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Nutrition in Hospitalized Patient
Created by Dr. Fraz Harji
Objectives:
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Identify three deleterious consequences of malnutrition.
List three ways to assess the nutritional status of a hospitalized patient.
List 3 clinical indications for initiation of artificial nutritional support.
Choose appropriate route of nutrition and monitoring parameters based on a
patient's clinical scenario.
Reference:
1. Waitzberg, Dan L., Correia, Maria Isabel T.D. Nutritional Assessment in
Hospitalized Patient. Current Opinion in Clinical Nutrition and Metabolic
Care, Vol 6 (5), September 2003, pp 531-538
2. Uptodate online, www.utdol.com, accessed July 2007, Overview of parenteral
and enteral nutrition.
3. American Gastroenterological Association medical position statement:
parenteral nutrition. Gastroenterology 2001 Oct;121(4):966-9.
4. Kirby DF, DeLegge MH, Fleming CR. American Gastroenterological
Association technical review on tube feeding for enteral nutrition.
Gastroenterology 1995;108:1282-1301.
Discussion Outline:
Importance of Nutrition
Some degree of malnutrition occurs during most hospitalizations. Malnutrition in
hospitalized patients can lead to a number of deleterious consequences, such as:
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Increased susceptibility to infection
Poor wound healing
Increased frequency of decubitus ulcers
Overgrowth of bacteria in the gastrointestinal tract
Abnormal nutrient losses through the stool
Increased hospital length of stay
Increased morbidity and mortality
Addressing nutritional status is most important during critical illness since the body loses
its ability to conserve during such stress. Identifying malnutrition early and selecting
appropriate intervention can prevent these deleterious effects.
I. Assessment of Nutritional Status
1. History
a. History of weight loss or pre-existing malnutrition history
One study showed that the accuracy of weight loss by history was 0.67 and the
predictive power was 0.75. This suggests that 33% of patients who indeed had loss
weight would not have been identified and 25% of patients who had stable weight
would have been identified as having lost weight.
b. Altered food consumption
c. Gastrointestinal derangements
d. Decreased functional capacity
2. Physical exam
a. Muscle wasting or loss of adipose tissue
b. Presence of edema or ascites
c. Current BMI (Difficult to measure height in critically ill patients)
3. Laboratory assessment
a. Albumin
- Long half life of 14-21 days makes it less responsive to acute changes in
nutritional status.
- Albumin level is a reflection of a balance between hepatic synthesis,
degradation and losses from the body
- Levels may be altered for factors other than malnutrition.
- In acute stress due to infection, surgery, and multi-trauma, albumin
levels are generally very low as a consequence of decreased synthesis,
increased degradation, transcapillary losses and fluid replacement.
b. Prealbumin
- More reliable indicator of nutritional status than albumin because
its half life of 24 to 48 hours makes the plasma concentration more
reflective of the current nutritional state
- However prealbumin may also be altered by other situations such
as hepatic or renal failure, and infection
II. Indications for initiation of artificial nutritional support
Preexisting nutritional deprivation.
Anticipated or actual inadequate intake by mouth. For well-nourished adults,
inadequate oral intake of 7-14 days. Earlier intervention is necessary in patients
who are already malnourished. However the length of starvation tolerated by
each patient will vary depending on previous nutritional status and reserves, and
current metabolic demands.
3. Significant multiorgan system disease or critically ill patients.
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III. Route of artificial nutrition
Enteral vs Parenteral Route: "If the gut works, use it." The enteral route is preferred over
the parenteral route provided that there is a functional gut and there are no
contraindications such as ileus, gastrointestinal ischemia, bilious or persistent vomiting,
or mechanical obstruction.
IV. Type of Access and Site of Administration
Access can be intragastric (eg, nasogastric or gastrostomy tubes), or transpyloric (eg,
nasoduodenal, nasojejunal). Intragastric feedings are generally preferred due to their
more physiologic nature, but transpyloric feedings may be selected in patients at risk for
aspiration.
