1. Basics of enteral and parenteral nutrition
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
We now come to the implementation part of the surgical nutrition training module. How do we deliver enteral (EN) and parenteral nutrition (PN) and what are the indications for choosing either EN or PN or both?

2. Objectives
To discuss the different feeding pathways for the surgical patients
To define and discuss key points of enteral and parenteral nutrition
To discuss the monitoring process and expected outcomes for surgical patients
These are the objectives of this session:
To discuss the different feeding pathways for surgical patients
To define and discuss key points of enteral and parenteral nutrition
To discuss the monitoring process and expected outcomes for surgical patients

3. Feeding Pathways Can the GIT be used? Yes No Parenteral nutrition Oral
< 75% intake
Tube feed
Short term
Long term
Peripheral PN
Central PN
More than 3-4 weeks
NGT
Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
We revisit the feeding algorithm which was discussed earlier in session 3 “The impact of nutrition care in surgery”. Here the priority is always the use of the gut (=“If the gut works use it”) and when we fail to deliver 60% to 70% of the patient’s computed intake then that is the only time when we resort to parenteral nutrition. However one has always to try to give some degree of enteral nutrition whenever possible due to the role of the gut in immune function and other related metabolic functions.

4. EARLY ENTERAL NUTRITION
We again re-emphasize the value of early enteral nutrition after surgery or when resuscitation from a critical care state is able to have stable vital signs for the patient.
EARLY ENTERAL NUTRITION

5. Early enteral nutrition: definition
Enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury
Zaloga GP. Crit Care Med 1999; 27: 259
Early enteral nutrition is enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury.
Zaloga GP. Crit Care Med 1999; 27: 259

6. Why early enteral nutrition?
The normal and designed route for nutrient intake, digestion, and absorption
Immunocompetence is a major function of the gastrointestinal tract
Non-utilization of the gastrointestinal tract even on a short term basis leads to complications in critical care or geriatric patient management
Cost-effective
Why is early enteral nutrition important? These are the major reasons:
The normal and designed route for nutrient intake, digestion, and absorption is the GIT
Immune competence is a major function of the gastrointestinal tract and to sustain this the gut has to be used continually
Non-utilization of the gastrointestinal tract even on a short term basis leads to complications in critical care or geriatric patient management secondary due to disuse, atrophy and reduction of function of the gut associated lymphoid tissue system (GALT)
Cost-effective

7. Early enteral feeding: goal
To maintain intestinal mucosal integrity
– Normal microvilli
Height and number
– Normal intestinal barrier
– Intestinal mucosal immunity
This is the goal of early enteral feeding:
To sustain the normal height and number of the microvilli
This architecture sustains the normal intestinal barrier by the mucosal epithelium
This set up also sustains intestinal mucosal immunity through the humoral immunity (=IgA secretion) and cellular immunity (=M cells, mucosal macrophages and T-lymphocytes)

8. Early enteral feeding: rationale
Provide nutrients required during metabolic stress
Maintain GI integrity
Reduce morbidity compared with parenteral nutrition
Reduce cost compared with parenteral nutrition
How does enteral feeding do all of the above?
By providing nutrients required during metabolic stress
By maintaining GI integrity
By reducing morbidity which is higher with patients on long termparenteral nutrition
By reduce cost compared with parenteral nutrition

9. Early enteral nutrition vs standard nutritional support on mortality
Comparison: mortality
Outcome: early enteral nutrition vs. control
Study
Treatment n/N
Control
n/N
Cerra et al 1990
Gottschlich et al, 1990
Brown et al, 1994
Moore et al, 1994
Bower et al, 1996
Kudsk et al, 1996
Engel et al, 1997
Weimann et al, 1998
1/11
2/17
0/19
1/51
24/163
1/16
7/18
2/16
1/9
1/14
0/18
2/47
12/143
1/17
5/18
4/13
0.01
0.1 10
100
Higher for control
Higher for treatment
Ross Products, 1996
20/87
8/83
Mendez et al, 1997
1/22
1/21
Rodrigo et al, 1997
2/13
Atkinson et al, 1998
96/197
86/193
Galban et al, 2000
17/89
28/87
Heyland et al. JAMA, 2001
Pooled Risk Ratio 1
This meta-analysis done in 2001 shows the value of early enteral nutrition in reducing mortality in critical care patients compared to the standard NPO for more than three days.
Heyland et al. JAMA, 2001

10. What are the access routes of enteral nutrition?

11. Enteral nutrition access
STOMACH
JEJUNUM
Nasogastric tube
Nasojejunal tube
PEG
PEJ
BUTTON
PLG
JET-PEG
PLJ
NCJ
PSJ
PFJ
PSG
PFG
Witzel, Stamm, Janeway
Loser C et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy (PEG)
E: Endoscopic
G: Gastrostomy
J: Jejunostomy
L: Laparoscopic
NC: Needle Catheter
S: Sonographic
F: Fluoroscopic
These are the access points through the stomach and jejunum.

