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Nutrition Support. Ahmed Mayet, Pharm.D Associate Professor King Saud University. Questions. What medical history support that the patient is “at risk” of malnutrition? What physical findings support that the patient is “at risk” of malnutrition?. Nutrition.

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Nutrition support
Nutrition Support

Ahmed Mayet, Pharm.D

Associate Professor

King Saud University


Questions
Questions

  • What medical history support that the patient is “at risk” of malnutrition?

  • What physical findings support that the patient is “at risk” of malnutrition?


Nutrition
Nutrition

  • Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.


Malnutrition
Malnutrition

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


Types of malnutrition
Types of malnutrition

  • Kwashiorkor: (kwa-shior-kor) is protein malnutrition

  • Marasmus: (ma-ras-mus) is protein-calorie malnutrition


Kwashiorkor
Kwashiorkor

  • Protein malnutrition - caused by inadequate protein 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


Clinical manifestations
Clinical Manifestations

  • Marked hypoalbuminemia

  • Anemia

  • Edema

  • Muscle atrophy

  • Delayed wound healing

  • Impaired immune function


Marasmus
Marasmus

  • The patient with severe protein-calorie 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


Marasmus1
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


Clinical manifestations1
Clinical Manifestations

  • Weight loss

  • Reduced basal metabolism

  • Depletion skeletal muscle and adipose (fat) stores

  • Decrease tissue turgor

  • Bradycardia

  • Hypothermia


Risk factors for malnutrition
Risk factors for malnutrition

  • Medical causes

  • Psychological and social causes


Medical causes risk factors for malnutrition
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


Psychosocial causes
Psychosocial causes

  • Alcoholism, drug addiction

  • Poverty, isolation

  • Disability

  • Anorexia nervosa

  • Fashion or limited diet


Consequences of malnutrition
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


Nutrition support
Cont:

  • Muscle atrophy

  • Impaired cardiac function

  • Impaired respiratory function

  • Reduced renal function

  • mental dysfunction

  • Delayed bone callus formation

  • Atrophic skin


Nutrition support

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


Nutrition support

International,multicentre study to implement nutritional risk screening and evaluate clinical outcome

ClinicalNutrition(2008)27,340e349


Metabolic rate
Metabolic Rate risk screening and evaluate clinical outcome

Normal range

Long CL, et al.JPEN 1979;3:452-6


Protein catabolism
Protein Catabolism risk screening and evaluate clinical outcome

Normal range

Long CL.Contemp Surg 1980;16:29-42


Answer medical history
Answer risk screening and evaluate clinical outcome(medical history)

What medical history support that the patient is “at risk” of malnutrition?

  • Nausea

  • Abdominal pain

  • Diarrhea

  • Loss of appetite

  • Weight loss


Answer physical finding
Answer risk screening and evaluate clinical outcome(physical finding)

Cont;

What physical findings support that the patient is “at risk” of malnutrition?

  • Pale

  • Lethargic

  • Muscle wasting

  • cachecxia

  • Edematous

  • Hypotensive

  • Tachycardia

  • Burses and patichiae on the limbs


Question
Question risk screening and evaluate clinical outcome

  • What biochemical, anthropometric, indirect calorimetric, and other testes are suggesting that your patient is malnourish?


Nutrition support
Cont: risk screening and evaluate clinical outcome

  • The initial assessment of nutritional status requires a careful

  • History

  • Physical examination

  • Laboratory and other tests


Laboratory and other tests
Laboratory and other tests risk screening and evaluate clinical outcome

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support

Standard monogram for Height and Weight in adult-male risk screening and evaluate clinical outcome


Nutrition support

Percent weight loss risk screening and evaluate clinical outcome

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


Nutrition support

Severe weight lost risk screening and evaluate clinical outcome


Laboratory and other tests1
Laboratory and other tests risk screening and evaluate clinical outcome

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support

Average Body Mass Index (BMI) for Adult risk screening and evaluate clinical outcome

Our patient BMI = 16.3 kg/m2


Laboratory and other tests2
Laboratory and other tests risk screening and evaluate clinical outcome

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support
Fat risk screening and evaluate clinical outcome

  • Assessment of body fat

    • Triceps skinfold thickness (TSF)

    • Waist-hip circumference ratio

    • Waist circumference

    • Limb fat area

    • Compare the patient TSF to standard monogram


Laboratory and other tests3
Laboratory and other tests risk screening and evaluate clinical outcome

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Protein somatic protein
Protein risk screening and evaluate clinical outcome(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


Protein visceral protein
Protein risk screening and evaluate clinical outcome(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


Creatinine height index chi
Creatinine-height index (CHI risk screening and evaluate clinical outcome )

  • [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height]

