A-Nutritional requirements The nutritional requirements of any human are divided into 3 broad categories: The nutritional requirements of any human are divided into 3 broad categories: 1.Energy requirements: 2.Build-up requirements. 3.Vitality requirements

1.Energy requirements adult needs KCal/Kg/day adult needs KCal/Kg/day growing child needs up to KCal/Kg/day growing child needs up to KCal/Kg/day Provided mainly by carbohydrates(1gm leads to 4 KCaL) and fat (1gb leads to 9 KCaL). Provided mainly by carbohydrates(1gm leads to 4 KCaL) and fat (1gb leads to 9 KCaL). In late starvation protein(1gm leads to 4KCL) becomes the only source after depletion of fat and carbohydrate stores. In late starvation protein(1gm leads to 4KCL) becomes the only source after depletion of fat and carbohydrate stores.

2.Build-up requirements Provided by protein Provided by protein The minimum for dynamic keep a healthy adult in a positive nitrogen balance is estimated at g protein/day. The minimum for dynamic keep a healthy adult in a positive nitrogen balance is estimated at g protein/day. The hypercatabolic patient [severe sepsis, severe trauma and burns and in severe disease conditions as pancreatitis.] may need 3 or 4 times this amount. The hypercatabolic patient [severe sepsis, severe trauma and burns and in severe disease conditions as pancreatitis.] may need 3 or 4 times this amount.

3.Vitality requirements 1-Water : resting individual need 30 mL/Kg/day 2-VitaminsA : balanced diet usually provides sufficient vitamins -Vitamin C -Vitamin B12 -Folinic acid -Vitamin A -Vitamin K 3-Minerals and trace elements: Na, K, Fe, Ca and Mg

B. Assessment of nutritional status 1.Body weight. 2.Body mass index [BMI]. BMI = WEIGHT [Kg]/ HEIGHT2 [M2]. Normally, it ranges between 20 and Upper arm circumference. Feeding is indicated if < 25 cm in the male or < 23 cm in the female. 4.Triceps skin fold thickness. The minimum is 10 mm in the male and 13 mm in the female. 5.Serum albumin shouldn't be < 3.5 g/dL.

C. Malnutrition 1.Etiology: 1.Etiology: a. Preoperative malnutrition may result from: (1)Starvation, which may be secondary to: (a)Poverty and inability to obtain food. (a)Poverty and inability to obtain food. (b)Dysphagia. (c)Vomiting (b)Dysphagia. (c)Vomiting (d)Self neglect, eg alcoholics and the elderly. (d)Self neglect, eg alcoholics and the elderly. (2)Failure of digestion, eg (a)Pancreatic or biliary disease, eg carcinoma, stone. (a)Pancreatic or biliary disease, eg carcinoma, stone. (b)Duodenal or jejunal disease, eg fistula, blind loop syndrome. (b)Duodenal or jejunal disease, eg fistula, blind loop syndrome.

b.Postoperative malnutrition is usually the result of the stress of surgery and is of a transient nature. However, it may be as severe with such major operations as esophagectomy and with paralytic ileus.

2.Manifestations: 2.Manifestations: a. General: a. General: (1)Physical and mental exhaustion (1)Physical and mental exhaustion (2)Infection, due to immunosuppression (2)Infection, due to immunosuppression (3)Intolerance to radio- and chemo-therapy (3)Intolerance to radio- and chemo-therapyb.Metabolic: (1)Lowered rates of enzyme synthesis (1)Lowered rates of enzyme synthesis (2)Impaired oxidative metabolism of drugs by the liver (2)Impaired oxidative metabolism of drugs by the liver c.Healing problems: (1)Wound dehiscence (1)Wound dehiscence (2)Leakage from bowel anastomoses (2)Leakage from bowel anastomoses (3)Delayed callus formation (3)Delayed callus formation (4)Disordered coagulation (4)Disordered coagulation

D.Indications of nutritional support 1.Diminished food intake in: a. Preoperative malnutrition b.Coma a. Preoperative malnutrition b.Coma c.Postoperative ileus lasting for > 4 days c.Postoperative ileus lasting for > 4 days 2.Diminished digestion and absorption, eg: A-Pyloric stenosis b.Pancreatic disease c.Biliary disease d.Malabsorption syndrome c.Biliary disease d.Malabsorption syndrome e.Short bowel syndrome f.Radiation enteritis e.Short bowel syndrome f.Radiation enteritis g.Ulcerative colitis h.Duodenal fistula

3.Chronic disease, eg: a. Chronic cardiac, hepatic or renal disease a. Chronic cardiac, hepatic or renal disease b.Malignant disease b.Malignant disease 4.Hypercatabolic states: 4.Hypercatabolic states: a.Polytrauma a.Polytrauma b.Burn b.Burn c.Sepsis c.Sepsis

ENTERAL NUTRITION A. By mouth: Other routes should be attempted only when it is not possible to use this route. A. By mouth: Other routes should be attempted only when it is not possible to use this route. B. By nasogastric tube: B. By nasogastric tube:1.Types a.Ordinary Ryle's tube b. Fine-bore NG tube a.Ordinary Ryle's tube b. Fine-bore NG tube2.Indications: a.To overcome a severe esophageal stricture. b.To feed the comatosed, enabling the tube to reach the duodenum, thus decreasing the risk of pulmonary aspiration in this high-risk group.

