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Parenteral &

Enteral Feeding

Aim of Nutritional Support

To ensure that the nutritional requirements are met
in patients at risk of malnutrition, by the most
appropriate route in a way that minimizes


Parenteral feeding: the provision of all nutritional
requirements by means of IV route without the use
of the GIT

Enteral feeding: delivery of nutrients into the GIT;
either by standard oral intake or by direct
administration into the stomach or a small intestine
via a feeding tube

[Nutritional requirements: macronutrients,
carbohydrates, fat, proteins, vitamins, trace elements,
electrolytes & water]

Enteral Feeding

When possible, enteral feeding is preferred as a
nutritional support, why?

Because it maintains gut mucosal integrity, protects
against mucosal atrophy & reduces complications.

Enteral Feeding  Types: 1. Sip feeding 2. Jujenostomy . Gastrostomy 4. Nasogastric tube 3.

1. Sip Feeding  By using small amounts of special formula  Indicated in patients who can take fluids only (in case of weakness in the mouth or the mastication muscles) .

In ICU . With CVA 3.2. Nasogastric Tube  Fine bore tube (1mm) inserted into the stomach via the nose  Indicated in patients: 1. In coma 4. Unable to swallow 2.


where a specific amount of normal saline is administered into the stomach. to compare both amounts. After 2 hours. Nasogastric Tube [cont]  Intact gag reflex is a must in case of using this type of feeding  Good gastric peristalsis is a must (to prevent gastric stasis which can lead to gastric ulceration) • How to check for peristalsis?  By motility study. suction from the stomach is done.2. then there’s gastric stasis) . (if the amount after suction was the same as the administered one.

used for maximum of 2 months • Gastroesophageal reflux & aspiration (due to the incomplete closure of esophageal sphincter in the presence of NG tube) .2. ulceration & pressure necrosis • Offensive in conscious or semi-conscious patients • Duration limited. Nasogastric Tube [cont]  Disadvantages: • Nose irritation.

3. used nowadays instead of open surgery  Good evacuation (good peristalsis) is also needed here. which can be confirmed by motility study . Gastrostomy  Tube inserted directly to the stomach through the abdominal wall  PEG [percutaneous endoscopic gastrostomy]: insertion of the tube by endoscope.



Gastrostomy [cont]  Indicated in: • Obstructed GI tract before the stomach (tumors in oropharynx or lower esophagus) • Loss of peristalsis due to neuromuscular disorder • Need for nutritional support for long time (e.g: head trauma.2. coma) .

Jujenostomy  Post-pyloric feeding  decreases risk of aspiration but difficult to place  Over distention could result from flooding of GIT by feeding  Indicated in: • Gastric obstruction (advanced gastric CA) • Major resection of upper GIT. like whipple procedure (pancreaticoduodenectomy & gastrojejunostomy) .4.


displacement.. endogenous.. abdominal cramps.  Infective: handling contamination..Complications of Enteral Feeding  Tube-related: malposition. .. vomiting.. blockage.. drug interactions...  Metabolic: electrolyte disorders. nausea.  GI: diarrhea.

Inability to cope . Fistula 5. Obstruction 2. Short bowel syndrome 3. Inflammation 4.Total Parenteral Nutrition  Indications: 1.

Pancreatic tumor: causes malabsorption & obstruction .Total Parenteral Nutrition Indications: 1. e. Obstruction •. Irremovable advanced tumors.g lymphoma •.

steatorrhea. which is treated by resection  Crohn’s disease: recurrent surgical resection of the bowel . Short bowel syndrome (<1m of small intestine)  A disorder clinically defined by malabsorption.Total Parenteral Nutrition 2. fluid & electrolyte disturbances and malnutrition caused by loss of large segment of small intestine  Causes :  Mesenteric ischemia: superior mesenteric embolism if left untreated for 5 hrs may lead to gangrene & resection. diarrhea.  Volvulus neonatorum: bowel twisted around itself.

Total Parenteral Nutrition 3. Inflammation  Ulcerative colitis & crohn’s disease. TPN used to rest the bowel .

etc..)  Managed conservatively & need 6 wks to improve by using TPN to rest the bowel . feces or bowel contents (gastric juice.Total Parenteral Nutrition 4. Fistula  Fistula in the upper GIT  Causes leak of pus. enzymes. bile.

especially proteins:  Sever sepsis. Inability to cope In cases of increased catabolic rate where the bowel can’t compensate the body demand.Total Parenteral Nutrition 5. .  Extensive burning.

Femoral V: rarely used.Subclavian V: commonly used .Total Parenteral Nutrition  How to perform TPN? Through the central line access: 1. because it’s low and away from the heart 2.Internal jugular V: commonly used in anesthesia 3.

it can’t be easily washed by saline because of the narrow lumen of peripheral veins  If central access  Does not cause irritation due to high blood flow  If complicated.Total Parenteral Nutrition Why central not peripheral?  Because the nutrition used is hyperosmolar. so:  If peripheral access  causes irritation. can be easily washed out by saline . inflammation & thrombosis due to poor flow  If complicated.

