ENTERAL AND PARENTERAL NUTRITION

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ENTERAL AND PARENTERAL NUTRITION

• DR.ANOOP RAJ GOGIA
• HOD DEPARTMENT OF ANAESTHESIOLOGY INTENSIVE
  CARE
• VMMC SAFDARJANG HOSPITAL ,
• NEW DELHI

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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DELETERIOUS EFFCTS OF MALNUTRITION

• ALTERATION IN IMMUNITY
• ? SUSCEPTIBILITY TO NOSOCOMIAL INFECTION
• ? WOUND HEALING
• ALTERATION IN FUNCTION OF VITAL ORGANS
• PROMOTING ORGAN FAILURE

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INITIATION OF NUTRITIONAL SUPPORT

• PRE ILLNESS NUTRITIONAL STATUS
• TYPE , SEVERITY STAGE OF CRITICAL ILLNESS
• PRESENCE OF ORGAN FAILURE
• ROUTE OF FEEDING
• USE OF SPECIAL DIET INCLUDING IMMUNONUTRIENTS
  ANTIOXIDENTS

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NUTRIONAL SUPPORT

• SHORT STARVATION OF 5-7 DAYS NOT DELETERIOUS IN
  PATIENTS WITHOUT PREEXISTING MALNUTRITION
• PATIENTS WITH INADEQUATE ORAL INTAKE FOR 7-14
  DAYS ,NUTRIONAL SUPPORT SHOULD BE STARTED
• CONVENTIONAL FEEDING TO BE INITIATED WITH IN 3-10
  DAYS
• LATE FEEDING-AFTER 10 th DAY

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INDICATIONS OF EARLY ENTERAL FEEDING

• SEVERE TRAUMA
• MAJOR BURNS
• LIVER TRANSPLANT
• ARDS
• MAJOR ABDOMINAL CANCER SURGERY
• ACTUAL MALNUTRITION

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CONTRAINDICATIONS OF ENTERAL FEEDING

• LOSS OF ANATOMICAL BOWEL INTEGRITY
• PARALYTIC ILEUS
• SEVERE SPLANCHNIC ISCHEMIA
• ACUTE CIRCULATORY FAILURE
• SEVERE DIARRHOEA
• HIGH OUTPUT CUTANEOUS FISTULAE

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ADVANTAGES OF ENTERAL NUTRITION

• LOW COST
• REDUCED INFECTIONS
• ? HOSPITAL STAY
• BETTER MAINTENANCE OF GUT INTEGRITY
• PREVENTS TRANSLOCATION OF BACTERIA

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READINESS FOR ENTERAL NUTRITION

• MOST PATIENTS ARE READY WITH IN 24-48 hrs OF
  ADMISSION TO ICU
• PATIENTS ON VASOPRESSORS, NM BLOCKERS UNSTABLE
  HAEMODYNAMICS ARE NOT READY
• ADEQUATE ENTERAL PERFUSION SHOULD BE RESTORED
• NASO GASTRIC ASPIRATE SHOULD BElt 200-300 ml/24hrs
• LOOK FOR PRESENCE OF BOWEL SOUNDS
• EXAMINE FOR S/S INTESTIONAL OBSTRUCTION BOWEL
  DISRUPTION ,ISCHEMIA ,DISTENSION DIARRHOEA

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ENERGY REQUIREMENT

• POST SURGICAL 25 Kcal/kg/24hrs
• POLYTRAUMA, SEPSIS,BURNS
• 35kcal/kg/24hrs
• BASE LINE WATER REQUIREMENT -30-35
  ml/kg/24hrs OR 1ml/Kcal/24hrs
• IN CASES OF FEVERADD 300-500 ml/ 24hrs
• CARBOHYDRATES-50-60 OF TOTAL CALORIES
• PROTEINS-10-20 OF TOTAL CALORIES
• FATS- NOT gt30 OF TOTAL CALORIES

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PROTEINS

• THREE TYPES FORMULATIONS
• INTACT PROTEINS-NORMAL LEVEL OF PANCREATIC
  ENZYMES
• PARTIALLY DIGESTED PROTEIN-PANCREATIC
  INSUFFICIENCY,SEPSIS,,MULTIPLE TRAUMA, SHOCK
• CRYSTALLINE L-AMINO ACIDS-DIGESTION NOT REQUIRED
• DIS ADV. OF AMINO ACID BASED DIET-GUT
  ATROPHY,BACTERIAL TRANSLOCATION,?GROWTH WOUND
  HEALING
• SOYgtWHEYgtCASEIN

