Nutritional Assessment and Support
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Transcript of Nutritional Assessment and Support
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Nutritional Assessmentand
Support
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Clinical Nutrition
Outline• Malnutrition
- definition- types
• Physiology- fasting- starvation- effects of stress & trauma
• Nutritional Assessment- presence & degree of malnutrition
• Nutritional Support- who benefits- proper timing- enteral vs. parenteral- simple calculations
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Clinical Nutrition
Nutrition
• intake of nutrients to provide energy for…- performance of mechanical work- maintenance of organ/tissue function- heat production- maintenance of metabolic homeostasis
• TEE (total energy expenditure)- REE or BEE (fasting resting or basal energy expenditure) ~ 70%
(~1 kcal/kg/hr)- activity expenditure ~ 20% avg. but very variable- thermic effect of feeding ~ 10% (intake increases the metabolic rate)
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Clinical Nutrition
Malnutrition
• estimated that >50% of hospitalized patients exhibit malnutrition• results in the catabolism of energy stores
- adipose (oxidation of triglycerides) ~ 13kg in average person- glycogen (glucose) ~ 0.5kg, mostly in muscle- protein (not stored - in use by the body)
• skeletal muscle ~ 6-12 kg• other protein stores (organs, visceral proteins, nerve tissue) ~ few hundred grams
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Clinical Nutrition
Types of MalnutritionMarasmus
- cachexia- chronic calorie malnutrition – relatively balanced diet, but too little for too long- usually the result of a longstanding problem (months)- see wasting of fat, skeletal muscle (weakness)- visceral protein stores less affected
Kwashiorkor (West African term – “disease of the displaced child”)- “malnourished African child” (after weaning) with edema and protuberant abdomen- more rapid development and worse prognosis- chronic protein malnutrition (unbalanced diet) and the presence of physiologic stress- fat & skeletal muscle reserves are less depleted (carbohydrates drive insulin)- visceral protein stores & immunity are affected early
Marasmic kwashiorkor- combined features – usually what is seen in ICU / ill patients- malnurished person with stress of illness (hypermetabolic state)- worst prognosis – nutritional support tends to only increase fat mass unless the
underlying stressors are reversed
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Clinical Nutrition
Adipose&
circulatingFFA & TG
amino acids
glycerol
fatty acids
Liver
gluconeogenesis
Early Fasting Human(Day One)
FFA oxidationin mitochondria
ketones
glucose
CNS
MuscleHeart
Kidney
lactatepyruvate
glycogen
fuelsupply
consumption
PNSMedulla Marrow
Eyes
Circulatingglucose
Muscle glycogen & protein
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Clinical Nutrition
Adipose
amino acids
glycerol
fatty acids
Liver
gluconeogenesis
Early Fasting Human(Days 2-14)
FFA oxidationin mitochondria
ketones
glucose
CNS
MuscleHeart
Kidney
lactatepyruvate
fuelsupply
consumption
* lose 5% body protein stores per week
Renal Marrow
PNSEyes
Muscle75 g/d
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Clinical Nutrition
Adipose
amino acids
glycerol
fatty acids
Liver
gluconeogenesis
Adapted Fasting Human(2 to 6 weeks)
FFA oxidation in mitochondria
ketones
glucose
CNS
MuscleHeart
Kidney
lactatepyruvate
fuelsupply
consumption
Muscle20 g/d
Renal Marrow
PNSEyes
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Clinical Nutrition
Adipose
amino acids
glycerol
fatty acids
Liver
gluconeogenesis
Traumatized Human
FFA oxidation in mitochondria
ketones
glucose
CNS
MuscleHeart
Kidney
lactatepyruvate
glycogen
fuelsupply
consumption
ReparativeProcess
Renal Marrow
PNSEyes
Visceral& MuscleProtein250 g/d
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Clinical Nutrition
Nutritional Assessment
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Clinical Nutrition
Normal Nutrition
Calories- US standard diet for 70kg active man contains ~2700 kcal- protein ~325 kcal (81 grams)- fat ~1125 kcal (125 grams)- carbohydrates ~1250 kcal (312 grams)- amount needs to be decreased for inactivity
Protein- US standard diet ~80 grams/d (12% of caloric intake)- protein-free diets result in negative nitrogen balance
• lose .34 grams protein/kg/d (nitrogen in urine, feces, skin, breath, sputum, etc.)
