1. Prof . M.C. Bansal. MBBS; MS. MICOG. FICOG. Founder principal & Controller ; Jhalawar Medical College And Hospital , Jhalawar. Ex Principal & Controller ; Mahatma Gandhi Medical College And Hospital ; Sitapur., Jaipur.

2. We now need more attention to patients diet and dietary habits; but more often we send him away with quick Verbal advice and hastily written prescription . 3. Principles of Nutrition Avoiding malnutrition is the main goal of nutrition therapy; as mal nutrition is associated with increased morbidity and mortality of any disease or operative procedure done / to be done in near future. Malnutrition increases chances of sepsis, poor recovery , wound healing , increased respiratory complications and decrease tolerance to many drugs(chemotherapy) and radiotherapy. Whenever possible GIT ( enteral ) route of nutrition should be used ideally. If it is not possible than only parenteral route is to be used. 4. Principles of Nutrition--- Over feeding should be avoided as it causes hyper glycaemia, Hepatic steatosis , raised BUN and excessive CO2 Production. Timing and type is also equally important. Properly planned nutritional therapy reduces protein wasting. Immunomodulators like glutamin , arginin and mega3 fatty acids are also need supplementation. Glutamin is a non essential amino acid synthesized in skeletal muscles. It is necessary for cell proliferation during tissue repair . Glutamin helps in GI mucosal proliferation , maintains mucosal integrity . Improves immune function and prevent translocation of bacteria. 5. Caloric Requirement Normal adult = 40 Kcal / KG / Day . Adult with catabolism = 60Kcal / KG / Day. It is given as --- > Carbohydrates50%. > Fat -30 40 % . > Protein 10 15 % . Caloric Value --- Carbohydrate4 Kcal / gm. Fat --- 9 Kcal / gm. Protein --- 3 Kcal / gm. 6. Water requirement 1-1.5 ml / Kcal of energy required., in normal physiological conditions ; to be increased in cicustences like excessive sweating , fever , vomiting , diuresis. Diarrhoea and diseases with water and electrolyte loss. Calculation of normal water loss =50-100ml in feces + 500-1000ml in exhalation + 1000 ml by kidney depending on solute load +Temperature ( add 100 ml for each centigrade rise in temperature). 7. Indications for Nutritional Support Preoperative nutritional depletion to be corrected. Post operative complicationssepsis, ileus , fistula. Anorexia nervosa and intractable vomiting . Malignant disease. Patient with Renal / hepatic failure. Post delivery . Special attention to diabetics , hypertensive PIH ,Obese patients in OB Gy Floors. 8. Assessment Body weight . Mid arm circumference. Triceps skin Thickness. Serum Albumin level . Lymphocyte count . Nutritional Requirements: Carbohydrates, fats, proteins, vitamins, minerals , anti oxidants and trace elements . Water and plenty of fibers in diet . 9. Methods of Feeding Enteral a. Gastro intestinal tract is the best route of feeding. b. Enteral feeding can be given by bolus(oral semisolid/solid / liquid food may need ingestion ,Chewing and deglutination ), By gravity or using mechanical pump to push it down in GI. c. By mouth : requires common sense , cleanliness and compassion . d. By Nasogastric Tube : Nasogastric tube (ryles tube ) is put in and its right introduction is confirmed by pushing 5ml of air and auscultation of bubbling sound in stomach area. Feeding rate is 30- 50 ml / hour . %hours gap at night is given to let gastric Ph return to normal . Problems with Tube feeding are Blockage , nausea and vomiting Aspiration, Hyperosmolality , Diarrhoea , tube discomfort , Cholestasis , Pull out by patient . e. By Enterostomy Gastrostomy, Jejunestomy., soluble fiber containing diet with sufficiently required nutrients and calori a re better to prevent diarrhoea. 10. Methods of feeding --Enteral Complication of tube Feeding > Aspiration, wound infection and leakin cases of gastrostomy and jejunostomy. > Diarrhoea due to rapid feeding and Hypo - osmolality. > Hyperglycaemia , hypokalaemia. > Refeeding syndrome due to hypokalaemia and hypophophataemia. 