Concepts in Clinical Nutrition Özlem Korkmaz Dilmen Associate Professor of Anesthesiology and Intensive Care Cerrahpasa School of Medicine Types of Malnutrition Marasmus ID: 311151
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Slide1
Basic Concepts in Clinical Nutrition
Özlem Korkmaz Dilmen Associate Professor of Anesthesiology and Intensive CareCerrahpasa School of MedicineSlide2
Types of Malnutrition Marasmus
KwashiorkorMixedBecause this is a disease with multiple etiologies, the best terminology would probably be polydeficient malnutrition.
Green CJ.
Clin Nutr
1999;18(s):3-28
Slide3
Hospital Malnutrition: Critical EvidenceThe Skeleton in the Hospital Closet
Height not recorded in 56% of casesBody weight not recorded in 23% of cases61% of those whose weight was recorded lost > 6 kg37% had albumin < 3.0 g/dL
Butterworth CE.
Nutr Today
1974
“
I am convinced that iatrogenic malnutrition has become a significant factor in determining disease outcomes in many patients.
”Slide4
Hospital Malnutrition: Prevalence Numerous
studies on hospital malnutrition have been published.Prevalence of
malnutrition
in U.S.
hospitals
today
ranges
from
30%
to
50%.
Patient’s nutritional status declines with extended hospital stay.
Coats KG et al.
J Am Diet
Assoc
1993Slide5
Malnutrition Among Hospitalized Patients:A Problem of Physician AwarenessUp to 50% of hospitalized patients may be malnourished on admission
Before nutritional assessment training: – Only 12.5% of malnourished patients are identifiedAfter 4 hours of training: – 100% of patients are identified
Roubenoff
et al.
Arch Intern Med
1987 Slide6
Prevalence of Malnutrition in Hospitalized PatientsIn a
published British study:46% of general medicine patients 45% of patients with respiratory problems27% of surgical patients43% of elderly patients Percentage of malnourished patients at time of
admission
McWhirter
et al.
Br Med J
1994Slide7
Prevalence of Malnutrition inHospitalized Patients
69% Adequate Nutritional State
21%
Moderately
Malnourished
10%
Severely
Malnourished
Detsky
et al.
JPEN
1987Slide8
Malnutrition and its ConsequencesChanges in intestinal barrierReduction in glomerular filtration
Alterations in cardiac functionAltered drug pharmacokineticsRoediger 1994; Green 1999; Zarowitz 1990Slide9
Malnutrition and its ConsequencesLoss of weightSlow wound healing
Impaired immunity Increase in length of hospital staysIncreased treatment costsIncrease in mortality Slide10
Malnutrition and Increased ComplicationsMany studies have shown that complications are 2 to 20 times more frequent in malnourished patients than in well-nourished patients.
Buzby et al. Am J Surg 1980Hickman et al. JPEN 1980
Klidjian
et al.
JPEN
1982Slide11
Malnutrition and Slow Wound HealingFoot
Amputation86% of well-nourished patients healed without problemsOnly 20% of malnourished patients healed successfully Dickhaut SC et al. J Bone Joint
Surg
Am
1984Slide12
Malnutrition and Increased Complications42% of severely malnourished patients suffer major complications9% of moderately malnourished patients suffer major complications
Severely malnourished patients are four times more likely to suffer postoperative complications than well-nourished patients Detsky et al. JAMA 1994 Slide13
Risk of Malnutrition – Hospital Costs
Cost per Patient(US dollars)
Pneumonia Intestinal Surgery Complications
Reilly J et al.
JPEN
1988
Slide14
Nutritional Assessment Collect and evaluate clinical conditions, diet, body composition and biochemical data, among othersClassify patients by nutritional state: well-nourished or malnourishedSlide15
Nutritional Assessment Slide16
Nutritional Assessment Slide17
Nutritional Screening Involuntary increase or decrease in weight > 10% of usual weight over 6 months or
> 5% of usual weight over 1 monthInadequate oral intakeBarrocas et al. J Am Diet Assoc 1995;95:647-648. Slide18
Nutritional Assessment: Body Composition Parameters Weight and height
BMI = weight / height2Triceps or subscapular thickness of skin fold Mid-arm muscle circumference and mid-arm muscle areaSlide19
Nutritional Assessment:Biochemical Parameters Heymsfield SB, et al. In: Modern Nutrition in Health and Disease.
Philadelphia, PA: Lea & Febiger;1994:812-841.
