MARSIPAN Medical assessment Alastair Forbes Norwich Medical School University of East Anglia England Starvation • Humans well adapted • Intermittent food consumption • Continuous energy expenditure Starvation Stores of • Carbohydrate • Fat •
Download ReportTranscript MARSIPAN Medical assessment Alastair Forbes Norwich Medical School University of East Anglia England Starvation • Humans well adapted • Intermittent food consumption • Continuous energy expenditure Starvation Stores of • Carbohydrate • Fat •
MARSIPAN Medical assessment Alastair Forbes Norwich Medical School University of East Anglia England Starvation • Humans well adapted • Intermittent food consumption • Continuous energy expenditure Starvation Stores of • Carbohydrate • Fat • (and protein) Reduced expenditure Starvation Survival ? Marasmus vs Kwashiorkor Starvation Stores of • Carbohydrate and fat • Calorific value Muscle sparing Starvation • • • • Insulin lower Glucagon & catecholamines higher Glycogenolysis & lipolysis Free fatty acids & ketones Starvation <72h • Energy mainly from glycogenolysis for ~24h at rest • Thereafter from gluconeogenesis • Brain adapts to ketones • Effects on appetite Starvation >72h • • • • • • No glycogen Glucose from gluconeogenesis Never from free fatty acids Amino acids become glucose source Negative nitrogen balance 200g muscle/day Starvation >72h • Ketones support brain & muscle • Some muscle sparing effect Starvation >72h • Change in body composition • Classic Keys study 1950 • 50% diet for 24 weeks The Minnesota experiment Starvation 24 weeks • • • • • 23% loss of weight 71% loss of fat 24% cell mass loss Basal Metabolic Rate 60% of baseline Various mechanisms Malnutrition in hospitals • Common • Still 30-40% on admission • Worsens during admission Nutrition screening • • • • • Several tools What do they do ? Are they feasible in practice ? Are they valuable ? Are they relevant to eating disorders ? Albumin and nutritional status • Highly relevant to prognosis • Many different clinical contexts • Unrelated to nutritional status?? Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only Albumin and nutritional status David Blaine 2003 Starved for 44 days – water only Weight 96.0 to 71.5kg = -25.5%; BMI 28.3 to 18.9 Jackson JM ‘06 Albumin and nutritional status Albumin at 44 days …… Albumin and nutritional status Albumin at 44 days …… 52.9 ! Special aspects in Eating Disorders (ED) • Usually thought of as simple (!) starvation • Probably not actually true Special aspects in ED • Usually thought of as simple (!) starvation • Probably not actually true • Metabolic aspects from pharmacological manipulation – especially laxatives and diuretics • Inflammatory aspects from immunosuppression and element of infection Special aspects in ED • Usually thought of as simple (!) starvation • Probably not actually true • Deception in Anorexia Nervosa (AN) – Water-loading before weighing – Extra weights concealed in clothing Special aspects in ED • Usually thought of as simple (!) starvation • Probably not actually true • Deception in AN – Water-loading before weighing – Extra weights concealed in clothing • Exercise in AN – Overt – Microexercise Special aspects in ED • Bulimia also complex • Nutrition risk may be under-recognised Assessment in ED • • • • Simple anthropometry Weight and BMI – challenge/threat Nutrition screening tools – depend on former Do other tests contribute? Assessment in ED – other tests • • • • When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy Assessment in ED – other tests • • • • • When BMI >16 no special concerns Similar to other malnourished patients No special tests needed But important to agree assessment strategy For example – weekly weighing Assessment in ED – other tests • • • • When BMI <16 concerns increase Cardiovascular instability Significant immunosuppression Possibility of added self-induced metabolic upset Assessment in ED – other tests • When BMI <16 - and increasingly critically as it falls lower • Must assess cardiac and electrolyte status • Postural hypotension (Wikipedia emphasis) • Should assess muscle function but often refused • Assume high risk if refused Assessment in ED with BMI <<16 • • • • • • ECG/EKG - and preferably echo Serum electrolytes Magnesium Phosphate Liver function tests Micronutrients (but assume abnormal) Assessment in ED with BMI <<16 • ECG/EKG and preferably echo • Bradycardia • Long QTc >450ms Assessment in ED with BMI <<16 Look ! - QTC 477 Assessment in ED with BMI <<16 Long QTc >450ms Assessment in ED with BMI <<16 • • • • Other functional tests Spirometry Stand from crouch Sit Up Squat Stand (SUSS) test SUSS Scoring (Sit-up and Squat-Stand tests separately) • 0: Unable • 1: Able