1

ARTIFICIAL NUTRITIONAL SUPPORT Ref: Baily & Love 26th 266

Indication: Any patient having inadequate intake for consecutive ( successive ) 5–7 days or patient with
anticipated no intake for this period should be considered for nutritional support. [ The periods may be less in
patients with pre-existing malnutrition. ]
Examples: Patients with Crohn’s disease or pancreatitis, patient with gastrointestinal resections.

Enteral nutrition
The term ‘enteral feeding’ means delivery of nutrients into the gastrointestinal tract.

The alimentary tract should be used whenever possible.

Enterra feeding can be achieved with oral supplements (sip feeding ) or with a variety of tube-feeding techniques
delivering food into the stomach, duodenum or jejunum , with a variety of nutrient formulations available.

These vary with respect to energy content, osmolarity, fat and nitrogen content and nutrient complexity; most
contain up to 1–2 kcal/mL and up to 0.6 g/mL of protein.

Polymeric feeds contain intact protein and hence require digestion, whereas monomeric/elemental feeds
contain nitrogen in the form of either free amino acids or, in some cases, peptides.

These are less palatable and are used much less frequently than in previous years. Newer feeding formulations
are available that include glutamine and fibre to optimise intestinal nutrition or immuno-nutrients such as
arginine and fish oils, but these are expensive and their use is controversial.

Sip feeding
1. Commercially available supplementary sip feeds are used in patients who can drink but whose appetites are
impaired or in whom adequate intakes cannot be maintained with ad libitum intakes.

2 These Sip feeds typically provide 200 kcal and 2 g of nitrogen per 200 mL carton ( Extra calorie and nitrogen
intakes in addition to patients spontaneous nutrition. ) But extra benefit from Sip feeding in not proved.

Routes of Enteral Feeding: Enteral nutrition can be achieved through:

1. Nasogastric tubes (Ryle’s tube)- conventional technique. John Alfred Ryle, 1889–1950, Professor of Medicine, Cambridge
University and Prof. Oxford University, UK, introduced Ryle’s tube in 1921.

2. Fine-bore feeding tubes inserted into the stomach  Surgical or percutaneous endoscopic gastrostomy (PEG)

3. Post-pyloric feeding utilising nasojejunal tubes or various types of jejunostomy.

Tube-feeding techniques
1. Tube feeding method is determined by local circumstances and preference in many patients, under
supervision of an experienced dietician who will calculate the patient’s requirements and aim to achieve
these within 2–3 days of the instigation of feeds.
 2

2. Amount : 20–30 mL / hour are administered , gradually increasing to goal rates within 48–72 hours.

3. Resting time: Feeding is discontinued for 4–5 hours overnight to allow gastric pH to return to normal. 
This might reduce the incidence of nosocomial pneumonia and aspiration.

4. Feeding protocols should be optimized according to tolerance of enteral nutrition, determined by a

regular gastric , and if they exceed 200 mL in any 2-hour period, then feeding is temporarily discontinued.

5. Tube blockage is common. All tubes should be flushed with water at least twice daily. If a build up of
solidified diet occurs, instillation into the tube of agents such as chymotrypsin or papain may salvage a
partially obstructed tube. Guidewires should not be used to clear blockages to avoid tube perforation
and adjacent tissue damae.

6. Nasogastric tubes are appropriate in a majority of patients.

7. Long term feeding for more than one week , Fine-bore feeding tube ( made of soft polyurethane or silicone
elastomer & <3 mm internal diameter ) is preferable with less chance of gastric and oesophageal erosions.

Fine-bore tube insertion

1. Position: semi-recumbent.

2. The Guide wire (introducer wire) is lubricated and inserted into the fine-bore tube (Figure 20.4).

3. The tube is passed through the nose and into the stomach via the nasopharynx and oesophagus.

4. The wire is withdrawn and the tube is taped to the patient.

5. Complications: Malposition into the bronchus , Pneumothorax.

6. The position of the tube should be checked using plain abdominal radiography (Figure 20.5).

7. Alternatively, 5 mL of air can be injected and a stethoscope used to confirm bubbling from the stomach.

8. Confirmation of position by pH testing is possible but limited by the difficulty of obtaining a fluid aspirate
with narrow lumen tubes.

Gastrostomy
1. Def: The placement of a tube through the abdominal wall directly into stomach is termed
‘gastrostomy’.

2. Types:
 Surgically at the time of laparotomy (Historic).
 Percutaneous insertion under endoscopic control using local anaesthesia - PEG (percutaneous
endoscopic gastrostomy) tubes .
3. Two methods of PEG are commonly used. The first is called the ‘direct-stab’ technique in which the
endoscope is passed and the stomach filled with air.
 3

4. The endoscopist then watches a cannula entering the stomach having been inserted directly through the
anterior abdominal wall.