For the short-term feeding (<30 days), nasogastric or nasoenteric tubes are preferred over
gastrostomy or jejunostomy tubes
A. Enteral Feeding
1. Gastric Feeding
a. Intragastric feeding is well tolerated by most patients.
b. It is a physiological route - it can buffer gastric acid better and is able to
tolerate a larger volume and osmotic load than post-pyloric feedings.
c. Easy to place; Orogastric or Nasogastric tubes are relatively safe
procedure and requires minimal training
2. Post-pyloric feeding
a. The most common indications are:
 Pulmonary aspiration
 Severe GERD and esophagitis
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Recurrent emesis
Post surgery/multiple trauma
Gastric, antroduodenal dysmotility
Patients with decreased bowel sounds and those on paralytic
agents. In both settings gastric motility may be impaired more
than intestinal motility.
3. Jejunal feeding
a. The most common indications are:
 Recurrent aspiration of gastric contents
 Esophageal dysmotility with a history of regurgitation
 Delayed gastric emptying
Frequency of Feeding, Tolerance and Monitoring
1. The initial feeding regimen should be dictated by the patient's clinical status. A stable
patient can be started on bolus NG feeds, whereas less stable patients may be started with
continuous gastric feeds.
2. Feeding tolerance must be continually assessed by monitoring stool frequency, the
presence of diarrhea, abdominal distension, urinary output, and vomiting.
3. Monitoring of gastric residual volumes needs to be done frequently to assess
tolerance, although a single high residual volume should not lead to unnecessary
interruption of feed but should be rechecked in 1 hour.
B. Parenteral Feeding
1. After literature review, and based on meta-analysis of 82 randomized controlled trials,
American Gastroenterological Association (AGA) recommends parenteral nutrition may
improve clinical outcomes in patients with short bowel syndrome and in post-operative
patients with esophageal or gastric cancers.
2. No clear benefit in mild acute pancreatitis, acute exacerbation of IBD, chronic
pulmonary disease, or AIDS.
3. Parenteral nutrition (TPN and PPN) increases catheter-associated infections and
thrombosis
a. Nutrition solutions should be infused into a large central vein and location of
the catheter tip must be confirmed radiographically and must be documented in
the medical record.
b. There is risk of intimal damage from the catheter and infusate and
thrombophlebitis.
c. Solutions infused in a non-central catheter should be limited in osmolarity and
these generally provide inadequate calories unless infused at a high rate.
Review Questions:
1. A 74-year-old man is transported to the emergency department by ambulance for
evaluation of cough, dyspnea, and altered mental status. Upon arrival, the patient is noted
to be minimally responsive. Results of physical examination are as follows: temperature,
102.1, heart rate, 116 beats/min; blood pressure, 94/62 mm Hg; respiratory rate, 34
breaths/min; and O2 saturation, 72% on 100% O2 with a nonrebreather mask. The patient
is intubated in the emergency department, and mechanical ventilation is initiated, and the
patient is admitted to the medical intensive care unit for further management. The intern
on call inquires about the appropriateness of initiating nutritional support (enteral or
parenteral feeds) at this time.
Which of the following statements regarding nutritional support is true?
A. Enteral nutrition is less likely to cause infection than parenteral nutrition.
B. Parenteral nutrition has consistently been shown to result in a decrease in
mortality, compared with standard care
C. The use of oral supplements in hospitalized elderly patients has been shown to
be harmful
D. Parenteral nutrition is the preferred mode of nutrition in cancer patients
because of its lower incidence of infections
Answer: A
Concept: To understand that enteral nutrition is less likely to cause infection
than parenteral nutrition
Comparisons of enteral nutrition with parenteral nutrition have consistently
shown fewer infectious complications with enteral nutrition. Elderly should
receive supplemental feeding, if they are incapable of eating adequately. A trial of
elderly hospitalized patients showed that patients receiving oral supplements had
lower mortality, better mobility, and shorter hospital stay.
2. A 64-year-old man with a long history of poorly controlled diabetes is diagnosed as
having gastroparesis on the basis of his medical history and transit tests showing delayed
gastric emptying. He is referred to you for long-term treatment.
Which of the following should NOT be included in your treatment strategy?
E.
F.
