Parenteral &

Enteral Feeding

Aim of Nutritional Support

To ensure that the nutritional requirements are met

in patients at risk of malnutrition, by the most
appropriate route in a way that minimizes
complications

Definition

Parenteral feeding: the provision of all nutritional

requirements by means of IV route without the use
of the GIT

Enteral feeding: delivery of nutrients into the GIT;

either by standard oral intake or by direct
administration into the stomach or a small intestine
via a feeding tube

[Nutritional requirements: macronutrients,

carbohydrates, fat, proteins, vitamins, trace elements,
electrolytes & water]

Enteral Feeding

When possible, enteral feeding is preferred as a

nutritional support, why?

Because it maintains gut mucosal integrity, protects

against mucosal atrophy & reduces complications.

Enteral Feeding

Types:

1. Sip feeding
2. Nasogastric tube
3. Gastrostomy
4. Jujenostomy

1. Sip Feeding

By using small amounts of special formula

Indicated in patients who can take fluids only (in

case of weakness in the mouth or the mastication
muscles)

2. Nasogastric Tube

Fine bore tube (1mm) inserted into the stomach via

the nose

Indicated in patients:

1. Unable to swallow
2. With CVA
3. In coma
4. In ICU

2. Nasogastric Tube
[cont]

Intact gag reflex is a must in case of using this type

of feeding

Good gastric peristalsis is a must (to prevent gastric

stasis which can lead to gastric ulceration)

How to check for peristalsis?

By motility study; where a specific amount of

normal saline is administered into the stomach.
After 2 hours, suction from the stomach is done, to
compare both amounts.
(if the amount after suction was the same as the
administered one, then theres gastric stasis)

2. Nasogastric Tube
[cont]

Disadvantages:

Nose irritation, ulceration & pressure necrosis

Offensive in conscious or semi-conscious patients

Duration limited; used for maximum of 2 months

Gastroesophageal reflux & aspiration (due to the

incomplete closure of esophageal sphincter in the
presence of NG tube)

3. Gastrostomy

Tube inserted directly to the stomach through the

abdominal wall

PEG [percutaneous endoscopic gastrostomy]:

insertion of the tube by endoscope, used nowadays
instead of open surgery

Good evacuation (good peristalsis) is also needed

here, which can be confirmed by motility study

2. Gastrostomy
[cont]

Indicated in:

Obstructed GI tract before the stomach (tumors in

oropharynx or lower esophagus)

Loss of peristalsis due to neuromuscular disorder

Need for nutritional support for long time (e.g: head

trauma, coma)

4. Jujenostomy

Post-pyloric feeding decreases risk of aspiration

but difficult to place

Over distention could result from flooding of GIT by

feeding

Indicated in:

Gastric obstruction (advanced gastric CA)

Major resection of upper GIT, like whipple procedure

(pancreaticoduodenectomy & gastrojejunostomy)

Complications of Enteral
Feeding

Tube-related: malposition, displacement, blockage,..

GI: diarrhea, nausea, vomiting, abdominal cramps,..

Metabolic: electrolyte disorders, drug interactions,..

Infective: handling contamination, endogenous,..

Total Parenteral Nutrition

Indications:

1. Obstruction
2. Short bowel syndrome
3. Inflammation
4. Fistula
5. Inability to cope

Total Parenteral Nutrition

Indications:
1. Obstruction
. Irremovable advanced tumors; e.g lymphoma
. Pancreatic tumor: causes malabsorption &
obstruction

Total Parenteral Nutrition

2. Short bowel syndrome (<1m of small intestine)

A disorder clinically defined by malabsorption, diarrhea,

steatorrhea, fluid & electrolyte disturbances and
malnutrition caused by loss of large segment of small
intestine

Causes :
Mesenteric ischemia: superior mesenteric embolism
if left untreated for 5 hrs may lead to gangrene &
resection.
Volvulus neonatorum: bowel twisted around itself,
which is treated by resection
Crohns disease: recurrent surgical resection of the
bowel

Total Parenteral Nutrition

3. Inflammation

Ulcerative colitis & crohns disease; TPN used to rest

the bowel

Total Parenteral Nutrition

4. Fistula

Fistula in the upper GIT

Causes leak of pus, feces or bowel contents (gastric

juice, bile, enzymes, etc..)

Managed conservatively & need 6 wks to improve

by using TPN to rest the bowel

Total Parenteral Nutrition

5. Inability to cope
In cases of increased catabolic rate where the bowel
cant compensate the body demand, especially
proteins:
Sever sepsis.
Extensive burning.

Total Parenteral Nutrition

How to perform TPN?

Through the central line access:

1- Femoral V: rarely used, because its low and
away from the heart
2- Internal jugular V: commonly used in anesthesia
3- Subclavian V: commonly used

Total Parenteral Nutrition

Why central not peripheral?

Because the nutrition used is hyperosmolar, so:

If peripheral access
causes irritation, inflammation & thrombosis due to
poor flow
If complicated, it cant be easily washed by saline
because of the narrow lumen of peripheral veins
If central access
Does not cause irritation due to high blood flow
If complicated, can be easily washed out by saline

Total Parenteral Nutrition

How to insert an IV central line?

1.