5. A guidewire is then passed through the cannula into the stomach.

6. A gastrostomy tube (commercially available) may then be introduced into the stomach through a ‘peel
away’ sheath.

7. The alternative technique is the transoral or push-through technique, whereby a guidewire

or suture is brought out of the stomach by the endoscope after transabdominal percutaneous insertion
and is either attached to a gastrostomy tube or the tube is pushed over a guidewire. Figure 20.4

8. The abdominal end of the wire is then pulled, advancing the gastrostomy tube through the oesophagus
and into the stomach.

9. Continued pulling abuts it up against the abdominal wall.

10. If patients require enteral nutrition for prolonged periods (4–6 weeks), then PEG is preferable to an
indwelling nasogastric tube; this minimises the traumatic complications related to indwelling tubes.

11. Complications of PEG : Necrotising fasciitis , Intra-abdominal wall abscesses . both are rare.
Sepsis around the PEG site is more common ( Systemic antibiotics or repositioning. )
Persistent gastric fistula during removal of a PEG : if it has been in place for prolonged periods and
epithelialisation of the tract has occurred. This necessitates surgical closure.

Jejunostomy
1. Def: Jejunostomy can be achieved using nasojejunal tubes or by placement of needle jejunostomy at the
time of laparotomy. Jejunal feeding is becoming more popular , In recent years.

2. Advantages of jejunostomy : Post-pyloric feeding is associated with a reduction in aspiration or

enhanced tolerance of enteral nutrition.

3. Indications: Patients with severe pancreatitis, with a degree of gastric outlet obstruction , due to
oedematous head of pancreas.

4. Procedure: Nasojejunal tubes often necessitate the use of fluoroscopy or endoscopy to achieve
placement, which may delay commencement of feeding.

5. Complications: Surgical jejunostomies, even using commercially available needle-insertion techniques:

Creating a defect in the jejunum with leakage or tube displacement; both of these complications result
in peritonitis.
 4

Complications of Enteral Nutrition: Summary box 20.3. Baily & Love:

Tube related: Malposition, Prevention of Complications by Enteral Nutrition:

Displacement.
Those resulting from 1. By caareful attention to detail and appropriate
intubation of the Blockage , Breakage , infusion rates, most complications can be avoided.
gastrointestinal tract : Leakage.
Occurs frequently 2. Patients should be nursed semi-recumbent to
with more invasive Local complications reduce the possibility of aspiration.
means of gaining e.g. erosion of skin /
access to the 3. Introduction of normal feeds at a reduced rate
mucosa
intestinal tract. according to patient tolerance.

Gastro-intestinal: Diarrhoea ( Occurs in > 4. Overfeeding related metabolic complications are

30 % patients receiving rare (uncommon) in enterally fed patients.
Those related to enteral nutrition & common
5. Nosocomial enteric infections associated with
nutrient delivery in critically ill patient. )
contamination of feeds can be avoided by keeping
Nausea, Vomiting , the food in sealed containers at 4°C and discarded
Bloating. once opened.

Abdominal cramp, 6. Monitoring of intakes accurately as target intakes

Constipation, are often not achieved with enteral nutrition.

Aspiration.
Metbolic / Electrolyte imbalance:
Biochemical : Vitamin, Mineral ,
Trace element
deficiency.
Drug interaction.
Infective : Exogenous : handling
contamination.
Endogenous : Patient.
222

Parenteral nutrition
Def: Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the
intravenous route and without the use of the gastrointestinal tract.

1. Parenteral nutrition is indicated when energy and protein needs cannot be met by the enteral
administration of these substrates.

2. The most frequent clinical indications:

 Patients having massive resection of the small intestine,

 Patients having intestinal fistula or who have prolonged intestinal failure for other reasons.

