Nutrition Support

Dr. Ahmed Mayet Associate Professor King Saud University

Nutrition

 Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

Malnutrition

 Malnutrition—extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body.

Types of malnutrition

  Kwashiorkor: (kwa-shior-kor) is protein malnutrition Marasmus: (ma-ras-mus) is protein calorie malnutrition

Kwashiorkor

  Protein malnutrition - caused by inadequate response protein intake in the presence of fair to good calories intake in combination with the stress Common causes - chronic diarrhea, chronic kidney disease, infection, trauma , burns, hemorrhage, liver cirrhosis and critical illness

Clinical Manifestations

       Marked hypoalbuminemia Anemia Edema Ascites Muscle atrophy Delayed wound healing Impaired immune function

Marasmus

  The patient with severe

calorie

malnutrition characterized by calories deficiency Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation

Clinical Manifestations

     Weight loss lethargy Depletion skeletal muscle and adipose (fat) stores Bradycardia Hypothermia

Risk factors for malnutrition

  Medical causes Psychological and social causes

Medical causes

(

Risk factors for malnutrition)

          Recent surgery or trauma Sepsis Chronic illness Gastrointestinal disorders Anorexia, other eating disorders Dysphagia Recurrent nausea, vomiting, or diarrhea Pancreatitis Inflammatory bowel disease Gastrointestinal fistulas

Psychosocial causes

     Alcoholism, drug addiction Poverty, isolation Disability Anorexia nervosa Fashion or limited diet

Consequences of Malnutrition

     Malnutrition places patients at a greatly increased risk for morbidity and mortality Longer recovery period from illnesses Impaired host defenses Impaired wound healing Impaired GI tract function

Cont:

       Muscle atrophy Impaired cardiac function Impaired respiratory function Reduced renal function Mental dysfunction Delayed bone callus formation Atrophic skin

International, multicentre study to implement nutritional risk screening and evaluate clinical outcome “Not at risk” = good nutrition status “At risk” = poor nutrition status Results: Of the 5051 study patients, 32.6% were defined as ‘at risk’. At-risk’ patients had more complications, higher mortality

and longer lengths of stay than ‘not at-risk’ patients.

Sorensen J et al ClinicalNutrition(2008)27,340 349

International,multicentre study to implement nutritional risk screening and evaluate clinical outcome

ClinicalNutrition(2008)27,340e349

Nutritional Assessment



Nutritional assessment (NA) is the first step in the treatment of malnutrition

Cont:

    The initial assessment of nutritional status requires a careful History Physical examination Laboratory and other tests

Laboratory and other tests

    Weight BMI Fat storage Somatic and visceral protein

Standard monogram for Height and Weight in adult-male Height 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" Small Frame 102-111 103-113 104-115 106-118 108-121 111-124 114-127 117-130 120-133 123-136 126-139 129-142 132-145 135-148 138-151 Medium Frame 109-121 111-123 113-126 115-129 118-132 121-135 124-138 127-141 130-144 133-147 136-150 139-153 142-156 145-159 148-162 Large Frame 118-131 120-134 122-137 125-140 128-143 131-147 134-151 137-155 140-159 143-163 146-167 149-170 152-173 155-176 158-179

Height Small Frame 5'9" 129-142 Medium Frame Large Frame 139-153 149-170

Percent weight loss Small frame 50kg x 2.2 = 110 lbs 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% Medium frame 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20%

Severe weight lost

Time 1 week Significant Weight Loss (%) 1-2 Severe Weight Loss (%) >2 1 month 5 3 months 7.5

6 months 10 >5 >7.5

>10

Laboratory and other tests

    Weight BMI Fat storage Somatic and visceral protein

Average Body Mass Index (BMI) for Adult Classification Underweight Normal Overweight Obesity Moderate obesity Extreme obesity BMI (kg/m 2 ) <18.5

18.5-24.9

25.0-29.9

30.0-34.9

35.0-39.9

>40.0

Obesity Class I II III

Laboratory and other tests

    Weight BMI Fat storage Somatic and visceral protein

Fat

 Assessment of body fat – – – – Triceps skinfold thickness (TSF) Waist-hip circumference ratio Waist circumference Limb fat area – Compare the patient TSF to standard monogram

Laboratory and other tests

    Weight BMI Fat storage Somatic and visceral protein

Protein

(Somatic Protein) 

Assessment of the fat-free muscle mass ( Somatic Protein ) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram

Protein

(visceral protein)

Cont;

 Assessment of visceral protein depletion Serum albumin <3.5 g/dL  Serum transferrin <200 mg/dL    Serum cholesterol <160 mg/dL Serum prealbumin <15 mg/mL Creatinine Height Index (CHI) <75%

Vitamins deficiency

     Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin C Vitamin A Vitamin D Vitamin K

Trace Minerals deficiency

     Zinc Copper Chromium Manganese Selenium 

Iron

Estimating Energy/Calorie

BEE

 Basal Metabolic Rate (BMR) or Basal Energy Expenditure ( energy requirements BEE ) accounts for the largest portion of total daily

