Something About Nutrition And Parenteral Nutrition.

1. By Dr Kaleem Ullah Bhatti
House Surgeon

2. The taking in and metabolism of nutrients so that life is maintained and
growth can take place.

3. Definition
A disorder of nutrition it may be due to
unbalanced or insufficient diet or to defective
assimilation or utilization of foods.

4. Following are the types of nutrition
 Enteral Nutrition
 Parenteral Nutrition

5.  Definition
 It is administration of nutrition exclusively
through intravenous route bypassing
gastrointestinal tract

6. Either who are malnourished
Have the potential for developing malnutrition
Are not candidates for enteral support

7. Parenteral nutrition is usually indicated in the
following situations: Parenteral nutrition maybe indicated in the
Documented inability to absorb adequate following situations:
nutrients via the gastrointestinal tract; this  Inflammatory bowel disease unresponsive
may be due to: to medical therapy
 Massive small-bowel resection / Short  Hyperemesis gravidarum when nausea
bowel syndrome (at least initially) and vomiting persist longer than 5 -7
 Radiation enteritis  days and enteral nutrition is not possible
 Severe diarrhea ,Steatorrhea  Partial small bowel obstruction
 Complete bowel obstruction, or intestinal  Intensive chemotherapy / severe mucositis
pseudo-obstruction  Major surgery/stress when enteral nutrition
 Severe catabolism with or without not expected to resume within 7-10 days
malnutrition when gastrointestinal tract is  Intractable vomiting and jejunal access is
not usable within 5-7 days not possible
 Inability to provide sufficient   Chylous ascites or chylothorax when
nutrients/fluids enterally EN(with a very low fat formula) does
 Persistent GI hemorrhage  not adequately decrease output
 Acute abdomen/ileus Lengthy GI work-up
requiring NPO status for several days in a
malnourished patient
 High output enterocutaneous fistula and
EN access cannot be obtained distal
 to the site.

8. History
Physical Examination
Anthropometric Measurements
Laboratory Investigations

9. It should include:
 Food habits
 Quality and quantity of ingested nutrients
 Appetite and changes in appetite
 Food intolerance and allergies
 Chewing or swallowing problems
 Significant weight loss within last 6 months
▪ > 15% loss of body weight
▪ compare with ideal weight
▪ Beware the patient with ascites/ oedema/amputations

10.  We will proceed step by step
 General Appereance
 Skin and appendages
 Eyes,Mouth
 Neurological

12. • Weight for Height comparison
• Body Mass Index (<19, or >10% decrease)
• Triceps-skinfold
• Mid arm muscle circumference
• Bioelectric impedance
• Hand grip dynamometry
• Urinary creatinine / height index

13.  Serum Albumins can provide useful
information
Low Level Serum Albumin+
raised C-reactive protein
Low level of Serum Albumins+
normal C-reactive proteins
Rising serum albumins levels

15. TEE = REE + Stress Factor + Activity
Factor
Rest Energy Expenditure
 Adults (18-65) 20-30 kcal/kg
 Elderly (65+)  kcal/kg
25
 For burns Patients 30-35kcal/kg
Other factors:
 Pregnancy: Add 300 kcal/day
 Lactation: Add 500 kcal/day
 Obese or Super obese 15-20 kcal/kg

16. peritonitis + 15%
• soft tissue trauma + 15%
• fracture + 20%
• fever (per oC rise) + 13%
• Moderate infection + 20%
• Severe infection + 40%
• <20% BSA Burns + 50%
• 20-40% BSA Burns + 80%
• >40% BSA Burns + 100%

18.  ESTIMATING ADULT FLUID REQUIREMENTS
 1. By caloric intake : 1ml/calorie
 Ex: 1800 calorie diet = 1800 calories x 1ml=
1800ml
 2. By body weight and age :
 Age Fluid requirements
 16-55 years 35 ml/kg/day
 56-65 years 30 ml/kg/day
 > 65 years 25 ml/kg/day

19.  Macronutrients
 Micronutrients

20.  Requirement 2g/kg/day
 1grams=5kcal/g
 40-50 percent of total nutrition

21.  Requirement 3 g/kg/day
 1 gram= 9kcal/g
 30-40 percent of nutrition

22.  Carbohydrate and fat,usually in
lipid:carbohydrate ratio of 60:40 or vice versa

23.  Requirement 0.2-0.5g/kg/day
 1 gram= 4kcal/g
 15-20 percent of nutrition
 Mild stress 1.0 -1.2 g/kg
 Moderate stress (most ICU patients) 1.5-2.0
g/kg
 Severe Obesity 1.5 g – 2.0 g/kg IBW
 Severe stress, catabolic, burns 2.0 –2.5 g/kg