Q-3: Total parenteral nutrition (TPN).
TPN is defined as intravenous provisions of all the nutritional support , without the use of gastrointestinal tract.
[
TPN should always be administered by using an electronically controlled volumetric infusion pump.
Indications of TPN: TPN is the treatment of choice in non functioning GIT.
[[111
1. Patients who can not
Ingest food :
Al Falouzi-56 -Only
2. Patient with
malfunctioning GIT:
3. Hypermetabolic
patient: Falouzi-56 -Only
Hypermetabolic patients are
patients with major diseases ,
fever > 380 C, Tachycardia,
Increased respiratory rate and
Urea production rate of more
than 20 g/ 24 h.
4. Infants with major GIT
anomalies:
/ Congenital anomalies:
5. Who fail to thrive
( Grow ? ) because of
5
Contraindications of TPN :
a. Aneroxia, Arif- 81-82 same , Shahid – 367
b. Neurological disorders ( Others cause)
c. Intracranial surgery.
d. Central nervous system trauma. 1. Heart failure
e. Coma. 2. Hepatic failure
f. Multiple injuries , especially maxillofacial and 3. Renal failure
Nead-Neck fractures. 4. Severe blood dyscrasias
a. Short bowel syndrome: due to: 5. Uncontrolled DM.
 Massive intestinal resection.
 Mesenteric resection
 Crohn‘s disease
b. Inflammatory bowel disease: Crohn’s
disease, Ulcerative colitis exacerbations.
c. Prolonged paralytic ileus due to any cause.
d. Proximal intestinal fistula, e.g.
 Entero-enteric fistula,
 Entero-cutaneous fistula,
 Entero-colic fistula,
 Entero-visceral fistula
e. In-operable obstruction, e.g.-
 Ca- oesophagus
 Gastric carcinoma / Ca- stomach
 Pyloric obstruction.
 Stricture,
 Achalasia:
 Intestinal Tumour / Ca- Colon, etc.
a. Severe trauma and Major fractures.
b. Extensive burn ( Others )
c. Selected Patients with chemotherapy or
radiotherapy, particularly for GIT tumours.
a. Tracheo-Oesophageal fistula.
b. Gastroschisis: (congenital defect characterized
by a defect in the anterior abdominal wall through
which the abdominal contents freely protrude )
c. Omphalocele.
d. Massive intestinal atresia.
a. GIT insufficiency from short bowel syndrome.
b. Malabsorption, Idiopathic diarrhea.
 6

: c. Enzyme deficiency.
Al Falouzi-56 -Only d. Meconium ileus.
222

Procedure of Central Venous Catheter Placement: Al Falouji-56

Under aseptic conditions and using local anaesthesia the Catheter is introduced through the subclavicular , midclavicular
point horizontally towards the supra-sternal notch.

The needle is attached to a Heparinized syringe to ensure intra-subclavicular Vein location.

The catheter is then threaded down and further confirmation is obtained By lowering the bottle below the patients head
position  Blood comes back via the catheter.

The catheter is then secured to the skin with sutures and dressing and subcutaneous Tunnelling may be performed.

A chest X-ray is obtained immediately thereafter to confirm the position of the Radioopaque catheter in the Superior
venacava and to check for induced Pneumothorax or Haemothorax.

Complications of Central Venous Catheter : Ref: Shahid-370

1. Air Embolism, Pneumothorax, Thrombosis, Catheter induced Staph. aureus or Staph. epidermidis infection.

2. Haemorrhage, Haematoma, Injury to adjacent Vessels, Nerves.

3. Arrhythmias, Sepsis, Endocarditis, Knotting or Catheter.

Formulation of TPN solution:

Source of energy of TPN: A. Component of 1 L of standard TPN:
1. 50 % from carbohydrate 1. 50% Dextrose in Aqua DA - 500ml

2. 35% from fat ( Faluzi) , 30% ( Arif) 2. 8% Amino Acid - 500ml

3. 15 % from protein. 3. NaCl, KCl

The patient should never receive Less than 12.5 % of Total 4. Na-acetate, K-acetate
energy from protein. 5. Calcium gluconate
6. H2-receptor antagonist
7. Regular insulin.
Calculation of Requirement of TPN: B. Fat Emulsion schedule:
1. Calorie : Nitrogen is 200 : 1 Infuse a 20% fat emulsion 500 ml intravenously via pump
2. Daily Nutritional requirement is 25-30 Kcal / Kg /Day. over 6-8 hours at least 3 times weekly.

Roughly 2000-4000 K cal in2 - 4 Lit of fluid can be given

daily.
Energy Value: C. Administration schedule:
1 gm Carbohydrate = 4 K cal. 1st day = 40ml/hour
1 gm Protein = 4.1 K cal. 2nd day= 80ml/hour
3rd day and subsequent day: 100-125 ml/hour.
1 gm Fat = 9.3 K cal.
 7

Route of delivery of TPN : Peripheral or Central venous access

1. TPN can be administered either by a catheter inserted in the central vein or via a peripheral line. In the
early days of parenteral nutrition, the only energy source available was hypertonic glucose, which, being
hypertonic, had to be given into a central vein to avoid thrombophlebitis.

2. These include the identification of safe and non-toxic fat emulsions that are isotonic; pharmaceutical
developments that permit carbohydrates, fats and amino acids to be mixed in single containers; and a
recognition that the provision of energy during parenteral nutrition should be a mixture of glucose and
fat and that energy requirements are rarely in excess of 2000 kcal/day (25–30 kcal/kg per day). These
changes enabled the development of peripheral parenteral nutrition.

