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Nutritional assessment and provision

Nutritional assessment and provision. Yousif .A Qari MD, FRCPC, ABIM Consultant Gastroenterologist KAUH ,Jeddah. Selection of patients for nutritional support. Aim: To decrease mortality and morbidity related to defecate of energy, protein and other nutrients

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Nutritional assessment and provision

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  1. Nutritional assessment and provision Yousif .A Qari MD, FRCPC, ABIM Consultant Gastroenterologist KAUH ,Jeddah

  2. Selection of patients for nutritional support Aim: • To decrease mortality and morbidity related to defecate of energy, protein and other nutrients • To provide nutrition support only to those patients in whom the benefits will exceed risks.

  3. Indications for nutrition support

  4. 4 Traditional Indicators Of Nutritional Status 1. Body Composition • Body weight • Anthropometry • Urinary cratenine excretion 2. Plasma Proteins • Albumin • Prealbumin • Retinol-binding protein • Tranferrin 3. Immune System Function • Total lymphocyte count • Delayed cutaneous hypersensitivity 4. Multivariate Analyses • Prognostic nutritional index • Nutrition risk index

  5. Body Composition • Body weight: • 10% or greater unintentional loss in body weight is associated with an adverse clinical outcome. • <70% of Ideal body weight (IBW) • Anthropometry: • Triceps and sub scapular skin fold thicknesses • provides an index of body fat and muscle mass, which is compared with standard tables. • markedly abnormal values (below the fifth percentile) usually predict a poor clinical outcome. • urinary creatinine excretion: • Assessment of body muscle mass • Values can be compared with tables providing an expected amount of creatinine excretion in relationship to height in subjects consuming a meat-free diet.

  6. Plasma Proteins • Albumin (< 2.1g/dl ) • correlate with clinical outcome • increased incidence of medical complications • Other causes of Hypoalbuminemia • Inflammation and injury • Decreases albumin synthesis • Increases albumin degradation • Increases albumin transcapillary losses • Losses through the gut or kidney • GI • renal, • cardiac diseases • Losses from surface tissues. • Wounds • Burns • Peritonitis • Transferrin ( < 100 mg/dl )

  7. Immune system function • Measured by • Total lymphocyte count (< 800/mm³ ) • delayed cutaneous hypersensitivity • Associated with a poor clinical outcome.

  8. Multivariate Analyses • Prognostic nutritional index • Correlated with postoperative mortality and complications • 4 variables • Alb = serum albumin (g/dl) • TSF = triceps skin fold thickness ( mm ) • TFN =serum (transferrin (mg/dL) • DH = delayed hypersensitivity • 0=nonreactive • 1=<5mm induration • 2=>5mm induration • 158 – 16.6 (Alb) – 0.78 (TSF) – 0.2( TFN) – 5.8 (DH) • When > 50% ------› increased risk • Subjective Global assessment

  9. Subjective Global Assessment (SGA) • TABLE 51-5 Subjective Global Assessment (SGA) Of Nutritional Status A. History 1. Weight change Overall loss in past 6 months: amount = # _________________ kg Change in past wk: ____________ increase ____________ no change ____________ decrease 2. Dietary intake change (relative to normal) ______________ No change ______________ Change: duration = # __________ wk type: ______ suboptimal solid diet ________ full liquid diet ______ hypocaloric liquids ________ starvation 3. Gastrointestinal symptoms (that persisted >2 wk) _________ none __________ anorexia ___________ nausea ___________ vomiting ___________ diarrhea 4. Functional capacity ______________ No dysfunction (e.g. full capacity) ______________ Dysfunction: duration = # ___________ wk ___________ working sub optimally ___________ ambulatory ___________ bedridden 5. Disease and its relation to nutritional requirements Primary diagnosis (specify) _________________________ Metabolic demand (stress) _____ none ______ low ______ moderate _____high B. Physical (for each trait specify : 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe) # _______________ loss of subcutaneous fat (triceps, chest) # _______________ muscle wasting (quadriceps, deltoids, temporals) # _______________ ankle edema, sacral edema # _______________ ascites # _______________ tongue of skin lesions suggesting nutrient deficiency C. SGA rating (select one) ____________ A = Well nourished (minimal or no restriction of food intake or absorption, minimal change in function, weight stable or increasing) ____________ B = Moderately malnourished (food restriction, some function changes, little or no change in body mass) ____________ C = Severely malnourished (definitely decreased intake, function, and body mass)

  10. Summery of indications of malnutrition • Weight loss > 10% in 6 months • Minimal subcutaneous fat in non-athletes ( measure or estimate by pinching) • Muscle wasting in the absence of neurological cause(estimate visually and by palpation) • Serum albumin less than 3 g/dl not resulting from overhydration,liver disease,or chronic excessive loss from the intestinal tract or kidneys