12. Access and delivery Nasogastric tube Nasoentericor jejunal tube
PEG tube
Nasoentericor jejunal tube
These are the different tubes currently used. The earlier and still commonly used tube type is polyvinyl chloride (PVC) but it tends to be uncomfortable for the patient. The better quality and acceptability for the patient is obtained with polyurethane and silicon tubes. Silicon tubes tend to be smaller in internal diameter compared with polyurethane tubes so care to avoid clogging is very important for these tube types.

13. Gastrostomy PEG placement PEG placement, St Luke’s Medical Center
Regarding gastrostomy:
Gastric access may be obtained for short-term feeding via the nasogastric route using “blind” or manual placement at the bedside or with the use of radiologic guidance.
For long-term use, gastric access may be obtained via a gastrostomy placement using endoscopic, radiologic, or surgical techniques.
The technique used for gastric access is based on the expertise of the physician placing the tube as well as the patient’s condition. For example, if the patient has an esophageal tumor, the narrowed esophagus may prevent passage of the endoscope.
Rugeles S et al. Universitas Medica 1993;34(I):19-23.
PEG placement
PEG placement,
St Luke’s Medical Center

14. Post-pyloric feeding Short Term Nasoenteric – Nasoduodenal
– Nasojejunal
Long Term (operative)
Jejunostomy
– Percutaneous endoscopic jejunostomy or through the PEG tube
– Surgical jejunostomy
These are the different types of small bowel feeding where the end of the tube is in the small intestine. There is a short term use and long term use depending on the indication. If one foresees there will be slow recovery of oral intake in the post-operative period (beyond two weeks) it will be prudent to place a needle catheter jejunostomy and have it in place until the patient is able to achieve 70% oral intake of his requirements.
Gauderer MW, et al. J Pediatr Surg 1980;15:
Gauderer MW, et al. J Pediatr Surg 1980;15:

15. Enteral Formulas – what type?
Polymeric formulas (80-90%)
Commercial (preferred)
Blenderized (If not critically ill, not severely malnourished)
Oligomeric formulas
Disease-specific formulas
Modular formulas (concentrated protein and carbohydrate preparations)
What are the enteral nutrition formulas that are available?
Enteral formula categories include polymeric, both commercial and blenderized, oligomeric, and disease-specific formulas.
Modular formulas include concentrated protein and carbohydrate preparations to enhance protein and caloric content of enteral formulas.

16. Enteral nutrition delivery
These are the modes of tube feeding delivery to the patient. Note that the nurses have specific protocols on how to feed the patient from positioning to rate and volume of delivery.
Gravity Feeding
Enteral Pump Delivered

17. Practical points: enteral nutrition
If intake is within the range of 60% to 70% start oral supplement
Choose the product or preparation that meets all the daily requirements
If oral intake is 50% or less
You may give parenteral nutrition to supplement (good for a week – expensive, but more comfortable for the patient)
Cost-effective: NGT
If tube feeding duration will exceed 2 weeks and you are looking at long term (stroke or critical care) – gastrostomy is easier to maintain with lesser complications (aspiration)
Here are some practical points on enteral nutrition:
If intake is within the range of 60% to 70% start oral supplement
Choose the product or preparation that meets all the daily requirements
If oral intake is 50% or less
You may give parenteral nutrition to supplement (good for a week – expensive, but more comfortable for the patient)
Cost-effective: NGT
If tube feeding duration will exceed 2 weeks and you are looking at long term (stroke or critical care) – gastrostomy is easier to maintain with lesser complications (aspiration)

18. Practical points: enteral nutrition
If patient will undergo surgery and you doubt patient will be able to have adequate intake for longer term:
Place gastrostomy during the surgery
If gastric function return is in doubt for more than a week:
Gastrostomy with jejunostomy tube extension
Surgical Jejunostomy
Main goal: adequate intake
More practical points in enteral nutrition:
If patient will undergo surgery and you doubt the patient will be able to have adequate intake for longer term:
Place gastrostomy during the surgery
If gastric function return is in doubt for more than a week:
Gastrostomy with jejunostomy tube extension
Surgical Jejunostomy
Main goal: adequate intake

