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Transcript of [Telmeds.org]_17uncn7e.ppt_29-3-2010. (3)
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Volume 361:1088-1097 September 10, 2009 Number 11
Parenteral Nutrition in the Critically Ill Patient
Thomas R. Ziegler, M.D.
http://content.nejm.org/content/vol361/issue11/index.dtlhttp://content.nejm.org/cgi/content/short/361/11/1098?query=nextarrowhttp://content.nejm.org/cgi/content/short/361/11/1098?query=nextarrowhttp://content.nejm.org/content/vol361/issue11/index.dtl -
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A 67-year-old woman with type 2 diabetesmellitus undergoes extensive resection ofthe small bowel and right colon with ajejunostomy and colostomy because ofmesenteric ischemia. In the surgicalintensive care unit, severe systemic
inflammatory response syndrome withpossible sepsis develops. The patient istreated with volume resuscitation,
vasopressor support, mechanicalventilation, broad-spectrum antibiotics, andintravenous insulin infusion.
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Low-dose tube feedings are initiatedpostoperatively through a nasogastric tube.However, these feedings are discontinuedafter the development of escalatingvasopressor requirements, worseningabdominal distention, and increased gastricresidual volume, along with an episode ofemesis. The hospital nutritional-support
service is consulted for feedingrecommendations.
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A discussion with the patient's familyreveals that during the previous 6 months,she lost approximately 15% of her usualbody weight and decreased her food intakebecause of abdominal pain associated witheating. Her preoperative body weight was 51
kg (112 lb), or 90% of her ideal body weight.The physical examination reveals mildwasting of skeletal muscle and fat. Blood
tests show hypomagnesemia,hypophosphatemia, and normal hepatic andrenal function. Central venous parenteralnutrition is recommended.
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The Clinical Problem Malnutrition, including the depletion of essentialmicronutrients and erosion of lean body mass,
is very common in patients who are critically ill,with 20 to 40% of such patients showingevidence of protein-energy malnutrition. Theincidence of malnutrition worsens over time inpatients who require prolonged hospitalization.
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Protein-energy malnutrition before and duringhospitalization is associated with increasedmorbidity and mortality in hospitalized patients.Adequate nutrient intake is critical for optimalcell and organ function and wound repair.Protein-energy malnutrition is associated withskeletal-muscle weakness, an increased rate ofhospital-acquired infection, impaired wound
healing, and prolonged convalescence inpatients who are admitted to an intensive careunit (ICU).
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However, the relationship between malnutritionand adverse clinical outcomes is complex,because malnutrition may contribute tocomplications that worsen nutritional status,and patients who are more difficult to feed aremore critically ill and at higher risk for death andcomplications. Thus, the true cost ofmalnutrition cannot be estimated with accuracy
in critically ill patients.
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Pathophysiology and Effect of Therapy The pathophysiology of malnutrition in patientsin the ICU is multifactorial. Critical illness isassociated with catabolic hormonal andcytokine responses. These include increasedblood levels of counterregulatory hormones(e.g., cortisol, catecholamines, and glucagon),increased blood and tissue levels ofproinflammatory cytokines (e.g., interleukin-1,
interleukin-6, interleukin-8, and tumor necrosisfactor ), and peripheral-tissue resistance toendogenous anabolic hormones (e.g., insulin
and insulin-like growth factor 1).
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This hormonal milieu increases glycogenolysisand gluconeogenesis, causes a net breakdownof skeletal muscle, and enhances lipolysis,
which together provide endogenous glucose,amino acids, and free fatty acids that arerequired for cellular and organ function andwound healing. Unfortunately, although plasmasubstrate levels may be increased, theiravailability for use by peripheral tissues may beblunted (because of factors such as insulin
resistance and inhibition of lipoprotein lipase),and plasma levels of certain substrates (e.g.,glutamine) may be insufficient to meetmetabolic demands.
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Critically ill patients often have a history ofdecreased spontaneous food intake before ICUadmission, because of anorexia,gastrointestinal symptoms, depression, anxiety,and other medical and surgical factors. Inaddition, their food intake may have been
restricted for diagnostic or therapeuticprocedures. Such patients commonly haveepisodes of abnormal nutrient loss from
diarrhea, vomiting, polyuria, wounds, drainagetubes, renal-replacement therapy, and othercauses.
