Download Nutritional assessment and provission

Nutritional assessment and provision
Yousif .A Qari MD, FRCPC, ABIM
Consultant Gastroenterologist
KAUH ,Jeddah
Selection of patients for nutritional support
Aim:

To decrease mortality and morbidity related
to defecate of energy, protein and other
nutrients

To provide nutrition support only to those
patients in whom the benefits will exceed
risks.
Indications for nutrition support
Decreased intake
or absorption
Protein-calorie
malnutrition
Increased utilization
4 Traditional Indicators Of Nutritional Status
1. Body Composition



Body weight
Anthropometry
Urinary cratenine excretion
2. Plasma Proteins




Albumin
Prealbumin
Retinol-binding protein
Tranferrin
3. Immune System Function


Total lymphocyte count
Delayed cutaneous hypersensitivity
4. Multivariate Analyses


Prognostic nutritional index
Nutrition risk index
Body Composition

Body weight:



10% or greater unintentional loss in body weight is associated with an adverse
clinical outcome.
<70% of Ideal body weight (IBW)
Anthropometry:

Triceps and sub scapular skin fold thicknesses



provides an index of body fat and muscle mass, which is compared with standard
tables.
markedly abnormal values (below the fifth percentile) usually predict a poor clinical
outcome.
urinary creatinine excretion:


Assessment of body muscle mass
Values can be compared with tables providing an expected amount of creatinine
excretion in relationship to height in subjects consuming a meat-free diet.
Plasma Proteins

Albumin (< 2.1g/dl )

correlate with clinical outcome
increased incidence of medical complications

Other causes of Hypoalbuminemia


Inflammation and injury




Losses through the gut or kidney




GI
renal,
cardiac diseases
Losses from surface tissues.




Decreases albumin synthesis
Increases albumin degradation
Increases albumin transcapillary losses
Wounds
Burns
Peritonitis
Transferrin ( < 100 mg/dl )
Immune system function

Measured by



Total lymphocyte count (< 800/mm³ )
delayed cutaneous hypersensitivity
Associated with a poor clinical outcome.
Multivariate Analyses

Prognostic nutritional index


Correlated with postoperative mortality and complications
4 variables







Alb = serum albumin (g/dl)
TSF = triceps skin fold thickness ( mm )
TFN =serum (transferrin (mg/dL)
DH = delayed hypersensitivity
 0=nonreactive
 1=<5mm induration
 2=>5mm induration
158 – 16.6 (Alb) – 0.78 (TSF) – 0.2( TFN) – 5.8 (DH)
When > 50% ------› increased risk
Subjective Global assessment
Subjective Global Assessment (SGA)

TABLE 51-5 Subjective Global Assessment (SGA) Of Nutritional Status
A. History
1. Weight change
Overall loss in past 6 months: amount = # _________________ kg
Change in past wk: ____________ increase
____________ no change
____________ decrease
2. Dietary intake change (relative to normal)
______________ No change
______________ Change: duration = # __________ wk
type: ______ suboptimal solid diet ________ full liquid diet
______ hypocaloric liquids ________ starvation
3. Gastrointestinal symptoms (that persisted >2 wk)
_________ none __________ anorexia ___________ nausea ___________ vomiting ___________ diarrhea
4. Functional capacity
______________ No dysfunction (e.g. full capacity)
______________ Dysfunction: duration = # ___________ wk
___________ working sub optimally
___________ ambulatory
___________ bedridden
5. Disease and its relation to nutritional requirements
Primary diagnosis (specify) _________________________
Metabolic demand (stress) _____ none ______ low ______ moderate _____high
B. Physical (for each trait specify : 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)
# _______________ loss of subcutaneous fat (triceps, chest)
# _______________ muscle wasting (quadriceps, deltoids, temporals)
# _______________ ankle edema, sacral edema
# _______________ ascites
# _______________ tongue of skin lesions suggesting nutrient deficiency
C. SGA rating (select one)
____________ A = Well nourished (minimal or no restriction of food intake or absorption, minimal change in function, weight stable or increasing)
____________ B = Moderately malnourished (food restriction, some function changes, little or no change in body mass)
____________ C = Severely malnourished (definitely decreased intake, function, and body mass)
Summery of indications of malnutrition

