Enteral and Parenteral Nutrition
Presented By:
Mr. Sultan Alenazi
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•Definitions .
•Conditions that require nutrition support.
•Enteral nutrition access.
•Enteral nutrition compositions.
•Administration of EN.
•Enteral nutrition complications.
•Parenteral nutrition access.
•Parenteral nutrition solutions.
•Administration of PN.
•Complications of PN.
•Calculations of EN.
•Assignment.
•Bonus.
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Nutrition support: is the delivery of formulated enteral
and parenteral nutrients to appropriate patients for
the purpose of maintaining or restoring nutritional
status.
Enteral nutrition: the provision of nutrients into the
gastrointestinal tract through a tube or catheter when
oral intake is inadequate. Also it may include the use
of formula as oral supplements or meal replacement.
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Parenteral nutrition:
The provision of nutrients
bloodstream intravenously.
directly
into
the
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The following criteria can be applied to select appropriate
patient for nutrition support:
Enteral nutrition
Parenteral nutrition
Should be used in Pt. who have at least Who
do
not
have
sufficient
2-3 ft of functional gastrointestinal tract. gastrointestinal function to be able to
restore or maintain optimal nutritional
status.
Who are or will become malnourished.
Who are or will become malnourished.
In whom oral intake is inadequate to
restore or maintain optimal nutritional
status.
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Recommended route of
feeding
Enteral feeding
Condition
Typical disorder
Impaired nutrient ingestion
Neurologic disorders. HIV / AIDS.
Facial trauma. Oral or esophageal
trauma. Congenital anomalies.
Respiratory failure. Cystic fibrosis,
Traumatic brain injury.
Inadequate oral intake
Hyperemesis of pregnancy.
Hypermetabolic states such as burns.
Comatose states. Anorexia in
congestive heart failure, cancer,
COPD,ED. Congenital heart disease.
Impaired intake after orofacial
surgery or injury. Spinal cord injury.
Impaired digestion,
absorption, metabolism
Severe gastroparesis. Inborn errors of
metabolism. Crohn’s disease. Short
bowel syndrome with minimal
resection.
Severe wasting or depressed
growth.
Cystic fibrosis. Failure to thrive.
Cancer. Sepsis. Cerebral palsy.
Myasthenia gravis.
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Recommended route of
feeding
Parenteral nutrition
Condition
Typical disorder
Gastrointestinal
incompetency
Short bowel syndrome with major
resection. Severe acute pancreatitis.
Severe inflammatory bowel disease.
Small bowel ischemia. Intestinal
atresia. Severe liver failure. Major
gastrointestinal surgery.
Critical illness with poor
enteral tolerance or
accessibility.
Multiorgan system failure. Major trauma or
burns. Bone marrow transplant. Acute
respiratory failure with ventilator
dependency and gastrointestinal
malfunction. Severe wasting in renal failure
with dialysis. Small bowel transplant,
immediate postoperatively.
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Enteral access:
•Nasogastric route.
•Nasoduodenal or Nasojejunal route.
•Percutaneous Endoscopic Gastrostomy or
Jejunostomy. (PEG or PEJ).
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•For short-term enteral nutrition of 3-4 weeks.
•Nasogastric tube passed through the nose into the
stomach is appropriate.
•Patients with normal gastrointestinal function and
gag reflex tolerate this method, which takes
advantage of normal digestive, hormonal and
bacterial processes in the stomach.
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•For short-term enteral nutrition of 3-4 weeks in
patients with gastric motility disorders, esophageal
reflux, or persistent nausea and vomiting.
•Nasogastric tube placed postpylorically ( into the
small intestine) are appropriate.
•The tube passed through the nose and esophagus and
inserted into the stomach. The tip of the tube
migrates into the small bowel via peristaltic activity.
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•For patients requiring tube feeding for more than 3 to
4 weeks.
•Placing tube directly into the stomach through the
abdominal wall by using an endoscope and this tube
is endoscopically guided into the stomach (PEG) or
the jejunum (PEJ) and then brought out through the
abdominal wall to provide the access route for enteral
feeding.
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•A wide variety of enteral feeding products are
commercially available.
•Formulas are classified in a variety of ways, usually
based on protein or overall macronutrients
composition.
