Transcript Nutritional support

Nutrition in the Patient with
Anorexia and Cachexia
Jeanette N. Keith, M.D.
Associate Professor of Medicine
Departments of Nutrition Sciences and Medicine
University of Alabama at Birmingham
Protein-Energy Malnutrition
Two major types
• Marasmus
• Kwashiorkor
(AKA: Protein Calorie Malnutrition)
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Marasmus
Clinical setting
Decreased energy intake
Time course to develop
Months or years
Clinical features
Starved appearance
Weight < 80% standard for height
Triceps skinfold < 3 mm
Mid-arm muscle circumference
< 15 cm
Creatinine-height index <60%
standard
Laboratory findings
Clinical course
Reasonably preserved
responsiveness to short term
stress
Mortality
Low, unless related to underlying
disease
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Kwashiorkor
Clinical setting
Time course to develop
Clinical features
Laboratory findings
Clinical course
Mortality
Decreased protein intake during
stress state
Weeks
Well-nourished appearance
Easy hair pluckability
Edema
Serum albumin < 2.8 g/dl
TIBC < 200 μg/dl
Lymphocytes < 1500/mm3
Anergy
Infections
Poor wound healing, pressure
sores, skin breakdown
High
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Minimum Diagnostic Criteria
Kwashiorkor
• Serum albumin < 2.8 g/dl
• At least one of the
following:
Marasmus
• Triceps skinfold < 3 mm
• Mid-arm muscle
circumference < 15 cm
• Poor wound healing,
decubitus ulcers, or skin
breakdown
• Easy hair pluckability
• Edema
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Physiology of Starvation & Stress
Physiologic characteristics Hypometabolic,
non-stressed
patient (cachectic,
marasmic)
Hypermetabolic,
stressed patient
(kwashiorkor-risk)
Cytokines,
catecholamines, glucagon,
cortisol, insulin
↓
↑
Metabolic rate
↓
↓
↑
↑
↓
↑
↑
↑
Normal
Abnormal
Proteolysis,
gluconeogenesis
Urea excretion
Fat catabolism,
fatty acid utilization
Adaptation to starvation
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Metabolic Rate
Resting metabolism (% of normal)
Major burn
Sepsis
Trauma
Partial starvation
Total starvation
180
160
140
120
100
Normal range
80
60
0
10
20
30
Days
40
50
Long CL, et al. JPEN 1979;3:452-6
Protein Catabolism
Major burn
Trauma
Sepsis
Partial starvation
Total starvation
Nitrogen excretion (g/day)
30
25
20
15
10
Normal range
5
0
0
10
20
30
40
Days
Long CL. Contemp Surg 1980;16:29-42
Severity of PEM
The Course of Protein-Energy Malnutrition
Mild
Moderate
Severe
Kwashiorkor
Days
Weeks
Marasmus
Months
Years
Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006
Case Presentation
• 27-year old female with a 35 pound weight loss in
the last six months presents to your morning
clinic with her mother
• In the last two weeks, she has lost an additional
10 pounds. She reports decreased po intake, mild
epigastric discomfort and bloating
• The patient’s main concern is the loss of appetite,
and fatigue
• She is 5’7” tall and weighs 67 pounds,
(BP 90/40, P60, R18, T97.8)
Case Presentation
• The patient’s mother calls you at 6 pm stating that
her daughter is having palpitations and is on her
way to the emergency room.
• The ER staff pages you. Her ECG reveals torsade
des pointes and her potassium is 1.9.
• She is admitted to the Cardiology service and you
are consulted for feeding recommendations.
Case Presentation
• What do you recommend now?
– Immediate placement of a PICC catheter for TPN
initiation.
– Have the inpatient team place a dobhoff and
begin tube feedings
– Call GI procedures to arrange for PEG
placement and enteral feedings.
– Call Dietary for a 1600 kcal diet and begin a
calorie count
– Intravenous fluids while correcting the
potassium and awaiting other lab studies.
Case Presentation
• The patient’s potassium is now normal but her
course has been complicated by recurrent
vomiting.
• EGD reveals a decreased gastric motility and a
dilated duodenum bulb with normal motility in the
second portion of the duodenum.
• What do you recommend next?
– Advance her diet to clear liquids
– Begin TPN
– Place a post-pyloric feeding tube and begin enteral
nutrition
Case Presentation
• You place a post pyloric feeding tube for
enteral nutrition.
• What weight do you use for caloric
provision?
– Ideal Body Weight
– Actual Weight
– Adjusted Body Weight
• How many calories per kilogram per day
do you recommend?
–
–
–
–
35-40 kcal/kg/d
25-30 kcal/kg/d
15-20 kcal/kg/d
20-30 kcal/kg/d
Case Presentation
• On the morning after beginning her enteral
feeding, the patient complains of palpitations and
pain in her hands.
• On exam, her hands are swollen and she has
pedal edema. Pulmonary exam reveals rales.
• Her potassium is now 2.9, phophorus is 1.8 and
magnesium is 1.4.
• Diagnosis?
Refeeding Syndrome
Patient at risk = cachectic/marasmic patient
Underlying low
cardiac output:
Superimposed
demand for
increased CO:
Heart failure:
Cardiac
atrophy
Fluid challenge
Fluid overload
Glucose
challenge
Cardiac &
respiratory
decompensation
Low metabolic
rate
Predominantly
fatty acid
utilization
Increased
catecholamines
& metabolic
rate
Hypophosphatemia
Case Presentation
• The patient is admitted to inpatient
psychiatry for the treatment of
anorexia/bulimia nervosa.
• After 4 weeks on tube feedings, she was
successfully transitioned to oral diet.
• At discharge, her weight was 99 pounds.
Selective Refeeding Approaches
• Hypometabolic, cachectic/marasmic patient
– Aim = rebuild cautiously to avoid hypophosphatemia & repletion
heart failure
– Refeed gradually with
» a portion of fuel as fat
» ADEQUATE PHOSPHORUS
– Days 1-2 – BEE x 0.8
– Days 3-4 – BEE x 1.0
– Days 4-6 – BEE x 1.1-1.4
– Days 7+ – BEE x 2 if weight gain is desired
Selective Refeeding Approaches
• Hypermetabolic, stressed patient
– Aim = Replace catabolic losses
– Refeed aggressively but not excessively
– Can often achieve calorie & protein goals within 48 hours
• Patient with mixed marasmic/kwashiorkor
(starved but also stressed)
– Metabolism is accelerated by stress
– Therefore, generally feed as you would a patient with
kwashiorkor
– But watch carefully for refeeding syndrome
Key Points To Remember
• The metabolic response to starvation for the
hypometabolic patient is to reduce their metabolic
rate and use fat as the primary fuel source
• Visceral protein stores are preserved in early in the
clinical course of the hypometabolic, starved state
• In underweight patients, use the actual body weight
to avoid overfeeding.
• Monitor for re-feeding syndrome with oral, enteral or
parenteral nutrition.
Take Home Points
• The stressed hypermetabolic patient is more likely to
suffer the consequences of underfeeding.
• The starved, unstressed patient is at risk for the
complications of overfeeding and rapid re-feeding.
• If protein calorie malnutrition (kwashiorkor-type)
predominates, vigorous nutrition therapy is urgent.
• If marasmus predominates, feeding should be more
cautious.