بسم الله الرحمن الرحيم. Nutritional assessment in hospitalized patients...
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Transcript of بسم الله الرحمن الرحيم. Nutritional assessment in hospitalized patients...
بسم الله الرحمن الرحيم
Nutritional assessment Nutritional assessment in hospitalized patients in hospitalized patients
M. Safarian, MD PhD.M. Safarian, MD PhD.
Nutrition Care Process Nutrition Care Process StepsSteps
Nutrition AssessmentNutrition Assessment
Nutrition DiagnosisNutrition Diagnosis
Nutrition Intervention Nutrition Intervention
Nutrition Monitoring and Nutrition Monitoring and EvaluationEvaluation
Nutritional care process
W t. ch an ge
W e ig h t
H e ig h t
N u trit io n a lsc re en ing
S u b je c tive g lo b a l a sse ssm e nt
S k in fo ld
T ra n s fe rrin
P re -a lb u m in
A lb u m in
B M I
N u trit io n a la sse ssm e nt
N u trit io n a lca re p la n*
Im p le m e n ta tiono f p lan
C o m p lica tio ns
N u tritio n a l s ta tus
P a tie n tm o n ito ring
N u trit ion a l ca rep ro ce ss
Nutritional assessment tools
Anthropometrics
Nutritional AssessmentNutritional Assessment
Anthropometric assessmentAnthropometric assessment
Clinical evaluationClinical evaluation
Biochemical, laboratory Biochemical, laboratory assessmentassessment
Dietary evaluationDietary evaluation
ESPEN guidelinesESPEN guidelines
Questions to be answered:Questions to be answered:
What is the condition now?What is the condition now?
Is the condition stable?Is the condition stable?
Will the condition get worse?Will the condition get worse?
Will the disease process accelerate Will the disease process accelerate nutritional deterioration?nutritional deterioration?
Anthropometric methods in Anthropometric methods in ICUICU
Weight Weight
Height estimationHeight estimation
Mid-arm circumferenceMid-arm circumference
Skin fold thicknessSkin fold thickness
Head circumferenceHead circumference
WeightWeight
Ideal Body Weight (kg)Ideal Body Weight (kg)
Men=48+ 2.3 for each inch over 152 mMen=48+ 2.3 for each inch over 152 m
Women=45.3+2.3 for each inch over Women=45.3+2.3 for each inch over 152 cm152 cm
Correction for skeletal sizeCorrection for skeletal size::
Ideal Body Weight (kg)Ideal Body Weight (kg) Add 10% if SS is largeAdd 10% if SS is large
Subtract 10% if SS is smallSubtract 10% if SS is small
Adjusted body weightAdjusted body weight
Used when actual body weight is Used when actual body weight is more than 120% of IBW:more than 120% of IBW:
ABW=IBW+ 25% of (actual body weight - IBW)
Height in ICU patientsHeight in ICU patients
Alternative measurementsAlternative measurementsEstimating Height from ulna lengthEstimating Height from ulna length
Estimations of heightEstimations of height
Body composition (BIA)Body composition (BIA)
Very popularVery popular SafeSafe NoninvasiveNoninvasive PortablePortable RapidRapid
معرف ميزان چربي زير پوستي و درنتيجه ميزان معرف ميزان چربي زير پوستي و درنتيجه ميزانچاقي خواهد بود.چاقي خواهد بود.
محلهاي اندازه گيري: تريسپس، بايسپس،زير کتف و محلهاي اندازه گيري: تريسپس، بايسپس،زير کتف وباالي تيغه ايلياک .باالي تيغه ايلياک .
:مشکالت عملي:مشکالت عملي
خطاي در اندازه گيري.خطاي در اندازه گيري.1.1.
مشکالت اندازه گيري. مشکالت اندازه گيري. 2.2.
وارياسيون توزيع چربي در افراد مختلف (فردي وارياسيون توزيع چربي در افراد مختلف (فردي 3.3.وجمعيتي).وجمعيتي).
حساسيت کم. حساسيت کم. 4.4.