•General purpose formulas are tolerated by most
patients and most of these formulas provide
1 kcal / ml.
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•General formulas that provide 1.5 to 2 kcal / ml are
used when it necessary to restrict fluid for patients
with cardiopulmonary, renal, and hepatic failure.
•High nitrogen formulas are used for patients with
increased protein requirements such as those with
burns, fistulas, sepsis or trauma.
•Disease specific formulas for patients with renal,
hepatic or cardiopulmonary disease, metabolic stress,
immunosuppression, or glucose intolerance.
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General
purpose / intact
(polymeric)
Defined /
hydrolyzed
(monomeric)
Semielemental
* Use in patients with normal digestion and absorption.
* Contain intact protein.
* Instituted at full strength ; low viscosity; 300-500 mOsm / kg.
* Provide 1-2 kcal / ml.
* Lactose free.
* 30-40 gm protein / L.
• Use in patients with GI compromise.
(hydrolyzed nutrients to improve digestion).
• Osmolality depends on hydrolysis.
• Provide 1-2 kcal / ml.
• Lactose free.
• 30-45 gm protein / L.
Also known as chemically defined, peptide based and elemental formula.
• use in patients with limited GI function.
• contains free amino acids, minimal fat and minimal residue.
• hyperosmolar and low viscosity.
• provide 1 kcal / ml.
•40 gm protein / L.
Also known as free amino acid formula.
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Disease specific
Redehydration
Modular
•Designed for specific organ dysfunction or metabolic disorder.
• May not nutritionally complete.
• Most are hyperosmolar.
• For patient requiring an optimal ratio of simple carbohydrate to
electrolytes for the purpose of maximizing fluid and electrolyte
absorption and rehydration.
• Formula providing protein, fat or carbohydrate as single nutrients
to alter the nutrient composition of commercial formulas or food.
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The three common methods of tube feeding
administration are :
1. Bolus feeding: infusion of up to 5oo ml of enteral formula into
the stomach over 5 to 20 minutes usually by large-bore syringe .
2. Intermittent drip feeding: administered of enteral feeding at
specified times throughout the day; generally in smaller volume
and at a slower rate than a bolus feeding but in large volume and
faster rate than continuous feeding.
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3. Continuous drip feeding: administered of enteral formula
into the gastrointestinal tract via pump, usually over 8 to 24 hours
of day.
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Access problems:
• Pressure necrosis / ulceration / stenosis.
• Tube displacement / migration.
• Tube obstruction.
• leakage from ostomy / stoma site.
Administration problems:
• Regurgitation.
• Aspiration.
• Microbial contamination.
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Gastrointestinal complications:
• Nausea / vomiting.
• Distention / cramping.
• Delayed gastric emptying.
• Constipation.
• High gastric residuals.
• Diarrhea.
Metabolic complications:
•Refeeding syndrome.
• Drug-nutrient interactions.
• Glucose intolerance / hyperglycemia / hypoglycemia.
• Dehydration / overhydration.
• Hypernatremia / hyponatremia.
•Hyperkalemia / hypokalemia.
•Hyperphosphatemia / hypophosphatemia .
• Micronutrients deficiencies.
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Parenteral access:
• Peripheral access.
• Central access.
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•Peripheral access refers to catheter tip placement in a
small vein typically in the arm.
• PPN is short-term therapy with minimal impact on
nutritional status than TPN.
• PPN can be used as a supplemental feeding or in
transitional phase to enteral or oral feeding.
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• PPN veins can’t tolerated concentrated solutions;
therefore, diluted larger-volume infusions are
often necessary to meet nutritional requirements.
• Nutrient solutions not exceeding 800 to 900
mOsm per kg of solvent can be infused through a
peripheral intravenous catheter.
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• Central access refers to catheter tip placement in a
large, high blood flow vein such as the superior vena
cava.
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Protein:
* Standard solutions: are composed of both essential
and nonessential crystalline amino acids.
* Specialized solutions: with adjusted amino acid
content for patient with hypermetabolism or renal or
liver disease.
-The concentration of A.A. in these solutions ranges
from 3% to 15%. Thus, 10% solution of A.A. supplies
100 gm of protein / L .