Weight loss > 10% in 6 months

Minimal subcutaneous fat in non-athletes ( measure or estimate
by pinching)

Muscle wasting in the absence of neurological cause(estimate
visually and by palpation)

Serum albumin less than 3 g/dl not resulting from
overhydration,liver disease,or chronic excessive loss from the
intestinal tract or kidneys
Time for beginning nutrition support
Patient nutrition
status
Begin tube feeding if
possible
Begin TPN
Neither hypercatabolic or
malnourished
7 days
14 days
Either hypercatabolic or
malnourished
1 - 5 days
6 -1 0 days
1 - 3 days
1 - 7 days
Patient both hypercatabolic and
malnourished
Calculating calorie and protein goals

Non protein calorie goal:


25-35 kcal/kg/d
Protein goal

1 -2 kcal/kg/d
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
1.
Basal energy expenditure (BEE)

Is the energy used for normal body functions when well,
awake, in a thermoneutral environment, and in a basal
fasting state after overnight bed rest

On average = 20 kcal/kg/d

More accurately calculated by Harris-Benedict equations


Women (kcal/d) = 655 + [9.6 × wt(cm)] +[1.7 × hight(cm)] – [ 4.7
× age(years)]
Men (kcal/d) = 66 + [13.7 × wt (kg)] + [ 5 × hight(cm)] – 6.8 ×
age (years)]
Components of daily energy expenditure (DEE)
Harris-Benedict equations(contd)

These formulas will overestimate energy expenditure for obese
patients. To improve the estimate , we should use the mean of
actual body weight (ABW) + desirable body weight ( DBW)

DBW

Males = 106 pounds + 6 pounds for each inch above 5 feet.

Females = 100 pounds + 5 pounds for each inch above 5 feet.



1 foot = 12 inches = 20 cm
1 inch = 2.5 cm
1 kg = 2.2 pounds
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
2.
Stress hypermetabolism
Calculated by:
BEE × Stress factor [according to medical condition (special
tables values vary from 0.5 to 2.0)] = Resting Energy
Expenditure (REE)
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
3. Non shivering thermogenesis

The energy required to maintain body temperature above
ambient temperature

It is minimal for intact patients with intact skin in temperaturecontrolled environments

Can be ignored.
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
4. Diet-induced thermogenesis:

The energy required to digest, absorb, transport, metabolize, and
store nutrients.

About 10% - 15% of energy administered
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
5. Abnormal energy loss in urine, stool, and drainage from
fistulae ad wounds .

Seldom significant

can be ignored
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
6. Energy expenditure of activity

Ranges from 10% - 30% for most hospitalized patients
Components of daily energy expenditure (DEE)
1.
2.
3.
4.
5.
6.
7.
Basal energy expenditure (BEE)
Stress hyermetabolism
Non shivering thermogenesis
Diet induced thermogenesis
Abnormal energy loss in urine, stool, and drainage from
fistulae and wounds
Energy expenditure from activity
Energy expenditure for weight gain
Components of daily energy expenditure (DEE)
7. Energy expenditure for weight gain:

For 1 pound weight gain we need 3500 kcal
When weight gain is required :
500 kcal /day can be added to the energy goal
= 1pound/week weight gain


Should not be attempted in patients with stress factor above
1.2.

Can be set at 20% of BEE.
General recommendations for
calculating nonprotein calorie intake

Estimate BEE (Harris-benedict formula or 20 kcal/d

Stress hypermetabolism = BEE × stress factor

Add for activity 10% to 30% of BEE

Add for weight gain if indicated 500 to 1000 kcal/d
N.B:

REE = BEE + stress hypermetabolism + non-shivering
thermogenesis
Indirect Calorimetry

The standard method

By measuring carbon dioxide (CO2) production and oxygen (O2)
consumption

the amount of heat produced during substrate oxidation is proportional to
the amount of CO2 produced and O2 consumed.