11. Advantages of Enteral Feeding Enteral feeding preserves mucosal proteins , digestive enzymes , IgA secretion ; prevents mucosal atrophy and bacterial translocation. It is more physiological as nutrients absorbed in jejunum and ileum pass through liver first before processing / storage. Gallstone formation is prevented as gall bladder maintains its contractility. It is cost effective with minimal problems and complications even after long term feeding. It supplies glutamine and short chain fatty acids to gut . 12. Contra Indication of Entreat feeding Intestinal obstruction , GI bleed, paralytic ileums , severe diarrhea and high out put fistula. Low cardiac out put / aerodynamically unstable patient. If safe assess to entreat feeding is not available . Complications are anticipitated. 13. Total Pareteral Nutrition ( TPN) All nutrition requirements are given through intravenous route. About 5% hospitalized patient need TPN. Central venous catheter ---Put in Subclavian , internal jugular where tip of venous catheter reaches at distal part of superior vena cava. It can be peripheralPerenteral nutrition ---Through a peripherally inserted venous catheter / canula/ butter fly or vene section 14. Technique Of TNP Using a needle or guide wire a subclavian vein catheter is passed just below clavicle and fixed to skin with micropore adhesive tap . TPN is better given through central vein and not through peripheral vein( butterfly , small canola/ needle of 22/ 24 gaze ) . Peripherally inserted central vein catheter(as in Femoral Veininferior vena cava) can also be used . 15. Indication Of TPN Failure or any contra indication for enteral nutrition for 7- 10 days. High out put abdominal fistula, duodenal , biliary / pancreatic fistula. Major abdominal surgery . Septicaemia. Multiple trauma. peritonitis , paralytic Ileus. Massive GI bleed / unstable haemodynamics. High risk of aspiration . Hyper emesis Gravidorum . MODS , head injury , coma. Severe burns. 16. Goal Factors For TPN To decrease adverse effects of catabolism. To increase protein synthesis, to reduce protein break down and to prevent weight loss. To support on going metabolism . To improve immune function. To improve cardiac and respiratory function. To maintain glycogen reserve in cardiac and skeletal muscles. To maintain acid base and electrolyte metabolism . 17. Assessment in TPN Age, morbid state, muscle mass and weight should be noted. Underlying disease, its severity, therapies given / continued till date , GI function is to be assessed. Biochemical tests > serum albumin level , Serum electrolytes, p02.pco2. ph , Blood sugar , Blood urea, serum retaining , SGOT and SGPT other enzyme study as per individual case. > CBP, Platelet count , BT, CT and clot retraction time and coagulation / fibrinolysis as per need of case. > urine analysis Ph , Na+ , urea , Protein ,casts and hourly output. (a) Assessment of fluid requirement 1500 ml for 20 kg body weight + 20 ml / kg for additional weight. (b) Energy requirement assessment Resting Energy expenditure ( REE) .1. by simple calculation : REE in Kcal /day = 25 X Wt in KG. 2. Herris Benedict equation : REE in woman =655+ (9.6 X weight ) + (1.8 X ht)- ( 4.7X Age ) Physical activity / disease / body temperature are also added. 3. Indirect Calorimettry : it is more accurate method. , done by using special instrument . REE =(3.9 X Vo2 ) + (1.1 X Vco2 ) 61. Note VCo2 means--- Vo2 Means ------ 18. Component Used in TPN Carbohydrates Fat Amino acids --- Vitamins--- Trace Elements --- Electrolytes --- Minerals --- Fluids as vehicle and to meet its daily requirement as calculated . 19. Components in TPN----Carbohydrates Dextrose is less costly and provide 3.4 Kcal / gm , can be used in 50-70% concentration through central venous catheter/ per oral . It supplies 50- 60 % of require calories, stimulate insulin release and aerobic oxidation of glucose, prevents neo glucogenesis, there by prevents muscle protein breakdown and thus has nitrogen sparing ability and prevention of metabolic acidosis. Problems : 1. low caloric value as compared to fats. 2.Require large fluid volume to infuse . 3. Hyperglycemia if develops causes more CO2 production 4. High osmolality in High concentration( > 10% solution ) causes thrombophlebitis. 