Nutrition Support
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Transcript Nutrition Support
Basic Clinical Nutrition
Pranithi Hongsprabhas MD.
Objective
Etiology of PEM
Types/ prevalence of
malnutrition
Consequences of malnutrition
How to diagnose and assess
nutritional status
Effect of nutrition therapy
Nutrition for specific diseases
References
Shils M, Olson JA, Shike M, Modern Nutrition in
Health and Diseases. 2005
ASPEN manual of nutrition 2005
ESPEN guideline for EN 2006
ASPEN guideline 2009
Malnutrition
State of nutrition in which a deficiency or
excess (or imbalance) of energy, protein,
and other nutrients caused measurable
adverse effects on tissue/body form and
function and clinical outcome
Malnutrition
Over nutrition
obesity
dietary induced dyslipidemia
Under nutrition
protein energy malnutrition
specific nutrient deficiency
Hospital Malnutrition
Incidence
Community setting (common in chronically ill; cancer,
lungs etc.)
Hospital setting: 30-60 % (10-25% are severe)
Progression
Get worse in hospital
Effect on
Health
Diseases
Prognosis
Mortality
Relationship Between Loss of Lean Mass and
Degree of Mortality
LBM
(% loss of
total)
10
Complications (related to
LBM loss
Associated
mortality
Impaired immunity,
increased infection
10
20
Decreased healing,
weakness, infection
30
30
To weak to sit, pressure
sore, pneumonia, no
healing
Death usually from
50
40
100
Diseases and Conditions Predisposing to
Malnutrition
Hypermetabolic
State
Excessive activity
Difficult eating
Medication
Cytokines
Nutrient
intake
Nutrient utilization
Anorexia
Physiologic Demand
Depression
Nutrient Loss
dementia
Socioeconomic
Malabsorption
Diseases and Conditions Predisposing
to Malnutrition
Decreased intake
Decreased absorption
Increased losses
Altered metabolism
Increased requirement
Hensrud DD. Nutrition screening and assessment. Med Clin North Am 1999;83:1525-47
Substrate Utilization in Starvation
Glucose utilized (g/hora)
I
II
IV
III
V
Exogenous
Glycogen
Gluconeogenesis
40
30
20
10
LEGEND
I
II
III
Fuel for
brain
Glucose
Glucose
Glucose
IV
Glucose,
ketones
V
Fatty acid
Glucose
Ruderman NB. Annu Rev Med 1975;26:248
Simple Starvation: Marasmic Wasting
Response to total/partial cessation
of energy intake
Short
term starvation (<72 hr)
Prolonged starvation (>72 hr)
RMR, DIT, activity
gluconeogenesis from aa, lactate
tissue utilization of ketone, FFA
Nitrogen excretion in Starvation
Nitrogen Excretion (g/day)
12
Normal Range
8
Partial Starvation
4
Total Starvation
0
10
20
Days
Long CL et al. JPEN 1979;3:452-456
30
40
Marasmus: Simple starvation
Decreased metabolic
rate
Weight loss mainly from
fat and also LBM
Normal albumin level
Bone and skin appearance
Metabolic Response to Stress: Trauma/Sepsis
Flow Phase
Energy Expenditure
Ebb Phase
Time
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Metabolic Response to Stress: Protein
Catabolism
Nitrogen Excretion (g/day)
28
24
20
16
12
8
4
0
10
20
30
Days
Long CL, et al. JPEN 1979;3:452-456
40
Metabolic Response to Stress
Fatty Deposits
Endocrine
Response
Fatty Acids
Liver & Muscle
(glycogen)
Muscle (amino
acids)
Glucose
Amino Acids
Stress Starvation
Response to starvation and inflammation
Days to weeks or months
Depend on hormonal and cytokine control
Cytokine response
Catabolic (IL-1, IL-6, TNF-)
increased RMR
decreased LBM
increased protein breakdown
Vascular permeability
Hormonal response
Aldosterone/ADH
salt/ water retention
Epinephrine, glucagon,
cortisol
lipolysis
gluconeogenesis
severe protein
catabolism
Catabolic state cannot be reversed by nutrition alone:
Nutritional Resistance
Stress Starvation
Kwashiorkor or
hypoalbuminemic
malnutrition
Low albumin level/
edema
Loss of body protein:
functional change
Chronic Stress Starvation
Mild -moderate stress
+ starvation
Develops in months
Complication of Malnutrition
Reduced renal function:
GFR and concentrating
ability
inability to handle Na load, acid
load
polyuria
Liver: fatty liver
Cardiac function
GI: intestinal barrier
Altered drug Pk
Perspect Crit Care 1989; 2:1
Malnutrition Related Complication
Impaired immunity:
CMI, chemotaxis, phagocytosis, complement
Slow wound healing
Muscle atrophy
Compromised respiratory function: hypoxic
ventilatory drive, impaired resp muscle, VC, MV
LOS, treatment cost
Mortality
Risk of Malnutrition
Hospital cost
Cumulative
mortality
26,359
Hospital Stay
50
(US D)
Cost per Patient
Mortality
%status
Nutritional
30,000
Ri sk of Mal nut r i t i on
18,896
PEM
40
25,000
Severe
No Ri sk of
non-PEM
20,000
30