- titrate dietary protein to just keep a positive nitrogen balance• need .38 to .52 grams protein/kg/d (higher estimate b/o inefficiency in utilization)
- most use .43 as a minimum and 0.5 - 0.8 gm/kg/d as average- amount needs to be increased for stress (hypercatabolic)
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Clinical Nutrition
Nutritional Assessment
• Every patient should prompt three questions- Does pre-existing malnutrition exist?- Is malnutrition likely to occur?- When and how to correct the situation?
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Clinical Nutrition
Does malnutrition exist?• poor intake
- weight loss last 6 months (25% false positive, 33% false negative)• <5% considered mild malnutrition; 10% is a useful cut-off in nutritional support decisions• >20% considered severe malnutrition
- GI symptoms of anorexia, N/V, diarrhea, malabsorption, obstruction• hypercatabolic pre-admission
- infection, sepsis- trauma, burns- major surgery or pulmonary disease
• anthropometric changes- loss of SQ fat, muscle wasting, BMI < 18
• functional changes- muscle weakness, respiratory effort, daily activity performance
• lab studies- albumin, transferrin, prealbumin, RBP, cholesterol, immune function- affected by by critical illness and become less useful in stressed pts
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Clinical Nutrition
Does malnutrition exist?Subjective Global Assessment Scale (SGA Scale)
• graded on 6 featuresweight changeintakeGI symptomsfunctional capacityphysiologic stressphysical alterations
• each feature is ratedA = no deficitB = mild deficitC = severe deficit
• scored overallA = well nourished = 16% septic complicationsB = mild to moderate malnutrition = 43% septic complicationsC = severe malnutrition = 69% septic complications
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Clinical Nutrition
Is Malnutrition Likely to Occur?
• poor intake- NPO for more than 5 days- GI symptoms of anorexia, N/V, diarrhea, malabsorption, obstruction
• hypercatabolic- infection, sepsis- trauma, burns- major surgery or pulmonary disease
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Clinical Nutrition
Nutritional Support
• Theoretical goals of improving the nutritional status of hospitalized patients- improve wound healing- decrease infectious complications (in the severely malnourished)- decrease non-septic complications- decrease ventilator weaning time- shorten hospital stays- decrease mortality rate
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Clinical Nutrition
Enteral vs Parenteral Nutritional Support
• Acute critical illness see catabolism>>anabolism, fat mobilization is impaired. Enteral and parenteral support confer DIFFERENT clinical outcomes in critically ill patients.
• Enteral nutrition: when started early in the disease (first 48 hrs) may decrease risk of infection compared to delayed initiation (day 8 or >). Barely reaches statistical significance in meta-analyses. Mortality reduction trends lower, but never reaches significance in meta-analyses. Benefit > harm, but positive trials mostly in SICU, not MICU, pts.
• Parenteral nutrition: no evidence of benefit by early initiation vs late. There is good evidence of harm
- 69 trial meta-analysis with 3750 pts comparing early TPN vs none found higher infection rates and no diff in other outcomes or mortality.
- 2 studies adding TPN (1 early and 1 late) to enteral nutrition (hyperalimentation) found increased infection rates, days on vent, days in hosp, and mortality in 1 trial.
- Head to head studies, mostly SICU (TPN vs enteral): lower infection rate (RR 0.61) and no mortality difference with enteral support.
• Studies are needed to define roles of each in medical pts (more pre-existing malnutrition) vs surgical (acute illness with less pre-existing malnutrition).