5.Rate of dextrose infusion is 5mg / kg / min. 20. Components In TPN Fats Fats give high calorie (1gm = 9 Kcal.) Essential fatty acids given as emulsion containing Triglycerides---Emulsion is prepared from Sunflower/soybean oil with egg phospholipids (emulsifying factor) and Glycerin (isotonic ). Fat has low osmolality (260m mol /L); It is available as 10%, 20% ,30% emulsion . Advantage of fat in TPN : high calorie input , prevents hyperglycemia, Lees CO2 and insulin production , prevents essential Fatty acids deficiency ; if given 3times a week and reduces thrombophlebitis i.e. prevention of problems which may develop with high concentration dextrose therapy. Problems with Fats IN TPN : Hypertrigyceraemia, sepsis , fat embolism , fat over load , hepatic dysfunction, delayed gastric emptying and Pancreatitis, Lipid emulsion is good culture media for bacteria and fungi -- > chances of development of sepsis. Triglyceride levels should be monitored weekly ; if > than 400mg% , infusion should be discontinued . Mixture of long and medium chain fatty acids is better tolerated and more efficient . Lipid emulsions are avoided in in hyperlipidaemia, obesity , anaemia and acidosis. 21. Components In TPN--- Amino acids They are source of proteins. Caloric Value 1gm=3-4 Kcal ; ^.25 gm protein contains 1 gm Nitrogen. IN TPN 20% calories are provided by proteins ; daily need is 0.8 -1.5 gm/ Kg . Less protein is given in cases of chronic live and renal disease as blood urea and serum creatinin levels are high . It is used in more ratio in cases of burns , trauma, sepsis, enteropathy. Protein supplement should not exceed 1.7 gm/ Kg/day, if so it will cause raise blood urea . Uses of amino acids in TPN ---in protein anabolism , prevents catabolism . Monitoring --- by doing BUN / ammonia level . 22. Vitamins,electrolyts minerals trace elements : Electrolytes like Na+, K=, Cl-, Mg++, Ca++, HCO3 phosphates . Fat soluble Vitamins: Vitamin A , D , E, K. Water soluble vitamins : B 1, 2,6,12,Methyl cholamin,Folic acid and C. Trace elements : iodine , zinc , Copper , chromium , iron, manganese and selenium. Anti Oxidants : Vat: C,A, Zinc, selenium etc. 23. Monitoring The Patient On TPN Body weight recording . Fluid balance ( input and out put recording ). Biochemical tests done on alternate day or twice awake : blood sugar , urea, Electrolytes(Na, K, Magma and Phosphates ),Triglycerides , serum creatinin , Total proteins and AG ratio , LFT. Weight gain > 1 KG / day signifies Fluid over load ; to be avoided. 24. Complication Of TPN A. Technical Air embolism , pneumothorax , bleeding , Venous Catheter (displacement , sepsis , block)., infection and thrombosis. B. Biochemical electrolyte imbalance , hyper / hypo osmolality , hyperglycaesmia, dehydration / fluid over loading . Altered immunological and reticulo- endothelial function., azotaemia. C . Others Dermatitis , anaemia, increased capillary permeability , Cholestatic Jaundice; severe hepatic statuses, metabolic acidosis, candidasis, staphylo cocal infection ( 10-15% cases ). 25. Contra Indications For TPN Cardiac Failure . Blood dyscrasias. Altered fat metabolism. Anabolic steroid Durabolin( 25mg) Injection is given weekly to improve nitrogen balance. 26. Home Parenteral TPN It is becoming popular . It is common in western countries. It is indicate in short bowel syndrome or any condition where enteral therapy is not feasible . Pt himself uses the TPN fluid as advise at his home; he is permitted to go home with TPN catheter. Patient should attend TPN clinic weekly for follow-up , monitoring and admission if any problem / complication is suspected. Patient will have better psychology, comfortable and can attend his job. It decreases hospital bed load . It is cost effective. 27. Re Feeding Syndrome Re feeding syndrome is occurrence of severe fluid and electrolyte imbalance in severely malnourished patient while starting the proper feeding enteral or parenteral nutrition It is more common in TPN . It causes hypomagnesaemia, hypocalcaemia and hypo phosphataemia leading to cardiac dysfunction, altered level of consciousness, convulsion and often death. Gradual feeding and correction of Mg ,Ca, phosphorus deficiency and other electrolyte imbalance. Condition is more common in chronic starvation , severe anorexia and chronic alcoholics. s