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Correction of dehydration and electrolyte and nutritional deficiencies
Pro-kinetic therapy with metoclopramide or erythromycin
Vagotomy
Anti-emetics as needed
Answer: C
Concept: To know the major modalities used in the treatment of gastroparesis
The major treatment approaches for the patient with a gastric or small bowel
motility disorder include correction of fluid, electrolyte, and nutritional
deficiencies; the use of pro-kinetic agents such as metoclopramide and
erythromycin; the use of anti-emetic agents for symptomatic relief; suppression of
bacterial overgrowth (if present); decompression in severe cases; and surgical
resection if the disorder is determined to be isolated to one discrete area of the
gut. Vagotomy can actually cause gastroparesis and should be avoided.
3. A 38-year-old man with debilitating Crohn's disease who is status post a 40 cm ileal
resection presents for evaluation. He recounts progressive non-bloody diarrhea since his
surgery 9 months ago, which is worse in the evening. He denies having abdominal pain,
nausea or vomiting, fevers, chills, or sweats. He reports no recent travel, camping, or use
of antibiotics. The exam is unrevealing. Chemistries show modest hypokalemia and mild
non-anion gap acidosis. Fecal fat quantitative analysis reveals minimal steatorrhea.
Which therapy is most likely to help this patient?
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B.
C.
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E.
Cholestyramine
Loperamide
Tetracycline
High-protein, low-fat diet
Safflower oil before meals
Answer: A
Concept: To understand the effects of ileal resection on absorption, and
recognize the appropriate therapy to minimize these effects
Ileal involvement is a common component of Crohn disease (regional enteritis)
and may result in a poorly functioning ileum or even require resection. With
moderate resections (30 to 100 cm), as in this case, malabsorption of bile salts is
significant and results in bile salts entering the colon. This can lead to a secretory
diarrhea known as choleretic enteropathy, the causal mechanism of which is bile
salt-induced chloride secretion. Cholestyramine reduces the distal delivery of bile
salts, thus lessening the diarrhea, and would be the most appropriate therapy in
this patient. With larger ileal resections (>100 cm), steatorrhea predominates and
cholestyramine may actually exacerbate the diarrhea. Therapy for patients
undergoing larger resections is similar to that for patients with short bowel
syndrome, antimotility agents such as loperamide, and steps to increase the
proportion of medium-chain fatty acids, which do not require bile salts for
absorption. Safflower oil may also be used preprandially to act via peptide YY to
slow gastric emptying, but it would be less useful in bile salt-induced diarrhea.
Tetracycline is used to treat the bacterial overgrowth syndrome.
4. A 32-year-old man with AIDS who is experiencing chronic diarrhea, anorexia, and
wasting is referred for evaluation for nutritional support. Results of physical
examination are as follows: temperature, 97.6 F; heart rate, 67 beats/min; blood
pressure, 102/62 mm HG; respiratory rate, 12 breaths/min; height, 70 in; and weight,
50 kg. The patient appears chronically ill; there is bitemporal wasting, and his hair is
easily pluckable. The patient says he has friends with AIDS who are receiving “I.V.
nutrition,” and he would like to know if such therapy would benefit him.
Which of the following statements regarding home total parenteral nutrition
(TPN) is true?
I. Evidence demonstrates improved survival and quality of life in patients with
metastatic cancer who are receiving home TPN.
J. Evidence demonstrates improved survival and quality of life in patients with
AIDS who are receiving home TPN
K. Evidence demonstrates improved survival and quality of life in patients with
short bowel from Crohn disease who are receiving home TPN
L. No evidence supports the use of home TPN in any patient population
Answer: C
Concept: To understand which patients clearly benefit from home TPN
Patients with intestinal failure from a short bowel, chronic bowel obstruction,
radiation enteritis, or untreatable malabsorption can be nourished by TPN at
home. Long-term success has been achieved with tunneled silicone rubber
catheter or an implanted reservoir. Premixed nutrients are infused overnight. The
catheter is then disconnected and a heparin lock applied, leaving the patient free
to attend to daily activities. Survival of patients with short bowel resulting from
the treatment of Crohn disease or pseudo-obstruction is excellent. Home TPN
increases quality-adjusted years of life in these patients and is cost-effective. On
the other hand, mean survival in AIDS patients or those with metastatic cancer
who receive home TPN is about 3 months. There is no evidence that home TPN
prolongs survival for these patients or enhances their quality of life. Trials are
urgently required to justify the use of home TPN in patients with terminal cancer
and AIDS.