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CARBOHYDRATES

• FORM CONC.OF CARBOHYDRATES DIFFER AMONG THE
  FORMULAE
• STARCH(HYDROLYZED CEREAL OR CORN STARCH,FLOUR)
• GLUCOSE POLYMERS(MALTODEXTRINS, CORN SYRUPS,
  GLUCOSE OLIGOSACCHARIDES)
• DISACCHARIDES(SUCROSE, MALTOSE)
• MONOSACCHARIDES(GLUCOSE, FRUCTOSE)

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FATS

• PROVIDES CONC. CALORIES, ESSENTIAL ACIDS,CARRIER
  FOR FAT SOLUBLE VITAMINS
• DIGESTION REQUIRES PANCREATIC ENZYMES, BILE FATTY
  SALTS,INTACT INTESTINAL WALL FLORA
• GIVEN AS MIXTURE OF MCTs(DO NOT REQUIRE PAN.
  LIPASE OR BILE SALTS ,GO DIRECTLY TO LIVER, NOT
  TRANSPORTED VIA LYMPHATICS),OMEGA 3 OMEGA6 PUFA
  (CANNOT BE SYNTHESIZED)
• FATS CONTAINED IN ENTERAL FORMULA-MCTs(USUALLY
  SATURATED, COCONUT OIL),LONG CHAIN(POLYUNSATURATED
  , CORN OIL, SAFFLOWER OIL,SOYABEAN OIL),
  PHOSPHOLIPIDS(POLYUNSATURATED, POLYGLYCOL ESTER
  OF FATTY ACIDS),GLYCERIDES(MONO,DI TRI
  GLYCERIDES)

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OTHER INGREDIENTS

• FIBRE CONTENT- SOY POLYSACCHARIDES(INSOLUBLE
  FIBRE TO ?STOOL BULK REGULATE TRANSIT TIME
• VITAMINS(A ,D, E, K,B COMPLEX, C) MINERALS (Na,K
  ,Ca,Mg, PHOSPHATE,Zn, Mn etc)
• NITROGENCALORIES(NON PROTEIN)1350 IN HEALTH, IN
  FORMULATIONS 1120-140
• FEEDS PASS THROUGH 10 FG NG TUBES
• ISOTONIC(OSMOLALITY 280-300mOsm/ Kg)-GIVEN AS
  FULL STRENGTH RATE? SLOWLY
• HYPERTONIC(OSMOLALITY 400-1100 mOsm/Kg )-GIVEN AS
  HALF STRENGTH

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COMMERCIAL FORMULAE
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GOALS MODE OF ADMINISTRATION

• FEEDING TO BE INITIATED AT 25 OF CALORIC
  REQUIREMENT
• 50- 60 OF CALORIC REQUIREMENT TO BE ACHIEVED
  WITH IN 3-5 DAYS
• ? TO 100 IN NEXT 1-2 DAYS
• BOLUS FEED-200-400 ml OVER 20-30 min 5-6 TIMES
  /DAY
• GIVEN THROUGH SYRINGE BY GRAVITY AT lt60 ml /min
• DIS ADV.- NAUSEA , DISTENSION , DIARRHOEA
• CONTINUOUS FEED -16-24ml/hr ,THROUGH ENTERAL
  PUMP,PREFERRED MODE IN INTESTINAL FEEDING

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INSTRUCTIONS

• NAME OF FORMULA
• MODE OF ADMINISTRATION
• WASH HANDS WEAR GLOVES
• CONFIRM POSITION OF NG TUBE
• ELEVATE HEAD END BY 30-45
• CHECK RESIDUAL VOLUME RETURN INTO THE STOMACH
• TAKE PREVENTIVE MEASURES FOR ORAL HYGIENE CARE
  OF THE SKIN
• IN CASE OF INTOLERANCE (NAUSEA, VOMITING,
  ABDOMINAL CRAMPS)-?RATE TO 25 ml/hr
• RECORD NO., VOL. CONSISTENCY OF BOWEL MOVEMENTS
• RECORD I/O CHART
• MONITOR-HAEMOGRAM, BLOOD UREA ,S. CREATININE,
  ELETROLYTES( BASELINE TWICE/ WEEK), BLOOD
  SUGAR(BASELINE, DAILY FOR 3 DAYS, TWICE /WEEK),
  CALCIUM,PHOSPHORUS,MAGNESIUM, ALBUMIN (BASELINE
  ONCE A WEEK.