only using hands to help • 2: Able with noticeable difficulty • 3: Able with no difficulty MARSIPAN Medical treatment in adults Assessment in ED • • • • • Simple anthropometry Weight and BMI Nutrition screening tools Laboratory tests Psychological status “Non-assessment” in ED • Emergency admission • Unplanned transfer • Additional problems “Non-assessment” in ED • • • • • Emergency admission Unplanned transfer Additional problems Liaison with EDU and team May need to be initiated – Previously unknown – Deliberate geographical displacement Planning management in ED • • • • Decisions needed on strategy Life-saving Part of continuing care plan Mixture Planning management in ED • • • • • • • What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion … Planning management in ED • What will the treatment be ? • … • Nutrition evidently but … Planning management in ED “Food is not the issue” Planning management in ED “Food is not the issue” Multidisciplinary approach crucial Remember “peripheral players” The hospital cleaner The hospital cleaner Planning management in ED What will the treatment be ? • Food • Oral supplements • Tube feed • Parenteral feed Planning management in ED How much ? • Enough • Harris-Benedict equation (etc) • Unreliable when low BMI • Indirect calorimetry Planning management in ED How much ? • Enough • Harris-Benedict equation (etc) • Unreliable when low BMI • Indirect calorimetry • Calories as basis for other nutrients Planning management in ED Which constituents ? • Complete balanced regimen • Obvious – but …. Planning management in ED Which constituents ? • Complete balanced regimen • Obvious – but …. • Easier to achieve with artificial feed Planning management in ED Micronutrients • Critical and potentially life-saving / losing Planning management in ED Micronutrients • Critical and potentially life-saving / losing • Especially thiamine = vitamin B1 • Deficiency likely • Demands increased • Risk of permanent damage Ophthalmoplegia Thiamine deficiency Scurvy Vitamin C deficiency Acrodermatitis enteropathica Zinc deficiency Dermatol On Line Planning management in ED How quickly ? • Difficult decision • Practical and influenced by risk of refeeding syndrome • Multidisciplinary approach • Influenced by severity of starting position Planning management in ED Which route ? • If the gut works use it Planning management in ED Which route ? • If the gut works use it • If the mouth works use it Planning management in ED Which route ? • If the gut works use it • If the mouth works use it But … • Intolerance / vomiting / monitoring issues Planning management in ED • • • • • • • Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate Planning management in ED • • • • • • • • Which route ? If the gut works use it If the mouth works use it But … Intolerance / vomiting / monitoring issues Nasogastric tube feed often needed Gastrostomy very rarely appropriate Parenteral nutrition – “never” Planning management in ED • • • • • • • What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion … Planning management in ED • • • • • • • What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion … Active management in ED • • • • • • • What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient Active management in ED • • • • • • • • What will the treatment be ? How much ? Which constituents ? Micronutrients ? How quickly ? Which route ? Discussion with the patient Negotiation Active management in ED • Start Active management in ED • Start • Careful monitoring • Good initial progress Active management in ED • • • • Start Careful monitoring Good initial progress Stop – all sorts of reasons Active management in ED • • • • • Start Careful monitoring Good initial progress Stop – all sorts of reasons Renegotiate Targets in ED management • Needed to some extent • Always contentious • Weight / BMI not ideal Targets in ED management • • • • • Needed to some extent Always contentious Weight / BMI not ideal Rule of engagement ! Never punitive Discharge planning in severe ED • Starts at admission • Close and frequent liaison with psychological (EDU) team • In-patient review Discharge planning in severe ED • Starts at admission • Close and frequent liaison with psychological (EDU team • In-patient review • Often can and should be staged • Use of day-care facility • In-patient transfer not always needed Medical withdrawal in ED • • • • • • • • When will the treatment be stopped ? How much has to be done first ? Which constituents can be omitted ? Micronutrients still important ? How quickly can this happen ? Which route can be avoided ? Discussion with the patient Negotiation Patient Doctor Active management in ED This is not an easy area! Aitäh Lõunasöök ?