1. Special nutritional needs

2. Nutrition support
A prepared nutrient formulation/solution that can meet the patient’s nutritional needs.
Enteral nutritional support
Utilised when patient’s GI tract is still functional; especially refers to tube feedings but include oral diets and supplements.
Parenteral nutritional support
Utilised in absence of ability to digest and/or absorb nutrients. Typically refer to intravenous feedings.

3. Understanding normal & clinical nutrition, 8th Edition

4. Enteral nutrition Four types
Standard (polymeric) – contain protein extracted from milk or soybeans or isolated from a combination of blended foods.
Elemental (hydrolysed, chemically defined or monomeric)– compromised digestive and/or absorption. Require little to no digestion e.g. MCFA in persons with Chylomicron syndrome or Type I hyperlipidemia.
Specialised (disease specific) – designed specifically to treat person with specific illness. Expensive & controversial.
Modular – Macronutrients are individually packaged (modules) and then combined to supply patient with the nutrients to meet their individual needs. Modules are sometimes combined with one of the other types.

5. Macronutrient Composition – 12-20% protein, 40-60% CHO, 30-40% kcal from fat depending on formula type; Metabolic stress =high protein, kidney disease = protein restrictions
Energy Density – high energy density = minimize amount of liquid, kcal/ml; 1-1.2kcal = usually adequate
Fiber Content – important to afford good GI health. Contraindicated in pancreatitis & acute intestinal disorders
Osmolality

7. Where do these macronutrients come from?

8. Parenteral nutrition
Must provide nutrients in a form that is safe to inject directly into bloodstream e.g. amino acids, glucose, fluid & electrolytes, TAGs.
May be
Peripheral parenteral nutrition (PPN) – needs are met using only the peripheral veins; short term intravenous feeding (7-10 days); osmolarity must stay within mOsm/L, phlebitis can occur.
Total parenteral nutrition (TPN) – long term intravenous feeding, large volume of blood dilutes the parenteral solution allowing very nutrient dense solutions.

9. Concentrations of parenteral solutions
Amino acids: 3.5 – 15%  4kcal/g
Glucose:
supplied as dextrose monohydrate; 2.5 – 70%  3.4kcal/g; may be given in a water or normal saline base.
Lipids:
Emulsion contain TAGs from safflower & soybean oil using PL as the emulsifier and glycerol to keep the solution isotonic; available as 10%, 20% & 30% solutions  1.1kcal, 2.0kcal & 3.0kcal per ml
Fluids & electrolytes:
30-40ml/kg in young adults & 25-30ml/kg in older persons  ml; Na, K, Cl, Ca, Mg, P; expressed as mEq

10. Estimation of the osmolarity of a 1-liter parenteral solution
Multiply the grams of amino acids in the solution by 10.
Multiply the grams of dextrose in the solution by 5.
Multiply the milliequivalents of electrolytes in the solution by 2.
Multiply the grams of lipids in the solution by 1.5.
Add the values obtained to determine the approximate osmolarity.

11. Calculate osmolarity & energy content
Amino acids: 30 g
Sodium: 45 mEq
Calcium: 2.8 mEq
Dextrose: 150 g
Potassium: 5 mEq
Magnesium: 5 mEq
Lipids: 30 g
Chloride: 107 mEq
Phosphate: 21 mEq