1b Malnutrition and Nutrition Intervention In the Hospitalised Adult

Question 1

What is meant by malnutrition?

Answer 1

A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome.

Question 2

Which demographic is malnutrition most common in?

Answer 2

Older females, white

Question 3

Which groups are at the highest risk of malnutrition?

Answer 3

Over 65 over, alcohol or drug dependency or chronic progressive disease are at the highest risk of malnutrition

Question 4

What are the three broad categories of causes of malnutrition?

Answer 4

Reduced intake
Maldigestion / malabsorption
Altered metabolism

Question 5

What is disease related anorexia?

Answer 5

Disease = upregulation of pro-inflammatory cytokines which upregulate anorectic cytokines and reduce appetite

Question 6

What are causes of maldigestion / malabsorption in the hospital?

Answer 6

Function
Length
Losses
Drug-nutrient interactions

Question 7

Describe the changes in altered metabolism over the course of a hospital stay?

Answer 7

Initially = hypometabolism

Then increases to hypermetabolism

Question 8

What is the impact of malnutrition ?

Answer 8

Physical and functional decline and poorer clinical outcomes

↑ Mortality, septic and post surgical complications, length of hospital-stay, pressure sores, re-admissions, dependency

↓ Wound healing, response to treatment, rehabilitation potential, quality of life

Question 9

What is the MUST?

Answer 9

Malnutrition Universal Screening Tool - used to idenfity risk, not assessment or diagnosis

Question 10

What are the three stages of diagnosing malnutrition?

Answer 10

Screen -> Assess (dietician collects information to determine the nature and cause of the nutrient imbalance) -> Diagnose

Question 11

What are the requirements for being malnourished?

Answer 11

BMI < 18.5 kg/m2 or

Unintentional weight loss >10 % past 3 - 6 / 12 or

BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.

Question 12

What are the requirements for being at risk of malnourishment?

Answer 12

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or

Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

Question 13

How is the treatment of malnutrition established?

Answer 13

Ir oral nutrition safe and possible? - if yes then nutritional support, if no -> then artificial nutrition

If GI tract is functional and accessible, then Enteral tube feeding, if not, then parenteral nutrition

Question 14

What are the nutritional options available via the oral route?

Answer 14

Fortification of meals and snacks
Altered meal patterns
Practical support
Oral nutritional supplements (ONS)
Tailored dietary counselling

Question 15

Which patients are considered for oral nutritional support?

Answer 15

Consider for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function or if no benefit is anticipated e.g. end of life care.

Question 16

Q. What is artificial nutrition support?

Answer 16

A. The provision of enteral or parenteral nutrients to treat or prevent malnutrition.

Question 17

Which nutritional support is preferred, enteral nutrition and parenteral nutrition?

Answer 17

Enteral nutrition (EN) is superior to parenteral nutrition (PN)

Question 18

How to decide which enteral nutrition to use? Access

Answer 18

Is gastric feeding possible?

Yes = Naso-gastric tube (NGT)
No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Long term (> 3 months) = Gastrostomy / jejunostomy

Question 19

What is in the nutritional feeds which are fed via the enteral route?

Answer 19

Nutritional feeds → renal, low sodium, respiratory, immune, elemental, peptide.

Question 20

What would you do with a patient who has a gastric outlet obstruction?

Answer 20

Gastric outlet obstruction = NGT feeding contraindicated → NJT

Question 21

What are the complications associated with enteral feeding?

Answer 21

Mechanical: misplacement, blockage, buried bumper

Metabolic: hypergylcaemia, deranged electrolytes

GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea.

Question 22

How to determine if NGT is misplaced?

Answer 22

Aspirate pH less than or equal to 5.5
If pH > 5.5 → chest x-ray, interpreted by trained professional following NPSA guidelines.

if pH if less than 5.5, then it means the tube is in the stomach

Question 23

What is parenteral nutrition?

Answer 23

Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.

Question 24

What are the indications for parenteral?

Answer 24

Indications:

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

Question 25

What is the composition for parenteral?

Answer 25

Ready made / bespoke “scratch” bags.

MDT → fluid and electrolyte targets

Question 26

What is the access point for parenteral nutrition?