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Clinical Nutrition
Simplified Approach• severe burn or trauma early enteral NS within 24-36 hours• severe physiologic stress and diet will be compromised early enteral• well-nourished on admit, no hurry• malnourished (remember wt loss, BMI <18.5, alb < 3.2, TLC < 1500 can
be from catabolism) use decision chart
patient statusdays beforetube feeding
days beforeTPN
no malnutritionand no stress
7-10 ? (>10-14)
malnourished only 1-7 ? (>7)
stressed only (critically-ill) 2-3 ? (>10, never)
both 1-3 ? (>10, never)
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Clinical Nutrition
Nutritional Support
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Clinical Nutrition
Route of Administration
• Enteral- more physiologic (doesn’t bypass gut mucosa and liver)- less complicated (supplements, NG tube, PEG, DHT, naso-jejunal tube)- less costly (especially cyclic, intermittent, or bolus feeding)- fewer infectious and other complications- better at preserving gut mucosal integrity and preventing microbial
translocation• Parenteral
- use only if you cannot use the gut• bowel leak (not just bowel surgery; enteral feeding may help fresh anastomosis)• bowel obstruction• prolonged ileus• short bowel / severe malabsorption• mesenteric ischemia• no gut access
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Clinical Nutrition
Estimate Needs (weight based)
• If malnourished (BMI <18.5), use actual body weight to avoid refeeding syndrome
• Devine formula, 1974- males
IBW = 50 kg + 2.3 kg for each inch over 5 feet- females
IBW = 45.5 kg + 2.3 kg for each inch over 5 feet- underestimates IBW for short women
• Robinson formula, 1983- males
IBW = 52 kg + 1.9 kg for each inch over 5 feet- females
IBW = 49 kg + 1.7 kg for each inch over 5 feet- better estimate for females
• Obesity correction (BMI ≥ 30)- adjusted IBW = IBW + (ABW - IBW)/4
for pts with BMI between 18.5 and 29,
most useABW – edema weight
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Clinical Nutrition
Estimate Needscalories
- basal or resting energy expenditure (BEE or REE)men: 66 + (13.7 x kg wt) + (5 x cm ht) – (6.8 x age) or 879 + (10.2 x kg wt)women: 665 + (9.6 x kg wt) + (1.7 x cm ht) – (4.7 x age) or 795 + (7.18 x kg wt)- activity factorbed rest: +5-10% light activity: +50%ambulatory: +20-30% moderate activity: +75%- stress factorminor surgery: +10% appendicitis, long bone fracture: +20%major infection: +30-40% multiple trauma: +60% burns: +30-70%- special cases (unstable sepsis, hypotension)reduce or hold caloric support to avoid hyperglycemia (<110, NEJM 2001) and
immune suppression
protein- basal0.5 - 0.8 gm/kg/d- adjust for stress/illness
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Clinical Nutrition
Estimate Needs(Practical Method)
• calories per kg/daycritically ill: 15-20 (18)bed rest/mod ill: 25mild stress or activity: 30for weight gain: 35burn patient: 40
• protein grams per kg/dayno stress: 0.8mild stress: 1.0dialysis 1.3moderate stress: 1.2severe stress: 1.5burn patient: 2.0+
80 kg patient
2400 kcal
100 grams protein
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Clinical Nutrition
TPN Calculations
dextrose=3.45 kcal/gramD70=70 grams/dlD70=241 kcal/dlD70=2.4 kcal/cc
carbo=D70
lipid=F20
protein=AA10
fat=9 kcal/gramF20=20 grams/dlF20=180 kcal/dlF20=1.8 kcal/cc
protein=4 kcal/gramAA10=10 grams/dlAA10 =40 kcal/dlAA10 =0.4 kcal/cc
80 kg patient2400 kcal
100 grams protein
protein100x4=400 kcal480/0.4=1000 cc
lipid2400x30%=720 kcal
720/1.8=400 cc
2400-400=2000 kcal
2000-720=1280 kcal
carbo1280/2.4=530 cc
*propofol is ~F10 = 1 kcal/cc
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Clinical Nutrition
Monitoring Nutritional Status/Support• correct osmolality, volume, glucose and electrolyte abnormalities first• watch for refeeding syndrome (fluid retention/CHF, low phos, K, Mg, high glucose)• if serum glucose is hard to control, increase lipid ratio (up to 50-66% of calories), but
remember that lipid is less nitrogen preserving than dextrose (below 150 g/d dextrose)• if triglycerides are hard to control, lower the lipid ratio (can be removed for periods)• follow weights daily, consider prealbumin weekly, and UUN occasionally (rare)
N balance = (grams protein intake/6.25) - (grams UUN + 4)
grams N deficit x 6.25 = extra grams protein needed
albumin rise prealbumin rise
transferrin rise
sensitivity 61% 88% 67%
specificity 41% 70% 55%
PPV 86% 93% 87%
NPV 17% 56% 27%