• Gastrostomy
  
• Perforation
• Bit of colon trapped between stomach and abdominal wall (blind procedure)
• Peritonitis
• Pain
• Remember they may be unable to express
• Parenteral
• Infection from line
• Thrombosis
• Electrolyte/LFT derangement
  

Parenteral nutrition

• Placement
• Lower third of SVC
• Careful you don't go into the RA
• Feeds
• Off-the-shelf
• Often don't contain any micronutrients
• Can be modified in lab
• Customised
  
• Indications
• Obstruction
• Perforation
• Short bowel
• Anatomical
• Functional
• High output small bowel fistula
• Prolonged ileus (in extreme cases)
• NOT for PN
• Post-GI surgery
• Passage of food normally helps anasatmoses
• Acute pancreatitis
• Absent bowel sounds
• These come mostly from the colon - so small bowel may still be working

Nutritional requirements

• Energy 25-35 kcal/kg
• Protein 0.8-1.5 g
• Fluids 30-35 ml/kg
• Electrolytes
• Micronutrients

Refeeding syndrome

• Key change is hypophosphataemia
• NB affects oxygen dissociation curve
• Also:
• Changes in Na/K as ATPase starts working again
• Co-factors taken up by cells (thimine, Mg)
• Salt and water retention
• Can cause oedema
• Beware giving fluids if urine o/p falls!
• Avoidance:
• Start at 50% of requirements
• Increase slowly
• Give:
• Thiamine 200 mg OD
• Vitamin B co-strong TT QDS

Medico-legal

• Withdrawing nutrition support is equivalent to withholding
• Artificial support is deemed medical treatment, not basic care
  

Notes

• Nursing homes will typically take PEGs but not NGs
• => Questionable indication