nutrition risk assessment 2017

CURRICULUM VITAE

Officer Position/Rank : Senior Lecturer/ IV ePhone : Office : 0411- 585705, 0411-585 706, Home : 0411- 586-545, Fax: 0411.586 984Email : pudji_taslim@yahoo.com

EDUCATION : Dokter (FK UNHAS, 1984)

Diploma Community Nutrition (SEAMEO UI, 1990)

MPH Nutrition (Univ. of Carolina at ChapeI Hill, USA (1994)

Doktor, Pasca Sarjana Universitas Hasanuddin (2004)

Guru Besar UNHAS (2006)

Job Description: Ketua Perhimpunan Dokter Gizi Klinik Indonesia

Ketua SMF Gizi Klinik RS Wahidin Sudirohusodo, Makassar

Ketua Komisi 2 Senat Akademk Bidang Penelitian & Pengabdian Masyarakat

Ketua Senat Fakultas Kedokteran Univ Hasanuddin

Anggota Pokja Ahli Dewan Ketahanan Pangan Nasional, Kementerian Pertanian RI

Anggota Panel Ahli HIV/AIDS Kementerian Kesehatan RI

Ketua SP3T Prov.Sulawesi Selatan

Prof DR dr Nurpudji A Taslim, MPH, SpGK (K)

NUTRITIONAL ASSESSMENT AND APLICATION IN CRITICAL

ILL PATIENTS

Nurpudji A. Taslim

Dept. of Nutrition School of Medicine Universitas Hasanuddin

Clinical Nutrition Functional Unit Wahidin Sudirohusodo Hospital

2017

Workshop Update in Nutrition : Optimizing Nutrition Therapy in Critical Care, 12/11/2017

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OUTLINE

• Learning objective

• Overview

• Screening and assessment of nutrition in critical ill patients

• Nutritional management on critical ill patients

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Therapy in Critical Care 3

LEARNING OBJECTIVE

• able to know nutritional screening andnutritional assessment in critical ill patients

• able to do nutritional screening and nutritionalassessment in critical ill patients

• able to know nutritional therapy in critical illpatients

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OVERVIEW

• Identifying patients at nutrition risk difficult inthe intensive care unit (ICU) due to the nature ofcritical illness.

• Traditional screens and assessments are oftenlimited due to their subjective nature.

• Accurately identifying patients at risk formalnutrition is essential to decrease negativeoutcomes during hospitalization.

• Inflammation was the importance factor causemalnutrition.

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Therapy in Critical Care 5

OVERVIEW

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Screening tools recommended by ESPEN (2017)

Community: Malnutrition Universal Screening Tool (MUST) rapid estimate grade undernutrition

Hospital: Nutritional Risk Screening (NRS)

simple and well validated (Quesionaires)

Elderly: Mini Nutritional Assessment (MNA) pt >65 y,o—combination screening & assessment tool

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Nutrition Therapy in Critical Care7

Nutric-Score for Risk Screening in the ICU(age, apache II, sofa, co-morbid, days from hospital to ICU, IL-6)

SCREENING AND ASSESSMENT OF

NUTRITIONAL RISK IN CRITICAL ILL

PATIENTS

• Many of criteria to identifying nutrition riskwere difficult to obtain such as :– food intake histories

– functional status and gastrointestinal (GI) symptoms

because it require patient interview or previousknowledge of body habitus.

• Many traditional tools do not provideinformation regarding inflammatory status.

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Therapy in Critical Care 8

SCREENING AND ASSESSMENT OF

NUTRITIONAL RISK IN CRITICAL ILL

PATIENTS

• The institution’s routine screening :– recent unintentional weight loss (5% in 1 month, 10% in 6

month)

– BMI < 18.5 or > 40

– presence of dysphagia/inadequate food intake prior toadmittance or use of enteral nutrition (EN)/parenteral nutrition(PN)

• Patient meeting at least 1 criterion were deemedat risk for malnutrition

• This screening do not provide inflammatorystatus

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Therapy in Critical Care 9

SCREENING AND ASSESSMENT OF NUTRITIONAL

RISK IN CRITICAL ILL PATIENTS

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Therapy in Critical Care 10

SCREENING AND ASSESSMENT OF NUTRITIONAL

RISK IN CRITICAL ILL PATIENTS

• Subjective Global Assessment (SGA) :– this tools had a variety of criteria to identify nutrition risk,

including clinical diagnosis, laboratory data, physicalexamination, anthropometric data, food/nutrient intake andfunctional assessment.

– these indicators were primarily validated in outpatients orgeneral hospitalized population, they were not specificallydesigned for use in the ICU.

– many of these criteria may be difficult to obtain in critically illpatients.

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Therapy in Critical Care 11

SCREENING AND ASSESSMENT OF NUTRITIONAL RISK IN CRITICAL ILL PATIENTS

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SCREENING AND ASSESSMENT OF

NUTRITIONAL RISK IN CRITICAL ILL

PATIENTS

• The NUTrition Risk in Critically ill (NUTRIC)score :– a tool introduced by Heyland et al, to identify patients who

would most benefit form aggressive nutrition support in the ICU

– this tool linking starvation, inflammation and outcomes

– however, this tool includes no traditional markers of nutritionrisk, such as body mass index (BMI), weight status, oral intakeor physical assessment, and may have limited clinicalapplication due to its exclusion of nutritional history variables.

