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Enteral and
parenteral
nutrition
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Nutrition Screening
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BMI, Wt loss, fat

composition MAC)
Disease, drug, GIT,
Fluid balance, signs
Dysphagia, Fasting,
inadequate Energy,
history f intake

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Components of Assessment Sheet(ABCDE)

As per the American Society for

Parenteral and Enteral Nutrition (ASPEN)
guidelines
BMI, Wt loss, fat
1.Anthropometric Data composition MAC)

2.Biochemical analysis
Disease, drug, GIT,
3.Clinical examination Fluid balance, signs
Dysphagia, Fasting,
4.Dietry analysis inadequate Energy,
history f intake
5.Environmental

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Nutritional Diagnosis or problem

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 Indication of Enteral
nutrition
EN is indicated for the patient
who:

1- Cannot or will not eat enough

to meet nutritional requirements

2-Who has a functioning GI

tract.

3-a method of enteral access

must be possible
Enteral nutrition Type of EN feeding tube

 Definition: is the delivery of nutrients by tube

or mouth into the GI tract.
 The most common is through a feeding tube
 Tubes can be placed through the nose or oral
into the stomach , or even directly into small
intestine, called short term no more than 3 to 4
weeks
 Long –term enteral nutrition (more than 3-4
weeks or artificial orifice called Gastrostomy or
jejunostomy
 The goal of EN is to: Provide calories,
macronutrients, and micronutrients to patients
who are unable to achieve these requirements
from an oral diet
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 Enteral nutrition Benefits

 1.Utilize the normal route and absorption Advantageous versus peripheral nutrition
of the GI tract
 2. Maintaining GI tract structure and
function
 3. Nutrients provided via enteral route
undergo first-pass metabolism promoting
efficient utilization of nutrients
 4. Simpler and cheaper than parenteral
nutrition
 5. Stimulate intestinal blood flow
 6.Fewer metabolic, infectious and
technical complications.
 7. Avoid TPN-induced immuno-
supresstion.
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ADMINISTRATION METHODS OF EN

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Early initiation

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within 24 to 48
hours of
hospitalization is
recommended for
critically ill
patients, because
this decreases
infectious
complications and
reduce mortality
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Contraindication of EN

Inability to gain access to GI tract

(severe burn or trauma /vomiting
Non operative mechanical GI
obstruction.
Severe GI malabsorption (e.g.: enteral Sever pancreatitis
nutrition failed as evidenced by progressive Severe short-bowel syndrome
deterioration in nutritional status). (less than 100 cm of small bowel
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TYPES OF EN
FORMULA 1.Standard Formulas, intact or polymeric formula 22

It is designed for adults or children who have normal digestion.

They typically contain 1-1.2 kcal/ml.

They are inexpensive and an appropriate first choice.

Some Standard formulas are designed for oral administration and

used to supplement the patient diet.

2.Elemental or Semi-elemental formula: partially or fully

hydrolyzed; used for individuals with dysfunction in the GI

More expensive than polymeric

3.Disease-specific enteral formula: specialty formulas are available

for medical conditions including diabetes, liver failure, etc
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Monitoring of EN
• Confirm proper tube placement and
maintain head of bed elevation to 30–45
degrees(daily )
• Gastric residuals are checked
• Signs and symptoms of edema or
dehydration (daily)
• Fluid intake and output
• Stool frequency and volume (daily )
• Weight (at least 3/week)
• Nutritional intake adequacy (daily)
• Serum sodium and other electrolytes
(daily till stable then 2 to 3 times /week
• Blood glucose concentration, calcium,
magnesium , phosphorous (daily )
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Parenteral Nutrition (PN)

Parenteral nutrition is a way for you to receive

nutrients by central or peripheral venous access ,
through an IV catheter.
PN is used for patients who have a functional
impairment of the gastrointestinal tract that
prevents nutrients from being absorbed well to
maintain nutritional status.
Used for inpatient and also can take for
outpatient (patient home)
 rout of administration :It can be peripheral vein
or central vein (subclavian) .
 Component: Parenteral nutrition can be
supplementary (partial PPN) or complete (total
parenteral nutrition TPN).
In may classified as 2 in 1 or 3 in 1 formula
 Indication of parenteral nutrition
 A. Gastrointestinal incompetency 32
1. Sever acute pancreatitis

 2. Active inflammatory disease of intestine

 3. Intractable vomiting or diarrhea

 4.Short bowel syndrome

 5. Intestinal atresia

 6. High output fistula

 7. Chronic GI obstruction as in intestinal cancer Or hemorrhage

 8.Intensive chemotherapy

 9. Infant’s GIT is immature

 B. Critical illness with poor enteral tolerance (hyper catabolic states)

1. Trauma or burns or sepsis

2. Bone marrow transplantation

3. Sever wasting in renal failure with dialysis

4. Multi organ system failure


Goals of parenteral nutrition
1.Maintain nutritional balance when oral
or enteral routes are inadequate
2.Restore protein metabolism
3.Prevent malnutrition
4. Promote wound healing
5- expect body weight improvement
6- improve nutritional deficit
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Contraindication of PN
1. Functional GIT tract or pt is taking oral diet
2. Venous access isn't available
3. Expected duration of PN is less than 5 days
4. Prognosis doesn’t warrant aggressive
nutrition support (terminally ill)
5. Hemodynamic unstability
6. When the risks exceed the benefits
Type of PN Central parenteral nutrition Peripheral parenteral nutrition
administration (CPN) (PPN) 34
Location • subclavian veins • Do not use veins in lower limbs
• internal and external jugular vein • mid arm
• Femoral vein • Upper part of hands
Terminate in the superior vena cava or right atrium
Concentration Higher conc are allowed due to large veins and Solutions contain diluted amino acids and
rapid dilution (glucose can used in high dextrose(½ that of CPN ) conc used 12.5%
concentration in this formula 70%) (so not suitable for fluid restriction)
May contain glutamine and omega 3 Total calories 1000-1500 k cal/day
Duration Longer than 2weeks (long term therapy Short-term: up to 2 weeks