Routes of Administration of TPN : Ref: Baily & Love, Arif-82, Al Falouji-56,

Central TPN: Central Parenteral Nutrition: Peripheral Parenteral Nutrition:

Def: Total nutrition is provided and patient does not receive Def: PPN is only partial and patient getting nutrition , from
any other form of nutrition. other source also.
TPN comes in a higher concentration, and Administrated PPN comes in a lesser concentration, delivered through a
through a larger vein: peripheral vein.
TPN is Caustic as it contains Glucose, Mineral and Electrolyte.
Long term use Short term , upto 2 weeks.
Digestive disorder. GIT blocked or patient not getting enough nutrition.
222.

1. Central veins: 2. Peripheral vein:

a. Subclavian vein (ideally) When TPN is needed for Less than 2 weeks.
b. Internal jugular vein (rarely). Use Fine Bore Cannula or CV catheter.
c. Femoral vein. Use of Heparin in the Line of Filtration.
If Fever and Leukocytosis develop and other causes are not Cortisol and Local application of GTN patch.
found, then it is thought to be Catheter Related sepsis, and
Catheter should be replaced.
By 16 Fr silicon catheter Disadvantages of giving TPN to peripheral vein:
These vein ( a,b,c ) Ultimately drains into Right Atrium of Heart. 1. Damage of Endothelium of the Peripheral vein.
Rate of Flow of TPN is kept Low , Less than 3 Lit / Day. And Lipid 2. Chance of thrombophlebitis.
based solution should be employed.
A central venous catheter of 16 Fr size , made of Silicone All precautions are taken for prevention of
( Inert, soft, Flexible, and Radioopaque) is Directly inserted Thrombophelbitis.
into the Superior Venacava via a Subclavian vein or Rarely
Internal Jugular vein.
Primary source of Calories  Fat metabolism.
An occlusive dressing is given below the Clavicle in case of
Subclavian vein, and ensure optimal catheter care, patients
comfort and mobility.  the route SCV is safe as the solution of
1500 mol/ Lit , infused at a rate of 2-3 ml/ min, are immediately
 8
diluted a Thousand fold by a blood flow of 2-3 Lit/ Min. Such
Large vein also decreases the likelihood of Thrombophelbitis.
1. Routes of central venous administration: via the subclavian
or internal or external jugular vein.
2. Safest method of establishing central venous access is by
insertion of lines under ultrasound guidance.
Internal or external jugular vein route for TPN:
3. Most intensive care physicians and anaesthetists favour
cannulation of internal or external jugular veins as these
vessels are easily accessible.
4. Disadvantage : The exit site is situated inconveniently on the
side of the neck, where repeated movements result in
disruption of the dressing with the attendant risk of sepsis.
Infraclavicular subclavian approach:
5. Advantage: more suitable for feeding as the catheter then
lies flat on the chest wall, which optimises nursing care
(Figure 20.8).
Hickman lines :
1. For longer-term parenteral nutrition, Hickman lines are
preferable. These are often inserted by a radiologist with
fluoroscopic guidance or ultrasound.
2. They incorporate a small cuff, which sits at the exit site of a
subcutaneous tunnel. This is thought
to minimise the possibility of line dislodgement and reduce
the possibility of line sepsis.
3. Precaution before Central Venous TPN:
4. A post-insertion chest x-ray is essential before start feeding is
to confirm the absence of pneumothorax and that the
catheter tip lies in the distal superior vena cava to minimize
the risk of central venous or cardiac thrombosis.
5. Multi-lumen catheters can be used for the administration of
TPN; one port should be employed for that sole purpose and
strict protocols of care employed.
PICC technique under ultrasound guidance to cannulate the
cephalic vein:
6. An alternative technique for central intravenous access
allows the PICC technique under ultrasound guidance to
cannulate the cephalic vein in the arm which facilitates
passage of a catheter into the bracheocephalic vein or
superior vena cava.
7. Advantages ( Many ) : It minimises the risks of insertion and
ensures distance between the site of skin entry and the tip of
the catheter.
Disadvantage : Thrombophlebitis .
Access can be achieved either by means of a dedicated
catheter inserted into a peripheral vein and
manoeuvred into the central venous system
(peripherally inserted central venous catheter (PICC)
line) or by using a conventional short cannula in the
wrist veins.
peripherally inserted central venous catheter
(PICC):
Advantage:
Minimum inconvenience to the patient and clinician.
Duration of use : mean 7 days.
Disadvantage : If Thrombophlebitis occurs, the vein is
irrevocably destroyed.
1. In the alternative approach, intravenous
nutrients are administered through a short
cannula in wrist veins, infusing the patient’s
nutritional requirements on a cyclical basis
over 12 hours.
2. The cannula is then removed and resited in
the contralateral arm. Peripheral parenteral
nutrition has the advantage that it avoids the
complications associated with central venous
administration, but suffers the disadvantage
that it is limited by the development of
thrombophlebitis (Figure 20.7).
3. Peripheral feeding is not indicated if patients
already have an indwelling central venous line
or in those in whom long-term feeding is
anticipated.
Complications of Central Venous Catheter : Ref: Shahid-370
4. Air Embolism, Pneumothorax, Thrombosis,
Catheter induced Staph. aureus or Staph.
epidermidis infection.
5. Haemorrhage, Haematoma, Injury to adjacent
Vessels, Nerves.
6. Arrhythmias, Sepsis, Endocarditis,
Knotting or Catheter.
 9