Mal nut r i t i on
15,000
20
7,902
10,000
11,174
6,858
Mild
4,979
10
5,000
0 0
0
0
Normal
1
2
Pneumonia
3
4
5
Intestinal surgery
6
7
8
Complication
5
10
15
Months
After Hospitalization
9
20
Reilly
J et al. JPEN 1988
American Journal of Medicine (Cederholm T, Jägrén C, Hellström K. Outcome
of Protein-Energy
Malnutrition in
Robinson et al. JPEN 1987
Elderly Medical Patients, 1995;98:67-74)
Characteristic Differentiating of Marasmus and
Marasmic kwashiorkor
Marasmus
Marasmic kwashiorkor
Develops over mo-yr
Develops over weeks
Low intake
Usually from low intake and
Usually emaciated
Edema not prominent
Usually normal albumin
Lower mortality than
kwashiorkor
stress
Appear well nourished
Edema is characteristic
May be no wt loss
Usually low serum protein
Higher mortality
How to Detect Patients at Risk?
Nutritional screening
Identify
the characteristics associated with nutritional
problems
Identify patients at nutritional risk
Nutritional assessment
Collect
and evaluate clinical conditions, diet, body
composition and biochemical data, among others
Classify patients by nutritional state: well-nourished
or malnourished
Nutritional Screening
Involuntary increase or decrease in weight >
10% of usual weight over 6 months or > 5%
of usual weight over 1 months
Inadequate oral intake
Barrocas et al. J Am Diet Assoc 1995: 95: 648
Nutrition Screening Tool
Nutritional Risk Screening
A) Body mass index
0 = greater than 20
1 = 18-20
2 = < 18
score
B) Has the patient unintentional loss BW over the past 3
months
0 = no
1 = a little up to 3 kg
2 = a lot
more than 3 kg
score
C) Food intake- has this decrease over the last month prior to
admission
0 = no
2 = yes
score
D)Stress factor/ severity of illness
0 = non
1 = moderate
2 = severe
score
Screening
If score 0-2 No action
If score 3-4 Monitor + review in a week/ food record chart
If score > 5 refer to dietitic advice
University hospital Nottingham: A. Micklewright, S.P. Allison and Z. Stanga
Total score
Nutritional Assessment
Clinical assessment
Subjective
Global Assessment
Body composition
Biochemical data
Functional assessment
Subjective Global Assessment
History
Wt change
Changes in dietary intake
Gastrointestinal symptoms
Functional capacity
Link between disease and nutritional requirement
PE focused on nutritional aspects
degree of fat loss
muscle wasting
edema/ ascites
clinical signs of nutritional deficiency
Detsky AS, et al. JPEN 1987; 11: 8-15.
SGA
SGA: Classification
Well nourished
Moderately malnourished or suspected
malnutrition
Severely malnourished
Class A:
no change in BW, normal intake,
< 5 % wt loss, or > 5% wt loss but recent gain and improve appetite
Class B:
5-10% wt loss without recent stabilization or gain, poor dietary
intake and mild loss of subcutaneous tissue
Class C:
ongoing wt loss of > 10% with severe subcutaneous tissue loss and
muscle wasting often with edema
General: Muscle Wasting
Hair
Flaky paint dermatosis: protein deficiency
Essential fatty acid deficiency syndromes
(EFADs)
Zinc deficiency
Pellagra
•dermatitis
•dementia
•diarrhea
•death
niacin
deficiency
Perifollicular Petechia: Vitamin C deficiency
Vitamin K deficiency
Nutritional Assessment
Body Composition Parameter
Weight and height
BMI = weight/ height2
Triceps or subscapular
thickness of skin fold
Mid-arm muscle
circumference and midarm muscle area
Anthropometric Measurement Limitation
Fluid: overhydration, dehydration
Technique: reproducibility
Do not reflect variation in bone size, skin
compressibility
Creatinine Height Index
Correlates with lean body mass
CHI
= actual 24-hr Cr excretion
expected Cr excretion
estimated 18-20 kg muscle produce 1 g Cr
expected Cr excretion
female
male
interpretation
> 80 %
60-80%
< 60%
18 mg/kg
23 mg/kg
0-mild depletion
moderate depletion
severe depletion
Creatinine Height Index/ Excretion
Factors affecting CHI reliability
renal insufficiency
rhabdomyolysis
bed rest
catabolic state
incomplete collection
Laboratory Assessment: Visceral Protein
Reserve
Hepatic secretory protein
Protein
MW
T 1/2
Normal range
Albumin
65,000
18-20 d
3.5-5.5 g/dl
TFN
76,000
7-10 d
1.6-3.6 g/l
12-24 hr
160-350 mg/l
2-4 hr
0.10-0.40 mg/l
Prealbumin 54,980
RBP
21,000
Nutritional Assessment: Biochemical
Parameters
Serum albumin
Total lymphocyte count
Serum transferrin
Serum prealbumin
TIBC
Serum cholesterol
At risk level
< 3.5 g/dl
< 1500 cell/mm3
< 140 mg/dl
<17 mg/dl
<250 mg/dl
<150 mg/dl
Heymsfield SB, et al. In: Modern Nutrition in Health and Disease. Phiadelphia, PA: Lea& Febiger; 1994: 812-41.
