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Nutrition Support

Ahmed Mayet Associate Professor King Saud University. Nutrition Support. Nutrition. Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein. Malnutrition.

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Nutrition Support

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  1. Ahmed Mayet Associate Professor King Saud University Nutrition Support

  2. Nutrition • Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein

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

  4. Types of malnutrition • Kwashiorkor: (kwa-shior-kor) is protein malnutrition • Marasmus: (ma-ras-mus) is protein-calorie malnutrition

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

  6. Clinical Manifestations • Marked hypoalbuminemia • Anemia • Edema and ascites • Muscle atrophy • Delayed wound healing • Impaired immune function

  7. Marasmus protein-calorie • The patient with severe 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

  8. Clinical Manifestations • Weight loss • Reduced basal metabolism • Depletion skeletal muscle and adipose (fat) stores • Decrease tissue turgor • Bradycardia • Hypothermia

  9. Risk factors for malnutrition • Medical causes • Psychological and social causes

  10. 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

  11. Psychosocial causes • Alcoholism, drug addiction • Poverty, isolation • Disability • Anorexia nervosa • Fashion or limited diet

  12. 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

  13. Cont: • Muscle atrophy • Impaired cardiac function • Impaired respiratory function • Reduced renal function • mental dysfunction • Delayed bone callus formation • Atrophic skin

  14. 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

  15. Metabolic Rate Normal range Long CL, et al.JPEN 1979;3:452-6

  16. Protein Catabolism Normal range Long CL.Contemp Surg 1980;16:29-42

  17. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  18. Standard monogram for Height and Weight in adult-male

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

  20. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  21. Average Body Mass Index (BMI) for Adult Our patient BMI = 16.3 kg/m2

  22. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  23. 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

  24. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  25. 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

  26. 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% Our patient has albumin of 2.2 g/dl

  27. Vitamins deficiency • Vitamin Bs (B1,B2, B6, B 9, B12, ) • Vitamin C • Vitamin A • Vitamin D • Vitamin K

  28. Trace Minerals deficiency • Zinc • Copper • Chromium • Manganese • Selenium • Iron

  29. Estimating Energy/Calorie

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

  31. Total Energy Expenditure • TEE (kcal/day) = BEE x stress/activity factor

  32. BEE • The Harris-Benedict equation is a mathematical formula used to calculate BEE

  33. 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)

  34. 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

  35. Calculation Our patient Wt = 50 kg Age = 45 yrs Height = 5 feet 9 inches (175 cm) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) =66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) =66 + ( 685) + (875) – (306) = 1320 kcal TEE = 1320 x 1.25 (normal activity) = 1650 kcal

  36. Calorie sources

  37. 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

  38. Fluid Requirements

  39. 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

  40. Fluid • 1st 10 kilogram 100 cc/kg • 2nd 10 kilogram 50 cc/kg • Rest of the weight 20 to 30 cc/kg Example: Our patient 1st 10 kg x 100cc = 1000 cc 2nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc

  41. Protein Needs

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

  43. 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

  44. Routes of Nutrition Support

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

  46. Enteral Nutrition

  47. 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

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