Advantages of TPN:
1. Glucose, Protein , Lipid and Electrolyte can be given.
Disadvantages of TPN:
2. Thrombo-embolism can occur.
3. All Micromolecules can not be given.
4. Mucosal Atrophy of Intestine.

Monitoring of the patient having TPN : Baily & Love Table 20.4 Monitoring Feeding Regimens

Arif – 82 , Same Shahid-368 Al Falouji- 58 , same Shahid- 363 Baily and Love- 26th , 264 pg Table-20.4

A. Daily monitoring: Daily: Daily:

1. Total blood count (CBC) Blood Glucose. Blood Urea. Body weight, Temperature, Fluid Balance.

2. RBS S. Electrolytes. Full blood Count.

3. Blood Urea, Serum creatinine Blood Glucose. Blood Urea.

4. Serum electrolytes. S. Electrolytes

Electrolyte content and volume of Urine

and/or Urine and Interestitial losses.

B. 3 days interval: Twice Weekly: Weekly or More frequently , if Clinically

1. Liver function tests
S. Bilirubin, SGPT, Alkaline
Phosphatase, PT, CT
2. Serum bilirubin
indicated:
Plasma Calcium, Phosphate,
Urine and Plasma Osmolarity.
S. Albumin,
Calcium, Magnesium, Zinc and Phosphate.
Full blood count.
Plasma protein including Albumin.

3. Serum Ca++, Serum Mg++, etc. Weekly: Liver Function Test including Clotting factors.
Liver Function test.  Thiamine
Bilirubin, SGPT, Alkaline
Phosphatase, PT, CT Acid - Base status.

Plasma Lipid, Triglycerides.

S. Magnesium.

C. 10 days interval: Monthly: Fortnightly :

1. Trace element Vit-B12 and Folate, Iron , Zinc and Serum Vit-B12
Prothrombin Time.
2. Serum folic acid, Vit-B12, Folate, Iron ,
ferritin, etc.
Lactate.

Trace elements ( Zinc, Copper, Manganese) .

 10

Complications of TPN : Complications of parenteral nutrition : Baily & Love-26th ed. 270
Summary Box 20.4
Arif- 82 , same Shahid-368 Shahid-363 & Falouji-56 Complications of parenteral nutrition aily & Love-26th
ed. 270 Box-20.4
A. Related to catheter:
Related to Hypoglycaemia/hypocalcaemia/
1. Air embolism
Nutrient hypophosphataemia/hypomagnesaemia (refeeding
2. Pneumothorax, Haemothorax , Hydrothorax syndrome)
Deficiency:
3. Injury to : Chronic deficiency syndromes (Essential fatty acids,
Zinc, Mineral and Trace elements)
a. Carotid artery , Subclavian artery.
Related to Excess glucose: hyperglycaemia, hyperosmolar
b. Internal Jugular Vein , Subclavian Overfeeding dehydration, hepatic steatosis, hypercapnia,
vein. increased sympathetic activity, fluid retention,
electrolyte abnormalities
c. Thoracic duct , d. Brachial
plexus.
Excess fat: hypercholesterolaemia and formation of
4. Cardiac perforation, Cardiac Arrhythmia if lipoprotein X, Hyper-triglyceridaemia,
Ventricle hypersensitivity
reactions.
5. Catheter related infection and sepsis
6. Infective endocarditis
Excess amino acids: hyperchloraemic metabolic
7. Cardiac and subclavian vein thrombosis. If acidosis, hypercalcaemia, aminoacidaemia, uraemia
Infection 1. Catheter-related sepsis
Related to
8. Catheter fracture, displaced, migration, etc. Sepsis 2. Possible increased predisposition to systemic
sepsis
B. Related to feeding regimen/metabolic:
Related to On insertion: pneumothorax, damage to adjacent
1. Azotaemia  Mild Pre-renal Azotaemia. Line artery, air embolism, thoracic duct damage,
cardiac perforation or tamponade, Pleural effusion,
2. Fluid overload Hydro-mediastinum

