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Nutritional Assessment and Support

Nutritional Assessment and Support. 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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Nutritional Assessment and Support

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  1. Nutritional AssessmentandSupport

  2. 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

  3. 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)

  4. 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

  5. Types of Malnutrition Marasmus • 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 thepresence 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

  6. Early Fasting Human(Day One) fuelsupply consumption Circulatingglucose CNS Liver glycogen glucose Muscleglycogen & protein amino acids PNSMedulla Marrow Eyes gluconeogenesis lactatepyruvate glycerol Adipose&circulatingFFA & TG FFA oxidationin mitochondria MuscleHeartKidney fatty acids ketones

  7. Early Fasting Human(Days 2-14) fuelsupply consumption CNS Liver Muscle75 g/d amino acids glucose Renal Marrow PNSEyes gluconeogenesis lactatepyruvate glycerol Adipose FFA oxidationin mitochondria MuscleHeartKidney fatty acids ketones * lose 5% body protein stores per week

  8. Adapted Fasting Human(2 to 6 weeks) fuelsupply consumption CNS Liver Muscle20 g/d amino acids glucose Renal Marrow PNSEyes gluconeogenesis lactatepyruvate glycerol Adipose FFA oxidation in mitochondria MuscleHeartKidney fatty acids ketones

  9. Traumatized Human fuelsupply consumption ReparativeProcess Visceral& MuscleProtein250 g/d CNS Liver amino acids glycogen glucose Renal Marrow PNSEyes gluconeogenesis lactatepyruvate glycerol Adipose FFA oxidation in mitochondria MuscleHeartKidney fatty acids ketones

  10. Nutritional Assessment

  11. 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)

  12. 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?

  13. 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

  14. Does malnutrition exist? Subjective Global Assessment Scale (SGA Scale) • graded on 6 features weight change intake GI symptoms functional capacity physiologic stress physical alterations • each feature is rated A = no deficit B = mild deficit C = severe deficit • scored overall A = well nourished = 16% septic complications B = mild to moderate malnutrition = 43% septic complications C = severe malnutrition = 69% septic complications

  15. 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

  16. 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

  17. 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. • Parenteralnutrition: 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).

  18. 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

  19. Nutritional Support

  20. 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

  21. Estimate Needs (weight based) • If malnourished (BMI <18.5), use actual body weight to avoid refeeding syndrome • Devine formula, 1974 • malesIBW = 50 kg + 2.3 kg for each inch over 5 feet • femalesIBW = 45.5 kg + 2.3 kg for each inch over 5 feet • underestimates IBW for short women • Robinson formula, 1983 • malesIBW = 52 kg + 1.9 kg for each inch over 5 feet • femalesIBW = 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

  22. Estimate Needs calories • 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 factor bed rest: +5-10% lightactivity: +50% ambulatory: +20-30% moderateactivity: +75% • stress factor minorsurgery: +10% appendicitis, long bone fracture: +20% major infection: +30-40% multipletrauma: +60% burns: +30-70% • special cases (unstable sepsis, hypotension) reduce or hold caloric support to avoid hyperglycemia (<110, NEJM 2001) and immune suppression protein • basal 0.5 - 0.8 gm/kg/d • adjust for stress/illness

  23. Estimate Needs(Practical Method) • calories per kg/day critically ill: 15-20 (18) bed rest/mod ill: 25 mild stress or activity: 30 for weight gain: 35 burn patient: 40 • protein grams per kg/day no stress: 0.8 mild stress: 1.0 dialysis 1.3 moderate stress: 1.2 severe stress: 1.5 burn patient: 2.0+ 80 kg patient 2400 kcal 100 grams protein

  24. TPN Calculations carbo=D70 lipid=F20 protein=AA10 80 kg patient 2400 kcal 100 grams protein protein=4 kcal/gram AA10=10 grams/dl AA10 =40 kcal/dl AA10 =0.4 kcal/cc protein 100x4=400 kcal 480/0.4=1000 cc 2400-400=2000 kcal fat=9 kcal/gram F20=20 grams/dl F20=180 kcal/dl F20=1.8 kcal/cc lipid 2400x30%=720 kcal 720/1.8=400 cc 2000-720=1280 kcal dextrose=3.45 kcal/gram D70=70 grams/dl D70=241 kcal/dl D70=2.4 kcal/cc carbo 1280/2.4=530 cc *propofol is ~F10 = 1 kcal/cc

  25. 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

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