Gastro - Malnutrition Flashcards
What is the definition of malnutrition
A state resulting from a lack of uptake or intake of nutrition leading to altered body composition and body cell mass, leading to diminished physical and mental function and impaired clinical outcome from disease
What ages does malnutrition affect
Most commonly affects younger and older patients
What gender does malnutrition affect more
Females
What wards does malnutrition affect more
Geriatrics
Oncology
What conditions malnutrition occur more in
Gastrointestinal
What are the risk factors for malnutrition
- 65+ (especially if hospitalised)
- Long term condition e.g. diabetes, CKD
- Chronic progressive condition e.g. cancer, dementia
- Alcohol/drug abuse
- Gastrointestinal disorders
How many patients are malnourished upon admission
1 in 3 - it often goes unnoticed and under diagnosed
What things may lead to malnutrition in hospital
Disease related anorexia Metabolic response to illness Repeated NBM status Excess nutritional losses Polypharmacy Co-morbidities
How does disease related anorexia cause malnutrition
Loss of appetite due to pathophysiological changes to the central system regulating feeding behaviour that occurs in the presence of the disease
What is the metabolic response to stress with regards to malnutrition
Muscle is broken down to amino acids for gluconeogenesis and protein synthesis for the immune response and tissue repair
How else may illness cause malnutrition
Increased demand for energy, protein and micronutrients leads to loss of body mass/protein. In extreme cases, loss of tissue causes a threat to survival
Why are patients with a history of malnutrition more at risk
These patients have less caloric reserve.
E.g. A 74kg man has a reserve of around 192,000 Kcal
How do hospital meals affect malnutrition
40% of food is left uneaten therefore patients don’t receive appropriate proteins or calories. This is because of:
- GI symptoms
- Depression/low mood
- Lack of motivation
- Inflexible meal times
- Patients think low appetite when ill is normal
- Inactivity
What is the impact of malnutrition with regards to operation fitness
Patients having an operation for a perforated duodenal ulcer had 10x higher mortality if they had lost more than 20% bodyweight pre-op compared to those who had lost less
why do the malnourished perform worse in operations
Patients are unable to mobilise adequate amounts of endogenous nitrogen in response to stress therefore experience greater morbidity and mortality compared to those who can generate a catabolic response to stress
What is the mortality of malnutrition
Direct cause of 66 hospital deaths
Contributes to 285 hospital deaths
What increases with malnutrition
Mortality Septic/post surgical complications Length of hospital stay Pressure sores Re-admission Dependency
What decreases with malnutrition
Wound healing
Response to treatment
Rehabilitation potential
Quality of life
What is the cost of malnutrition
19.6 billion per year from the NHS - malnourished patient is 3x more expensive to treat - going up due to ageing population
What tool do we use to diagnose malnutrition in the acute setting
Malnutrition Universal Screening Tool
Give an overview of the MUST
Commonly used in the UK
Rapid, simple
Based on BMI, unplanned weight loss and acute presence of disease to generate low, medium or high risk, and immediate guidance for these groups
What are the steps of diagnosing malnutrition
Screen
Assess
Diagnose
Plan
Implement
Monitor
Evaluate
By when do we have to screen a patient
Within 6 weeks of admission and then weekly
What are the limits of the screening with MUST
Misses malnourishment in those with over hydration such as oedema or ascites
Who assesses the patient if the screening provides a trigger
Dietician
What is the assessment stage
Systematic process of collecting and interpreting information to determine the nature and cause of the nutrient imbalance
What do we assess
Anthropometry Biochemistry Clinical Dietary Nutrition requirement Social + physical
What is anthropometry
Measurement of the physical properties of the body as different parts of the body are affected by malnutrition differently
What can we look at in terms of anthropometry
Recent loss of weight
(BMI only used if very low ad varies a lot)
Mid upper arm circumference + tricep skin fold test
CT
Hang grip strength
What is the limitation of using a respirator gas canopy for RMR
Predictive estimate- 70% accuracy therefore not perfect
What do we look at in biochemistry
Nutrient availability in tissues and fluid
What are the limitations of biochemistry
Time consuming and expensive
Skewed results due to acute inflammation therefore we dont test until CRP < 10 µg/L
What is our clinical assessment
PMH Alcohol drug use Chronic disease Recent surgery Recent GI problems Change in appetite or diet
What is our social + physical assessment
Socioeconomic status
Addiction
Living status
Who do we consider for nutrition support
People who are:
Malnourished
At risk of malnutrition
How does someone qualify for being malnourished
BMI < 18.5 or
Unintentional weight loss >10% past 3-6 months or
BMI < 20 + unintentional weight loss >5% past 3-6 months
How does someone qualify for being at risk of malnutrition
Have eaten little or nothing for >5 days and/or are likely to carry on for the next 5+ days or
Have poor absorptive capacity and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
What is artificial nutrition support
Provision of enteral or parental nutrients to prevent or treat malnutrition
What types of nutrition support do we have
Oral nutritional support
Enteral tube feeding
Parenteral nutrition
When do we use oral nutrition support
If oral nutrition is safe and possible - may need thickeners or additional support if required e.g. dysphagia
When do we use parenteral nutrition
If oral nutrition not safe or possible and the Gi tract is not functional or accessible
When do we use enteral nutrition
If oral nutrition not safe or possible but the Gi tract is functional or accessible
Why do we prefer enteral nutrition
It uses the gut
What is the 1st line approach to EN
Nasogastric tube through the nose and into the stomach
Why might be an NGT be contraindicated
Gastric outlet obstruction
What do we use if NGT is contraindicated
Feeding tube is placed distal to the stomach e.g. through a NDT or NJT
If we require longer term feeding whilst on EN (3+ months) - what should we do
Gastrostomy or jejunostomy tube
What factors determine the nutritional feed the patient receives
Renal function Sodium levles Respiratory function Immune function Elemental balance Peptides
What are the types of complications arising form EN
Mechanical
Metabolic
GI
What are the mechanical complications of EN
Misplaced NGT can be a cause of death - when it is placed, we need an aspirate of a pH less than 5.5 due to HCl - if it is greater then we need a CXR.
