Presentation on theme: "Enteral and Parenteral Nutrition Presented By: Mr. Sultan Alenazi"— Presentation transcript:
1 Enteral and Parenteral Nutrition Presented By: Mr. Sultan Alenazi Nutrition SupportEnteral and Parenteral NutritionPresented By:Mr. Sultan Alenazi
2 Outline 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.
3 DefinitionsNutrition 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.
4 Parenteral nutrition: The provision of nutrients directly into the bloodstream intravenously.
5 Which patient is eligible for nutrition support ? The following criteria can be applied to select appropriate patient for nutrition support:Enteral nutritionParenteral nutritionShould be used in Pt. who have at least ft of functional gastrointestinal tract.Who do not have sufficient gastrointestinal function to be able to restore or maintain optimal nutritional status.Who are or will become malnourished.In whom oral intake is inadequate to restore or maintain optimal nutritional status.
6 Conditions that require nutrition support Recommended route of feedingConditionTypical disorderEnteral feedingImpaired nutrient ingestionNeurologic disorders. HIV / AIDS. Facial trauma. Oral or esophageal trauma. Congenital anomalies. Respiratory failure. Cystic fibrosis, Traumatic brain injury.Inadequate oral intakeHyperemesis 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, metabolismSevere 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.
7 Recommended route of feeding ConditionTypical disorderParenteral nutritionGastrointestinal incompetencyShort 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.
8 Enteral Nutrition Enteral access: Nasogastric route. Nasoduodenal or Nasojejunal route.Percutaneous Endoscopic Gastrostomy orJejunostomy. (PEG or PEJ).
9 Nasogastric route For short-term enteral nutrition of 3-4 weeks. Nasogastric tube passed through the nose into thestomach is appropriate.Patients with normal gastrointestinal function andgag reflex tolerate this method, which takesadvantage of normal digestive, hormonal andbacterial processes in the stomach.
10 Nasoduodenal or Nasojejunal route For short-term enteral nutrition of 3-4 weeks inpatients with gastric motility disorders, esophagealreflux, or persistent nausea and vomiting.Nasogastric tube placed postpylorically ( into thesmall intestine) are appropriate.The tube passed through the nose and esophagus andinserted into the stomach. The tip of the tubemigrates into the small bowel via peristaltic activity.
11 Percutaneous Endoscopic Gastrostomy or Jejunostomy. (PEG or PEJ) For patients requiring tube feeding for more than 3 to4 weeks.Placing tube directly into the stomach through theabdominal wall by using an endoscope and this tubeis endoscopically guided into the stomach (PEG) orthe jejunum (PEJ) and then brought out through theabdominal wall to provide the access route for enteralfeeding.
12 Enteral Formula Composition A wide variety of enteral feeding products arecommercially available.Formulas are classified in a variety of ways, usuallybased on protein or overall macronutrientscomposition.General purpose formulas are tolerated by mostpatients and most of these formulas provide1 kcal / ml.
13 General formulas that provide 1.5 to 2 kcal / ml are used when it necessary to restrict fluid for patientswith cardiopulmonary, renal, and hepatic failure.High nitrogen formulas are used for patients withincreased protein requirements such as those withburns, fistulas, sepsis or trauma.Disease specific formulas for patients with renal,hepatic or cardiopulmonary disease, metabolic stress,immunosuppression, or glucose intolerance.
14 Enteral Formula Categories Generalpurpose / intact(polymeric)* Use in patients with normal digestion and absorption.* Contain intact protein.* Instituted at full strength ; low viscosity; mOsm / kg.* Provide 1-2 kcal / ml.* Lactose free.* gm protein / L.Defined / hydrolyzed(monomeric)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.Semielementaluse 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.
15 Enteral Formula Categories (cont.) Disease specificDesigned for specific organ dysfunction or metabolic disorder.May not nutritionally complete.Most are hyperosmolar.RedehydrationFor patient requiring an optimal ratio of simple carbohydrate toelectrolytes for the purpose of maximizing fluid and electrolyteabsorption and rehydration.ModularFormula providing protein, fat or carbohydrate as single nutrientsto alter the nutrient composition of commercial formulas or food.
16 Administration 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.
17 3. Continuous drip feeding: administered of enteral formula into the gastrointestinal tract via pump, usually over 8 to 24 hours of day.
21 Peripheral access ( peripheral parenteral nutrition PPN) Peripheral access refers to catheter tip placement in asmall vein typically in the arm.PPN is short-term therapy with minimal impact onnutritional status than TPN.PPN can be used as a supplemental feeding or intransitional phase to enteral or oral feeding.
22 PPN veins can’t tolerated concentrated solutions; therefore, diluted larger-volume infusions areoften necessary to meet nutritional requirements.Nutrient solutions not exceeding 800 to 900mOsm per kg of solvent can be infused through aperipheral intravenous catheter.
23 Central Access (total parenteral nutrition TPN) Central access refers to catheter tip placement in alarge, high blood flow vein such as the superior venacava.
24 Parenteral Nutrition solution Protein:* Standard solutions: are composed of both essentialand nonessential crystalline amino acids.* Specialized solutions: with adjusted amino acidcontent for patient with hypermetabolism or renal orliver disease.-The concentration of A.A. in these solutions rangesfrom 3% to 15%. Thus, 10% solution of A.A. supplies100 gm of protein / L .-The caloric content of A.A. solutions is approximately4 kcal / gm protein provided.
25 Carbohydrate CHO supplied as dextrose monohydrate in concentration from 5% to 70%.Dextrose monohydrate yields 3.4 calories / gm.Maximal rates of CHO administration should notexceed 5 mg / kg / min.
26 Lipid Lipid emulsions composed of aqueous suspensions of soybean or safflower oil with egg yolk phospholipid asthe emulsifier. The three carbon molecule, glycerol,which is water soluble, is added to the emulsion toprovide 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 / kgof body weight daily.
27 Electrolytes, Vitamins, and Trace elements The recommendations of vitamins and trace elementare lower than the DRIs, because parenterallyadministered of these elements do not go through thedigestive and absorptive processes.Parenteral solutions also represent a significantportion 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.
28 Fluid Maximum volumes of TPN rarely exceed 3 L daily, with typical prescriptions of 1.5 to 3 L daily.Patient with cardiopulmonary, renal and hepaticfailure needs carefully monitoring.FluidTo prevent edema and ascites.
29 Administration 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.
35 AssignmentsYou 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 muchgrams of both that pt. needs?* Types of formula are Ensure & Jevity.
36 Bonus 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.