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Bed rest, decreased physical activity, andneuromuscular blockade during mechanicalventilation cause skeletal-muscle wasting andinhibit protein anabolic responses. Drugs thatare frequently administered to patients in theICU may themselves increase skeletal-muscle
breakdown (corticosteroids), decreasesplanchnic blood flow (pressor agents), orincrease urinary loss of electrolytes, minerals,
and water-soluble vitamins (diuretics). Infection,operative trauma, and other stresses mayincrease energy expenditure and protein andmicronutrient needs.
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Most critically ill patients who requirespecialized nutrition (85 to 90%) can be fedenterally through gastric or intestinal tubes andthen transitioned to an oral diet withsupplements. However, in approximately 10 to15% of such patients, enteral nutrition iscontraindicated. Complete intravenousparenteral nutrition provides fluid, dextrose,
amino acids, lipid emulsion, electrolytes,vitamins, and minerals.
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Insulin and selected drugs may also be added.Therapeutic effects of parenteral nutritionaccrue through the combined provision ofenergy (primarily as the dextrose and lipidcomponents), essential and nonessential aminoacids, essential fatty acids, vitamins, minerals,and electrolytes. These elements support vitalcellular and organ functions, immunity, tissue
repair, protein synthesis, and capacity ofskeletal, cardiac, and respiratory muscles.
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Nutrition Care and
Assessment
Chapter 17
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Nutrition in Health Care
Many medical conditions can lead tomalnutrition
Poor nutrition can influence The course of disease The bodys response to treatment
Malnutrition reported in 40-60% of patients hospitalized with acute illness
Healthy patients often exhibit decline innutrition status within 3 weeks of admission
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Nutrition in Health Care
Early recognition and treatment of nutritional problems Improve effectiveness of medical
treatment
Prevent complications
Registered dietician or similarlytrained nutrition professional provides
services to Assess Diagnose Treat
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Illness and Nutrition Status
Reduced food intake
Impaired digestion and absorption
Altered nutrient metabolism/excretion
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Health Professionals andNutrition Care
Nutrition care is often incorporated
into the medical plan using: Critical Pathways Clinical Pathways
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Health Professionals andNutrition Care
Physicians Prescribe diet orders (nutrition
assessment and diet counseling)
Registered Dietitians Conduct dietary assessments Diagnose nutritional problems Develop, implement and evaluate nutrition
care plans Plan and approve menus
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Health Professionals andNutrition Care
Nurses Screen patients for nutrition problems
may participate in nutrition and dietaryassessments
Provide diet / nutrition care Encouraging patients to eat
Finding practical solutions to food-relatedproblems Recording patients food intake Answering questions about specific diets
Administering tube and intravenous feedings
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Health Professionals andNutrition Care
Registered Dietetic Technicians Work with dietician
Assist in implementation and monitoring of nutrition services Screen patients for nutritional problems Provide patient education and counseling
Develop menus and recipes Ensure appropriate meal delivery Monitor patients food choices and intakes Often have supervisory positions in foodservice
operations
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Health Professionals andNutrition Care
Other Health Care Professionals Pharmacists, physical therapists,
occupational therapists, speech therapists,social workers, nursing assistants, homehealth care aides
Assist with nutrition care
Can be instrumental in alerting dietitiansor nurses to nutrition problems May share relevant information about a
patients health status or personal needs
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Quality of CareJoint Commission on Accreditation of
healthcare Organizations (JCAHO) independent, non-profit organizationthat has developed an accreditationprocess that helps to ensure high-quality health care and awardsaccreditation to health care
organizations based on how wellstandards are met. Conductsextensive on-site reviews at least once
every three years. ( www.jcaho.org )
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Nutrition Screening
Conducted within 24 hours admissionto hospital or other type of extended-care facility (JACHO) Accurate to identify nutritional risk, yet
simple enough to be completed in 5 15minutes.
Conducted by nurse, nursing assistant,registered dietician or dietetic technician--varies among health care settings.
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Nutrition Screening
Often included in outpatient servicesand community health programs
Nutrition Screening Initiative projectsponsored by more than 25 nationalhealth, aging, and medical organizationsto promote nutrition screening in the
elderly
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Nutrition Screening
DETERMINE mnemonic forremembering the common warningsigns of malnutrition.
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Nutrition Screening
D isease. E ating poorly. T ooth loss or mouth pain.
E conomic
hardship. R educed social contact. M ultiple medications . I nvoluntary weight loss or gain . N eed for assistance in self care. E lder years (above age 80).
