery of nutrients intravenously, e.g. via
the bloodstream.
– Central Parenteral Nutrition: often called
Total Parenteral Nutrition (TPN); delivered into
a central vein
– Peripheral Parenteral Nutrition (PPN):
delivered into a smaller or peripheral vein

54. Common Indications for PN
• Patient has failed EN with appropriate tube
placement
• Severe acute pancreatitis
• Severe short bowel syndrome
• Mesenteric ischemia
• Paralytic ileus
• Small bowel obstruction
• GI fistula unless enteral access can be placed
distal to the fistula or where volume of output
warrants trial of EN

55. Contraindications
• Functional and accessible GI tract
• Patient is taking oral diet
• Patient expected to meet needs within 14 days

56. PERIPHERAL PARENTERAL
NUTRITION (PPN)
•Administered through a peripheral intravenous catheter.
•The osmolarity of PPN solutions generally is limited to 1,000
mOsm (approximately 12% dextrose solution) to avoid phlebitis.
•Thus, large volumes (>2,500 ml) are needed.
•Temporary nutritional supplementation with PPN may be useful

57. Peripheral Parenteral Nutrition
• Generally intended as supplement to oral feeding
• And is not optimal for critically ill pts
• New catheters allow longer support via
this method
• More commonly used in infants and children

58. • Significant malnutrition
• Severe metabolic stress
• Large nutrition or electrolyte needs (potassium
is a strong vascular irritant)
• Fluid restriction
• Need for prolonged PN (>2 weeks)
• Renal or liver compromise
Contraindications to PPN

59. TOTAL PARENTERAL
NUTRITION (TPN)
Provides complete nutritional support via a central
catheter
The solution, volume of administration, and additives
are individualized based on an assessment of the
nutritional requirements.
Nutrition delivered by PICC or CVC (tunneled or non
tunneled)

61. ADVANTAGES DISADVANTAGES
Bed side technique
Avoids complications
of central venous
catheter
Avoid multiple venous
Cannulations
Hypertonic solutions
can be given
Trained personnel is
Needed
Line blockage
Mal position
Phlebitis
Line sepsis
Thrombosis

62. PICC Lines
• PICC lines may be used in ambulatory settings or
for long term therapy
• Used for delivery of medication as well as PN
• Inserted in the cephalic, basilic, median basilic, or
median cephalic veins and threaded into the
superior vena cava
• Can remain in place for up to 1 year with proper
maintenance and without complications

63. advantages disadvantages
Central access needed
Multiple lumen can be
used in acute
emergency
Hypertonic solutions
can be given
Can be placed for than
6 weeks
Inserted in theatre
Increase infection rate
Multiple complications

64. advantages disadvantages
Convenient exit site
Long lasting than non
tunnels
Hypertonic solutions
can be given
Removal needs surgical
dissection
Catheter related sepsis
Other complications

65. NON TUNNELLED V/S TUNNELLED CENTRAL
VENOUS CATHETERS

66. INFUSION TECHNIQUE AND PATIENT
MONITORING
• Solutions with an osmolarity >900-1000
mOsm/L (e.g., those which contain >3% amino
acids and 5% glucose [290 kcal/L]) are poorly
tolerated peripherally.
• Peripheral PN may be enhanced by small
amounts of heparin (1000 U/L) and co-nfusion
with parenteral fat to reduce osmolarity

67. • The subclavian approach is best tolerated by
the patient and is the easiest to dress
• Jugular approach is less likely to cause a
pneumothorax
• Femoral vein catheterization is strongly
discouraged because of the risk of catheter
infection

68. • The addition of 6000 U of heparin to the daily
parenteral formula for hospitalized patients
with temporary catheters reduces the risk of
fibrin sheath formation and catheter infection.
• Temporary catheters that develop a thrombus
should be removed and, according to clinical
findings, treated with anticoagulants
• Low-dose warfarin therapy (1 mg/d) reduces
the risk of thrombosis in permanent catheters

69. FORMULATIONS FOR TPN
• Emulsions, or admixtures of nutrients that are
administered in an elemental form.
• 2-in-1 or 3-in-1 formulations available with
carbohydrate + amino acids +/- lipid emulsions
• Additives like : insulin, H2 blockers, vitamins
can be added

70. Calculations
Water = 25 to 35 ml / kg /day = 30x70 = 2100 ml / day
Calculating the requirement of TPN
formulation for a 70 year old patient :