At Risk Level
Serum albumin < 3.5 g/dL
Total lymphocyte count < 1500 cell/mm
3
Serum transferrin <140 mg/dL
Serum pre-albumin < 17 mg/dL
Total iron-binding capacity < 250 mcg/dL
Serum cholesterol < 150 mg/dL Slide20
Identification of malnutrition(biochemical parameters)Serum Proteins
Serum albumine 13 – 19 days Serum transferrine 7.5 days Serum prealbumine 1.9 days Ferritin binding protein 2.1 days IgA & IgM 5 – 6 daysSerum cholesterol < 150Total lymphocytes count < 1500 mm3Slide21
Subjective Global Assessment (SGA)Detsky AS, et al.
JPEN 1987;11:8-15.
1. Weight changes
2 Changes in dietary intake
3. Gastrointestinal symptoms
4. Functional capacity
5. Link between disease and nutritional requirements
6. Physical exam focused on nutritional aspectsSlide22
Nitrogen excretion and balanceUrine (urea,
amonium, creatinine)Stool (nonabsorbable proteins)Dermis (absorbable proteins)Nasal secr., hair loss, menstruation N balance = N intake – N loss (
+) (-)Slide23
Nutritional AssessmentEvery patient should prompt three questionsDoes malnutrition exist?Is malnutrition likely to occur?When and how to correct the situation?Slide24
Does malnutrition exist?anthropometric changesloss of SQ fat, muscle wasting, BMI < 14functional changesmuscle weakness, respiratory effortlab studiesalbumin, transferrin, prealbumin
, RBP, cholesterol, immune functionSlide25
Nutrients necessary for cell metabolism
Macronutrientscarbohydrate 4 kcal/gprotein 4 kcal/gfat 9 kcal/gMicronutrientsVitamins, minerals 0 trace elements, water 0 Slide26
Body CompositionSlide27
Body Mass Index (BW/h2)
14-15 kg/m2 mortality <18.5 - 25> kg/m2 N
>
30 kg/m
2
mortality
Slide28
Nutritional Deficiencydecrease
of food intakeincrease of metabolic requirementsSlide29
Nutritional Deficiency
decrease of food intakeoral feeding is restricted/limitedmalabsorptionneurogenic & psychogenic disordersSlide30
Nutritional Deficiency
increase of metabolic requirements - infection, sepsis, critical illness - major trauma - surgery & postoperative
period
-
cancer
patients
-
painful
stimuli
-
elevated body temperature - burns Slide31
Methods for determining caloric needsResting
energy expenditure (REE) (BEE) (Harris-Benedict, Aub-Dubois, Schoefield) kcal x stress factor
Indirect
calorimetry
(VO2 ; VCO2)
25 – 35
kcal
/kg body
weight
Diet
induced thermogenesis (DEE) fat carbohydrate
protein
Activity
induced
energy
expenditure
(AEE
)Slide32
Total nutritional therapyCaloric provision (30 kcal/kg)
Carbohydrate 50 % 15 kcal/kg (sol. 5 - 50 %) - Protein 20 % 6 kcal/kg (sol. 3 - 10 %) Lipid 30 % 9
kcal/kg
(sol. 3 - 10 %)
Slide33
Nutritional requirements Injury
Minor surgeryLong bone fractureCancerPeritonitis / sepsisSevere infect / traumaMOF syndromeBurnsTemperature +1 C°
Stress
factor
1.00 – 1.1
1.15 – 1.30
1.10 – 1.30
1.10 – 1.30
1.20 – 1.40
1.20 – 1.40
1.20 – 2.00 1.10 – Slide34
Metabolic Response to Injury
“Ebb” Phase (24-48 h)Aims to maintain Homeostasis
Cardiac
output
VO
2
blood
pressure
Tissue
perfusion
Body T°
metabolic
rate
“
Flow
”
Phase
Catecholamins
glucocorticoids
glucagon
Cytokin
release
Release
of
lipid
mediators
,
Production
of
acute
phase
proteinsSlide35
Metabolic response to Injury/Starvation
starvation
injury
/
illness
Metabolic
rate
Body
fuels
conserved
vasted
Body
proteins
conserved
vasted
Urinary
Nitrogen
Weight
loss
slow
rapidSlide36
Route of AdministrationEnteralParenteralCombined; enteral & parenteralSlide37
Route of AdministrationEnteralmore 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 complicationsbetter at preserving gut mucosal integrity and preventing microbial translocationSlide38
Route of AdministrationParenteraluse only if you cannot use the gutbowel surgerybowel obstructionileusnot enough bowel / severe malabsorption
no gut accessSlide39
Use itif the GUT
works