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The Nutrition Care Process
NutritionAssessment
Nutrition Diagnosis
Nutritionintervention
Nutrition monitoringand evaluation
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Nutrition Assessment
Medical, social, and dietary histories.
Anthropometric data.
Biochemical analyses.
Physical examinations.
Will be addressed in further depth in slidepresentation .
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Nutrition Diagnosis
Similar to nursing diagnoses
Stated in format that includes:
A specific nutrition problem
The etiology or cause
The signs and symptoms that provideevidence of the problem
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Nutrition Intervention
Treatments that can improve riskfactors and correct nutrition problems including: Dietary modifications Nutrition handouts Change in medication
Evidenced-based on scientific rationaleand supported by results of high-quality research
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Nutrition Intervention
Goals of nutrition interventions arestated in terms of:
Measurable outcomes results of lab testsor anthropometric data
Positive changes in dietary behaviors andlifestyle
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Nutrition Monitoring andEvaluation
Original goals and outcomemeasures are Reviewed at previously designated
dates Compared with earlier assessment
data and diagnoses
If the goals are not met The care plan must be redesigned Include motivation techniques or
additional patient education
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Historical Information
Medical History
Current complaints
Past medical conditions Family history of illness Surgical history Medication history Use of dietary/herbal supplements
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Historical Information
Social History
Socioeconomic status
Cultural/ethnic identity Educational level Living situation Shopping arrangements Cooking facilities
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Historical Information
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Historical Information
Diet History
Dietary pattern
Dietary restrictions Use of alcohol Rood allergies and intolerances Chewing and swallowing ability Need for feeding assistance
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Dietary Assessment Methods
The 24-hour recall
Food frequency questionnaire
Food record
Direct observation
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Sample section of a food frequency questionnaire
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Anthropometric Measurements
Height/length and weight
Height/length and weight can help assessgrowth in children and undernutrition andovernutrition in adults.
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Anthropometric Measurements
Length Measured in infants and children up
to age two or three
Height Measured in older children and
adults
See Box 17-1, p. 591.
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Anthropometric Measurements
Weight Body Mass Index (BMI) Ideal Body Weight (%IBW)
Usual Body Weight (%UBW) Obtaining a valid weight
Same calibrated scales
Same time of day Same amount of clothing After patient has voided
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Anthropometric Measurements
See Figure 17-4, Weight Measurement of anInfant, p. 592.
See Figure 17-5, Weight Measurement of an
Older Child or Adult, p. 592.
See Table 17-6, Quick Estimate of DesirableBody Weight, p. 592.
See Table 17-7, Use of Body Weight forAssessing Nutritional Risk, p.593.
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Anthropometric Measurements
Head circumference Can help assess brain growth andmalnutrition in children up to three yearsof age.
To measure encircle the largestcircumference measure of a childs headwith a non-stretchable measuring tape
just above the eyebrows and ears, and
around the occipital prominence at theback of the head
*This measure may not necessarily be reducedin a malnourished child.
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Anthropometric Measurements
Circumferences of waist and limbs
Helps to evaluate body fat and musclemass content
Waist circumference correlates withvisceral fat evaluates overnutrition
Limb circumference more sensitive thanbody weight as indicators of muscle loss
In addition, skinfold measurements tocorrect for the subcutaneous fat in limbs
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Anthropometric Measurements
Anthropometric assessment in infantsand children
Monitored and compared with standardreference values on growth charts
Growth charts with BMI-for-agepercentiles used to assess risk of underweight and overweight in children
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Anthropometric Measurements
Anthropometric assessment in adults Values recorded in charts and monitored
Weight loss can indicate malnutrition 10percent weight loss within a six monthperiod is significant
Weight gain may suggest fluid retention worsening of disease state (heart failure,liver cirrhosis, and kidney failure)
h
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Anthropometric Measurements Anthropometric assessment in adults
Fluid retention can mask weight lossassociated with protein-energymalnutrition.
Changes in body composition mayaccompany illness and aging.
Losses of height and lean tissue are
common in aging. Skinfold measurements and limb
circumferences help identify bodycomposition changes.
i h i l l
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Biochemical Analyses Help to determine what is happening
to the body internally
Analyses of blood and urine samples,
which contain proteins, nutrients, andmetabolites that reflect nutritionstatus.
Lab values help to present a clearerpicture when utilized with otherassessment data.
