1. Nutritional therapy

2. Provide a life sustained therapy for the patient who can not take adequate food by mouth who consequently at risk for malnutrition and its complications Nutritional therapy

3. Benefits of Nutritional Support Preservation of nutritional status Prevention of complications of protein malnutrition  Post-operative complications

4. Who Requires Nutritional Support? Patients already with malnutrition – surgery / trauma/sepsis Patients at risk of malnutrition

5. Patients at Risk of Malnutrition  Cannot eat for >9 days  Vomiting : acute pancreatitis,hperemesis gravidarum  GIT obstruction: malignancy  neurological : coma, swallowing dis.  Abdominal pain : A. pancreatitis

6. Patients at Risk of Malnutrition  Can not absorb: intestinal fistula,short bowel syndrome  Should not eat: bowel rest in a.pancreatitis Intestinal fistula

7. Others nutritional support in patient with malignancy nutritional support in malnourished patient before surgery Who Requires Nutritional Support?

8. Type of the nutritional rehabilitation Normal diet mild malnutrition and treatable disease Supplement high energy and protein content used if normal diet cant give sufficient nutrition Specific Nutritional support Enteral feeding Parentral feeding

9. Types of Nutritional Support Enteral Nutrition Parenteral Nutrition

10. Enteral Feeding Is Best More physiologic Less complications Gut mucosa preserved No bacterial infection Cheaper

11. Enteral Feeding Is Indicated When nutritional support is needed Functioning gut present No contra-indications –no ileus, no recent anastomosis, no fistula

12. Types of Feeding Tubes Naso-gastric tubes Naso-jejunal tubes Tubes inserted down the upper GIT, following normal anatomy

13. Types of Feeding Tubes Gastrostomy tubes Percutaneous Endoscopic Gastrostomy (PEG) Open Gastrostomy Jejunostomy tubes Percutaneous endoscopic jejunostomy (PEJ) open jejenostomy Tubes that require an invasive procedure for insertion (feeding for long time)

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16. What Can We Give in Tube Feeding? Blenderised feeds Commercially prepared feeds e.g. Vivonex

17. Complications of Enteral Feeding Gastrointestinal complications Mechanical complications Metabolic complications Infectious complications

18. Complications of Enteral Feeding Gastrointestinal Distension Nausea and vomiting Diarrhoea Constipation

19. Complications of Enteral Feeding Infectious Aspiration pneumonia Bacterial contamination

20. Complications of Enteral Feeding Mechanical Malposition of feeding tube Sinusitis Ulcerations / erosions of nasal and esoph Blockage of tubes

21. Parenteral Nutrition

22. Allows greater caloric intake BUT Is more expensive Has more complications Needs more technical expertise

23. Who Will Benefit From Parenteral Nutrition? Patients with/who  Abnormal gut function  Cannot consume adequate amounts of nutrients by enteral feeding  Prognosis warrants aggressive nutritional support

24. Two Main Forms of Parenteral Nutrition Peripheral Parenteral Nutrition Central (Total) Parenteral Nutrition

25. Peripheral Parenteral Nutrition Given through peripheral vein Short term use Mildly stressed patients Low caloric requirements Contraindications to central TPN

26. What to Do Before Starting TPN Nutritional Assessment Venous access evaluation Baseline weight Baseline lab investigations

27. Baseline Lab Investigations Daily : urea, electrolytes, glucose Twice weekly : LFT, calcium, phosphate, magnesium Weekly: CBC, zinc, triglycerides Monthly: copper, selenium, manganese

28. Formula of the TPN Dextrose 10%,20% glucose Intralipid 10%, 20% fatty acid Vamine ( amino acid) 8%, 14% Vitamins Minerals Trace elements

29. Complications Related to TPN Mechanical Complications Metabolic Complications Infectious Complications

30. Mechanical Complications Related to vascular access technique pneumothoraxpneumothorax air embolismair embolism arterial injuryarterial injury bleedingbleeding brachial plexus injurybrachial plexus injury thoracic duct injurythoracic duct injury

31. Mechanical Complications Venous thrombosis Catheter occlusion Related to catheter in situ

32. Abnormalities related to excessive or inadequate administration –hyper / hypoglycemia refeeding syndrome –Fluid and electrolyte Congestive heart failure –Acid-base disorders Metabolic Complications

33. –Refeeding syndrome due to rapid glucose load hypomagnesemia hypokalemia hypophosphatemia Cardiac arrythmia Cardiopulmonary dysfunction Neurologic symptoms

34. Hepatic complications Biochemical abnormalities Cholestatic jaundice Hepatic steatosis Gall stones Acalculous cholecystitis Metabolic Complications

35. Infectious Complications ◦ Insertion site contamination ◦ contaminated TPN solution ◦ contaminated tubing Secondary contamination –septicaemia

36. Thanks