CASE
You are consulted by the orthopaedic physician to evaluate a 96 yo female, s/p hip
fracture and subsequent ORIF 1 week ago, for management of diabetes and
hypoglycemic episodes. You find that patient has been placed on her regular outpatient
medications for diabetes which includes Lantus 10 units SQ qam and a regular sliding
scale insulin. Her cbg’s for the past few days have been fluctuating between 40 and 150.
You proceed to patient’s bedside and find a very thin elderly woman who appears to be
sleeping/sedated on her morphine pca; she is arousable, but falls back asleep quickly.
Patient’s family indicates that patient has been suffering from a lot of pain and the pca
pump is helping manage it. You also note a physical therapy note which indicates that
patient is weak, groggy and in pain, unable to participate in therapy most days. Family is
concerned that patient is weak and not going to make it and asks you for help. With
regards to her diabetes, they tell you that that the patient has been taking this current
amount of Lantus for the past several years without adverse effects and don’t understand
why she is getting low blood sugars now.
1. What is your differential for her hypoglycemic episodes?
Most likely is that she is not eating adequately after the surgery suggested by her being
groggy on most of the physical therapy notes. The amount of insulin she is given is
probably too much in the current situation. The amount of insulin which she required
before the hospitalization (Lantus 10 units) was the right amount for her then, and reflects
her amount of oral intake and food choices at home, both of which are altered currently.
Other considerations are that there is a medication error and she was given more insulin
than recorded, although the hypoglycemic episodes have occurred multiple times over
several days.
2. How would you like to adjust her insulin?
Many approaches, but until you can document her actual po intake, it would be unsafe to
continue her insulin.
3. What do you think is her current amount of oral intake and how can you assess
that over the next few days?
Probably not adequate given her groggy and hypoglycemic episodes
You could order a 48 hour calorie count or have nurses document % meal eaten at each
meal for the next two days.
4. What should you do about her pain control and her sedated state?
You should turn down or turn off the pca pump so you can evaluate the patient while she
is more alert and assess her needs for pain control and adjust apropriately. You should
find out more about the pain. Find out if she has pain during the day, throughout the day,
during the night, first thing in the morning, whether this is constant or recurs every few
hours, etc.
Patients on the pca sometimes do not do well for several reasons. When they fall asleep,
without a basal rate, the pain would probably wake them up in a few hours when the iv
morphine has worn out and this doesn’t allow for adequate rest. If they sleep through the
night, without a basal rate, they have now probably not pushed any pca button for 4-6
hours (while asleep) and will wake up with severe pain. Because the pca rate and
frequency is set, they cannot bolus themselves when they wake up in severe pain.
Morphine and a lot of other narcotics are associated with nausea which interferes with
eating.
So the ideal situation would be to address her pain needs, maintain alertness so the patient
is able to participate with rehab and eat adequately.
5. What is the nutritional status of this hospitalized patient provided by the
information above?
History and limited physical exam reveals:
 pre-existing malnutrition status: suggested by patient being very thin with
probably little nutritional reserve
 Altered food consumption: now groggy for days as noted in therapy notes,
interfering with her ability to eat
 Gastrointestinal derangements: Patient may also have gastroparesis and it needs to
be evaluated once patient is able to wake up and have a discussion.
 Decreased functional capacity: due to surgery itself and not participating with
physical therapy.
Further examination may reveal muscle wasting or loss of adipose tissue, presence of
edema or ascites
6. What lab would be helpful to assess her past and current nutritional status?
Patient has been hospitalized for about 10 days now, and therefore albumin would be a
good marker for her previous nutritional status since the half-life is 14-21 days
For her current nutritional status, pre-albumin level would serve well.
7. Does this patient have indications for initiation of artificial nutritional support?
Yes, this patient probably has preexisting nutritional deprivation given her body habitus
and an actual inadequate intake by mouth currently for several days to a week estimated.
8. What would be most appropriate route of nutrition in this patient, enteral or
parenteral nutrition?
Enteral nutrition via nasogastric route, no contraindications exist in this patient that we
know of yet.
9. Should the patient be allowed to eat or remain NPO while she receives tube
feeding?
Patient should be allowed to eat and when able to take adequate nutrition, tube should be
discontinued.
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
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