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Bi h i l A l
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Biochemical Analyses Plasma proteins
Levels affected by hydration, pregnancy,kidney function, some medications
Should be considered with other data toevaluate nutrition status
Albumin Most abundant plasma protein
Slow to reflect changes in nutrition status Not a sensitive indicator of response to
nutrition therapy half-life of 3 weeks
Bi h i l A l
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Biochemical Analyses
Transferrin Transports iron concentrations respond
to both protein-energy malnutrition and
iron status Broken down more rapidly than albumin Relatively slow to respond to nutrition
therapy Levels rise as iron deficiency worsens andfall as iron status improves
Half-life 8-10 days
Bi h i l A l
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Biochemical Analyses Prealbumin and retinol-binding protein
Decrease rapidly during protein-energymalnutrition
Respond quickly to changes in protein
intake More sensitive than albumin to changes in
protein status
Half-life of 2 days to 12 hours More expensive to measure than albumin
not routinely included during nutritionalassessment
Ph i l E i ti
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Physical Examination
Clinical signs of malnutrition
See Table 17-9, p. 596.
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Ph i l E i ti
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Physical Examination
Hydration state Affected by medications
Important to consider when interpretinglab tests.
Must be considered when developingmedical and nutrition care plans
Ph i l E i ti
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Physical Examination
Dehydration Causes Fever Sweating
Vomiting Diarrhea Excessive urination Skin injury Burns
Ph i l E i ti
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Physical Examination
Dehydration Symptoms Thirst Dry skin or mouth
Reduced skin turgor Urine - dark yellow, or amber volume usually
low Headache Feel weak Confusion
Ph sic l E min tion
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Physical Examination
Dehydration
Early recognition important can causecoma or death.
Elderly at risk for dehydration reducedthirst responses to water deprivation.
Physical Examination
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Physical Examination
Fluid retention May accompany malnutrition, infection, or
injury common side effect of meds.
Caused by impaired blood circulation diseases of heart, kidney, liver, and lungs.
Physical Examination
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Physical Examination
Fluid retention Physical signs
Weight gain
Facial puffiness Swelling of limbs Abdominal distention Tight-fitting shoes
Ascites complication of liver cirrhosis accumulation of fluid in the abdominal cavity.
Physical Examination
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Physical Examination
Functional assessment - use functionaltests to evaluate changes inphysiological functions and losses in
body strength Treadmill or cycle ergometer
assessment of exercise tolerance
Hand dynamometer measure strengthand endurance of hand muscle
Skin testing assessment of immunity
Integrating Assessment Data
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Integrating Assessment Data
Several tools have been developed tocombine results from differentassessment methods Subjective Global Assessment applicable
to different patient populations
See Table 17-10, p. 597.
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Nutrition and Immunity
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Nutrition and Immunity
Tissues of the immune system Lymphoid tissues thymus gland, bone
marrow, spleen, tonsils, adenoids, lymph
nodes Cells active in immunity include
leukocytes (white blood cells) andaccessory cells
White blood cells travel in lymphaticvessels
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Nutrition and Immunity
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Nutrition and Immunity
Examples of innate immunity Physical barriers to infection
Skin
Mucous membranes Defensive proteins
Acute-phase proteins C-reactive protein Complement group of about 25 plasma
proteins that complement antibodies Lysozyme
Nutrition and Immunity
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Nutrition and Immunity
Examples of innate immunity Phagocytes
Engulf and digest bacteria, debris and foreign
particles phagocytosis Neutrophils Macrophages
A macrophage extends a pseudopod to pull in andlf b i
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engulf a bacterium.
Nutrition and Immunity
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Nutrition and Immunity
Examples of innate immunity Natural killer cells
Examples of adaptive immunity B cells
Confer humoral immunity Produce antibodies or immunoglobulins
T cells Participate in cell-mediated immunity
Nutrition and Immunity
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Nutrition and Immunity
Undesirable effects of immunity Hypersensitivity discomfort or illness
owing to excessive or inappropriate
immune reaction Allergy exaggerated response to
allergen Autoimmune diseases
The rash that appears after contact with poison oak isl f ki h iti it
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2006 Thomson-Wadsworth
an example of skin hypersensitivity.
Nutrition and Immunity
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Nutrition and Immunity
Malnutrition, immunity, and infection Malnutrition and infection risk
PEM
Nutrient deficiencies Effect of infection on nutrition status
Recurrent infections worsen nutrientdeficiencies
Infection causes physical and metabolicchanges that worsen malnutrition