3. Metabolic acidosis  Hyper-chloraemic M.

Acidosis Long-term use: occlusion, venous thrombosis

4. Hyper kalaemia / Hypokalaemia  Metabolic Fluid overload (Daily weighing : weight change of >1

Hyper Kalaemia and Metabolic Acidosis. complication: kg/day indicates fluid retention)

5. Hypernatraemia / Hyponatraemia. Hyperglycaemia (because of insulin resistance

in critically ill patients )
6. Hypo-magnesaemia, Hypophosphataemia.
Abnormalities of liver function
7. Hypoglycaemia / Hyperglycaemia ( &
(Abnormalities of liver enzymes are common, but
glycosuria)
mechanisms are unclear, intra-hepatic cholestasis
8. Metabolic bone disease may occur and hepatic steatosis and hepatomegaly
reported
9. Trace element deficiency.  Essential Fatty acid
Infusion of fat-free TPN may be required , If liver
Deficiency. enzymes continue to deteriorate, TPN should be
10. Jaundice. temporarily discontinued

Overfeeding is also a major factor in hepatic and

11. Hyperosmolar Non-Ketotic Hyperglycaemic
Coma. other metabolic complications associated with TPN )
 11

Vitamin deficiencies

Conclusion:
Complication rate related to TPN can be minimized by careful attention and regular monitoring by multidisciplinary team.

Complications of parenteral nutrition

1. The commencement of TPN may precipitate or accentuate underlying nutrient deficiency by encouraging
anabolism.

2. Supplemental parenteral glutamine during parental nutrition should be considered, particularly in the
critically ill patient.

3. Catheter-related sepsis : occurs in 3–14 % patients. It may occur at the time of line insertion or
afterwards by migration of skin bacteria along the external catheter surface. [ Dx confirm by: Removal of
catheter line and culture with finding of same organism in catheter & blood . 2nd method: Culture of blood
withdrawn through the suspected catheter and another peripheral site , with both blood cultures and the colony
count from the catheter sample is five times higher than peripheral blood.

4. Contamination of the infusate is rare. Seeding on the catheter at the time of bacteraemia from
a remote source may also cause catheter infection.

Re-feeding syndrome :
1. Refeeding syndrome is characterised by severe fluid and electrolyte imbalance ( shifts ) in malnourished
patients undergoing refeeding.
2. It can occur in both enteral or parenteral ( commonly)nutrition.
3. Problems:
 Hypo-phosphataemia,
 Hypocalcaemia
 Hypomagnesaemia.
4. Manifestations: These electrolyte disorders can result in :
 altered myocardial function, arrhythmias,
 Deteriorating respiratory function,
 Liver dysfunction,
 Seizures, confusion, coma, tetany and death.
5. Patients at risk include those with alcohol dependency, those suffering severe malnutrition, anorexics
and those who have undergone prolonged periods of fasting.
6. Treatment  Matching intakes with requirements and accordingly avoiding overfeeding.
7. Calorie delivery should be increased slowly and vitamins administered regularly.
8. Hypophosphataemia and hypomagnesaemia require treatment.
 12

Nutrition support teams

Multidisciplinary nutrition teams ensure cost-effective and nutritional support, irrespective of how this is
administered. The incidence of catheter-related sepsis is significantly reduced.

SUMMARY

1. Fluid therapy and nutritional support are fundamental to good surgical practice.

2. Accurate fluid administration demands an understanding of maintenance requirements and an appreciation of the
consequences of surgical disease on fluid losses.

3. This requires knowledge of the consequences of surgical intervention and, in particular, intestinal resection.

4. Malnutrition is common in hospital patients. All patients who have sustained or who are likely to sustain 7 days of
inadequate oral intake should be considered for nutritional support.

5. This may be dietetic advice alone, sip feeding or enteral or parenteral nutrition. These are not mutually exclusive.

6. The success or otherwise of nutritional support should be determined by tolerance to nutrients provided
and nutritional end points, such as weight.

7. It is unrealistic to expect nutritional support to alter the natural history of disease.

8. It is imperative that nutrition-related morbidity is kept to a minimum. This necessitates the appropriate selection of
feeding method, careful assessment of fluid, energy and protein requirements, which are regularly monitored, and
the avoidance of overfeeding.

NUTRITION

Q-1: Nutritional assessment of a surgical patient.

Nutritional assessment is an important tool for the management of surgical patient and for a good surgical outcome.

