nutrition risk assessment 2017
Upload: department-of-anesthesiology-faculty-of-medicine-hasanuddin-university
Post on 22-Jan-2018
176 views
TRANSCRIPT
CURRICULUM VITAE
Officer Position/Rank : Senior Lecturer/ IV ePhone : Office : 0411- 585705, 0411-585 706, Home : 0411- 586-545, Fax: 0411.586 984Email : [email protected]
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
2
OUTLINE
• Learning objective
• Overview
• Screening and assessment of nutrition in critical ill patients
• Nutritional management on critical ill patients
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 4
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.
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 5
OVERVIEW
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 6
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
11/13/2017Workshop Update in Nutrition : Optimizing
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.
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 9
SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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.
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 11
SCREENING AND ASSESSMENT OF NUTRITIONAL RISK IN CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition Therapy in Critical Care
12
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 18
SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 22
NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
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
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 24
NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 25
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.
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 26
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;
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 27
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.
11/13/2017Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 28
NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing
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.
11/13/2017Workshop Update in Nutrition : Optimizing
Nutrition Therapy in Critical Care30
THANK YOUHave a nice day
11/13/2017 31Workshop Update in Nutrition : Optimizing Nutrition Therapy in Critical Care