  • Ideal Cr = IBW x 23 mg/kg male

  • = IBW x 18 mg/kg female

  • CHI > 80 mild depletion

  • CHI 60 – 80 moderate

  • CHI < 60 severe

    Assuming that our patient IBW 59 kg (from chart)

    990mg/ 59 kg x 23 = 73% (mild depletion)


Vitamins deficiency
Vitamins deficiency risk screening and evaluate clinical outcome

  • Vitamin Bs (B1,B2, B6, B 9, B12, )

  • Vitamin C

  • Vitamin A

  • Vitamin D

  • Vitamin K


Trace minerals deficiency
Trace Minerals deficiency risk screening and evaluate clinical outcome

  • Zinc

  • Copper

  • Chromium

  • Manganese

  • Selenium

  • Iron


Nutrition support

Folate, iron, vitamin B12, copper risk screening and evaluate clinical outcome

*Pallor

*Bruising

Vitamin C, vitamin K

*Our patient


Nutrition support

*Edema risk screening and evaluate clinical outcome

Protein, thiamine

*Hyporeflexia

Thiamine

*Spooning

Iron


Estimating energy calorie
Estimating Energy/Calorie risk screening and evaluate clinical outcome


Nutrition support
BEE risk screening and evaluate clinical outcome

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


Total energy expenditure
Total Energy Expenditure risk screening and evaluate clinical outcome

  • TEE (kcal/day) = BEE x stress/activity factor


Nutrition support
BEE risk screening and evaluate clinical outcome

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


Harris benedict equations
Harris–Benedict Equations risk screening and evaluate clinical outcome

  • 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)


A correlation factor that estimates the extent of hyper metabolism
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


Calculation
Calculation hyper-metabolism

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


Calorie sources
Calorie sources hyper-metabolism


Calories
Calories hyper-metabolism

  • 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


Fluid requirements
Fluid Requirements hyper-metabolism


Fluid
Fluid hyper-metabolism

  • 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


Fluid1
Fluid hyper-metabolism

  • 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


Fluid2
Fluid hyper-metabolism

  • Fluid needs are altered by the patient's functional cardiac, hepatic, pulmonary, and renal status

  • Fluid needs increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin integrity like burns, open wounds


Protein needs
Protein Needs hyper-metabolism


Protein
Protein hyper-metabolism

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


Protein1
Protein hyper-metabolism

  • The initial protein goals are estimated according to the following general guidelines


Protein2
Protein hyper-metabolism

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



Nitrogen balance nb calculation
Nitrogen Balance (NB) Calculation hyper-metabolism

  • NB is an important calculation for assessing nutritional response

  • NB is used to evaluate the adequacy of protein intake as well as to estimate current protein requirements


Calculations
Calculations hyper-metabolism

  • NB = N intake – N losses

  • N intake = Protein intake (g/day) / 6.25gm

  • N losses = UUN (g/day) + 4g*

  • UUN is determined from a 24 hour urine collection

  • *4g is a "fudge factor" to account for miscellaneous nitrogen losses


Nutrition support
Cont: hyper-metabolism

  • Positive NB indicates an anabolic state, with a net gain in body protein

  • Negative NB indicates a catabolic state, with a net loss of protein

  • With adequate feeding

  • NB 0 –5 g/day indicates moderate stress

  • NB > –5 g/day indicates severe stress


Routes of nutrition support
Routes of Nutrition Support hyper-metabolism


Nutrition support


Enteral nutrition
Enteral Nutrition hyper-metabolism


Enteral
Enteral hyper-metabolism

  • 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


Potential benefits of en over pn
Potential benefits of EN over PN hyper-metabolism

  • Nutrients are metabolized and utilized more effectively via the enteral than parenteral route

  • Gut and liver process EN before their release into systemic circulation

  • Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue


En immunologic
EN hyper-metabolism(Immunologic)

  • Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis


Safety
Safety hyper-metabolism

  • Catheter sepsis

  • Pneumothorax

  • Catheter embolism

  • Arterial laceration


Cost en
Cost (EN) hyper-metabolism

  • Cost of EN formula is less than PN

  • Less labor intensive


Contraindications
Contraindications hyper-metabolism

  • Gastrointestinal obstruction

  • Severe acute pancreatitis

  • High-output proximal fistulas

  • Intractable nausea and vomiting or osmotic diarrhea


Enteral nutrition en
Enteral nutrition (EN) hyper-metabolism

  • Long-term nutrition:

  • Gastrostomy

  • Jejunostomy

  • Short-term nutrition:

  • Nasogastric feeding

  • Nasoduodenal feeding

  • Nasojejunal feeding


Parenteral nutrition pn
Parenteral nutrition (PN) hyper-metabolism

  • Peripheral Parenteral Nutrition (PPN)