Indications:






Severely malnourished
Patients in heart failure, or respiratory failure
Diabetics
Morbid obesity
Closed head trauma
Paralysis
Protein goal

The reason for giving protein is to provide nitrogen, not energy

Excessive protein administration to patients may result in:






Azotemia
Osmotic diuresis
Hyperammonemia
Hepatic encephalopathy
Respiratory muscle fatigue
When energy intake is adequate, optimum protein intake for
hospitalized patients ranges from 0.8 to 2.0 g/kg/d
Access for Nutritional Support

Oral

Enteral

Parenteral (Intravenous)


Peripheral
Central
Peripheral TPN

Consists of mixture of





5% to 10% glucose
2% to 5% amino acid
Electrolytes
10% to 20% iv fat emulsion
Low rate of blood flow ( 10 – 50 mls/min) + High osmolality of
peripheral TPN fluid (600-900 mosm/kg) + large volume of
fluids ( 2-3 L/d) → raises osmolality in the vein →
Phlebitis.
Central TPN

Access:
Rt subclavian
 High blood flow (1.5- 2.0 L/min)

Optimal nutritional support
Lists of components
Keep patient nourished
Access
FACE-MTV
KCALS
Special monitoring
Calculate energy and nonprotein goal
Designing TPN formula

In addition to energy and protein content of a TPN formula,
the following are important to remember:
( FACE- MTV )
1.
2.
3.
4.
5.
6.
7.
(F) Fluids
(A) Amino acids
(C) Calories
(E) Electrolytes
(M) Miscellaneous Additives
(T) Trace elements
(V) Vitamins
Designing TPN formula
( FACE- MTV )
1. (F) Fluids:
When fluid restriction is needed ( patient can not take
more than 1000 – 1500 ml of fluids) use:



70% dextrose
15% A.A solution
20% fat emulsion
Designing TPN formula
( FACE- MTV )
2. (A) Amino acids:
A typical standard A.A mixture contains approximately 15 amino acids




45% are essential
20% branched chain (leucine, isoleucine, valine)
12% methionine plus aromatic amino acids(phenylalanine, tyrosine, tryptophan)
Spetial formulas:
Renal Failure:


Higher proportion of essential amino acids
Liver failure:



More branched chain A.A
Less methionine and aromatic amines
Designing TPN formula
( FACE- MTV )
3.(C)Calories:


Fat (10 - 45%)
Carbohydrate
Non protein calories
TPN

Fat

10 - 70% is well tolerated by most patients

20 - 30%

Fewer complication
Greater efficacy
> 50% appropriate for
Diabetics
Pulmonary failure
Designing TPN formula
( FACE- MTV )
3.(C)Calories:


Non protein calories
TPN

Fat

Lipid emulsions
Fat (10 - 45%)
Carbohydrate
Impaired macrophage function
↓ bacterial clearance
Alter immunocompetance
Impaired pulmonary function
Blocks reticuloendothelial system


In sepsis avoid > 1g/kg of lipid emulsions per day( ≤ 30g/d )
Other iv lipids: Fish oil, MCT, and Structured lipids.
Designing TPN formula
( FACE- MTV )
4. (E) Electrolytes:

Standard electrolyte mixtures are suitable for 50 – 80% of
patients receiving TPN.

Specifically adjusted mixtures are needed for Patients with





Electrolyte disturbances
Renal failure
Hepatic failure
Heart failure
Multi organ failure
Designing TPN formula
( FACE- MTV )
4. (E) Electrolytes:
Phosphorous:



15 mmol/800 glucose calories
↓ 2 – 4 days after starting TPN
Potassium:



30 – 40 mEq/800 glucose calories
↓ 6 – 12 hours after starting TPN
Sodium:




30 – 50 mEq/liter of formula
Most cases of hyponatremia are dilutional
True hyponatremia may occur in




Ileostomies
Fitulae
Diarrhea
Renal losses
Designing TPN formula
( FACE- MTV )
4. (E) Electrolytes:
Magnesium:


5 – 10 mEq/mlof TPN
Chloride/Acetate:


Small amount of chloride and larger amount of acetate is provided by
manufacturer in virtually all amino acid mixtures to prevent acidosis
resulting from metabolism of Lysine and Arginine.