There are varieties of techniques for the assessment of nutritional status, like-
1. Body weight and Anthropometric techniques
2. Measurement of organ function
3. Laboratory techniques.

1. Body weight and anthropometric techniques:

Anthropometry is a science of assessing body size, weight and proportion. By these the somatic and visceral protein mass
and fat reserve can be assessed.

1) Body weight: Subtraction of the present body weight from the previous body weight. Weight loss more
than 10% of patient‘s previous weight within 6 months means significant weight loss.
2) Body mass index (BMI):
Body weight in kg
 BMI= ------------------------------
 13

Height in (m) 2

 Normal BMI= 19-25 Kg / m2

 BMI < 18.5 Kg / m2 indicates nutritional impairment
 BMI < 15 Kg / m2 is associated with significant hospital mortality.

3) Triceps skin fold thickness (TSF): For rough estimation of fat reserve. Normal

a. TSF in male= 10 mm
b. TSF in female= 13 mm.

4) Mid-arm muscle circumference (MAMC): For estimation of somatic protein reserve.

MAMC= (Mid arm circumference – Triceps skin fold thickness x 0.314)

2. Measurement of organ function (Clinical and functional technique):

1) Clinical history:

a. Change of weight
b. Dietary intake
c. Gastrointestinal symptoms.
2) Physical signs:
a. Muscle wasting
b. Loss of subcutaneous fat
c. Alopecia
d. Oedema
e. Functional impairment assessed bya) Hand grip strength (hand grip dynamization)
f. Respiratory muscle function.
3) Laboratory techniques: Following biochemical markers are the indicators of visceral protein reserve and immune function

a. Serum Albumin (Normal level: 3.6 – 4.7 gm/dl)

b. Serum Pre-albumin
c. Retinol binding protein
d. Measurement of lymphocyte count
e. Skin test for hypersensitivity.  Delayed Hypersensitivity skin testing.

Conclusion:
Serum albumin is frequently used as a screening tool for nutritional assessment, but it can be affected by CRP
and may fall rapidly during inflammation irrespective of nutritional status. So, it is not a reliable indicator for
assessment of nutritional status.

Q-5: How do you prepare a malnourished patient for a major surgery?

First of all I will evaluate the patient by taking proper history, physical examination and by doing some investigations.

A. History taking:
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1. History of chronic diseases, 

a) Diabetes mellitus (DM)
b) HIV AIDS
c) Tuberculosis
d) Chronic liver disease
e) Chronic renal failure (CRF)
f) Peptic ulcer diseases (PUD)
g) Chronic diarrhea and vomiting
h) Fistula, etc.

2. History of alcoholism, smoking

3. History of malignancy
4. History of previous surgery: Gastrectomy, ileal resection
5. History of medication: Steroid
6. Socio-economical status of the patient.

B. Nutritional assessment:
1. Body weight and anthropometric techniques:

1. Unintensional Weight -loss more than 10% of patient‘s previous weight within 6 months means significant weight loss.
2. Total Body weight is compared with Ideal body weight, in respect of Height and Sex.

3. BMI < 18.5 Kg / m2 indicates Nutritional impairment and BMI < 15 Kg / m 2 is associated with significant
hospital mortality.

Anthropometric techniques:

1. Mid arm muscle circumference. (MAMC): For estimation of somatic protein reserve.
MAMC= (Mid arm circumference – Triceps skin fold thickness x 0.314)

2. Triceps Skin fold thickness: For rough estimation of fat reserve. Normal : TSF in male= 10 mm / TSF in female= 13mm.

3. Dynamometric tests for hand –grip strength.

2. Clinical and Functional technique / Measurement of organ function :

1) Clinical history:

a. Weight Change
b. Dietary intake
c. Gastrointestinal symptoms.
. d. Functional Impairment.  assessed by a) Hand grip strength (hand grip dynamization
2) Physical signs:
a. Muscle wasting, Muscle Power,
b. Loss of subcutaneous fat
c. Alopecia, Skin Rash, Glossitis , Angular Stomatitis. Neuropathy, Gingivitis, Nail abnormality. Paresthesia.
d. Oedema ( Peripheral Oedema)
e. Functional impairment  assessed by a) Hand grip strength (hand grip dynamization
f. Respiratory muscle function.
3) Laboratory techniques:
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a. Serum Albumin (Normal level: 3.6 – 4.7 gm/dl)

b. Serum Pre-albumin, Transferrin,
c. Retinol binding protein
d. Lymphocyte count
e. Delayed Hypersensitivity. Skin testing .