Skin Fold ThicknessSkin Fold Thickness
Skin Fold ThicknessSkin Fold Thickness
Mid arm circumferenceMid arm circumference
measured with a nonstretch measured with a nonstretch measuring tapemeasuring tape
midway between the acromion and midway between the acromion and olecranon of the nondominant arm olecranon of the nondominant arm
≤ ≤ 15 cm: severe depletion of muscle 15 cm: severe depletion of muscle massmass
16–19 cm: moderate depletion 16–19 cm: moderate depletion 20–22 cm: mild depletion 20–22 cm: mild depletion
Mid arm circumferenceMid arm circumference
If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2
BMI estimation
Clinical assessmentClinical assessment
CLINICAL ASSESSMENTCLINICAL ASSESSMENT
Detectiong of physical signs, (specific & Detectiong of physical signs, (specific & non specific), that may be associated non specific), that may be associated with malnutrition. with malnutrition.
Nutritional historyNutritional history
General clinical examination, with special General clinical examination, with special attention to organs like hair, angles of the attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland.muscles, bones, & thyroid gland.
Detection of relevant signs helps in Detection of relevant signs helps in establishing the nutritional diagnosisestablishing the nutritional diagnosis
CLINICAL ASSESSMENTCLINICAL ASSESSMENT
General: muscle wasting
Flaky paint dermatosis: protein deficiency
Essential fatty acid deficiency syndromes (EFADs)
Zinc deficiency
Zinc deficiency
59
Wasting ClavicleWasting Clavicle
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The Shoulder and ElbowThe Shoulder and Elbow
The shoulderThe shoulder Normal: rounded or Normal: rounded or
slopedsloped Abnormal: square, can Abnormal: square, can
see acromion processsee acromion process The elbow well padded The elbow well padded
and not showing jointand not showing joint
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The ArmThe Arm
Bend arm and pinch at Bend arm and pinch at triceps. Only pinch the triceps. Only pinch the fat, not the muscle. fat, not the muscle.
Normal: fingers donNormal: fingers don’’t t meetmeet
Abnormal: fingers meetAbnormal: fingers meet
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The Legs showing muscle The Legs showing muscle wastingwasting
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Quadriceps and KneesQuadriceps and Knees
Biochemical, Biochemical, laboratory laboratory assessmentassessment
The possibilities of The possibilities of biochemical monitoring biochemical monitoring
On-line monitoring (cardiosurgery On-line monitoring (cardiosurgery –– pH, pH, minerals (K), the electrodes are minerals (K), the electrodes are localized on central cateter, possibility localized on central cateter, possibility to check parameters on-line. to check parameters on-line.
bed side monitoring (glycaemia, bed side monitoring (glycaemia, urine /protein, pH, blood../,oximeter O2 urine /protein, pH, blood../,oximeter O2 saturation, acidobasis, drugs /dg.strips)saturation, acidobasis, drugs /dg.strips)
Biochemical analysis Biochemical analysis
Biochemical parametersBiochemical parameters
Na,K,Cl,Ca,P,Mg, osmolality - blood, urine Na,K,Cl,Ca,P,Mg, osmolality - blood, urine
Acidobasis, lactate Acidobasis, lactate
urea, creatinin, creatinin clearence, Nitrogen urea, creatinin, creatinin clearence, Nitrogen balancebalance
bilirubine, ALT, AST, LDbilirubine, ALT, AST, LDHH, amylase, lipase , amylase, lipase
cholesterol, triglycerides, glucose cholesterol, triglycerides, glucose –– blood, blood, urine urine
Biochemical parametersBiochemical parameters
Total protein, albumine, prealbumineTotal protein, albumine, prealbumine
CRPCRP
TSHTSH
Basic analysis are made at the first,must be Basic analysis are made at the first,must be done within 90minutes done within 90minutes
Other biochemical Other biochemical parametersparameters
Trace elements /Zn,Se../Trace elements /Zn,Se../ VitaminsVitamins Drugs /methotrexate, antiepileptics, Drugs /methotrexate, antiepileptics,
antibiotics.../antibiotics.../ Aminogram /glutamin../Aminogram /glutamin../ Interleucins,TNFInterleucins,TNF…… Hormones /cortisol, glucagone, Hormones /cortisol, glucagone,
adrenaline../.adrenaline../.
Biochemical markers of Biochemical markers of nutrition statusnutrition status::
Plasmatic proteins with short biologic Plasmatic proteins with short biologic half-lifehalf-life
AlbuminAlbumin– -syntetizate in liver, half-life time is 21 days-syntetizate in liver, half-life time is 21 days– Normal: Normal: 35-45g/l.35-45g/l.– Decrease of albDecrease of alb: : malnutrition malnutrition – Trends of changes alb.levels during Trends of changes alb.levels during
realimentation are criterium of succesfull realimentation are criterium of succesfull terapy.terapy.