Added to standard electrolyte mixtures to prevent metabolic acidosis in
patients with large gastric fluid losses who are not receiving a histamine
receptor antagonists
Designing TPN formula
( FACE- MTV )
5. (M) Miscellaneous additives
Heparin




1 unit/ml is added to central TPN mixtures.
Minimize clotting in the catheter
Decrease fibrin sheath formation on the surface of the
Insulin



Only to manage documented hyperglycemia
Should not exceed 10 units/800 glucose calories
Albumin


To patients with serum level below 2.5 g/dL in conditions like




Capillary leak ( sepsis & burns)
Proteinurea
Protein-losing enteropathy
Should be stopped when serum level reach 3.0 g/dL
Designing TPN formula
( FACE- MTV )
6. (T) Trace elements:

A typical trace element cocktail the is added to daily TPN provides the
following:





Zinc
Copper
Manganese
Chromium
Selenium
= 5.0 mg
= 1.0 mg
= 500 μg
= 10 μg
= 60 μg

No practical way to asses trace element status clinically

Serum levels are difficult to measure accurately

Zinc is the only element likely to be required in larger amounts in


Diarrheal illnesses
Ileostomy output
Designing TPN formula
( FACE- MTV )
7. Vitamins:
Vitamins
Amount
Vitamin A
3300 IU
Vitamin D
200 IU
Ascorbic acid (Vitamin C)
100 mg
Folic acid
400 μg
Niacin
40 mg
Riboflavin (VitaminB2)
3.6 mg
Thiamine (VitaminB1)
3.0 mg
Pyridoxine (VitaminB6)
4.0 mg
Cyanocobalamin (Vitaminb12)
5.0 μg
Pantothenic acid
15 mg
Biotin
60 μg
Vitamin E
10 IU
Vitamin K
1 mg
Central TPN

Special monitoring


Nitrogen balance is the most practical and effective way to estimate the
adequacy of nitrogen and energy administration
Patient should be on constant calorie and nitrogen intake


The test requires 24 h urine collection for urinary urea nitrogen (UUN)
Calculate total urea nitrogen (TUN) by the equation.


TUN = UUN/0.8
Nitrogen balance = N in – N out


N in = g amino acids administered /6.25
N out = TUN (g) + 1 g
Central TPN
Risks and complications



Mechanical
Septic
Metabolic
Central TPN
Metabolic complications










Hyperglycemia
Hypoglycemia
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Hyponatremia
Fluid overload/dehydration
Fat intolerance
Hypercalcemia
Liver test abnormality
Central TPN
Metabolic complications
Hyperglycemia

Serum glucose >200 mg/dL

May lead to dehydration, coma and death

Administration rate of TPN should be reduced if serum
glucose concentration exceeds 350 mg/dL

In a previously stable patient it usually indicates a new
metabolic stress, most often infection
Central TPN
Metabolic complications
Hypophosphatemia:

Intracellular shift caused by glucose

Patients at increased risks
 Chronic alcoholics
 Severely malnourished
 Patients taking anti acids

When severe May result in
 Hemolysis
 Serious effects on Cardio respiratory system
 Affects on WBC function
Central TPN
Metabolic complications
Hypokalemia:

May be caused by :




Glucose
Alkalosis
Hypomagnesemia
Occasionally as much as 150 to 200 mEq may be given per 24
hours.
Central TPN
Metabolic complications
Hypomagnesemia:

Most likely occurs in:




Chronic alcoholics
Severely malnourished
Patients receiving diuretics
When severe (<1.0 mEq/L) should be treated with up to 100
mEq of magnesium sulfate/24 hours via a separate line.
Central TPN
Metabolic complications

Hyponatremia:

Most often dilutional

Should be treated by fluid restriction