24. Nitrogen Balance = N input - N output
6.25 g protein provides 1 g of nitrogen,as 100grams
contains 16 g nitrogen
N input = (protein in g / 6.25)
N output = 24h urinary urea nitrogen + non-urinary
N losses
 +4 to + 6: Net anabolism
 +1 to - 1: Homeostasis
 -2 to – 1: Net catabolism

25.  Sodium 70 – 100 mEq/day
 Chloride 70 – 100 mEq/day
 Potassium 70 – 100 mEq/day
 Calcium 10 – 20 mEq/day
 Magnesium 15 – 20 mEq/day
 Phosphorus 40-60 mEq/day
 Acetate 0 – 60 mEq/day

26.  Vitamin A 3300 IU
 Vitamin D 200 IU
 Vitamin E 10 IU
 Vitamin K - 150 mcg
 Ascorbic acid 100 mg
 Folic Acid 0.4 mg
 Niacin 40 mg
 Riboflavin (B2) 3.6 mg
 Thiamin (B1) 3 mg
 Pyridoxine (B6) 4 mg
 Cyanocobalamin (B12) 5 mcg
 Pantothenic acid 15 mg
 Biotin 60 mcg

27.  Zinc 2.5-4 mg
 Copper 0.5-1.5mg
 Chromium 10-15 mcg
 Selenium 20-60 mcg
 Manganese 150-800 mcg

28.  It can be achieved either by peripheral line
indirectly or central line directly
 Every route have its own advantages and
disadvantages

29.  Short term PN may be  Long term access can
provided centrally via be achieved by
the subclavian or  Peripheral
internal jugular vein. Peripherally Inserted
Central CatheterLine
(PICC line), which is
passed via the
antecubital vein
 Non Cannulated
catheters(Hickman and
Groshong line)

30. ADVANTAGES DISADVANTAGES
 Bed side technique  Trained personnel is
 Avoids complications of needed
central venous catheter  Line blockage
 Avoid multiple venous  Mal position
cannulations  Phlebitis
 Hyperonic solutions can be  Line sepsis
given  thrombosis

33. ADVANTAGES DISADVANTAGES
 Central access needed  Inserted in theatre
 Multiple lumina can be  Increase infection rate
used in acute emergency  Multiple complications
 Hypertonic solutions can
be given
 Can be placed for than 6
weeks

35. ADVANTAGES DISADVANTAGES
 Convenient exit site  Removal needs surgical
 Long lasting than non dissection
tunnels  Catheter related sepsis
 Hypertonic solutions can  Other complications
be given

37.  Once the route is decided then we will
calculate daily requirements and proceed

38. Determine Total Fluid
Volume
Determine Non- Caloric
needs
Determine Protein
requirements
Determine Electrolyte and
Trace element requirements
Determine need for
additives

39.  Full Blood Count  weekly, unless indicated
 daily until stable, then 2x/wk
 Renal Function Test
 Ca++, Mg++, PO42-  daily until stable, then 2x/wk
 Liver Function Test  weekly
 Iron Panel  weekly
 Lipid Panel  1-2x/wk
 Nitrogen Balance  weekly

40. Mechanical
Complications
Of TPN
infectious metabolic

41. Related to vascular Access Related to catheter in situ
• Pneumothorax • Venous thrombosis
• Air embolism • catheter occlusion
• Bleeding
• Brachial plexus injury
• Catheter malplacement
• Catheter embolism
• Thoracic duct injury

42. Electrolyte • Hypo/hyperglycemia
• Hyponatremia,hypokalemia etc
imbalance
• Hepatic steatosis
Hepatic • Acalculous cholecystitis
Acid Base
Disorders

43. Insertion site
Contamination
• improper insertion technique
Catheter • use of catheter for non-feeding purposes
• contaminated TPN solution
Contamination • contaminated tubing
• septicemia
Secondary
Contamination

44.  Adult Enteral and Parenteral Nutrition
Handbook, 5th Ed
 Oxford Handbook Of Critical Care
 Internet