theoretical nutrition and patient assessment t r wilson
TRANSCRIPT
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Theoretical Nutrition and Patient Assessment
T R Wilson
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WHY IS NUTRITION IMPORTANT?
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Prevalence Malnutrition in Hospital
• 30% Overtly malnourished• 8% Severely malnourished
• Screen all hospital admissions– Weigh (BMI) – Ask if they have lost weight– Ask when they last ate properly
MUST SCORING
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Malnutrition and Surgical Complications
Morbidity Mortality0
10
20
30
40
50
60
70
80
Well NoursihedMalnourished
Perc
enta
ge P
atien
ts
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ASSESSING PATIENTS
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Who is at risk nutritional problems?
• Hospital patients (1/3)• Prolonged ITU stay• Prolonged fasting• Cancer patients• Crohn's Disease• Post (and Pre) bariatric surgery• Elderly• Chronic alcoholic abuse• Anorexia Nervosa
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MUST Score
• Screening tool• 3 elements– BMI
• >20 = 0 18.5-20 = 1 <18.5 = 2
– % Weight loss last 3-6 months• <5% = 0 5-10% = 1 >10% = 2
– Acute disease effect• Acute illness, no nutritional intake ≥ 5 Days = 2
• Score from 0 to 6• 2 or more is high risk → dietician input
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Assessment Nutritional Status
• Where has patient come from?– Long term history of nutritional problem– Risk factors– History of weight loss– History of inadequate intake
• Where is patient currently?– On going / current pathologies (cancer?)– Sepsis– Hydration/electrolyte status
• What you can do? – Where are you going?– What is likely course of their pathology– What is their likely nutritional intake in next 48 hours / week / longer?
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Meeting Nutritional NeedsAssessment Provision Monitoring
Normally Nourished Ward Staff Catering Admission weightWeekly Weight
Under Nourished(BMI < 20)
(Weight loss >10%)
Ward StaffDieticians
Catering+/- Sip Feeds
Admission weightWeekly WeightIntake RecordsBiochemistry
Partial Intestinal Failure
(Functioning Gut)
Ward StaffDieticians+/- NST
Enteral Feed+/- Sip Feeds+/- CateringVia NG/NJ/PEG
Admission weightWeekly WeightIntake RecordsBiochemistryClinical (≥2x/week)
Intestinal Failure(Gut not
functioning)
NST Parenteral Nutrition+/- Enteral FeedVia CVP line
Daily Assessment(Clinical, fluid balance, biochem)Weight 2x/week
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PATHOPHYSIOLOGY(WHAT GOES WRONG AND HOW TO FIX IT SAFELY)
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Reductive Adaptation of Malnutrition
Reduced Intake
Reduced Mass Reduced Work
Altered Metabolism and Physiology
Altered Body Composition
Loss of Reserve
Brittle Metabolism
Loss Homeostasis
InfectionTraumaSmall bowel overgrowth
Excess Energy/ProteinAbnormal LossesSpecific Deficiency
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Basal Metabolic Demand
• Mechanical Work– Cardiac Output/Ventilation/Movement
• Turnover Substances– Amino acids / Protein– Glucose / Glycogen– Fatty acids / TAG
• Transport across membranes– Substrates / Products– Electrolytes (Na/K pumps)
10%
20%
70%(67%)
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Electrolyte Shifts• Down regulation of Na/K pumps• Leaking of K, Mg, PO4 out of cells– → High serum K/Mg/PO4– → Renal excretion – → Decreased body levels
• Leaking of Na into cells– → Low serum Na– → Renal conservation– → Increased body levels Na
• Fluid follows Na– → General fluid retention → Oedema– → Fluid shift into cells
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Nutritional Oedema
• Impaired membrane function– Down regulation Na/K pumps– Free radical damage
• Salt and water retention– Impaired renal function– Potassium/phosphate depletion– Acid-base imbalance
• Hypoalbuminaemia– Decreased synthesis (minor long term)– Third space loss (SIRS, Sepsis, Membrane damage)
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Problems of Na, Cl and Fluid excess• Left ventricular failure• Oedema• Skin breakdown• Hyperchloraemic acidosis• Ileus• Anastomotic and wound dehiscence• ↑ PN requirement• ↑ Length of Stay• ↑ Death
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Loss Homeostasis
• Increased Toxins / Free radicals– Infection / Trauma– Iron (from RBC breakdown)– Small bowel overgrowth
• Reduced protection– Vitamins: B1, B2, B6, C, E, niacin, β carotene– Elements: Cu, Se, Zn, Mn– Other: Glutamine, Glycine, Cystine
• Electrolyte and fluid shifts• Decreased body stores – e.g. glycogen
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Starvation
AA
Micronutrients
Enzyme
Co Enzyme
(e.g. Thiamine, Riboflavin, Pyridine, Iron, Zinc, Copper)Catabolism
AA
PN
PROTEIN
Refeeding
AA AA
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Sepsis and malnutrition
• Malnourished → immunosuppression • May not mount typical immune response– Normal bloods– Hypothermia rather than temperature
• Refeeding / over feeding → further immunosuppression
• BEWARE THE DEADLY TRIAD– Low BMI– Hypoglycaemia– Hypothermia
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Problems of over feeding / over enthusiastic early nutritional support
• Excess Nitrogen delivery– May produce toxic amino-acids– Drive ammonia and urea production– High renal solute load → contribute to Na retention
• Metabolic instability• Insulin resistance and hyperglycaemia• Liver dysfunction/diversion• Immunosuppression• Re-feeding syndrome
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Refeeding Syndrome (definition)
• Potentially lethal• Occurs in malnourished patients undergoing
re-feeding• Can occur with any route of feeding • Results in severe electrolyte and fluid shifts• Associated with metabolic abnormalities• (Nearly 1% all hospital patients)
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Refeeding Pathophysiology
Starvation• Protein catabolism• Gluconeogensis• ↑ Insulin resistance• ↓ soluble B vit levels• Down regulation cellular
pumps– Extracellular leakage
K/PO4/Mg– Excretion of K/PO4/Mg– Intracellular Na retention– Renal Na conservation
Refeeding• On going aa metabolism• ↑glucose metabolism• ↑Insulin• ↑ Thiamine utilisation• Reactivation cellular
pumps– Intracellular uptake
Na/PO4/Mg– Low serum levels
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Specific refeeding problems
• Electrolyte disturbance– Weakness, seizures, arrhythmias, tetany,
paraesthesia• Heart failure / pulmonary oedema• Infection (CRP and WCC may not rise)• Hyper/hypoglycaemia– Risk of brain damage / Wernicke's
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Avoiding all refeeding syndromes
• Start at appropriate low rate– 5 Kcal/Kg/Day in extreme cases– 10 Kcal/Kg/Day in severe cases– Half requirements 20/Day for less severe re-feeding
risk• Gradually increase over 4-7 days• Replace electrolytes aggressively• Vitamin supplementation (Thiamine)• Monitor observations