– patients were classified as having a higher risk of malnutrition ifthe sum was 5 or greater

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Therapy in Critical Care 13

SCREENING AND ASSESSMENT OF NUTRITIONAL RISK IN CRITICAL ILL PATIENTS

Patients with a high Nutric-score at admittion to the intensive care have a highermortality risk.

Rosa Mendes, et al, Nutritional risk assessment and cultural validation of the modifiedNUTRIC score in critically ill patients—A multicenter prospective

cohort study, Journal of Critical Care 37 (2017) 45–49

Conclusions: Almost half of the patients in ICU are at high nutritional risk. NUTRIC score was strongly

associated with main clinical outcomes.

Anne Coltman,et al, Use of 3 Tools to Assess Nutrition Risk in the Intensive Care Unit, Journal of Parenteral and Enteral Nutrition Volume 39 Number 1 January 2015 28–33

1. The institution’s routine nutrition screening method,

2. the Subjective Global Assessment (SGA)

3. NUTRIC) score

SCREENING AND ASSESSMENT OF NUTRITIONAL

RISK IN CRITICAL ILL PATIENTS

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Therapy in Critical Care 18

SCREENING AND ASSESSMENT OF NUTRITIONAL

RISK IN CRITICAL ILL PATIENTS

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Therapy in Critical Care 19

many patients met criteria for more than 1 tool, furtherinvestigation into risk classification was needed toaccurately identified trends.only 9 (6%) patients met criteria for all 3 tools

SCREENING AND ASSESSMENT OF NUTRITIONAL RISK IN

CRITICAL ILL PATIENTS

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Therapy in Critical Care 20

patients identified as at nutrition risk or malnourished using both NUTRIC and SGA had the longest hospital LOS and ICU LOS

patients at nutrition risk using only the institution’s screening tool and NUTRIC had the shortest ICU LOS

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• Nutrition care is considered to be a basic andmandatory (essential) element of modern intensivecare treatment

• Nutrition care in the ICU has several challenges :– the usual control mechanism such as hunger and thirst may be

missing during critical illness

– the control of intake is under external control, nutrients may have acomplex interactions with various organ systems

– acute illness triggers internal production of nutrients, usually calledcatabolism, that does not immediately stop when external nutrientwere given

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Therapy in Critical Care 21

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• The challenge of nutrition science and nutritioncare is to define to margin :

– the minimal requirement for macro and micronutrientnecessary for acute illness and the maximum tolerable margin

– a new concept is that minimal requirements and maximumtolerable concentrations vary during the course of acute illness

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Therapy in Critical Care 22

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

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Therapy in Critical Care 23

Figure 3. Margins for macronutrient between minimum and danger zone

*during health conditions, minimum and danger zone was constantly

*but in acute illness, there is a change and endogenous mobilization ofmacronutrients combined with external supply of nutrients , thus thedanger limit and minimum may be changed

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• The ESPEN guidelines state that :

– 20-25 kcal/kg/d in the acute and initial phase ofcritical illness

– 25-30 kcal/kg/d in the anabolic recovery phase

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Therapy in Critical Care 24

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

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Figure 4. actual body weight vs calorie intake

The arrows represent the progressive increase in calories that may be appropriate after initial stabilization and when patients

are becoming anabolic

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• Amount of protein needed :

– In principle the amount of protein needed should besufficient to cover usual protein turn-over plus theadditional needs related to the increased proteinsynthesis in the liver and in injured tissues.

– 1.0 -1.5 g/kg/d is sufficient

– Protein breakdown associated with starvation needsseveral days before a decrease occurs.

– There is an additional breakdown associated with theinflammatory process but also with bed-rest and disuse ofmuscle.

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NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• Modifications in the composition of the diet are consideredin three clinical situations:

Difficult to handle hyperglycaemia

Excessive hyperlipidaemia ( > 400 mg.dl-1)

High CO2 values and weaning problems

• Increased nutritional requirements during critical illnessmust be matched by appropriate infusion of calories andnitrogen, especially when severe malnutrition is present, inthe case of insufficient oral intake or expected delay beforerecovery of eating;

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NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• Early enteral nutrition can be systematically considered inpatients unlikely to recover their ability to eat within 48hours after injury; if not achievable, parenteral nutritionshould be considered soon or later;

• Inappropriately high amounts of energy-yielding substratescan lead to detrimental effects, especially after a long periodof fasting;

• Avoid underfeeding in critical ill patients

• The administration of an appropriate amount of nutrients bythe oral or enteral route is preferred over a parenteralinfusion.

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NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

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Nutrition Therapy in Critical Care29

Figure 5. Algorithm to avoid underfeeding

NUTRITIONAL THERAPY IN

CRITICAL ILL PATIENTS

• However, significant barriers can impede the enteraladministration of nutrients, including gastroduodenaldysfunction reflected by high gastric residual volumes, anddiarrhoea and constipation.

• Possible solutions are suggested. In case of contraindicationor failure of enteral nutrition, parenteral nutrition isindicated -----as a replacement or a supplement to failingenteral feeding.

• The perfect timing of supplemental parenteral nutrition(early or late) remains uncertain, and parenteral nutritionshould be carefully monitored.

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Nutrition Therapy in Critical Care30

THANK YOUHave a nice day

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