– Acute decreaseAcute decrease: acute phase response.: acute phase response.
Biochemical markers of nutrition status :
TransferinTransferin: : syntesyntesized sized in in liver,liver, – biologbiolog HL: HL: 8days.Fysiolog. 8days.Fysiolog.– ValueValue 2-4g/l,2-4g/l,
RBPRBP: : syntesyntesized sized in in liverliver– BiologBiolog half-life half-life : : 12h.,12h.,– Normal Normal valuevalue:: 0,03-0,006g/l. 0,03-0,006g/l.– Acute phase reactant (negative)Acute phase reactant (negative)
Biochemical markers of nutrition status :
PPrealbuminrealbumin-synte-syntesizedsized in liver, in liver, – biolog.half-lifebiolog.half-life::1,5 days.1,5 days.– Normal Normal Value 0,15-0,4g/l.Value 0,15-0,4g/l.– Decrease in failure of proteosyntesis-Decrease in failure of proteosyntesis-
indicator of acute protein malnutrition.indicator of acute protein malnutrition.
NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT
Urine urea nitrogen (UUN): to Urine urea nitrogen (UUN): to evaluate degree of hypermetabolism evaluate degree of hypermetabolism (stress level):(stress level):– 0 0 ––5 g/d= normometabolism5 g/d= normometabolism– 5 5 –– 10 g/d = mild hypermetabolism 10 g/d = mild hypermetabolism
(level 1 stress)(level 1 stress)– 10 10 –– 15 = moderate (level 2 stress) 15 = moderate (level 2 stress)– >15 = severe (level 3 stress)>15 = severe (level 3 stress)
Nutrition Monitoring and Nutrition Monitoring and EvaluationEvaluation
Monitor progress and determine if Monitor progress and determine if goals are metgoals are met
Identifies patient/client outcomes Identifies patient/client outcomes relevant to the nutrition diagnosis relevant to the nutrition diagnosis and intervention plans and goalsand intervention plans and goals
Measure and compare to clientMeasure and compare to client’’s s previous status, nutrition goals, or previous status, nutrition goals, or reference standardsreference standards
Other OutcomesOther Outcomes
Food and Nutrient Food and Nutrient Intake (FI)Intake (FI)
Energy intakeEnergy intake Food and Beverage Food and Beverage Enteral and Enteral and
parenteralparenteral Bioactive Bioactive
substancessubstances Macronutrients Macronutrients Micronutrients Micronutrients
Physical Physical Signs/Symptoms Signs/Symptoms
AnthropometricAnthropometric Biochemical and Biochemical and
medical tests medical tests Physical Physical
examination examination
MonitoringMonitoring
Enteral Nutrition Monitoring: Enteral Nutrition Monitoring: Gastric ResidualsGastric Residuals
Clinically assess the patient for abdominal Clinically assess the patient for abdominal distension, fullness, bloating, discomfortdistension, fullness, bloating, discomfort
Place the pt on his/her right side for 15-20 Place the pt on his/her right side for 15-20 minutes before checking a RV to avoid minutes before checking a RV to avoid cascade effectcascade effect
Seek transpyloric access of feeding tubeSeek transpyloric access of feeding tube Raise threshold for RV to 200-300 mLRaise threshold for RV to 200-300 mL Consider stopping RV checks in stable ptsConsider stopping RV checks in stable pts
Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.