-The caloric content of A.A. solutions is approximately
4 kcal / gm protein provided.
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• CHO supplied as dextrose monohydrate in
concentration from 5% to 70%.
• Dextrose monohydrate yields 3.4 calories / gm.
• Maximal rates of CHO administration should not
exceed 5 mg / kg / min.
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• Lipid emulsions composed of aqueous suspensions of
soybean or safflower oil with egg yolk phospholipid as
the emulsifier. The three carbon molecule, glycerol,
which is water soluble, is added to the emulsion to
provide osmolarity.
•Lipid emulsions are available in 10% and 20%
concentrations.
• A 10% emulsion provides 1.1 kcal / ml.
• A 20% emulsion provides 2 kcal / ml.
• Maximal dosage of lipid should not exceed 2 gm / kg
of body weight daily.
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• The recommendations of vitamins and trace element
are lower than the DRIs, because parenterally
administered of these elements do not go through the
digestive and absorptive processes.
• Parenteral solutions also represent a significant
portion of total daily fluid and electrolyte intake.
• The choice of the salt form of electrolytes (chloride,
acetate) has an impact on acid-base balance.
• Iron is not normally part of parenteral infusions,
when needed it is given separately.
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• Maximum volumes of TPN rarely exceed 3 L daily,
with typical prescriptions of 1.5 to 3 L daily.
• Patient with cardiopulmonary, renal and hepatic
failure needs carefully monitoring.
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Continuous infusion (hourly):
Parenteral solutions are usually initiated below the
goal infusion rate and then increased incrementally
over 2 0r 3 day period to attain the goal infusion rate.
Cyclic infusion (cyclic total parenteral nutrition):
Administration of TPN solution for 12 to 18
consecutive hours, usually at night, followed by 6 to 12
hour period of no infusion.
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Mechanical complications:
1- Pneumothorax.
2- Hemothorax.
3- Hydrothorax.
4- Tension pneumothorax.
5- Subcutaneous emphysema. 6- Branchial plexus injury.
7- Subclavian artery injury.
8- subclavian hematoma.
9- Central vein thrombophlebitis.
10- Arteriovenous fistula.
11- Thoracic duct injury.
12- Hydromediastinum.
13- Air embolism.
14- Catheter fragment embolism.
15- Catheter misplacement. 16- Cardiac perforation.
17- Endocarditis.
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1- Catheter entrance site:
* Contamination during insertion.
* Long-term catheter placement.
2- Catheter seeding from bloodborne or distant
infection.
3- Solutions contaminations.
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1- Dehydration from osmotic diuresis.
2-Hyperosmolar, nonketonic, hyperglycemia and
hypoglycemia.
3- Hypomagnesemia.
4- Hypocalcemia and hypercalcemia.
5- Hypophosphatemia and hyperphosphatemia.
6- Hyperchloremic metabolic acidosis.
7- Uremia.
8- Hyperammonemia.
10- Electrolyte imbalance. 11- Trace mineral deficiencies.
12- Essential fatty acid deficiency.
13- Hyperlipidemia.
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1- Cholestasis.
2- Hepatic abnormalities.
3- Gastrointestinal villous atrophy.
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You have male patient old 45 years diagnosed as
hypertensive, his Wt. is 65 kg and Ht. is 160 cm. Write
complete SOAP note with food menu?
You have female patient old 35 years diagnosed as
dysphagia, her Wt. 45 kg and Ht. is 150 cm. She needs
enteral feeding. With calculating kcal & protein from formula, also
flushing water needed :
1- Calculate continues feeding rate ?
2- Calculate bolus feeding rate?( Q6 hrs., Q4 hrs., Q3 hrs. and Q8 hrs.)
3- If patient needs Beneprotein or Benefiber. Calculate how much
grams of both that pt. needs?
* Types of formula are Ensure & Jevity.
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Define the following diseases and conditions:
•Refeeding syndrome.
•Dehydration and Overhydration.
•Hypernatremia and Hyponatremia.
•Hyperkalemia and Hypokalemia.
•Osmolality and Osmolarity.
•Cholestasis.
•Cystic fibrosis.
•Macronutrients and Micronutrients.
•Cerebral palsy.
•Sepsis.
•Fistula.
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