Osmolarity Isotonic or hypertonic Must be isotonic having osmolarity

less than 800-900 m Osm/L

Ca gluconate No restriction Maximum rate 200 mg/kg/d

Amino acid >5%

 Central parenteral nutrition Peripheral parenteral nutrition
(CPN) (PPN)

Advantage 1. Nutritionally complete 1.Peripheral or midline placement instead of

2. Provide large calories and nutrients need central line (not required surgery)
3. Long-term use (2 weeks or more) 2. Cheaper than CPN
4. Little risk of phlebitis
5. Suitable for fluid restriction
6. Less risk for phlebitis
Disadvantage 1.High risk of venous injury or obstruction or 1.High conc of glucose cause inflammation of
embolism veins associated with blood clots
2. Need surgery to adjust the catheter (thrombophlebitis) maximum 12.5%
3. Increased cost 2. Daily requirements cannot be met without a
4.Infection – Localized infection or system large volume( not recommended for fluid
infection restriction)
5. Risk of Hyperglycemia or Hypoglycemia 3.Provides minimum calorie and protein( not
or Pneumothorax recommended for significant malnutrition or
severe metabolic stress)
4-large nutrient or electrolyte needs
5.Meant for short-term use only
 Components of PN 36
formulation
 Protein in the form of amino acids
 Calories in the form of :
dextrose or combination of dextrose and Fat (lipid)
emulsions
 Electrolytes – sodium, potassium, chloride,
magnesium, phosphorous, acetate, calcium
 Vitamins – A, B, C, D, E, K, biotin, folic acid
 Trace metals – zinc, copper, manganese, chromium,
selenium, iodine
 Other additives – iron, insulin, H2 blockers (e.g.
ranitidine), heparin, albumin, metoclopramide, L-
carnitine, choline
2 in 1 or PN 3 in 1 OR Total Nutrient Admixtures
-All nutrients are mixed in the same IV bag, except for (TNA) or all in one or “triple mix
lipids 37
-All nutrients are mixed in the same IV bags ( fat
-Fat emulsion is given separately using a 1.2-micron emulsion is added into the glucose and amino acid
filter solution).
-Lipid infusion time should be less than 12 hours -Administration tubing should be changed every 24
because of the potential for microbial growth after this hours
time
-Administration tubing for 2in 1 should be changed
every 24 hours , lipid tubing should be discarded after
use (12 hours). Advantage
Advantage 1. less risk for infection and human error
1. Adequate amounts of nutrients, calories, and 2. Simplified process (fewer pumps, sets, supplies
volume to be used long term needed)
2. Longer stability (2month) 3. Time efficient
3. Can use a micron filter(0.22) to filter out bacteria 4. Decrease vein irritation
4. Can visually see if there are issues with the Disadvantages
solution 1. Shorter stability (1-2 days)
Disadvantage 2. Not able to use bacteria micron filter(0.22)
1. More pumps, sets, and time needed 3. Cannot visually see issues with solution
2. Increase nursing time 4. Complex compounding (without automated
3. greater risk of infection compounding)
Advantages of providing lipid calorie:
1. Provides a balance diet (Consider oral fat introduction if not 38
administered through parenteral nutrition).
2. Decrease osmolality, decrease PH.
3. Decrease risk of cholestasis induced by excessive use of dextrose.
4. Decrease CO2 production, thus Decease RQ in patients with
pulmonary failure.
5. Prevents EFA deficiency; EFA (precursors of phospholipids of cell
membrane);
25-100 mg/kg/day or 2-4% of total calories or 8-10% of fat calories.
NB All PN (without lipids) need a 0.22 micron filter
All TPN solutions need a 1.2 micron filter
Filters, tubing, PN formula must be changed every 24 hours and kept as a
closed system whenever possible
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Presentation title
 Continuous TPN
Pattern Typically initiated over 24 hour
Advantage 1. Well tolerated by patient
2. Require less manipulation
3. Decrease nursing time
Disadvantage 1. Continuously connected to infusion
equipment
2. Interfere with daily activities
3. Perpetually immobilize the patient
Cyclic TPN
discontinuous infusion over 10-14 hours depending on the patient’s
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response and tolerance.
Reserved for patients that are metabolically
stable and can handle periods of infusion.
A patient may switch from continuous therapy to cyclic therapy by
decreasing infusion time
- high response for insulin, increase urinary volum
1. Improved quality of life and compliance by allowing patient to
resume normal daytime activities (Suitable for home patients & long
term
2. Can reduce liver problems because of rest period between
infusions
3.May help transition to oral diet by allowing hunger response to
resume during non-infusion hours
1.More nursing time may be needed.
2. It require higher infusion rate(not be appropriate for cardiovascula
and renal patient and critical ill pt )
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administration
 It is necessary to use a laminar flood hood for PN
 PN has to be prepared under sterile conditions
 High Efficiency Particulate Air (HEPA) filters remove
99.97% of particles
Automated admixture devices
 Automated compounding devices are preferred because of
increased accuracy and safety
 Requires less manipulation of final bag, streamlines
inventory, and is less labor intensive
Non-automated admixture
 Done by hand and follows a sequence of steps
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Gallbladder stasis

1. Insertion site contamination

2. Catheter contamination
3. improper insertion technique
4. contaminated TPN solution
5. contaminated tubing
6. Secondary contamination
7. Septicemia (blood poisoning)

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