Clinical Nutrition Flashcards
Define malnutrition
Where a deficiency, excess or imbalance of nutrients causes measurable adverse effects on:
- Tissue or body form
- Function and clinical outcomes
What are the signs and symptoms of malnutrition? (6)
- Loss of appetite
- Weight loss
- Tiredness, lack of energy
- Lethargy and depression
- Poor concentration
- Poor growth in children
What are the causes of malnutrition?
- Altered nutrient processing e.g. changes in metabolic demands, liver dysfunction
- Excess losses e.g. vomiting, nasogastric tube drainage, diarrhoea, surgical drains, fistulae, stomas
- Impaired intake e.g. poor diet, hospital catering, appetite, missed meals, pain/nausea with food, mucositis, dysphagia, depression/psychological
- Impaired digestion and absorption e.g. problems with stomach, intestine, pancreas and liver
Define the MUST score and the steps involved
The Malnutrition Universal Screening Tool
1) calculate BMI
2) Note % of unplanned weight loss
3) Establish acute disease effect
4) Add scores from steps 1-3 for complete score
5) Use management guidelines or local policies to create action plan
What are the principles of a nutritional assessment (ABCDE)
- Anthropometry (physical size)
- Biochemical
- Clinical
- Dietary
- Environment
What is the Basal Metabolic Rate?
The amount of energy expended by the body to maintain basic physiological functions over 24h
What factors are used to estimate Basal Metabolic Rate?
- Age
- Weight (kg)
- Gender
- Height
According to NICE, what characteristics make a person malnourished? (3)
- BMI < 18.5 kg/m2
- Unintentional weight loss of > 10% within last 3-6 months
- BMI < 20 kg/m2 AND unintentional weight loss > 5% within last 3-6 months
According to NICE, what characteristics consider someone to be at risk of malnutrition? (2)
- Eaten little or nothing for more than 5 days and/or are likely to not eat anything for another 5 days
- Poor absorptive capacity and/or nutrient losses and/or increased nutritional needs from causes such as catabolism
How is re-feeding syndrome caused?
- Caused when a person is in a state of prolonged starvation is given nutrition
What happens when someone has re-feeding syndrome?
Sudden shift in energy source results in:
- Insulin secretion
- Glycogen, fat and protein synthesis for which phosphate, magnesium and thiamine are required
- Increased absorption into cells
Leads to potentially fatal shifts in fluids and electrolytes within the body
What are the steps to avoiding re-feeding syndrome?
- Start nutrition at a MAX of 10 kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days
- Restore circulatory volume and monitor fluid balance and overall clinical status closely
What drugs and when should they be given to patients at high risk of re-feeding syndrome? (3)
Immediately before and during the first 10 days of feeding, provide:
- Oral Thiamine, 200-300mg daily
- Vitamin B co strong, 1 or 2 tablets QDS
- A balanced multivitamin/trace element supplement, OD
What else should be given to avoid re-feeding syndrome, unless pre-feeding plasma levels are high?
Provide oral, enteral or IV supplements of:
- Potassium
- Phosphate
- Magnesium
Which drugs/supplements can cause changes to absorption of nutrients?
- Magnesium or aluminium, antacids with phosphate
- Tetracyclines chelate with calcium, magnesium and iron
- Quinolones - Ciprofloxacin absorption reduces by 50% if given with enteral feed
What can cause changes in metabolism?
Grapefruit juice - Cytochrome P450 enzyme inhibitor therefore reduce metabolism of certain drugs hence plasma concentrations e.g. Ciclosporin, Simvastatin
Which drugs can cause changes to excretion?
- Diuretics
- Lithium
What is enteral nutrition?
‘Enteral’ = related to the intestine
A liquid mixture of all the needed nutrients given through a tube into the stomach or small intestine
What is Fortsip bottle?
Indicated for short term bowel syndrome, intractable malabsorption, pre-operative preparation of undernourished patients, IBD, total gastrectomy, dysphagia, bowel fistulae, disease related malnutrition
What are the different enteral routes? And their rationales?
- Nasogastric - good for short term i.e. < 4 weeks
- Nasojejunal - reduced risk of aspiration and important the feed is sterile as no gastric protection
- Gastrostomy - Good for longer term feeding e.g. PEG (stomach)
- Jejunostomy - Good for longer term feeding e.g. PEJ (intestine)
What decided whether enteral feed is given to stomach or intestine?
If the stomach empties, use it
In which conditions and instances would intestine enteral route (PEJ) be preferred to stomach (PEG)? (7)
- Gastroparesis
- Recent abdominal surgery
- Sepsis
- Significant gastroesophageal reflux
- Proximal enteric fistula or obstruction
- Aspiration
- Ileus (lack of normal muscle contractions in intestine)
What are the steps when choosing the kind of enteral feed? (5)
- Estimate energy, protein (nitrogen) and fluid needs
- Select most appropriate enteral formula
- Determine continuous or bolus feed
- Determine goal rate to meet estimate needs
- Write/recommend the enteral nutrition Rx
What are the 3 types of enteral feed? and which patients receive each?
- Polymeric - Whole protein for patients with normal GI function
- Pre-digested - peptide/semi-elemental/elemental for patients with severe GI function
- Disease specific - formulas available for respiratory disease, diabetes, renal failure, hepatic failure and immune compromised