71. For 2 in 1 formula ( without lipid )

72. For 3 in 1 formula ( with lipid )

74. Eg : 2100 kcal by 3-in-1 formulation

75. Compounding Methods
• Total nutrient admixture (TNA) or 3-in-1
– Dextrose, amino acids, lipid, additives are
mixed together in one container
• 2-in-1 solution of dextrose, amino acids,
additives
– Lipid is delivered as piggyback daily or
intermittently as a source of EFA

76. Advantages of TNA
(Total nutrient admixture)
• Decreased nursing time
• Decreased risk of touch contamination
• Decreased pharmacy prep time
• Cost savings
• Easier administration in home PN
• Better fat utilization in slow, continuous
infusion of fat
• Physiological balance of macronutrients

77. Disadvantages of TNA
• Diminished stability and compatibility
• IVFE (IV fat emulsions) limits the amount of
nutrients that can be compounded
• Limited visual inspection of TNA; reduced
ability to detect precipitates

78. PN Compounding Machines:

82. Initiation of PN
• Adults should be hemodynamically stable, able
to tolerate the fluid volume necessary to
deliver significant support, and have central
venous access
• If central access is not available, PPN should
be considered (more commonly used in
neonatal and peds population)
• Start slowly
(1 L 1st day; 2 L 2nd day)

83. Initiation of PN: formulation
• As protein associated with few metabolic
side effects, maximum amount of protein
can be given on the first day, up to 60-70
grams/liter
• Maximum CHO given first day 150-200
g/day or a 15-20% final dextrose
concentration
• In pts with glucose intolerance, 100-150 g
dextrose or 10-15% glucose concentration
may be given initially

84. Initiation of PN: Formulation
• Dextrose content of PN can be increased if
capillary blood glucose levels are consistently
<180 mg/dL
• IVFE in PN can be increased if triglycerides
are <400 mg/dL

85. Antioxidant Therapy
• Critical antioxidants shown to be situationally
deficient in clinical illness include glutamine,
selenium, zinc, copper, and manganese.
• Antioxidant supplements have been found to
mitigate systemic inflammatory responses,
prevent nosocomial pneumonia, and decrease
mortality in various critical care settings.

86. Burn Injury and the Metabolic Stress
Response
• Severe burns affecting approximately 30% or
more of the total body surface area are
associated with a major elevation in metabolic
rate represent one of the most severe forms
of trauma, and extreme and prolonged muscle
wasting
• Nutritional support should be initiated as
early as possible to supply vastly elevated
caloric and protein demands.

87. • functioning GI tract but may be incapable of
sufficient oral intake to meet requirements,
particularly after larger burns, and enteral
feeding is the route of choice to supplement
or replace oral intake

88. Organ Transplantation
• REEs up to 42% above predicted values have
been reported 10 days after liver
transplantation
• organ recipients do not have a propensity to
develop high metabolic rates unless secondary
conditions are present
• one should provide 1.3 to 1.5 times the
calculated basal energy expenditure, or 30 to
35 kcal/kg

89. Inflammatory Bowel Disease
• Sitophobia (aversion to food), diarrhea, protein-
wasting enteropathy, GI bleeding, development of
fistulas, and abdominal pain.
• When EN is indicated, formulas low in fat content have
better efficacy than elemental or semi elemental
formulas
• PN may be used temporarily (<2 weeks) in combination
with antibiotics with the intention of allowing the GI
mucosa to heal to facilitate surgery further

90. Short Bowel Syndrome
• If a patient is left with 1.5 feet of small bowel
anatomized to the left colon, hypertrophy of the
remaining small bowel in most cases enables survival,
while reducing the need for daily PN support to twice
weekly
• Patients receiving home TPN commonly survive for 10
to 20 years or longer
• Some patients undergo sufficient hypertrophy of the
remaining small bowel that the need for home TPN is
ultimately decreased or removed

91. Hepatic Insufficiency
• Hepatic insufficiency results in a catabolic
state similar to sepsis
• Lipids and proteins replace carbohydrates as
primary sources of energy, resulting in
depletion of lipid and protein reserves
• The increased protein catabolism does not
return to normal with feeding
• Parenteral formulations are tolerated better
than enteral formulations.