Blockage
Buried bumper
What are the metabolic complications of EN
Hyperglycaemia
Deranged electrolytes
What are the GI complications of EN
Aspirates Nasopharyngeal pain Laryngeal ulceration Vomiting Diarrhoea
What is parenteral nutrition
Feeding of nutrients and electrolytes directly into venous blood
What are the indications for PN
Inadequate or unsafe oral or enteral route
What are the main access points for a CVC (central venous catheter)
Superior vena cava and right atrium
What types of bag does the dietician give
Scratch bag or ready made bag - discussed in MDT based on nutrient/electrolyte targets for patient
What are the types of complications arising from PN
Mechanical
Metabolic
Catheter related infection
What are the metabolic complications of PN
Deranged electrolytes Hyperglycaemia Abnormal liver enzymes Oedema Hypertriglyceridaemia
What are the mechanical complications of PN
Pneumothorax Haemothorax Thrombosis Cardiac arrhythmias Catheter occlusion Thrombophlebitis Extravasation
What are the catheter problems with PN
Bacteraemia
Septicaemia
What are the benefits of nutritional support
Decreased non elective hospital readmission
Increases protein and energy intake therefore increases weight
What is the most abundant circulating plasma protein in health
Albumin
How much albumin is produced a day? By what?
10-15 grams/day produced by hepatocytes
What increases albumin
Insulin
Cortisol
Growth hormone
What decreases albumin
IL-6
TNF
pro-inflammatory cytokines
What is a negative acute phase protein e.g. albumin
A protein that lowers its levels in an inflammatory state
How is albumin reduced in inflammation
Increased trans capillary loss of albumin, degradation of albumin and downgrading of its synthesis
Can we use albumin as a marker for malnutrition or indicator for nutritional support
No - this is because it decreases during a moderate inflammatory response
What do we see in obsess trauma patients
Hypoalbuminaemia
What is refeeding syndrome
A group of biochemical shifts and clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition
Describe RFS
In starvation, we have a loss of insulin secretion, increased glucagon therefore gylcogenolysis, gluconeogenesis and protein catabolism in the liver. We have a depletion of protein, fats, minerals, electrolytes and vitamins. We eventually get ketogenesis too. The micronutrients in cells are used up but not replaced, as well as the cells trying to maintain serum levels of these micronutrients. As a result, the cells become deficient of them. Once the body is fed, there is a spike in insulin, so glucose is taken up into cells, and there is the stimulation of anabolic pathways. However, we cannot replace the micronutrients as quick as we use them in these anabolic pathways - this results in severe deficiency inside and outside the cell.
What is thiamine
Coenzyme in the carbohydrate metabolism; its deficiency may occur upon refeeding in a Vitamin B depleted patient
Why do we get oedema from RFS
When we have a spike on insulin it stimulates the kidneys not to excrete sodium and therefore water. This causes fluid overload and thus oedema
What are the consequences of RFS
Arrhythmia, tachycardia, congestive heart failure leading to cardiac arrest and possible sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis
Wernicke’s encephalography
Who is at risk of RFS
Very little of no food intake for more than 5 days
Who is at high risk of RFS
≥1 of the following: BMI < 16 kg/m2 Unintentional weight loss > 15 % 3 – 6 /12 Very little / no nutrition > 10 days 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)
Who is at extremely high risk of RFS
BMI < 14
Negligible intake > 15 days
How do we manage RFS
- Start: 10-20 kcal/kg - carbs should be providing 40-50% of the energy
- Micronutrients from onset of feeding
- Correct and monitor electrolytes daily
- Administer thiamine from onset of feeding
- Monitor fluid shifts and miniseries risk of fluid/sodium overload.
