PPT 1

• Enteral Nutrition

  Food administration via gastrointestinal tube (GIT), also known as tube feeding

  
• Parenteral Nutrition


  Delivery of nutrients to the body intravenously (IV), using catheters

  
• Indications for Nutrition Support


  • Severely malnourished
  • Post-op complications
  • Trauma burns
  • Malignant disease
  • Renal and liver failure
  • Short bowel syndrome

  
• Routes of Nutrition Support


  • Enteral
  • Parenteral
  • Total
  • Partial

  
• Enteral Nutrition


  Can include a normal oral diet, use of liquid supplements, or the delivery of part or all of the daily requirements
• Enteral Nutrition


  • The preferred method of feeding when patients are unable to consume enough calories by themselves

  
• Candidates eligible for enteral nutrition


  • Prolonged anorexia
  • Severe protein-energy undernutrition
  • Coma or depressed sensorium
  • Liver failure
  • Head or neck trauma resulting in the inability to take oral feeding
  • Critical illnesses (e.g. burns) causing metabolic stress

  
• Enteral Nutrition Formulas


  • Polymeric Formulas
  • Specialized Formulas
• Polymeric Formulas


  Blenderized food and milk-based or lactose-free commercial formulas, usually preferred to feeding modules
• Specialized Formulas


  Hydrolyzed carbohydrate or amino acid formulas for patients who have difficulty in complex protein digestion, calorie and protein-dense formulas for patients with fluid restrictions, fibre-enriched formulas for constipated patients
• Total Parenteral Nutrition (TPN)


  Nutrition delivery ONLY through the IV route, usually long term (>2 weeks)
• Partial Parenteral Nutrition


  Adds nutrients when the oral or enteral nutrition intake is inadequate, usually short term (within 1-2 weeks)
• Parenteral Nutrition Routes


  • Central vein access
  • Peripheral vein access
• Parenteral Nutrition Requirements


  • Training in access identification and entry
  • Strict aseptic technique in access and delivery
  • Knowledge of composition requirements and interactions
  • Knowledge of the medical/surgical condition of the patient, and reasons why parenteral nutrition is needed
  • Knowledge of "calorie counting" mechanics
• Parenteral Nutrition Contraindications


  • Ability to consume and absorb adequate nutrients orally or through enteral tube feeding
  • Hemodynamic instability
  • Ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failure

  
• Parenteral Nutrition Components


  • Macronutrients (Proteins, Fats, Carbohydrates)
  • Micronutrients (Electrolytes, Vitamins, Trace elements)
  • Pharmaconutrients (Glutamine, Fish oils, Arginine, Anti-oxidants)
• Dextrose


  Provides 3.4kcal/g, major source of non-protein calories, infusion rate should not exceed 5mg/kg/min, closely related to solution osmolality
• Amino Acids


  Energy value of 4 kcal/g, dose range of 0.6 g/kg - 2.5 g/kg depending on disease state, nitrogen (g) = protein (g) / 6.25, standard concentrations of AA solutions vary between 3% and 20%
• Lipids


  Provides 9kcal/g, non-protein source of calories in addition to carbohydrates, recommended dose of 1g/kg/day, prevents essential fatty acid deficiency, available in 10%, 20%, and 30% concentrations
• Types of Lipid Emulsions


  • Standard: Long-Chain Triglycerides (LCT)
  • New Lipids: LCT/MCT combinations (50%:50%), Structured lipids, SMOF lipids (soybean oil, medium chain triglycerides, olive oil, and fish oil)
• Parenteral Nutrition Micronutrients: Electrolytes


  • Ca, Mg, P, Cl-, K, Na, and acetate
• Lipids


  Non-protein source of kcal in addition to carbohydrates
• Lipids


  • Prevent essential fatty acid deficiency
  • The new lipids play significant roles in metabolism, inflammation, and immune response
• Lipid emulsions


  Available in 10%, 20%, and 30% concentrations
• Chapter 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003; 299-301.

  20 March 2024
• ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4): 381-462.

  20 March 2024
• Standard lipid emulsions


  Long-Chain Triglycerides (LCT)
• New lipid emulsions


  • LCT/MCT combinations (50%:50%)
  • Structured lipids
  • SMOF lipids (soybean oil, medium chain triglycerides, olive oil, and fish oil)
• Electrolytes in parenteral nutrition

  • Ca, Mg, P, Cl-, K, Na, and acetate
• Electrolyte forms and amounts


  • Titrated based on metabolic status, fluid/electrolyte status, acid-base status, and needs in correcting specific deficits
  • Always be aware of calcium-phosphate solubility complication
• Vitamins and minerals in parenteral nutrition


  • Added daily to parenteral nutrition formulations, with amended dosages nearing values recommended for the "normal" population
  • Acute illnesses, infections, pre-existing malnutrition, and excessive loss will increase requirements
  • Home parenteral nutrition patients develop unique vitamin requirements and deficiencies
• Trace elements in parenteral nutrition


  • Zn, Cu, Cr, and Mn
• Trace elements in parenteral nutrition


  • Different requirements are dictated by patient status and pathology
  • Patients under extended parenteral nutrition, i.e. home parenteral nutrition, require the addition of iron and selenium
• Zn in parenteral nutrition


  Enhanced renal function
• Pharmaconutrients


  Delivery of nutrients with specific metabolic or therapeutic effects, in doses above physiologic range
• Pharmaconutrients


  • Glutamine
  • Omega-3-fatty acids
  • Anti-oxidants (Selenium, Zinc, Vit. A, C, E)
  • Arginine
• Pharmaconutrients


  • Parenteral Nutrition provides a stable medium for delivery
  • Should not be given in excess as it can lead to toxicity
• Glutamine


  Common; fuel of GI tract and control glycogen synthesis and protein breakdown; prevent GI atrophy stress
• Omega-3-fatty acids


  Also Omega-6; regulate inflammatory response; improve survival of critically ill patients
• Anti-oxidants


  Prevent oxidative stress due to various diseases; occasionally provide benefits