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PARENTERAL NUTRITION

• INDICATIONS
• CALCULATE ENERGY REQUIREMENTS
• TAKE INTO ACCOUNT THE CALORIES FLUIDS SUPPLIED
  THROUGH ENTERAL ROUTE
• INITIATE WITH HYPOCALORIC NUTRITION. OVERFEEDING
  HYPERGYCEMIA ,FLUID OVERLOAD ,HYPOPHOSTEMIA,
  RESP. INSUFFICIENCY ELECTROLYTE IMBALANCE
• CALCULATE THE LIQUID NECESSARY AS CARRIER FOR
  ELECTROLYTES, INOTROPES,SEDATION, ANTIBIOTICS
• CALCULATE REQ. OF VARIOUS COMPONENTS OF TPN

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PARENTERAL NUTRITON(CONTD.)

• PROTEINS- DAILY REQ. OF ALL ESSENTIAL AMINO ACIDS
  TO BE MET
• SUFFICIENT QUANTITY OF NON -ESSENTIAL A.ACIDS( AS
  NITROGEN DONARS) SHOULD BE SUPPLIED
• DAILY REQ.- 0.5- 1.6 gm/kg/24 hrs
• 0.7-1 gm/kg/24 hrs-WITH GOOD NUTRITION MINIMAL
  STRESS
• 1-1.2gm/kg/24 hrs-WITH MAJOR SURGERY CHILDRENlt
  5YEARS
• 1.2- 1.6 gm/ kg/24 hrs- POOR NUTRITION, SEVERE
  CATABOLIC STATE ,SEPSIS BURNS

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PARENTERAL NUTRITION

• LIPIDS-NOT gt30 OF TOTAL CALORIES 2.5 OF TOTAL
  CALORIES AS ESSENTIAL FATTY ACIDS
• LIPID EMULSIONS- GLYCEROL WITH EMULSIFIER(PURIFIED
  EGG YOLK PHOSPHOLIPIDS),AVAILABLE AS 10 20
  CONC.10 EMULSION 1.1 kcal /ml
• INTRALIPID- SOYABEAN OIL ,HIGH CONTENT OF PUFA
  ,LEADS TO HIGH PEROXIDATIVE CATABOLITES
  IMMUNOSUPPRESSION
• .MIXTURE OF 80 OLIVE OIL 20 SOYABEAN OIL IS
  BETTER
• CARBOHYDRATES- 50- 60 OF TOTAL CALORIES 70-
  90 OF NON PROTIEN CALORIES
• TOTAL GLUCOSE LOAD MAY BE LIMITED TO 3.5 -5
  gm/kg/24 h
• 1 gm GLUCOSE 3.4 kcal( AS IT IS HYDRATED)

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PERIPHERAL vs CENTRAL

• FOR PPN OSMOLARITY lt900mOsm/L
• SOLUTIONS GIVEN SAFELY THROUGH PERIPHERAL ROUTE-
  10 20 LIPID (BOTH ARE ISO OSMOLAR),
  GLUCOSE(5- 10 ) , AMINO ACIDS(2-4)
• ADVANTAGESOF PPN- LOW COST,EASIER HANDLING, FEWER
  LESS SEVERE COMPLICATIONS
• NUTRIONAL SUPPORT OF 1200-1500 kcal/24 hrs UP TO
  2 WEEKS CAN BE PROVIDED
• UNSUITABLE-POOR VENOUS ACCESS, HIGH FLUID ,ENERGY
  NITROGEN REQUIRING PATIENTS,PATIENTS REQURING
  PN FOR LONGTIME
• ADD REQ OF ELETROLYTES ,TRACE ELEMENTS VITAMINS
• ADD MAGNESIUM AS MAG.SULFATE.CALCIUM AS CALCIUM
  GLUCONATE ,VITAMINS AS MVI,TRACE ELEMENTS
  WHENEVER POSSIBLE

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INSTRUCTIONS

• CATHETER SHOULD BE INSERTED UNDER ALL ASEPTIC
  PRECAUTIONS
• OBTAIN X-RAY CHEST FOR CONFIRMATION OF POSITION
• INSPECT DRESS DAILY
• AVOID DRAWING BLOOD FROM TPN LINE FOR
  MEDICATION
• ADM. SETS SHOULD BE CHANGED DAILY
• FOR 3 IN 1 SYSTEM 1.2µm FILTER FOR FAT
  EMULSIONS 0.22 µm FILTER REQUIRED
• RATE OF INFUSION- GLUCOSE(TARGET RATE 5mg/kg/min)
  , SUGAR ESTIMATION 6hrly
• DO NOT ADMINISTER FATS DURING SHOCK, START SLWLY
  TO A TARGET RATE OF 0.05gfm/kg/hr. DO NOT EXCEED
  0.11 gm/ kg hr.LIPIDS GIVEN ALONE SHOULD FINISH
  IN 12 hrs.MONITOR TRIGLYCERIDES. LEVEL NOT TO
  EXCEED 300 mg/dl.
• MAILLARD REACTION

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THANK YOU
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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