Answer 26

Central venous catheter (CVC): tip at superior vena cava and right atrium.

Question 27

What are the mechanical complications of parenteral nutrition?

Answer 27

Pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion

Question 28

what are the metabolic complications associated with parenteral nutrition?

Answer 28

Deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia

Question 29

What is the most common complication associated with parenteral nutrition?

Answer 29

Catheter related infections

Question 30

What is albumin and how does it relate to inflammation?

Answer 30

Albumin is synthesized in the liver, when it is low, there is a poor prognosis

Low albumin during inflammation

Question 31

Outline the acute phase response and relate it to albumin.

Answer 31

The acute phase response.

Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.

Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin.

Question 32

Which cytokines are activated in the inflammatory state?

Answer 32

IL-1, IL-6, TNF-alpha, IFN-gamma, TGF-B

Question 33

Is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 33

No. Albumin synthesis ↓es in response to inflammation ∴ poor predictor of malnutrition during acute phase. However, do consider the aetiology / impact of the inflammatory response on nutrition status.

Question 34

What is refeeding syndrome?

Answer 34

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.

Question 35

What are the consequences of refeeding syndrome?

Answer 35

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis,
Wernicke’s encephalopy

Question 36

Which patients are at risk of refeeding syndrome?

Answer 36

At risk:
Very little or no food intake for > 5 days
High risk:
 1 of the following:
BMI < 16 kg/m2
Unintentional weight loss > 15 % 3 – 6 /12
Very little / no nutrition > 10 days this
Low K+, Mg2+, PO4 prior to feeding

Or  2 of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10 % 3 – 6 / 12
Very little / no nutrition > 5 days
PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)

Extremely high risk:
BMI < 14 kg/m2
Negligible intake > 15 days

Question 37

Outline the pathogenesis of refeeding syndrome?

Answer 37

1. Starving / malnutrition -> leads to glycogenolysis, gluconeogenesis and protein catabolism, downregulation of insulin
2. This results in protein, fat and mineral depletion

(During starvation, there is an increase in extracellular water, total body water and sodium, and a depletion of total body potassium, magnesium and phosphate. Serum concentrations of these electrolytes are maintained whilst intracellular stores are depleted)

3. Refeeding

The introduction of carbohydrate results in the secretion of insulin, stimulating the sodium-potassium ATPase pump, requiring magnesium as a co-factor. This drives potassium into cells and sodium and fluid out of cells into the extracellular space. The carbohydrate and insulin secretion drives phosphate into cells as it’s required for energy storage as ATP. This results in an increased cellular uptake of glucose, potassium, magnesium and phosphate, and a subsequent reduction in extracellular concentrations.

hence:

Hypokalaemia
Hypomagnesaemia
Thiamine deficiency
Salt and water retention = odema

Question 38

Who is at extremely high risk of refeeding syndrome?

Answer 38

BMI < 14 kg/m2
Negligible intake > 15 days

Question 39

Outline the management of refeeding syndrome?

Answer 39

-Administer thiamine 30 minutes before and the first 10 days of feeding accoprding tot rust policy

• Correct and monitor electrolytes daily following trust polivcy

-Start: 10-20cal/kg
CHO 40-5-% energy
Micronutrients from onset of feeding

-Monitor fluid shifts and minimise risk of fluid and Na+ overload

Question 40

Outline feeding mode for patient with acute pancreatitis

Answer 40

ENTERAL- supports the functional and structural integrity of the gut, modulates immune system and attenuated disease severity

In pancreatitis, not only is enteral feeding possible but superior and preferred route of feeding

Question 41

If gastric residual volumes are trending upwards, how should feeding mode be changed?

Answer 41

Can start prokinetics

if duodenal stenosis—> NJT

Question 42

How are patients with dementia treated?

Answer 42

Parenteral - NG tube is contraindicated with severe dementia due to distress - they might pull it out due to being confused
Also patient is at risk of aspiration - refer to speech and language therapist

Question 43

What is the difference between clear and free fluids?

Answer 43

Clear = easy to digest and doesn’t leave bits in the digestive tract, water, tea, broth, and gelatin

free = any fluid which can be drunk through a straw,