Some Lab testsSome Lab tests
NaNa serum levelsserum levels
HypernatremiaHypernatremia:: Na Na over 150 mmol/lover 150 mmol/l hyperaldosteronism hyperaldosteronism hhypovolemiaypovolemia
renin-angiot-aldost. renin-angiot-aldost. Hypothalamic damage Hypothalamic damage Hypertonic hyperhydration Hypertonic hyperhydration Diabetes insipidusDiabetes insipidus Brain death Brain death
Na serum Na serum levelslevels((136-145136-145mEq/L))
HyponatremiaHyponatremia: Na : Na under 130 under 130 mEq/L
Na in the third space - ascites, Na in the third space - ascites, hydrothoraxhydrothorax
Cardiac failure Cardiac failure –– increase of increase of extracellular volume extracellular volume
Application of solutions without Application of solutions without electrolytes electrolytes
Hypersecretion of ADH Hypersecretion of ADH –– water water retention retention
K serum levels K serum levels (3.5-5.3(3.5-5.3mEq/L))
HyperkalemiaHyperkalemia: K : K over 5,0 - 5,5 over 5,0 - 5,5 mEq/L
– pH dependent /acidosis increases K levepH dependent /acidosis increases K levell– Bigger intake, low output or bothBigger intake, low output or both– Acute renal failure Acute renal failure – Acute metabolic acidosisAcute metabolic acidosis– Infusion with K Infusion with K
KK serum levels serum levels
HypokalemiaHypokalemia: K : K under 3,5under 3,5mEq/L
– Low intake, bigger uptake, or bothLow intake, bigger uptake, or both
– Emesis, diarrhoe / intestinal loss/ Emesis, diarrhoe / intestinal loss/
– Diuretics Diuretics
– Chemotherapy, antimycotics /renal tubules Chemotherapy, antimycotics /renal tubules failure/ failure/
– Anabolic phasis Anabolic phasis
– HyperaldosteronismHyperaldosteronism
– Acute metabolic alcalosis Acute metabolic alcalosis
BUN (5-20 BUN (5-20 mg/dlmg/dl))
Consider hydration and Nutrition. High level of urea
– high intake of N, – increase catabolism– polytrauma-muscele loss– GIT bleeding – dehydration – low output- renal failure,
Low level – malnutrition,serious hepatic failure- ureosyntetic cycle and gluconeogenesis dysfunction, pregnancy- increase ECF
BUN (5-20 BUN (5-20 mg/dlmg/dl))
Low level – – malnutrition,– serious hepatic failure- – ureosyntetic cycle and gluconeogenesis
dysfunction, – pregnancy- – increase ECF
UreaUrea
Urea in urine Urea in urine Increase Increase –– catabolism, prerenal catabolism, prerenal
failure failure Decrease Decrease –– chronic malnutrition, chronic malnutrition,
acute renal failure acute renal failure
Creatinine(0.5-1.1Creatinine(0.5-1.1 mg/dl)) Serum levels of creatinine evaluation together with Serum levels of creatinine evaluation together with
muscle mass, age, gender muscle mass, age, gender IncreaseIncrease
– bigger offer- destruction of muscle mass,bigger offer- destruction of muscle mass,– low output-renal failurelow output-renal failure
Decrease- Decrease- – low offer-low muscle masslow offer-low muscle mass– malnutrition malnutrition
Creatinine clearence, excretion fraction -renal Creatinine clearence, excretion fraction -renal functionfunction
N-balance N-balance –– catabolism catabolism –– the need of nitrogen the need of nitrogen Uratic acid Uratic acid –– cell damage, arthritis uratica cell damage, arthritis uratica
ALTALT(SGPT)(SGPT)
N V: M: 7-46 F:4-35 U/LN V: M: 7-46 F:4-35 U/L HighHigh level level ––
– hepatopathhepatopathologiaologia, , – steatosis, steatosis, – hepatitis, hepatitis, – cell damage, cell damage,
ASTAST(SGOT)(SGOT)
HighHigh level level –– – hypoperfusion, hypoperfusion, – hepatitis, hepatitis, – cell necrosis, cell necrosis, – muscles damage muscles damage
both aminotransferases increase both aminotransferases increase during damage of hepatic cells during damage of hepatic cells during inf.hepatitis. during inf.hepatitis.
TGTG(10-190 (10-190 mg/dl))
TG-increase TG-increase – during sepsis, mainly on the begining,during sepsis, mainly on the begining,– monitorate during parentermonitorate during parenteráál nutrition with l nutrition with
lipidlipid emulsionemulsion
Glycemia, serum, urine,Glycemia, serum, urine, Hypoglycemia below 2,5mmol/l-vital Hypoglycemia below 2,5mmol/l-vital
dangerdanger hyperglycemia- insulin.rezistence, hyperglycemia- insulin.rezistence,
recomendation level of glycemia 4,5-recomendation level of glycemia 4,5-8,2 /2006/ better survive in ICU patient8,2 /2006/ better survive in ICU patient
Glucose Glucose
Glycemia, serum, urine,Glycemia, serum, urine, Hypoglycemia below 2,5Hypoglycemia below 2,5mmol/l--(45 (45
mg/dl) ) vital dangervital danger hyperglycemia- insulin.rezistencehyperglycemia- insulin.rezistence
RecomendationRecomendation level of glycemia level of glycemia 4,5-8,24,5-8,2 (80-150 (80-150 mg/dlmg/dl))
PP–– serum levels serum levels(2.7-4.5 (2.7-4.5 mg/dl))
HypophosphataemiaHypophosphataemia:: under 1,9 under 1,9 mg/dl
– Acute wastage of energy after Acute wastage of energy after succesfully resuscitation, overfeeding succesfully resuscitation, overfeeding sy, anabolism (energetic substrates sy, anabolism (energetic substrates without K,Mg,P)without K,Mg,P)..