  11. Time for beginning nutrition support

  12. Calculating calorie and protein goals • Non protein calorie goal: • 25-35 kcal/kg/d • Protein goal • 1 -2 kcal/kg/d

  13. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  14. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Is the energy used for normal body functions when well, awake, in a thermoneutral environment, and in a basal fasting state after overnight bed rest • On average = 20 kcal/kg/d • More accurately calculated by Harris-Benedict equations • Women (kcal/d) = 655 + [9.6 × wt(cm)] +[1.7 × hight(cm)] – [ 4.7 × age(years)] • Men (kcal/d) = 66 + [13.7 × wt (kg)] + [ 5 × hight(cm)] – 6.8 × age (years)]

  15. Components of daily energy expenditure (DEE) Harris-Benedict equations(contd) • These formulas will overestimate energy expenditure for obese patients. To improve the estimate , we should use the mean of actual body weight (ABW) + desirable body weight ( DBW) • DBW • Males = 106 pounds + 6 pounds for each inch above 5 feet. • Females = 100 pounds + 5 pounds for each inch above 5 feet. • 1 foot = 12 inches = 20 cm • 1 inch = 2.5 cm • 1 kg = 2.2 pounds

  16. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  17. Components of daily energy expenditure (DEE) • Stress hypermetabolism Calculated by: BEE × Stress factor [according to medical condition (special tables values vary from 0.5 to 2.0)] = Resting Energy Expenditure (REE)

  18. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  19. Components of daily energy expenditure (DEE) 3. Non shivering thermogenesis • The energy required to maintain body temperature above ambient temperature • It is minimal for intact patients with intact skin in temperature-controlled environments • Can be ignored.

  20. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  21. Components of daily energy expenditure (DEE) 4. Diet-induced thermogenesis: • The energy required to digest, absorb, transport, metabolize, and store nutrients. • About 10% - 15% of energy administered

  22. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  23. Components of daily energy expenditure (DEE) 5. Abnormal energy loss in urine, stool, and drainage from fistulae ad wounds . • Seldom significant • can be ignored

  24. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  25. Components of daily energy expenditure (DEE) 6. Energy expenditure of activity • Ranges from 10% - 30% for most hospitalized patients

  26. Components of daily energy expenditure (DEE) • Basal energy expenditure (BEE) • Stress hyermetabolism • Non shivering thermogenesis • Diet induced thermogenesis • Abnormal energy loss in urine, stool, and drainage from fistulae and wounds • Energy expenditure from activity • Energy expenditure for weight gain

  27. Components of daily energy expenditure (DEE) 7. Energy expenditure for weight gain: • For 1 pound weight gain we need 3500 kcal • When weight gain is required : 500 kcal /day can be added to the energy goal = 1pound/week weight gain • Should not be attempted in patients with stress factor above 1.2. • Can be set at 20% of BEE.

  28. General recommendations for calculating nonprotein calorie intake • Estimate BEE (Harris-benedict formula or 20 kcal/d • Stress hypermetabolism = BEE × stress factor • Add for activity 10% to 30% of BEE • Add for weight gain if indicated 500 to 1000 kcal/d N.B: • REE = BEE + stress hypermetabolism + non-shivering thermogenesis

  29. Indirect Calorimetry • The standard method • By measuring carbon dioxide (CO2) production and oxygen (O2) consumption • the amount of heat produced during substrate oxidation is proportional to the amount of CO2 produced and O2 consumed. • Indications: • Severely malnourished • Patients in heart failure, or respiratory failure • Diabetics • Morbid obesity • Closed head trauma • Paralysis

  30. Protein goal • The reason for giving protein is to provide nitrogen, not energy • Excessive protein administration to patients may result in: • Azotemia • Osmotic diuresis • Hyperammonemia • Hepatic encephalopathy • Respiratory muscle fatigue • When energy intake is adequate, optimum protein intake for hospitalized patients ranges from 0.8 to 2.0 g/kg/d

  31. Access for Nutritional Support • Oral • Enteral • Parenteral (Intravenous) • Peripheral • Central

  32. Peripheral TPN • Consists of mixture of • 5% to 10% glucose • 2% to 5% amino acid • Electrolytes • 10% to 20% iv fat emulsion • Low rate of blood flow ( 10 – 50 mls/min) + High osmolality of peripheral TPN fluid (600-900 mosm/kg) + large volume of fluids ( 2-3 L/d) → raises osmolality in the vein → Phlebitis.

  33. Central TPN • Access: • Rt subclavian • High blood flow (1.5- 2.0 L/min)

  34. Optimal nutritional support KCALS Lists of components Keep patient nourished Access FACE-MTV Special monitoring Calculate energy and nonprotein goal

  35. Designing TPN formula • In addition to energy and protein content of a TPN formula, the following are important to remember: ( FACE- MTV ) • (F) Fluids • (A) Amino acids • (C) Calories • (E) Electrolytes • (M) Miscellaneous Additives • (T) Trace elements • (V) Vitamins

  36. Designing TPN formula ( FACE- MTV ) 1. (F) Fluids: When fluid restriction is needed ( patient can not take more than 1000 – 1500 ml of fluids) use: • 70% dextrose • 15% A.A solution • 20% fat emulsion