  • Total Parenteral Nutrition (TPN)


Cautious use of pn
Cautious use of PN: hyper-metabolism

  • Azotemia

  • Congestive heart failure

  • Diabetes Mellitus

  • Electrolyte disorders

  • Pulmonary disease


Nutrition support

Intact food hyper-metabolism

Predigested food


Nutrition support

TF = tube feeding hyper-metabolism


Total parentral nutrition
Total Parentral Nutrition hyper-metabolism


Purpose
Purpose hyper-metabolism

  • To maintain positive nitrogen balance through the intravenous administration of required nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals and trace elements


Patient selection
Patient Selection hyper-metabolism


General indications
General Indications hyper-metabolism

  • Requiring NPO > 5 - 7 days

  • Unable to meet all daily requirements through oral or enteral feedings

  • Severe gut dysfunction or inability to tolerate enteral feedings.

  • Can not eat, will not eat, should not eat



Nutrition support
Cont: hyper-metabolism

  • When enteral feeding can’t be established

  • After major surgery

  • Pt with hyperemesis gravidarum

  • Pt with small bowel obstruction

  • Pt with enterocutaneous fistulas (high and low)


Nutrition support
Cont: hyper-metabolism

  • Hyper-metabolic states:

  • Burns, sepsis, trauma, long bone fractures

  • Adjunct to chemotherapy

  • Nutritional deprivation

  • Multiple organ failure:

  • Renal, hepatic, respiratory, cardiac failure

  • Neuro-trauma

  • Immaturity


Calorie sources1
Calorie sources hyper-metabolism

  • 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat


Calculation1
Calculation hyper-metabolism

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


Nutrition support

total calculated calorie = 1650 kcal hyper-metabolism

80% from glucose 1650 x 80 =1320kcal

20% from fat (IL) 1650 x 20 = 330kcal

Protein 1.2gm/kg/day

1.2 x 50 = 60 gm


Nutrition support

Protein requirement hyper-metabolism

150 kcal to 6.25 gm of protein

1650 kcal/150 x 6.25 gm = 68.8 or 70gm


Glucose
Glucose hyper-metabolism

Cont;

  • Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult)

    Exp: our patient is 50 kg

    5mg x 50kg x 60min x 24 hr =360 gm

    360gm x 3.4 kcal/gm = 1224 kcal

    Maximum cal from glucose = 1224kcal


Fat emulsion
Fat emulsion hyper-metabolism

Maximum recommended allowance

  • 2.5 grams/kg/day

    Exp: 2.5 x 50 kg = 125 gm

    125gm x 9 kcal/gm = 1125 kcal


Calorie calculation
Calorie calculation hyper-metabolism

Total calorie requirement = 1650 kcal

calorie from glucose = 1224 kcal

_______

form lipid 436 kcal


Intralipid contraindications
Intralipid contraindications: hyper-metabolism

  • Hyperlipdemia

  • Acute pancreatitis

  • Previous history of fat embolism

  • Severe liver disease

  • Allergies to egg, soybean oil or safflower oil


Diabetic
Diabetic hyper-metabolism

  • DM is not contraindication to TPN

  • Use sliding-scale insulin to avoid hyperglycemia


Administration
Administration hyper-metabolism


Central pn tpn
Central PN (TPN) hyper-metabolism

  • Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only



Continuous vs cyclic administration1
Continuous vs Cyclic administration hyper-metabolism

  • It is given overnight and the patient is free during the day from the PN solution and associated administration paraphernalia (long-term care)

  • Continuous administration is preferred in hospitalized patients as they often have fluid and electrolyte disturbances


Monitoring
Monitoring hyper-metabolism


Complications of tpn
Complications of TPN hyper-metabolism


Complications associated with pn
Complications Associated with PN hyper-metabolism

  • Mechanical complication

  • Septic complication

  • Metabolic complication


Mechanical complication
Mechanical Complication hyper-metabolism

  • Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia

  • Venous thrombosis after central venous access


Infectious complications
Infectious Complications hyper-metabolism

PN imposes a chronic breech in the body's barrier system

  • The mortality rate from catheter sepsis as high as 15%

  • Inserting the venous catheter

  • Compounding the solution

  • Care-giver hanging the bag

  • Changing the site dressing


Metabolic complications
Metabolic Complications hyper-metabolism

  • Early complication -early in the process of feeding and may be anticipated

  • Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition


Nutrition support
Iron hyper-metabolism

  • Iron is not included in TPN solution and it can cause iron deficiency anemia

  • Add 100mg of iron 3 x weekly to PN solution or give separately


Vitamin k
Vitamin K hyper-metabolism

  • TPN solution does not contain vitamin K and it can predispose patient to deficiency

  • Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN


Thank you
Thank you hyper-metabolism


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