Hyperphosphataemia Hyperphosphataemia –– over over 5,85,8 mg/dl
– Renal failure Renal failure – Cell damageCell damage
Mg Mg –– serum levels serum levels (1,3-2,5 (1,3-2,5 mEq/LmEq/L))
Mg Mg –– together with potassium together with potassium Hypomagnesaemia Hypomagnesaemia –– under under 1,2 1,2
mEq/LmEq/L / / – renal failurerenal failure– low intake.low intake.
Monitoring of ENMonitoring of EN
For formula intolerance,For formula intolerance,
Hydration status,Hydration status,
Electrolyte status,Electrolyte status,
Nutritional status,Nutritional status,
MonitoringMonitoring
Monitoring in PN therapy
Weight(on a daily basis,initialy and )
BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases
Monitoring in PN therapy
Variable to be monitoredInitial Later period
Clinical statusDailyDaily
Catetheter siteDailyDaily
Temperature DailyDaily
Intake &OutputDailyDaily
Monitoring in PN therapy
Variable to be monitoredInitial Later period
Weight Daily Weekly
serum glucoseDaily3/wk
Electrolytes (Na+, K+, Cl-)Daily1-2//wk
BUN3/wkWeekly
Ca+, P,mg3/wkWeekly
Liver function Enzymes3/wkWeekly
Serum triglycerides weeklyweekly
CBCweeklyweekly
Problems
1. Catheter sepsis
2. Placement problems
3. Metabolic complications
Complications
Dehydration Possible cause:
Inadequate fluid support;Unaccounted fluid loss (e.g. diarrhea, fistulae, persistent high fever).
Management: Start second infusion of appropriate fluid, such as D5W, 1/2NS, NS.
Estimate fluid requirement and adjust PN accordingly.
Complications
OverhydrationPossible cause:
Excess fluid administration;Compromised renal or cardiac function.
Management: Consider D70 (can’t use with PPN) or 20% lipid as calorie sourceInitiate diuretics.Limit volume.
Complications
Alkalosis Possible cause:
Inadequate K to compensate for cellular uptake during glucose transport
Excessive GI or renal K losses.Inadequate Cl- in patients undergoing gastric decompression.
Management: KCl to PN. Assure adequate hydration.Discontinue acetate.
Complications
AcidosisPossible cause:
Excessive renal or GI losses of baseExcessive Cl- in PN.
Management: Rule out DKA and sepsis.Add acetate to PN.
Complications
HypercarbiaPossible cause:
Excessive calorie or carbohydrate load.Management:
Decrease total calories orCHO load.
Complications
HypocalcemiaPossible cause:
Excessive PO4 saltsLow serum albumin.Inadequate Ca in PN.
Management: Slowly increase calcium in PN prescription.
Complications
Hypercalcemia Possible cause:
Excessive Ca in PNAdministration of vitamin A in patients with renal failure. Can lead to pancreatitis.
Management: Decrease calcium in PN.Ensure adequate hydration.Limit vitamin supplements in patients with renal failure to vitamin C and B vitamins.
Complications
Hyperglycemia
Possible cause:Stress response. Occurs approximately 25% of cases.
Management: Rule out infection. Decrease carbohydrate in PN. Provide adequate insulin.
Complications
Hypoglycemia
Possible cause:Sudden withdrawal of concentrated glucose. More common in children.
Management: Taper PN. Start D10.
Complications
Cholestasis
Possible cause:Lack of GI stimulation.Sludge present in 50% of patients on PN for 4-6 weeks; resolves with resumption of enteral feeding.
Management: Promote enteral feeding.
Complications
Hepatic tissue damage and fat infiltration Possible cause:
Unclear etiology. May be related to excessive glucose or energy administration;
L-carnitine deficiency.
Management: Rule out all other causes of liver failure.Increase fat intake relative to CHO.Enteral feeding.
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