Supine position & head down (to congest neck veins) 2. Insert a cannula (backward medially & downward) until blood comes out 5.Total Parenteral Nutrition  How to insert an IV central line? 1. Local anesthesia below the clavicle 3. Fix the line by stitch . Introduce a catheter to reach SVC 6. By a wide bore needle (1mm) make incision in the inferior surface of clavicle 4.

Total Parenteral Nutrition  During the procedure: patient is asked to hold their breath to decrease risk of pneumothorax & air embolism  After the procedure: CXR is done to confirm the site of the catheter & to exclude pneumothorax .

Total Parenteral Nutrition  Complications of the procedure. injury of: 1) Brachial plexus 2) Subclavian artery (hematoma) 3) Thoracic duct 4) Phrenic nerve 5) Superior vena cava 6) Lungs (pneumothorax) 7) Cardiac muscles .

Total Parenteral Nutrition Complications of TPN: 1) Line infection 2) Fatty infiltration to the liver 3) Hyper-osmolarity 4) Re-feeding syndrome: metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are malnourished 5) Insulin rebound phenomenon (somogyi syndrome) .

and blood clots on this IV line are common. with a mortality rate of approximately 15% per infection.  Patients under long-term TPN will typically receive a periodic heparin flush to dissolve such clots before they become dangerous.  Fatty liver and liver failure  Fatty liver is usually a more long term complication of TPN. and the most common complication is infection of this catheter. . and death usually results from septic shock]  Blood clots  Chronic IV access leaves a foreign body in the vascular system. though over a long enough course it is fairly common. The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of soybean oil) as a major source of calories. Infection is a common cause of death in these patients. ] Death can result from pulmonary embolism wherein a clot that starts on the IV line but breaks off goes into the lungs. Infection  TPN requires a chronic IV access for the solution to run through.

In cases where the patient eats food despite the inability. and so the patient experiences hunger. the taste. Tract (fullness) and blood (nutrient levels) to determine conscious feelings of hunger. despite the fact that the body is being fully nourished. Hunger  Because patients are being fed intravenously. the stomach/ G. resulting in intense hunger pangs. the subject does not physically eat. smell and physical fullness requirements are not met. The brain uses signals from the mouth (taste and smell). . they can experience a wide range of complications.I. In cases of TPN.

2 g/kg/day  Na: 100mmol/day  K: 80mmol/day .15-0.Total Parenteral Nutrition  How to give nutrition by TPN? Normal body need:  Fluid: 30-40 mL/kg/day  Calories: 30-40 kcal/kg/day  Nitrogen: 0.

Total Parenteral Nutrition Example  A patient who weighs 70 Kg with fistula & fever 10 days post-op. How to calculate the need? ..

An amount of fluid is lost by the fistula. diarrhea. vomiting & drain all cause fluid loss] .Another amount must be added because of fluids lost in sweating (he’s feverish)  +200 mL/day 2800+1000+200=4000 mL/day [sweating. so we add an amount of fluid in order to compensate  +1000 mL/day . fistula.Total Parenteral Nutrition Fluids 70x40 = 2800 mL/day .

He has sepsis & post-op stress. so to compensate  +1200 kcal/day 2800+1200 = 4000 kcal/day .Total Parenteral Nutrition Calories: 70x40 = 2800 kcal/day . which causes a loss of more calories.

Due to increased catabolism (due to sepsis).Total Parenteral Nutrition Nitrogen: 70x0. this needs to be compensated  + 7 g 14+7 = 21 g .2 = 14 g .

Total Parenteral Nutrition How to give those nutrients as a source of energy?  Carbohydrates  50%  Protein  15%  Fat  35% .

5% form contains 50 g/L so  200 kcal/L .Total Parenteral Nutrition Glucose Water We have many forms: 5%. 50%.50% form contains 500 g/L so  2000 kcal/L    Our patient needs 4000kcal/day. 75% (1 g  4 kcal) . 25%. this can be achieved by: 20 L/day of 5% form or 2 L/day of 50% form So 50% is better to be used in this case . 10%.

so 1.5 L of 14% form can be given in this case . 5%. 10%.Total Parenteral Nutrition Nitrogen Different forms: 3%. 14%  14% form contains 14 g/L  Our patient needs 21g.

10% form contains 100 g. because it causes allergic reaction & interference with coagulation factor and it’s expensive]   Electrolytes Normal saline or ringer lactate .Total Parenteral Nutrition Lipid Different forms: (1g  9kcal) . so  900kcal/L [Not given daily.

& change site of cath .5L. increment of 300 g or more this is over feeding.Total Parenteral Nutrition General instructions:  TPN must be given by drips. so decrease doses  KFT & LFT weekly  Electrolytes & glucose level daily (for metabolic complication)  In case of sepsis: drain the cath. 3rd day 4.5L.)  Nutrients must not be given at once.. one bottle with fixed gradual rate (1st day 2.5.. this may cause hyperglycemia & rebound insulin phenomena  Pt must be weighed daily. culture.. 2nd day 3.

Thank You .