19. Enteral formula: commercial vs. blenderized
Commercial Formulas
Blenderized Formulas
Uniform contents
Sterile
Low viscosity
Lactose free
Defined caloric density
Daily nutrient variability
Non-sterile; high bacterial content and other pathogens
High viscosity
Does not provide adequate caloric density
Gallagher-Alfred. Nutrition Supp Svc 1983;
Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:

20. Bacterial contamination in standard tube feeds

21. Standard Feed: measured vs. expected
Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)
Commercial formula
Natural food formula

22. Monitoring Gastric Residuals
High volume gastric residuals are associated with greater incidence of intolerance of enteral nutrition. Controlling gastric residuals before beginning nutrition and periodically after it has begun helps to reduce the possibility of bronchial aspiration.
The presence of high volumes of gastric residuals indicates that close monitoring is required and that it may be necessary to hold tube feeding temporarily.
Mentec H, et al. Crit Care Med 2001;29:
Today, however, gastric residuals are managed by the following:
Use of enteral pumps with adjustments of the volume and rate of delivery
Use of prokinetics
Standardized protocol for feeding
There is no more excuse of holding feeding and forgetting to resume feeding within 24 hours
Monitor according to hospital protocol (e.g., every 3-4 hours)
Volume not to exceed 50% of the amount infused
Mentec H, et al. Crit Care Med 2001;29:

23. Parenteral nutrition still needs to be utilized more often
Parenteral nutrition still needs to be utilized more often. This session will be spent in discussing this mode of nutrient delivery.
PARENTERAL NUTRITION

24. Parenteral nutrition: Indications
To avoid periods of starvation within 24 to 72 hours when oral or enteral intake are insufficient to achieve adequate intake in moderate to severe malnourished patients
When unable to use the gut
Gut obstruction
Short bowel (intestinal failure)
High output enterocutaneous fistulae
Non-functional gastrointestinal tract
These are the indications for parenteral nutrition use:
To avoid periods of starvation within 24 to 72 hours when oral or enteral intake are insufficient to achieve adequate intake in moderate to severe malnourished patients
When unable to use the gut as in:
Gut obstruction
Short bowel (intestinal failure)
High output enterocutaneous fistulae
Non-functional gastrointestinal tract
ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4):
ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4):

25. Contraindications to PN
Gut can be used:
Ability to consume and absorb adequate nutrients orally or by enteral tube feeding
Hemodynamic instability
*Ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failure.
These are the contra-indications to parenteral nutrition use: when the gut is viable and can be used.
Ability to consume and absorb adequate nutrients orally or by enteral tube feeding
Hemodynamic instability
*Ineffective and probably harmful in non-aphagic oncological patients (=able to have oral intake) in whom there is no gastrointestinal reason for intestinal failure.
* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.
.* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.

26. Types of parenteral nutrition
Central
Peripheral
Amino acids ( > 5%)
Dextrose ( > 20%)
Lipids
Includes vitamins, minerals, and trace elements
Carrier of pharmaconutrients like glutamine or omega-3- fatty acids
Osmolality ( > 700 mOsm/kg H2O)
Volume restriction
Total kcal limited by concentration and ratio to volume being administered (usually delivers between to 1500 kcal/day)
The current formulations can now deliver the daily requirements of macro and micronutrients
Osmolality < 700 mOsm/kg
No volume restriction
These are the types of parenteral nutrition with their advantages and disadvantages

27. Types of parenteral nutrition
Central parenteral nutrition
Peripheral central parenteral nutrition
PICC =peripherally inserted
central catheter
Just to show how the central parenteral nutrition catheter is placed nowadays – there is now a peripherally inserted catheter, but the more frequently used is still the subclavian approach.

28. Catheters Subclavian catheter (3 ports) PICC line catheters
These are the catheters used.
Subclavian catheter (3 ports)
PICC line catheters

29. Types of parenteral nutrition
Peripheral parenteral nutrition
These are the more common areas where peripheral parenteral nutrition is inserted.

