Summary Inappropriate emphasis has been given to conflictingcamps in the debate over enteral nutrition versus parenteral nutrition.It is not a question of one or the other,but a question of finding the right balance between parenteral and enteral nutrition using both EN and PN to achieve the daily caloric needs of the patient.Not uncommonly,paitents receive inadequate nutrition support during the ramp-up of enteral feedings over several days under the perception that parenteral nutrition carries a high risk of complications,and therefore should be avoided.Properly administered parenteral nutrition is both safe and effective,especially when used with a “background patter”of enteral nutrition.Just a small amount of enteral nutrition significantly reduces the potential complications from parenteral nutrition associated with lack of gut barrier function and inadequate stimulation of the enteral-hepatic circulation.A small amount of background enteral nutrition paves the way for safe administration of apropriate parenteral nutrition to meet the caloric needs and achieve the necessary macro-and micro-nutrient balance to accelerate the recovery of medical and surgical patients otherwise suffering from nutritional compromise.Ⅰ.PN vs.EN Not either-or,but…BOTHⅡ.Risk Factors for EN*Mechanical*Septic*Obtunded patient*Gastroparesis*Frequently occurs for 1-3 days post op*More common and severe with diabetes*Uneven GI function*Stomach-jejunum-ileum-colon*Improperly placed feeding tube*Naso-gastric*Naso-jejunal*Importance of decompressing the stomach*Acquired lactase deficiency*Diarrhea*Constipation*Mechanical-related to insertion and maintenance of IV line*Septic-related to sterile technique,potential for bacterial contamination*Metabolic-issues of fluid balance and nutrition:electrolytes,fat,carbohydrate,protein,vitamins,trace elementsⅢ.Goals *Maintain appropriate level of nutrition support*Avoid complicationsⅣ.Keys to Success *Nutritional Assessment*Keep it simple*Base line*Ongoing*Understand the physiologic state of your patient*If the gut works.use it!*Give a combination of PN and EN*“Mix and Match”*Team approach:*One person in charge*Transition from PN to EN Ⅴ.Transition from PN to EN (see graph)Ⅵ.Pearls for PN *Protocol approach*Sterile technique*Expert line placement*Disciplined line-dressing changes*20-50% of daily calories as fat*Use only 20% lipid emulsion*Use MCT/LCT fat emulsion if available*Always give some ENAs little as 1-2cc/hr provides physiologic protection *Healthy gut with mucous production:minimizes bacterial translocation*Entero-hepatic circulation:minimizes fatty liver and cholestasis*Administer fat and blucose-amino acid solutions together*Add 1 IU/cc heparin to glucose-amino acid solution*Restrict osmolarity to <600 mosm*Ongoing fever work up*Ongoing global assessmentEN and PN *Set nutritional therapy goal*Give “background patter”of EN*Give the balance of calories-electrolytes-vitamins-trace elements as PNⅦ.Keep it Physiologic Keep it Simple