Supine position & head down (to congest neck

veins)

2.

Local anesthesia below the clavicle

3.

By a wide bore needle (1mm) make incision in the

inferior surface of clavicle

4.

Insert a cannula (backward medially & downward)

until blood comes out

5.

Introduce a catheter to reach SVC

6.

Fix the line by stitch

Total Parenteral Nutrition

During the procedure: patient is asked to hold their

breath to decrease risk of pneumothorax & air
embolism

After the procedure: CXR is done to confirm the

site of the catheter & to exclude pneumothorax

Total Parenteral Nutrition

Complications of the procedure; injury of:

1) Brachial plexus
2) Subclavian artery (hematoma)
3) Thoracic duct
4) Phrenic nerve
5) Superior vena cava
6) Lungs (pneumothorax)
7) Cardiac muscles

Total Parenteral Nutrition

Complications of TPN:
1) Line infection
2) Fatty infiltration to the liver
3) Hyper-osmolarity
4) Re-feeding syndrome: metabolic disturbances that
occur as a result of reinstitution of nutrition to
patients who are malnourished
5) Insulin rebound phenomenon (somogyi syndrome)

Infection

TPN requires a chronic IV access for the solution to run through,

and the most common complication is infection of this catheter.
Infection is a common cause of death in these patients, with a
mortality rate of approximately 15% per infection, and death
usually results from septic shock]

Blood clots

Chronic IV access leaves a foreign body in the vascular system, and

blood clots on this IV line are common. ] Death can result from
pulmonary embolism wherein a clot that starts on the IV line but
breaks off goes into the lungs.

Patients under long-term TPN will typically receive a periodic

heparin flush to dissolve such clots before they become dangerous.

Fatty liver and liver failure

Fatty liver is usually a more long term complication of TPN, though

over a long enough course it is fairly common. The pathogenesis is
due to using linoleic acid (an omega-6 fatty acid component of
soybean oil) as a major source of calories.

Hunger

Because patients are being fed intravenously, the subject does

not physically eat, resulting in intense hunger pangs. The brain
uses signals from the mouth (taste and smell), the stomach/
G.I. Tract (fullness) and blood (nutrient levels) to determine
conscious feelings of hunger. In cases of TPN, the taste, smell
and physical fullness requirements are not met, and so the
patient experiences hunger, despite the fact that the body is
being fully nourished. In cases where the patient eats food
despite the inability, they can experience a wide range of
complications.

Total Parenteral Nutrition

How to give nutrition by TPN?

Normal body need:

Fluid: 30-40 mL/kg/day

Calories: 30-40 kcal/kg/day

Nitrogen: 0.15-0.2 g/kg/day

Na: 100mmol/day

K: 80mmol/day

Total Parenteral Nutrition

Example

A patient who weighs 70 Kg with fistula & fever 10

days post-op.. How to calculate the need?

Total Parenteral Nutrition

Fluids
70x40 = 2800 mL/day
- An amount of fluid is lost by the fistula; so we add an
amount of fluid in order to compensate +1000 mL/day
- Another amount must be added because of fluids lost in
sweating (hes feverish) +200 mL/day
2800+1000+200=4000 mL/day
[sweating, fistula, diarrhea, vomiting & drain all cause fluid
loss]

Total Parenteral Nutrition

Calories:
70x40 = 2800 kcal/day
- He has sepsis & post-op stress, which causes a loss of
more calories, so to compensate +1200
kcal/day
2800+1200 = 4000 kcal/day

Total Parenteral Nutrition

Nitrogen:
70x0.2 = 14 g
- Due to increased catabolism (due to sepsis), this
needs to be compensated + 7 g
14+7 = 21 g

Total Parenteral Nutrition

How to give those nutrients as a source of energy?

Carbohydrates 50%

Protein 15%

Fat 35%

Total Parenteral Nutrition

Glucose Water
We have many forms: 5%, 10%, 25%, 50%, 75%
(1 g 4 kcal)
- 5% form contains 50 g/L so 200 kcal/L
- 50% form contains 500 g/L so 2000 kcal/L

Our patient needs 4000kcal/day, this can be achieved by:

20 L/day of 5% form or 2 L/day of 50% form

So 50% is better to be used in this case

Total Parenteral Nutrition

Nitrogen
Different forms: 3%, 5%, 10%, 14%

14% form contains 14 g/L

Our patient needs 21g, so 1.5 L of 14% form can be

given in this case

Total Parenteral Nutrition

Lipid
Different forms:
(1g 9kcal)
- 10% form contains 100 g, so 900kcal/L
[Not given daily, because it causes allergic reaction & interference with
coagulation factor and its expensive]

Electrolytes
Normal saline or ringer lactate

Total Parenteral Nutrition

General instructions:
TPN must be given by drips, one bottle with fixed gradual rate
(1st day 2.5.. 2nd day 3.5L.. 3rd day 4.5L..)
Nutrients must not be given at once, this may cause
hyperglycemia & rebound insulin phenomena
Pt must be weighed daily, increment of 300 g or more this is
over feeding, so decrease doses
KFT & LFT weekly
Electrolytes & glucose level daily (for metabolic complication)
In case of sepsis: drain the cath, culture, & change site of cath

Thank You