92. Intensive Insulin and Glycemic
Control
• Hyperglycemia increases inflammation and
has deleterious effects on the immune,
respiratory, renal, and nervous systems
• NICE-SUGAR trial established that a slightly
more moderate approach (i.e., maintaining
blood glucose levels<180 mg/dL) yielded
much of the benefits of tighter protocols,
without decreased morbidity and mortality
from hypoglycemia

93. Pancreatitis
• Patients have traditionally been kept NPO to
minimize pancreatic stimulation and decrease
subsequent pancreatic inflammation
• This practice is known to lead to intestinal
ischemia, bacterial translocation, and potential
sepsis
• Initial volume resuscitation and pain control
should be followed by early postpyloric enteral
feeding starting within 24 hours of admission

94. Infusion Schedules
• Continuous PN
Non-interrupted infusion of a PN solution over 24
hours via a central or peripheral venous access
• Well tolerated by most patients
• Requires less manipulation

95. Continuous PN
Disadvantages
• Persistent anabolic state
– altered insulin : glucagon ratios
– increased lipid storage by the liver
• Reduces mobility in ambulatory patients

96. Infusion Schedules
• Cyclic PN
– The intermittent administration
over a period of 12 – 18 hours
– Patients on continuous
therapy may be converted to
cyclic PN over 24-48 hours

97. Cyclic PN
• Advantages
–Approximates normal physiology of
intermittent feeding
–Maintains:
• Nitrogen balance
• Visceral proteins
–Ideal for ambulatory patients
• Allows normal activity
• Improves quality of life

98. Cyclic PN
• Disadvantages
–Not tolerated by critically ill patients
–Requires more nursing manipulation
• Increased potential for touch
contamination
• Increased nursing time

99. Home TPN
• Patient selection
–Reasonable life expectancy
–Demonstrates motivation, competence,
compliance
–Home environment conducive to sterile
technique

100. Complications
Of TPN
Mechanical
metabolicinfectious
COMPLICATIONS
OF TPN
MECHANICAL
METABOLICINFECTIVE

101.  Air embolism
 Pneumothorax
 Hemothorax
 Cardiac tamponade
 Injuries to arteries and veins
 Injury to thoracic duct
 Brachial plexus injury

105. Infections :
 Catheter related sepsis is most common life
threatening complication
Causes:
 Staph epidermidis and staph aureus,
 Enterococcus,
 Candida,
 Ecoli, psuedomonas,
 Klebsiella

106. PN Administration:Transition to
Enteral Feedings in Adults
•In adults receiving oral or enteral nutrition sufficient to
maintain blood glucose, need to taper PN
•When the patient can satisfy 75% of his or her caloric
needs with oral intake
•Reduce rate by half every 1 to 2 hrs or switch to 10%
dextrose IV) may prevent rebound hypoglycemia (not
necessary in PPN)
•Monitor blood glucose levels 30-60 minutes after
cessation

107. Medications That May Be Addedto
Total Nutrient Admixture (TNA)
• Phytonadione
(Vit K)
• Insulin
• Octreotide
• Metoclopromide
• Ranitidine
• Heparin

109. •Strict asepsis
•24-hr TPN prepared at a time
•Changing infusion sets daily
•New amino acid, lipid bottles daily
•Separate IV access for other drugs
•Serum Na, K on alt. days; renal parameters
biweekly; LFT, triglycerides weekly

110. PN Contaminants
• Most common contaminants are aluminum
and manganese
• Aluminum toxicity a problem in pts with
renal compromise on long-term PN and in
infants and neonates
• Can cause osteopenia in long term adult PN
patients
• Safe intake of aluminum in PN is set at 5
mcg/kg/day
ASPEN Nutrition Support Practice Manual 2005; p. 109

111. PN Contaminants
• Manganese toxicity
• May lead to neurological symptoms
• Manganese concentrations of 8 to 22
mcg/daily volume have been reported in
formulations with no added manganese
• switch to single-unit trace elements
that don’t include manganese
ASPEN Nutrition Support Practice Manual 2005; p. 98-99

112. Clinimix : dextrose + AA
Clinimix E : dextrose + AA + Electrolytes
Kabiven : 3 in 1 formulation
Vitrimix : Dextrose + AA
Intralipid : 20% lipid
Celepid : 20 % lipid
Celemin : AA 10 %

117. References :
1.Harrison’s : Textbook of Internal Medicine
2.Bailey and love : Text book of Surgery
3.Sabiston : Text book of Surgery
4.Maingot’s : Text book of Surgery