nutrition

Nutritional therapy

Provide a life sustained therapy for the patient who can not take adequate food by mouth who consequently at risk for malnutrition and its complications
Nutritional therapy

Benefits of Nutritional Support

Preservation of nutritional statusPrevention of complications of protein malnutrition  Post-operative complications

Who Requires Nutritional Support?

Patients already with malnutrition – surgery / trauma/sepsisPatients at risk of malnutrition

Patients at Risk of Malnutrition

Cannot eat for >9 days Vomiting : acute pancreatitis ,hperemesis gravidarum GIT obstruction: malignancy neurological : coma , swallowing dis. Abdominal pain : A. pancreatitis

Patients at Risk of Malnutrition

Can not absorb: intestinal fistula ,short bowel syndrome Should not eat: bowel rest in a.pancreatitis Intestinal fistula


Others nutritional support in patient with malignancy nutritional support in malnourished patient before surgery
Who Requires Nutritional Support?

Type of the nutritional rehabilitation

Normal diet mild malnutrition and treatable disease Supplement high energy and protein content used if normal diet cant give sufficient nutrition Specific Nutritional support Enteral feeding Parentral feeding

Types of Nutritional Support

Enteral Nutrition Parenteral Nutrition

Enteral Feeding Is Best

More physiologic Less complications Gut mucosa preserved No bacterial infection Cheaper

Enteral Feeding Is Indicated

When nutritional support is needed Functioning gut present No contra-indications no ileus, no recent anastomosis, no fistula

Types of Feeding Tubes

Naso-gastric tubes Naso-jejunal tubes
Tubes inserted down the upper GIT, following normal anatomy

Types of Feeding Tubes

Gastrostomy tubes Percutaneous Endoscopic Gastrostomy (PEG) Open Gastrostomy Jejunostomy tubes Percutaneous endoscopic jejunostomy (PEJ) open jejenostomy
Tubes that require an invasive procedure for insertion (feeding for long time)

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What Can We Givein Tube Feeding?
Blenderised feeds Commercially prepared feeds e.g. Vivonex

Complicationsof Enteral Feeding

Gastrointestinal complications Mechanical complications Metabolic complications Infectious complications

Complicationsof Enteral Feeding

Gastrointestinal Distension Nausea and vomiting Diarrhoea Constipation

Complicationsof Enteral Feeding

Infectious Aspiration pneumonia Bacterial contamination

Complicationsof Enteral Feeding

Mechanical Malposition of feeding tube Sinusitis Ulcerations / erosions of nasal and esoph Blockage of tubes

Parenteral Nutrition

Parenteral Nutrition
Allows greater caloric intake BUT Is more expensive Has more complications Needs more technical expertise

Who Will Benefit From Parenteral Nutrition?

Patients with/who Abnormal gut function Cannot consume adequate amounts of nutrients by enteral feeding Prognosis warrants aggressive nutritional support

Two Main Forms of Parenteral Nutrition

Peripheral Parenteral Nutrition Central (Total) Parenteral Nutrition

Peripheral Parenteral Nutrition

Given through peripheral vein Short term use Mildly stressed patients Low caloric requirements Contraindications to central TPN

What to Do Before Starting TPN

Nutritional Assessment Venous access evaluation Baseline weight Baseline lab investigations

Baseline Lab Investigations

Daily : urea , electrolytes, glucose Twice weekly : LFT, calcium, phosphate, magnesium Weekly: CBC, zinc, triglycerides Monthly: copper, selenium, manganese

Formula of the TPN

Dextrose 10% ,20% glucose Intralipid 10%, 20% fatty acid Vamine ( amino acid) 8%, 14% Vitamins Minerals Trace elements

Complications Related to TPN

Mechanical Complications Metabolic Complications Infectious Complications

Mechanical Complications

Related to vascular access technique
pneumothorax air embolism arterial injury bleeding
brachial plexus injury thoracic duct injury

Mechanical Complications

Venous thrombosis Catheter occlusion
Related to catheter in situ

Abnormalities related to excessive or inadequate administration hyper / hypoglycemia refeeding syndrome Fluid and electrolyte Congestive heart failure Acid-base disorders

Metabolic Complications

Metabolic Complications
Refeeding syndrome due to rapid glucose load hypomagnesemia hypokalemia hypophosphatemia Cardiac arrythmia Cardiopulmonary dysfunction Neurologic symptoms

Hepatic complications Biochemical abnormalities Cholestatic jaundice Hepatic steatosis Gall stones Acalculous cholecystitis
Metabolic Complications

Infectious Complications

Insertion site contamination contaminated TPN solution contaminated tubing Secondary contamination septicaemia



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