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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

Normal range

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


Protein catabolism

Protein Catabolism

Normal range

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


Answer medical history

Answer (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 (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

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


Nutrition support

Cont:

  • The initial assessment of nutritional status requires a careful

  • History

  • Physical examination

  • Laboratory and other tests


Laboratory and other tests

Laboratory and other tests

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support

Standard monogram for Height and Weight in adult-male


Nutrition support

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


Nutrition support

Severe weight lost


Laboratory and other tests1

Laboratory and other tests

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support

Average Body Mass Index (BMI) for Adult

Our patient BMI = 16.3 kg/m2


Laboratory and other tests2

Laboratory and other tests

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Nutrition support

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


Laboratory and other tests3

Laboratory and other tests

  • Weight

  • BMI

  • Fat storage

  • Somatic and visceral protein


Protein somatic protein

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


Protein visceral protein

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


Creatinine height index chi

Creatinine-height index (CHI )

  • [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

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

  • Vitamin C

  • Vitamin A

  • Vitamin D

  • Vitamin K


Trace minerals deficiency

Trace Minerals deficiency

  • Zinc

  • Copper

  • Chromium

  • Manganese

  • Selenium

  • Iron


Nutrition support

Folate, iron, vitamin B12, copper

*Pallor

*Bruising

Vitamin C, vitamin K

*Our patient


Nutrition support

*Edema

Protein, thiamine

*Hyporeflexia

Thiamine

*Spooning

Iron


Estimating energy calorie

Estimating Energy/Calorie


Nutrition support

BEE

  • 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

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


Nutrition support

BEE

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


Harris benedict equations

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)


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

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


Calories

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


Fluid requirements

Fluid Requirements


Fluid

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


Fluid1

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


Fluid2

Fluid

  • 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


Protein

Protein

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


Protein1

Protein

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


Protein2

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


Nitrogen balance calculation

Nitrogen Balance Calculation


Nitrogen balance nb calculation

Nitrogen Balance (NB) Calculation

  • 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

  • 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:

  • 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


Nutrition support

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


Enteral nutrition

Enteral Nutrition


Enteral

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


Potential benefits of en over pn

Potential benefits of EN over PN

  • 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 (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

  • Catheter sepsis

  • Pneumothorax

  • Catheter embolism

  • Arterial laceration


Cost en

Cost (EN)

  • Cost of EN formula is less than PN

  • Less labor intensive


Contraindications

Contraindications

  • Gastrointestinal obstruction

  • Severe acute pancreatitis

  • High-output proximal fistulas

  • Intractable nausea and vomiting or osmotic diarrhea


Enteral nutrition en

Enteral nutrition (EN)

  • Long-term nutrition:

  • Gastrostomy

  • Jejunostomy

  • Short-term nutrition:

  • Nasogastric feeding

  • Nasoduodenal feeding

  • Nasojejunal feeding


Parenteral nutrition pn

Parenteral nutrition (PN)

  • Peripheral Parenteral Nutrition (PPN)

  • Total Parenteral Nutrition (TPN)


Cautious use of pn

Cautious use of PN:

  • Azotemia

  • Congestive heart failure

  • Diabetes Mellitus

  • Electrolyte disorders

  • Pulmonary disease


Nutrition support

Intact food

Predigested food


Nutrition support

TF = tube feeding


Total parentral nutrition

Total Parentral Nutrition


Purpose

Purpose

  • 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


General indications

General Indications

  • 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

Special Indications (can not eat)


Nutrition support

Cont:

  • 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-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

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


Calculation1

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


Nutrition support

total calculated calorie = 1650 kcal

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

150 kcal to 6.25 gm of protein

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


Glucose

Glucose

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

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

Total calorie requirement = 1650 kcal

calorie from glucose = 1224 kcal

_______

form lipid 436 kcal


Intralipid contraindications

Intralipid contraindications:

  • Hyperlipdemia

  • Acute pancreatitis

  • Previous history of fat embolism

  • Severe liver disease

  • Allergies to egg, soybean oil or safflower oil


Diabetic

Diabetic

  • DM is not contraindication to TPN

  • Use sliding-scale insulin to avoid hyperglycemia


Administration

Administration


Central pn tpn

Central PN (TPN)

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


Continuous vs cyclic administration

Continuous vs Cyclic Administration


Continuous vs cyclic administration1

Continuous vs Cyclic administration

  • 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


Complications of tpn

Complications of TPN


Complications associated with pn

Complications Associated with PN

  • Mechanical complication

  • Septic complication

  • Metabolic complication


Mechanical complication

Mechanical Complication

  • 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

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

  • 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

  • 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

  • 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


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