thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk 
                         NUTRITION IN SURGICAL PATIENTS
         thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                                        ENTERAL NUTRITION
         Malnutrition in surgical patients is driven by the STRESS response and affects upto 60% of surgical patients on admission. 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                                                  
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   SUPPLEMENTATION of oral intake - 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     N.I.C.E. describes malnutrition as - 
                                                                                                      Where possible, feeding by enteral route should be maintained. 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        Body mass index (B.M.I) <18 Kg/m2
                                                                                                      Carbohydrate/ protein supplements should be used as ADJUNCT to oral intake
        Unintentional weight loss > 10% within last 3-6 months
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        B.M.I. <20Kg/m2 + unintentional weight loss >5% in the last 3-6 months
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Naso-Gastric feeding - 
     Stress response to surgery/critical illness is a myriad of metabolic and hormonal changes that create a CATABOLIC
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Indications - 
     state. Release of catecholamines causes Tachycardia + vasoconstriction. R.A.A.S activation causes sodium and water
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      If oral intake is deemed insufficient
     retention. Cortisol causes hyPERglycemia, proteolysis and lipolysis. GH promotes protein synthesis and along with cortisol
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Oral intake is deemed unsafe - Swallow problems, altered consciousness, etc
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     causes insulin resistance.
                                                                                                   Monitoring - 
                                                                                                                                                                     Image: NG/NJ feeding tube
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     As a result, a diabetes like state develops secondary to poor insulin release and increased insulin resistance.
                                                                                                      Confirm correct positioning prior to feeding - pH testing ( Normal 1 - 5.5) 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Chest X-Ray IF uncertain
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     At risk patients - 
                                                                                                      During feeding, 30-45 degree head up 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        Already have poor oral intake for >5days or likely to have poor oral intake for 5 days or longer
                                                                                                      Follow departmental feeding regimen  (e.g. 30ml/hr + 4hrly aspirate. If aspirate <250ml,
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        Poor absorptive capacity (Absorptive disorders, obstruction, short bowel syndrome)
                                                                                                      safe to increase volume of feed)
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        High nutrient losses (High stoma outputs/high NG aspirates)
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        Increased nutritional needs due to critical illness/ Surgery
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Naso-Jejunal feeding -
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     The most commonly used nutritional screening tool - MUST (Malnutrition Universal Screening tool - BAPEN)
                                                                                                   Indications - 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     In an acutely unwell patient, hyPOalbuminaemia is a marker of disease severity, not malnutrition. 
                                                                                                      Gastroparesis not responding to prokinetic agents
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Post-operative patients with upper G.I anastomosis
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Monitoring -  Same as NG feeding except, aspiration is not possible with NJ feeding
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   tubes
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                                                                               Image: Correct NG feeding tube position - visible
                                                                                                   Tube Enterostomy - 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                                                                                 guidewire (Case courtesy of Dr Ian Bickle,
                                                                                                   Indications - 
                                                                                                                                                                     Radiopaedia.org, rID: 29342)
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Patients requiring prolonged nutritional support (>4weeks)
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Access via nasal/oral route is not feasible - Increased risk of aspiration or major Upper
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      GI resection
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Can be placed using surgical, endoscopic (Percutaenous Endoscopic Gastrostomy -
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   P.E.G is most common) or radiological techniques
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                   Monitoring - 
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Can be used within 4 hours of insertion
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                                                      Regimen is the same as for NG/NJ feeding
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                     Flowchart: Methods of nutritional support (Adapted from chapter on nutrition, CcRISP textbook 2017)
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
       thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                             
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk 
                                                                                    PARENTERAL NUTRITION
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk 
      thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Indications - Patients with or at risk of malnutrition in whom;
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                1.Oral/enteral intake is unsafe or inadequate to meet nutritional requirements
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                2.Non-functional, inaccessible or perforated gastro-intestinal tract
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                Mechanical SBO, Intestinal fistulae, Short bowel syndrome (<300cm functional small bowel) or refractory I.B.D.
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Administration - All in one preparations usually given as continuous infusions (16hrs or 24hrs). See image on left. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Monitoring -  Regular dietician review
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                1.Regular blood sugar measurement (B.D) - HyPERglycemia is common with TPN
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                2.Daily U+Es - Risk of re-feeding syndrome (Below)
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                3.Once weekly Triglyceride levels - TPN is a lipid emulsion
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                4.LFTs - abnormal LFTs are seen with TPN (especially if duration >4weeks)
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                               Complications  of Parenteral feeding - 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                1. Catheter related 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Infection - Ideally catheter removal is advocated however where catheter benefit outweighs risk, dual blood and
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 line cultures should be sent + microbiology advice sought early.
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Line blockage – Can be due to clotted blood or TPN in line, kinking of the line or external compression due to
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 venous thrombosis. Flush with sterile 0.9% saline. Occasionally, thrombolytic agents (Alteplase) are needed.
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Central venous thrombosis – Doppler ultrasonography and managed with anticoagulants.
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                2.Metabolic
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Fluid-Overload - Maintenance fluids are not usually required once a patient is fully established on TPN
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 HyPERglycemia - Common occurrence with stress response and with TPN. Can use Variable rate insulin infusion. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 HyPERtriglyceridemia - Lipid emulsion in TPN poses a risk of pancreatitis. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                3.RE-FEEDING syndrome  - Characterised by marked hyPOphosphatemia following rapid re-introduction of
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 carbohydrate (Enterally or parenterally) in a malnourished patient. Can be FATAL. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Pathophysiology - During malnutrition, fat and protein metabolism provides energy supply. Intra-cellular mineral
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 stores become severely depleted over time. Introduction of carbohydrates results in release of Insulin and
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 stimulation of glycogen, fat and protein synthesis. These require a supply of minerals (Phosphorus, calcium,
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 magnesium and potassium) which become progressively depleted. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Diagnosis - No diagnostic test. High index of suspicion
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 Management - Correction of mineral and vitamin deficit. Initiation of feeding should always be under dietetic
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
                                                                 guidance. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        1.Central TPN - Due to HIGH osmolality, MUST be administered into a central vein to avoid thrombophlebitis. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
       2.Peripheral TPN - Low osmolality TEMPORARY alternative to central TPN. Can be delivered via blue cannula BUT
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
        NOT other cannulas. 
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
     thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk
    thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.uk thinklikeasurgeon.co.ukthinklikeasurgeon.co.uk thinklikeasurgeon.co.uk