Nutrition Support
Nutritional Support:Indication
NPO > 10-14 day
PEM or at nutritional risk
Inadequate
oral intake
Maldigestion, malabsorption
Nutrient loss fistula, dialysis, drainage
Hypercatabolic state: sepsis, burn, multiple
trauma
Perioperative severely malnorished
Nutrition Aim/ Goal
Improve nutritional
depletion
malnourished/ low
catabolism
Minimized nutritional
related complication
Maintain nutritional
status/ prevent
malnutrition
malabsorption
unable to eat
critically illness
moderate hypercatabolic
state
Improve clinical outcome
perioperative nutrition
nutrition in BMT
trauma
Estimated Energy Requirement
1. Requirement = BEE x AF x SF
Harris Benedict Equation
BEE m = 66+13.7 wt+5 ht-6.3 age
f = 655+9.6wt+17ht-4.7age
Activity factor = 1.2 (low), 1.3 ( moderate ) , 1.5 ( high )
Stress factor = mild 1-1.1, moderate 1.2-1.4, severe 1.5-2
2. Kcal/kg
25-30 kcal/kg/d
Protein Requirement
Population
Rates(g/kg/d)
normal/unstress
.8
postoperative*
1.1-1.5
septic
1.2-1.5
multiple trauma
1.8
burned
1.5-4.0
Nitrogen Balance
N balance = N output - N intake
N output = UUN+UNUN+ misc
= UUN +(2-4) (g)
N intake = Protein intake(g)
6.25
Fat Requirement
Essential fatty acid
linoleic:
4% of total calorie
linolenic: 0.2-0.4% of total calorie
Source of energy : 9kcal/1g
20-35%
Mineral Requirement
Mineral
Requirement
Na /Cl
2-3
K
2-3
Mg
0.125-0.2
(meq/kg/d)
Ca
60
(meq/d)
PO4
60
(meq/d)
(meq/kg/d)
(meq/kg/d)
Vitamin Requirement/ Trace Element Requirement
According to RDA
Key Vitamins and Minerals
Vitamin A
Wound healing and tissue repair
Vitamin C
Collagen synthesis, wound healing
B Vitamins
Metabolism, carbohydrate utilization
Pyridoxine
Essential for protein synthesis
Zinc
Wound healing, immune function, protein synthesis
Vitamin E
Antioxidant
Folic Acid,
Iron, B12
Required for synthesis and replacement of red blood
cells
How is Nutritional Support Prescribed?