Harris–Benedict Equations

   Energy calculation Male BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) Female BEE = 655 + (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y)

Total Energy Expenditure

 TEE (kcal/day) = BEE x stress/activity factor

A correlation factor that estimates the extent of hyper-metabolism

        1.15 for bedridden patients 1.10 for patients on ventilator support 1.25 for normal patients The stress factors are: 1.3 for low stress 1.5 for moderate stress 2.0 for severe stress 1.9-2.1 for burn

Calorie sources

Calories

  60 to 80% of the caloric requirement should be provided as glucose , the remainder 20% to 40% as fat To include protein calories in the provision of energy is controversial

Fluid Requirements

Fluid

  The average adult requires approximately 35-45 ml/kg/d NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure

*NRC= National research council

Fluid

   1 st 10 kilogram 100 cc/kg 2 nd 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kg

Example: 50 kg patient 1 st 10 kg x 100cc = 1000 cc 2 nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc

Fluid

  Fluid needs are altered by the patient's functional cardiac, hepatic, pulmonary, and renal status Fluid needs increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin integrity like burns, open wounds

Protein Need

Protein

 The average adult requires about 1 to 1.2 gm/kg 0r average of 70-80 grams of protein per day

Protein

Stress or activity level Initial protein requirement (g/kg/day)     

Baseline 1.4 g/kg/day Little stress 1.6 g/kg/day Mild stress 1.8 g/kg/day Moderate stress 2.0 g/kg/day Severe stress 2.2 g/kg/day

Routes of Nutrition Support

 The nutritional needs of patients are met through either parenteral or enteral delivery route

Enteral Nutrition

Enteral

   The gastrointestinal tract is always the preferred route of support (Physiologic) “If the gut works, use it” EN is safer, more cost effective, and more physiologic that PN

Potential benefits of EN over PN

   Nutrients are metabolized and utilized more effectively via the enteral than parenteral route Gut and liver process EN before their release into systemic circulation Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue

EN

(Immunologic)

 Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis

Cost (EN)

  Cost of EN formula is less than PN Less labor intensive

Contraindications

    Gastrointestinal obstruction Severe acute pancreatitis High-output proximal fistulas Intractable nausea and vomiting or osmotic diarrhea

Enteral nutrition (EN)

       Long-term nutrition: Gastrostomy Jejunostomy Short-term nutrition: Nasogastric feeding Nasoduodenal feeding Nasojejunal feeding

Intact food Predigested food

TF = tube feeding

Total Parentral Nutrition

Purpose

 To maintain positive nitrogen balance through the intravenous administration of required nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals and trace elements

PN Goal

      Provide patients with adequate calories and protein to prevent malnutrition and associated complication PN therapy must provide: Protein in the form of amino acids Carbohydrates in the form of glucose Fat as a lipid emulsion Electrolytes, vitamin, trace elements, min-

Patient Selection

General Indications

   

Requiring NPO > 5 - 7 days

Unable to meet all daily requirements through oral or enteral feedings Severe gut dysfunction or inability to tolerate enteral feedings Can not eat, will not eat, should not eat

Special Indications (can not eat)

Calorie sources

 60 to 80% of the caloric requirement should be provided as glucose , the remainder 20% to 40% as fat

total calculated calorie = 1650 kcal 80% from glucose 1650 x 80 =1320kcal 20% from fat (IL) 1650 x 20 = 330kcal Protein 1.2gm/kg/day 1.2 x 50 = 60 gm

Glucose

Cont;

 Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult) Exp: our patient is 50 kg 5mg x 50kg x 60min x 24 hr =360 gm 360gm x 3.4 kcal/gm = 1224 kcal Maximum cal from glucose = 1224kcal

Fat emulsion

Maximum recommended allowance  2.5 grams/kg/day Exp: 2.5 x 50 kg = 125 gm 125gm x 9 kcal/gm = 1125 kcal

Intralipid contraindications:

     Hyperlipdemia Acute pancreatitis Previous history of fat embolism Severe liver disease Allergies to egg, soybean oil or safflower oil

Diabetic

  DM is not contraindication to TPN Use sliding-scale insulin to avoid hyperglycemia

Administration

Central PN (TPN)

 Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only

Peripheral PN (PPN)

 PPN is a semi-concentrated formula and it can delivered reasonable quantity of calories via peripheral vein (10% dextrose and 2.8% AA)

Monitoring

Complications of TPN

Complications Associated with PN

  

Mechanical complication Septic complication Metabolic complication

Mechanical Complication

  Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia Venous thrombosis after central venous access

Infectious Complications

 The mortality rate from catheter sepsis as high as 15% Inserting the venous catheter    Compounding the solution Care-giver hanging the bag Changing the site dressing

Metabolic Complications

  Early complication process of feeding and may be anticipated -early in the Late complication caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition

Iron

  Iron is not included in TPN solution and it can cause iron deficiency anemia Add 100mg of iron 3 x weekly to PN solution or give separately

Vitamin K

  TPN solution does not contain vitamin K and it can predispose patient to deficiency Vitamin K 10 mg should be given weekly IV or IM if patient is on long term TPN

Thank you