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32  Nutritional Support
        Parenteral feeding                                     fevers or is clinically deteriorating, the parenteral catheter will need to
        Parenteral feeding can be given as an adjunct to other nutrition or as   be removed and the sepsis controlled before consideration is given to
        total parenteral nutrition if the period of starvation is prolonged or if   placing a new catheter, depending on the condition of the patient.
        enteral feeding is going to be impossible. Administration can be by a   Poor nutrition in the surgical patient affects the clinical course of the
        peripheral line for those requiring immediate support but whose con-  disease and the clinical outcome of the patient.
                                              11
        ditions are expected to improve within 1–2 weeks.  Lower dextrose   Prevention of Poor Nutrition
        concentrations of no more than 12.5% dextrose should be given through
        a peripheral vein. A peripheral vein can be used only for short-term   Nutrition starts in utero. Attention must be given to appropriate educa-
        infusion  and  must  be  checked  on  a  frequent  basis  and  discontinued   tional programmes to ensure that pregnant women are well nourished
        immediately if there are any signs of thrombophlebitis. A catheter can   and eating suitably balanced diets. This can involve addressing nutri-
        also be placed through a peripheral vein and then advanced until it is   tional taboos, such as the belief that if the mother eats eggs in preg-
        in a central position. The pressure from these catheters correlates well   nancy, the delivery will be difficult.
        with centrally inserted catheters. 12                    Nutrition for children younger than five years of age must ensure
           Administration can also be through a centrally placed venous line.   adequate intake of calories, minerals, and vitamins that will maximise
        It is important to ensure that the tip of the central catheter is adequately   their  growth.  Specific  known  dietary  deficiencies  peculiar  to  some
        placed before the solutions are infused. With centrally placed catheters,   areas (e.g., iodine deficiency, which causes specific surgical problems)
        it is possible to give higher concentrations of dextrose and thus deliver   need to be addressed.
        more calories.                                           Preoperative  assessment  of  surgical  patients  must  include  their
           In all cases, nutritional support must include lipid, an energy source   nutritional  status,  and  any  deficiencies  identified  must  be  corrected
        (usually  dextrose),  and  amino  acids.  In  environments  where  not  all   wherever  possible  before  surgical  intervention  is  undertaken.  Where
        of  these  preparations  are  available,  anecdotal  experiences  suggest   this  is  not  possible,  postoperative  management  must  include  special
        some  benefit  in  the  use  of  alternative  sources,  including  aliquots  of   attention to nutritional correction.
        fresh frozen plasma in the short term for small babies or intravenous    Ethical Issues
        preparations of amino acids, which can be administered with dextrose   Traditionally and culturally, food and water are considered basic to the
        preparations in the short term.                        needs  of  each  individual  person.  The  modern  practice  of  delivering
         Parameters for Monitoring Nutritional Outcomes        nutrition and fluids via enteral and parenteral routes now challenges
        Nutritional outcomes are monitored, including a daily assessment of the   these  values,  adding  on  religious  and  moral  dimensions  as  well  as
        overall clinical status of the patient, the state of hydration, and weight   playing out issues of human rights. This is particularly the case when
        change. Ideally, it is also necessary on a daily basis to estimate electro-  children have complex congenital abnormalities with poor prognosis.
        lyte, creatinine, and urea levels; serum glucose levels; and magnesium,   Decisions on starting or stopping feeding by oral, enteral, or parenteral
        phosphorus, and calcium. Once the patient has stabilised, these param-  means  in  most  countries  in  Africa  requires  physicians  to  adhere  to
        eters can be assessed much less frequently.            strict institutional policies, which should be developed for this purpose,
                                                               as the increasing possibility of legal challenges cannot be ruled out.
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                   Postoperative Complications                 More complex discussions of specific issues is beyond the scope of this
        Complications of Enteral Feeding                       book. Additionally, resource constraints in the region would affect the
        Complications with enteral feeding are less common than with parenteral   range of options available to the surgeon and the available modes of
        nutrition. Such complications are summarised here. If the feeding con-  administration in terms of equipment availability.
        tains an excess of electrolytes, these can be absorbed into the circulation,   Evidence-Based Research
        resulting in electrolyte imbalance. The concentration of the feeding or   Tables 6.5 and 6.6 present, respectively, a guideline for nasojejunal tube
        the rate of feeding may not be tolerated, with resultant nausea, abdomi-  placement and a review of various feeding issues in preterm babies.
        nal  cramps,  vomiting,  diarrhoea,  or—less  often—constipation.  These
        are usually managed symptomatically, and often just a dilution of the   Table 6.5: Evidence-based research.
        solution given by introducing water into the mixture or slowing the rate   Title  Naso-jejunal tube placement in paediatric intensive care
        of delivery will resolve the problem over a period of time. Rarely will   Authors  McDermott A, Tomkins N, Lazonby G
        the feeding have to be discontinued. Pulmonary aspiration may occur if
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        amounts fed are not controlled.  This is particularly true if the patient has   Institution  The General Infirmary at Leeds, UK
        swallowing problems and therefore cannot protect the airway.   Reference  Paediatr Nurs 2007; 19(2):26–28
           If there is any question about satisfactory placement of the tip of the   Problem  In critically ill children, intragastric feeding is often poorly
        enteral tube, a simple plain radiograph of the abdomen will be able to   tolerated.
        confirm the placement of the catheter if it is radio-opaque. If the tube   Intervention  A guideline for bedside nasojejunal tube (NJT) placement
        is not radio-opaque, a small amount (5 ml) of contrast can be placed in   has been developed by a multidisciplinary group.
        the catheter prior to the x-ray.                         Comparison/  Audit of the practice was carried out after the
                                                                 control    implementation of the guidelines. Fifty-eight percent of
        Complications of Parenteral Feeding                      (quality of   the children would have definitely or probably started on
        Complications of parenteral feeding are numerous and include bacter-  evidence)  parenteral nutrition.
        aemia and septicaemia, air embolus, pneumothorax, hypo- or hypergly-
        caemia, thrombosis, hyperosmolality, metabolic acidosis, and hyperam-  Outcome/  Reduction in requests for NJT placement under x-ray
        monaemia. Other complications include cholestasis, migration of the   effect  screening and reduction in the use of medication for the
                                                                            placement.
        catheter, and catheter blockage. Each complication has to be managed
        on  its  own  merits.  The  metabolic  complications,  such  as  hypo-  or   Historical   Improved tolerance of enteral feeding for better nutritional
        hyperglycaemia and metabolic acidosis, can be managed by adjusting   significance/   outcomes in intensive care units.
        the parenteral nutrition solution. The most serious complication is sep-  comments
        sis, for which antibiotics are given first and then adjusted based on the
        organisms identified by blood culture. If the patient continues to have
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