3.Precautions: a. Making sure that gastric emptying is normal a. Making sure that gastric emptying is normal b.Fine tube blockage can be overcome by 2 mL water. c. All feeds should be stored at 4o C until use, not exposed to room temperature for 8 h and discarded if not used after 12 h. b.Fine tube blockage can be overcome by 2 mL water. c. All feeds should be stored at 4o C until use, not exposed to room temperature for 8 h and discarded if not used after 12 h. d.Bacteriological monitoring is essential, as kitchens may be a source of Klebsiella infection d.Bacteriological monitoring is essential, as kitchens may be a source of Klebsiella infection

4.Complications: a. Nausea ± vomiting ± diarrhea, usually due to anaerobic contamination. This can simply be treated by metronidazole 500 mg bid. a. Nausea ± vomiting ± diarrhea, usually due to anaerobic contamination. This can simply be treated by metronidazole 500 mg bid. b. Gastro esophageal reflux and pulmonary aspiration, particularly with the nasogastric tube in the absence of the gag reflex and especially in the comatose. the gag reflex and especially in the comatose. c.Diabetes and hyperosmolar states, mainly related to a high carbohydrate intake, with particular hazard to the established diabetic.

C. By tube enterostomy C. By tube enterostomy 1.Definition. Tube enterostomy is the operative placement of a tube or catheter into the GIT. 2.Indications: a. Inability to insert a fine-bore NG tube a. Inability to insert a fine-bore NG tube b.When more than 4 weeks of enteral feeding is anticipated. b.When more than 4 weeks of enteral feeding is anticipated.3.Contraindications: a.To tube enterostomy in general: partial or complete gastric or intestinal obstruction. b.To gastrostomy: (1)Gastric disease (2)Impaired gastric emptying (3)Significant GER (4)Loss of the gag reflex

4.Types: a.Gastrostomies 4.Types: a.Gastrostomies b.Jejunostomies: b.Jejunostomies:

PARENTERAL NUTRITION A. Indications: A. Indications: 1.When enteral feeding is not feasible [ie intestinal failure, which may be temporary or permanent]. a. Temporary intestinal failure occurs as a consequence of the temporary ileus following any abdominal surgery. a. Temporary intestinal failure occurs as a consequence of the temporary ileus following any abdominal surgery. b.Permanent intestinal failure occurs with small bowel resection. It is an indication for home parenteral nutrition. b.Permanent intestinal failure occurs with small bowel resection. It is an indication for home parenteral nutrition. 2.To supplement the deficient items in enteral feeding.

B.Contraindications: B.Contraindications: The following are not absolute contraindications. They are relative contraindications, i.e. they need to be corrected first before the commencement of parenteral nutrition. 1.Heart disease 2.Shock 3.Blood dyscrasias 4.Chronic liver disease 5.Disorders of fat metabolism 6.Uncontrolled DM

C.Solutions: C.Solutions:1.Composition: a. Carbohydrates. The most commonly used are glucose, fructose and sorbitol. b.Fats. c.Amino acids. Essential and branched chain amino acids are the most important. They are available in a crystalline form. d.Na, K, Ca, PO4 and Mg are present in all the commercially available preparations. e.Other minerals, vitamins and trace elements are added to the infusions whenever indicated.

2.Preparations. 2.Preparations. a.Vamin a.Vamin b.Intralipid 20% b.Intralipid 20%

D. Route of administration: D. Route of administration: 1.This should be a central great vein, in order to avoid peripheral vein thrombosis by the irritant hypertonic solutions. This has traditionally been achieved by subclavian vein cannulation, with skin tunnel formation. The tip of the catheter should lie within the SVC in order to avoid the risk of subclavian venous thrombosis. 1.This should be a central great vein, in order to avoid peripheral vein thrombosis by the irritant hypertonic solutions. This has traditionally been achieved by subclavian vein cannulation, with skin tunnel formation. The tip of the catheter should lie within the SVC in order to avoid the risk of subclavian venous thrombosis. 2.Recently, silicone-rubber catheters have become available. They can be introduced via the cephalic vein and advanced to reach the SVC. Their advantage is that they can be left for as long as possible, even for years, unless they cause problems. This is particularly of benefit for the patient with permanent intestinal failure.