30. Central venous access
Allows delivery of nutrients into the superior vena cava or right atrium
Osmolarity - traditional cut off > 860 mOsm/L
Catheter differences :
According to duration of use
Various lengths, gauges, and number of ports
Catheters treated with antibacterials
Nutrient infusion via a dedicated catheter lumen
Central venous access:
Allows delivery of nutrients into the superior vena cava or right atrium
Osmolarity - traditional cut off > 860 mOsm/L
Catheter differences :
According to duration of use
Various lengths, gauges, and number of ports
Catheters treated with antibacterials
Nutrient infusion via a dedicated catheter lumen
Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters. Clin Nutr 2009; 28(4):

31. Formulations
1 Optimal nitrogen sparing is shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours.
The different forms of PN packaging and delivery:
2 Individualized
2 Compounded
1,2 “All in One”
How is parenteral nutrition formulated?
1 Optimal nitrogen sparing is shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours.
The different forms of PN packaging and delivery:
2 Individualized
2 Compounded
1,2 “All in One”
Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.
Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005;
Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.
Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005;

32. Formulation / Delivery
Break seal
Individualized
delivery system
“All in one” placed in
multi-chambered bags
cheaper
stable
none to minimum contamination
Compounding / clean
rooms
Development phases of the PN container system
This is how parenteral nutrition preparation, formulation and delivery evolved. Now from a separate two or three bottle system connected by Y-connectors there is now one bag that contains the three major macronutrients.This system is called the “3 in 1” or “All in One” preparations. The issue of contamination and frequency of infections through the parenteral nutrition formulation and route has been drastically reduced. Storage time is increased and the cost involved in mixing solutions has remarkable gone down. Technology has definitely improved patient safety in parenteral nutrition delivery.

33. Three in one bags: longer storage and less contamination
Safety issues
Three in one bags: longer storage and less contamination
Protocols:
Compounding
Incorporation – additives
Delivery (access, rates of infusion, infusion pumps)
In-lineFilters:
Fat emulsions
Three in one solutions
Micro-precipitates
These are the patient safety issues involved in parenteral nutrition preparation and delivery:
Compounding in a clean room is required
Three in one PN bags are preferred
On line filters for lipid emulsions are considered best practice

34. EN/PN monitoring parameters
Metabolic
Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholesterol
Assessment
Nutrient balance (calorie & protein intake)
Body weight
Nitrogen balance
Plasma protein (albumin, pre-albumin)
These are the monitoring parameters for enteral and parenteral nutrition. The goal is to maintain normal status in both clinical and laboratory parameters.
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992
Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003;
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992
Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003;

35. Key monitoring points
Fluid balance – avoid fluid accumulation within 4-5 days post op
Calorie balance
Gastric retention for enteral nutrition
Blood tests:
BUN high – dialyze
High triglycerides – lower lipid flow
Hyperglycemia – insulin
Weight once a week
These are the key monitoring points
Fluid balance – avoid fluid accumulation within 4-5 days post op
Calorie balance
Gastric retention for enteral nutrition
Blood tests:
BUN high – dialyze
High triglycerides – lower lipid flow
Hyperglycemia – insulin
Weight once a week
Jan Wernermann, “ICU Cookbook”. Franc-Asia Workshop, Singapore, 2003
Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

36. Outcome is dependent on the monitoring process
Outcome is dependent on the monitoring process especially on the patient’s nutrient intake.
Outcome is dependent on the monitoring process

37. Feeding Pathways Can the GIT be used? Yes No Parenteral nutrition Oral
< 75% intake
Tube feed
Short term
Long term
Peripheral PN
Central PN
More than 3-4 weeks
NGT
Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
The recommended cut-off value to say the patient has inadequate intake through either enteral or parenteral nutrition or combined is 75%. It means monitoring for calorie and protein intake on a regular basis is mandatory.

38. Calorie, protein, fluid balance form
This is the calorie, protein, and fluid balance form which is the standard data gathered by all members of the clinical nutrition service.

39. Nutrient monitor form
This is the final nutrient monitor form which is placed in the patient’s medical record – this will show the attending physician on the status of his patient’s nutrition care.

40. Monitoring
This is the sample data entry.

41. We will show again local data to reinforce the value of monitoring intake for surgical patients either pre-operative or post-operative.
Documented outcomes

42. Adequate intake in surgery patients
When adequate intake was achieved in both calorie and protein intake improvement in mortality and morbidity outcomes in the surgical patients were noted whether they are nutritionally high risk or low risk. In this study no significant difference is seen in the mortality rate.
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, Accessed in:
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

43. Nutrition team and intake
Llido et al. Nutrition team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from years 2000 to 2011 (for submission)
Finally the nutrition team is the best group that can achieve consistency in results. That is the goal of the surgical nutrition module – to create a team for the surgical nutrition care in the department of surgery and eventually in the hospital

44. Thank you