1. Enteral and Parenteral Nutrition Presented By: Mr. Sultan Alenazi
Nutrition Support
Enteral and Parenteral Nutrition
Presented 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. Definitions
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.

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 nutrition
Parenteral nutrition
Should 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 feeding
Condition
Typical disorder
Enteral feeding
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.

7. Recommended route of feeding
Condition
Typical disorder
Parenteral nutrition
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.

8. Enteral Nutrition Enteral access: Nasogastric route.
Nasoduodenal or Nasojejunal route.
Percutaneous Endoscopic Gastrostomy or
Jejunostomy. (PEG or PEJ).

9. Nasogastric route 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.

10. Nasoduodenal or Nasojejunal route
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.

11. Percutaneous Endoscopic Gastrostomy or Jejunostomy. (PEG or PEJ)
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.

12. Enteral Formula Composition
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.

13. 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.

14. Enteral Formula Categories
General
purpose / 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.
Semielemental
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.

15. Enteral Formula Categories (cont.)
Disease specific
Designed for specific organ dysfunction or metabolic disorder.
May not nutritionally complete.
Most are hyperosmolar.
Redehydration
For patient requiring an optimal ratio of simple carbohydrate to
electrolytes for the purpose of maximizing fluid and electrolyte
absorption and rehydration.
Modular
Formula providing protein, fat or carbohydrate as single nutrients
to 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.

18. Complications of Enteral Nutrition
Access problems:
Pressure necrosis / ulceration / stenosis.
Tube displacement / migration.
Tube obstruction.
leakage from ostomy / stoma site.
Administration problems:
Regurgitation.
Aspiration.
Microbial contamination.

19. Complications of Enteral Nutrition ( cont.)
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.

20. Parenteral access: Peripheral access. Central access.
Parenteral Nutrition
Parenteral access:
Peripheral access.
Central access.

21. Peripheral access ( peripheral parenteral nutrition PPN)
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.

22. 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.

23. Central Access (total parenteral nutrition TPN)
Central access refers to catheter tip placement in a
large, high blood flow vein such as the superior vena
cava.

24. Parenteral Nutrition solution
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.

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 not
exceed 5 mg / kg / min.

26. Lipid 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.

27. Electrolytes, Vitamins, and Trace elements
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.

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 hepatic
failure needs carefully monitoring.
Fluid
To 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.

30. Complications Mechanical complications:
1- Pneumothorax Hemothorax.
3- Hydrothorax Tension pneumothorax.
5- Subcutaneous emphysema. 6- Branchial plexus injury.
7- Subclavian artery injury subclavian hematoma.
9- Central vein thrombophlebitis.
10- Arteriovenous fistula Thoracic duct injury.
12- Hydromediastinum Air embolism.
14- Catheter fragment embolism.
15- Catheter misplacement Cardiac perforation.
17- Endocarditis.

31. Infection and Sepsis 1- Catheter entrance site:
* Contamination during insertion.
* Long-term catheter placement.
2- Catheter seeding from bloodborne or distant
infection.
3- Solutions contaminations.

32. Metabolic complications
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 Hyperammonemia.
10- Electrolyte imbalance Trace mineral deficiencies.
12- Essential fatty acid deficiency.
13- Hyperlipidemia.

33. Gastrointestinal Complications
1- Cholestasis.
2- Hepatic abnormalities.
3- Gastrointestinal villous atrophy.

34. Calculations

35. Assignments
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.

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.