Average nutritional prescription should
include
25-35
kcal/kg/day total energy,
0.8-1.5 g protein (0.13-0.24 g nitrogen)/kg/day,
30-35 ml fluid/kg,
electrolytes, minerals, micronutrients, and fiber
Contraindication of Nutrition Support
Unstable hemodynamics
Severe fluid, electrolyte, acid- base disorder
(esp. PN)
Uncontrolled infection
Enteral Nutrition: Contraindication
Unstable condition: hemodynamics
Intestinal obstruction
Massive GI bleeding
Intestinal ischemia
Severe malabsorption, inflammation, severe
ileus
Contraindication of Nutrition Support
Unstable hemodynamics
Severe fluid imbalance: overload or dehydration
Severe electrolyte, acid- base disorder
Uncontrolled sepsis
EN
PN
Gut obstruction
End stage malignancy:
EOL determined
Massive GI bleeding
Intestinal ischemia
Severe malabsorption,
inflammation
Nutritional Support For A Patient At Risk Of
Malnourishment
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Nutrition Support
Oral diet
Soft
Regular
For specific disease
Diabetic diet
High protein diet
Renal diet
Low sodium diet
Low fat diet
Oral supplement
Artificial Nutrition Support
Enteral tube feeding
Naso/Orogastric
gastrostomy
Enteric:
nasojejunostomy,
jejunostomy
Parenteral nutrition
PPN
TPN
Common Complications: ETF
Mechanical
Irritation or infection
Tube displacement
Aspiration
Tube clogging
Gastrointestinal
Nausea
Vomiting
Abdominal distention
Diarrhea
Constipation
Metabolic
Dehydration
Hyperglycemia
Elevated serum electrolytes
Low serum electrolytes
Mizock BA. J Crit Illness 1993;8:1116-1127, American Gastroenterological Association. Gastroenterol 1995;108:1280-1301, ottlieb K, Iber F. J Crit Illness 1991;6:817-824
Monitoring of EN
Assessment of GI
tolerance
Abdominal
discomfort
(fullness, cramping, pain)
Nausea and vomiting
Abdominal distention
Bowel sound
Stool pattern
Diarrhea
constipation
Monitoring of EN
Aspiration precaution
Tube feeding residual:
Gastric residual volume
(GRV)
Head lift ≥ 30o
Aspiration detection
Clinical signs and
symptoms
CXR
Hydration status
Assessment of hydration
status
Physical exam
I/O
Determine fluid
requirement
30-35 ml/kg/d
Extra fluid
Assessment of nutrition
intake
Caloric count
Parenteral Nutrition (PN)
PPN, TPN
Indication
GI tract failure
Inadequate EN
Contraindication
Unstable condition
Uncontrolled serious condition
Terminal stage conditions (EOL determined)
Complication of PN
Line sepsis: CRI
Metabolic derangement/ re-feeding
syndrome
Fluid/ electrolyte/ acid-base imbalance
Overfeeding syndrome
Liver complication
Infectious Complication
‘Catheter related infection’ (CRI)
Tunnel site infection
Hub contamination
Infusate contamination
Seeding of other site of infection
Guideline for prevention of intravascular device-related infection.Infectious control and hospital epidemiology 1996;17(7):438-473
Refeeding Syndrome (Nutrition Recovery Syndrome)
Metabolic complication occurs when nutritional
support given to severely malnourished
Electrolyte abnormalities
Hypo K+, Mg2+, PO43- from intracellular shift
Weakness
Respiratory failure
arrhythmia
Na/fluid retention from Insulin/Glucagon ratio
(antinatriuresis)
Refeeding edema, Fluid overload
Metabolic
thiamin demand
Substrate shift: from FA to glu VCO2/O2 and
work of breathing
Risk For Refeeding Syndrome
≥1
BMI
<16
Unintentional weight loss >15% in 3-6 months
≥ 10 days with little or no nutritional intake
Low Mg2+, K+, or PO43- before feeding
≥2
BMI
<18.5
Unintentional weight loss >15% in 3-6 months
≥ 5 days with little or no nutritional intake
Alcohol misuse, chronic diuretic, antacid, insulin use, or
chemotherapy
How To Prevent and Management of
Refeeding Syndrome
In high risk patients
Start 10 kcal/kg/d, gradually within a week
Before/during of 1st 10 d of feeding
oral thiamin 200-300 mg/day
+1-2 vitamin B co strong tablets 3 times/d or IV vitamin B
+balanced multivitamin and mineral supplement each day
monitor and supplement oral, enteral, or intravenous K,
PO43- and Mg intake.
K+
PO43Mg2+
2-4 mmol/kg/day
0.3-0.6 mmol/kg/d
0.2 mmol/kg/d IV or 0.4 mmol/kg/d oral
Metabolic Complication to Overfeeding
Hyperglycemia
Hypertriglyceridemia
Hypercapnia
Fatty liver
Hypophosphatemia,
hypomagnesemia, hypokalemia
Barton RG. Nutr Clin Pract 1994;9:127-139
Hepatobiliary Complication
Adults
Steatosis
Steatohepatitis
Cholestasis
Biliary sludge
Cholelithiasis
Acalculous cholecystitis
Fibrosis
Micronodular cirrhosis
Nutrition Monitoring
For nutrition response
Monitoring of complication
Monitoring
• Vital signs, body weight
• Fluid intake and output
• Electrolytes, glucose, BUN/Cr, Ca, P, Mg
• 24-hour total urinary urea nitrogen
• Estimated nutrient intake (all administration
routes)
• Liver enzymes