  37. Designing TPN formula ( FACE- MTV ) 2. (A) Amino acids: • A typical standard A.A mixture contains approximately 15 amino acids • 45% are essential • 20% branched chain (leucine, isoleucine, valine) • 12% methionine plus aromatic amino acids(phenylalanine, tyrosine, tryptophan) Spetial formulas: • Renal Failure: • Higher proportion of essential amino acids • Liver failure: • More branched chain A.A • Less methionine and aromatic amines

  38. Designing TPN formula ( FACE- MTV ) 3.(C)Calories: • Non protein calories • TPN • Fat • 10 - 70% is well tolerated by most patients • 20 - 30% • > 50% appropriate for Fat (10 - 45%) Carbohydrate Fewer complication Greater efficacy Diabetics Pulmonary failure

  39. Designing TPN formula ( FACE- MTV ) 3.(C)Calories: • Non protein calories • TPN • Fat • Lipid emulsions • In sepsis avoid > 1g/kg of lipid emulsions per day( ≤ 30g/d ) • Other iv lipids: Fish oil, MCT, and Structured lipids. Fat (10 - 45%) Carbohydrate Impaired macrophage function ↓ bacterial clearance Alter immunocompetance Impaired pulmonary function Blocks reticuloendothelial system

  40. Designing TPN formula ( FACE- MTV ) 4. (E) Electrolytes: • Standard electrolyte mixtures are suitable for 50 – 80% of patients receiving TPN. • Specifically adjusted mixtures are needed for Patients with • Electrolyte disturbances • Renal failure • Hepatic failure • Heart failure • Multi organ failure

  41. Designing TPN formula ( FACE- MTV ) 4. (E) Electrolytes: • Phosphorous: • 15 mmol/800 glucose calories • ↓ 2 – 4 days after starting TPN • Potassium: • 30 – 40 mEq/800 glucose calories • ↓ 6 – 12 hours after starting TPN • Sodium: • 30 – 50 mEq/liter of formula • Most cases of hyponatremia are dilutional • True hyponatremia may occur in • Ileostomies • Fitulae • Diarrhea • Renal losses

  42. Designing TPN formula ( FACE- MTV ) 4. (E) Electrolytes: • Magnesium: • 5 – 10 mEq/mlof TPN • Chloride/Acetate: • Small amount of chloride and larger amount of acetate is provided by manufacturer in virtually all amino acid mixtures to prevent acidosis resulting from metabolism of Lysine and Arginine. • Added to standard electrolyte mixtures to prevent metabolic acidosis in patients with large gastric fluid losses who are not receiving a histamine receptor antagonists

  43. Designing TPN formula ( FACE- MTV ) 5. (M) Miscellaneous additives • Heparin • 1 unit/ml is added to central TPN mixtures. • Minimize clotting in the catheter • Decrease fibrin sheath formation on the surface of the • Insulin • Only to manage documented hyperglycemia • Should not exceed 10 units/800 glucose calories • Albumin • To patients with serum level below 2.5 g/dL in conditions like • Capillary leak ( sepsis & burns) • Proteinurea • Protein-losing enteropathy • Should be stopped when serum level reach 3.0 g/dL

  44. Designing TPN formula ( FACE- MTV ) 6. (T) Trace elements: • A typical trace element cocktail the is added to daily TPN provides the following: • Zinc = 5.0 mg • Copper = 1.0 mg • Manganese = 500 μg • Chromium = 10 μg • Selenium = 60 μg • No practical way to asses trace element status clinically • Serum levels are difficult to measure accurately • Zinc is the only element likely to be required in larger amounts in • Diarrheal illnesses • Ileostomy output

  45. ( FACE- MTV ) 7. Vitamins: Designing TPN formula

  46. Central TPN • Special monitoring • Nitrogen balance is the most practical and effective way to estimate the adequacy of nitrogen and energy administration • Patient should be on constant calorie and nitrogen intake • The test requires 24 h urine collection for urinary urea nitrogen (UUN) • Calculate total urea nitrogen (TUN) by the equation. • TUN = UUN/0.8 • Nitrogen balance = N in – N out • N in = g amino acids administered /6.25 • N out = TUN (g) + 1 g

  47. Central TPNRisks and complications • Mechanical • Septic • Metabolic

  48. Central TPNMetabolic complications • Hyperglycemia • Hypoglycemia • Hypophosphatemia • Hypokalemia • Hypomagnesemia • Hyponatremia • Fluid overload/dehydration • Fat intolerance • Hypercalcemia • Liver test abnormality

  49. Central TPNMetabolic complications Hyperglycemia • Serum glucose >200 mg/dL • May lead to dehydration, coma and death • Administration rate of TPN should be reduced if serum glucose concentration exceeds 350 mg/dL • In a previously stable patient it usually indicates a new metabolic stress, most often infection

  50. Central TPNMetabolic complications Hypophosphatemia: • Intracellular shift caused by glucose • Patients at increased risks • Chronic alcoholics • Severely malnourished • Patients taking anti acids • When severe May result in • Hemolysis • Serious effects on Cardio respiratory system • Affects on WBC function

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