C. Treatment by nutritional support: (Prepare)

1. Enteral nutrition
2. Parenteral nutrition
3. Vitamin, mineral and trace element supplementation.
D. If patient‘s BMI >30 then diagnosed as malnourished due to obesity → control of obesity by reduction of weight pre-
operatively

Q-2: Different routes of nutritional therapy and nutritional support to surgical patient.

Nutritional support is essential for the management of surgical patients and for good surgical outcome.

Nutritional support influence on surgical practice:

1. Mal nutrition is a reason for poor surgical outcome
2. Following surgery, there is a period of increased metabolism to meet the increased body demand. There is
increased lypolysis, increased protein breakdown and negative nitrogen balance. If patient is malnourished,
he/she can‘t cope with this
3. Adequate preoperative nutrition maintenance is a must, protein energy malnutrition is associated with increased
post operative morbidity due toa. Immunocompromised
b. Impaired phagocytosis
c. Poor inflammatory response
d. Increased sepsis and wound infection
e. Delayed wound healing.

Routes of nutritional therapy:

A. Enteral: B. Parenteral:
1. Oral 1. Central vein:

2. Nasal: If nutrition is required for less than 2 weeks. a) Subclavian vein

a)Nasogastric - NG tube feeding
b) Naso-enteric ( Naso-Jejunal ).
b) Internal jugular vein

3. Percutaneous tube enterostomy ( PTE ): If nutrition is

required for > 2 weeks. c) Distal superior vena cava.
1) Feeding gastrostomy
2) Feeding jejunostomy
3) Feeding transgastric jejunostomy 2. Peripheral: via peripheral veins.
4) Oesophagostomy.

Indications of Enteral nutrition: Ref: Arif- 80 , Shahid- 360 & 364

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1. Protein energy malnutrition (PEM) with inadequate Indications of Feeding Jejunostomy / Feeding
oral intake. Enterostomy / Enteral Nutrition:
2. Dysphagia, except for fluid. 1. After Pancreatico-duodenectomy.
3. Inflammatory bowel disease. 2. Advanced Ca. Oesophagus.
4. Major trauma, major surgery. 3. Advanced Ca Stomach.
5. Distal low output (<200 ml/day) fistula 4. After Total Gastrectomy.
6. To enhance adaptation after surgery (enterectomy).
Contra indications of Enteral Nutrition : Ref: Shahid- 360 -361

1. Small Bowel Obstruction or Paralytic ileus.

2. Severe Diarrhoea.

3. Proximal Small intestinal fistula.

4. Severe Pancreatitis.

Benefits of Enteral Feeding : Ref: Shahid- 360 Types of Diet : Ref: Shahid- 361
1. Enteral diets are relatively Inexpensive. 1. Polymeric Diet:
2. Safer. More Physiological, 2. Pre-digested or Elemental diet : For Pancreatic
Insufficiency, Short Bowel Syndrome.
3. Maintain the Gut Muscosal mass & Gut barrier
function. Prevent disruption of Gut flora. 3. Disease Specific Diet : Low carbohydrate diet in
Respiratory failure.
4. Improve Anti-bacterial host Defense.
Blenderised , Partially Hydrolysed, Elemental Diet.
5. Blunt the Hyper-metabolic response to Trauma.
Polymeric Diet:
1. Whole Protein as a Nitrogen source.
2. Triglyceride.
3. Glucose polymer.
4. Standardized amount of Electrolytes. And Trace Elements and Vitamins.

PEM is associated with postoperative mortality and morbidity because of: Immunocompromised, Impaired Phagocytosis,
Poor Inflammatory Response , Increased Sepsis and Wound Infection, Delayed Wound Healing.

Parenteral nutrition: Parenteral nutrition is the treatment of choice in non functioning GIT.
1. Peripheral parenteral → For short term, less than 10 days.

2. Central parenteral→ For more than 10 days.

Indications for parenteral nutrition:

1. Short bowel syndrome due to:
a. Massive intestinal resection
b. Mesenteric infarction
c. Crohn‘s disease.
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2. Inflammatory bowel disease

3. Paralytic ileus (prolonged paralytic ileus)
4. Proximal intestinal fistula, e.g. Entero-enteric, entero-colic, entero-visceral, etc.
5. Inoperable obstruction:
a. Ca-oesophagus
b. Ca-stomach
c. Intestinal tumour, etc.
6. Others:
a. Neurological disorder
b. Multiple, severe injuries
c. Extensive burn
d. ICU.
7. Infant with congenital anomaly:
a. T-E fistula
b. Gastroschisis (congenital defect characterized by a defect in the anterior abdominal wall through which the abdominal contents freely protrude)
c. Omphalocele.

Conclusion:
Severe malnutrition may often life threatening, so preoperative assessment and nutritional support is mandatory.