Gastro - Malnutrition + Nutrition Intervention Flashcards
What is malnutrition?
→ a state resulting form lack of uptake or intake of nutrition leading to altered busy composition + body cell mass
→ leads to diminished physical + mental function and impaired clinical outcome from disease
What is the trend in prevalence of malnutrition across the age groups?
upside down bell curve relationship
Is more malnutrition more common in women or men?
women
What is the trend in prevalence of malnutrition across the wards?
v
What proportion of patients admitted to hospital are malnourished are admission?
1 in 3
What can contribute to malnutrition in hospital?
v
How much weight is lost at discharge who are malnourished and unnoticed?
70%
What are the trends in postoperative mortality for surgery in perforated duodenal ulcer in 1936? Why?
→ mortality 10x greater in those who had lost >20% bodyweight preoperatively, compared to those who lost less
→ they’re unable to mobilise adequate amounts of endogenous nitrogen in response to stress
How many deaths does malnutrition cause directly?
66 hospital death in 2016
How many deaths has malnutrition contributed to?
285 hospital deaths in 2016
What does malnutrition increasef?
→ mortality
→ sepsis
→ post-surgery complications
→ length of hospital stay
→ pressure sores
→ re-admissions
→ dependency
What does malnutrition decrease?
→ wound healing
→ response to treatment
→ rehabilitation potential
→ quality of life
What is the cost of malnutrition in England per year?
→ £19.6 billion
→ approx 15% of total expenditure on health + social care
What are the ways in which you can diagnose malnutrition?
→ screen
→ nutritional assessment
*What is screening for malnutrition?
→ simple tool to identify risk
→ carried out by HCP
→ not an assessment or diagnosis
→ required within 6 hours of hospital admission + weekly after that
What is the nutritional assessment for malnutrition?
→ systematic process of collecting + interpreting information to determine that nature + cause of the nutrient imbalance
→ carried out by a dietician
What does the nutritional assessment involve?
→ anthropometry
→ biochemistry
→ clinical history
→ dietary history
→ social history
→ physical history
→ nutrition requirements
What is anthropometry?
→ measurement of the physical properties of the body
→ different anthropometric tools are used to measure different compartments of the body
Outline the process of anthropometry.
→ scales used to measure weight (BMI has little significant unless it’s very low)
→ mid arm circumference to measure lean body mass
→ multi frequency biometrical impedance analysis
→ CT scans analyse muscle + fat composition and distribution, also looking at subcutaneous fat + visceral fat (very accurate)
→ hand grip strength to assess upper body strength (responds the most to nutritional changes)
How is the biochemistry component of the nutritional assessment done?
blood test for fluids + nutrients
looks for deficiencies in nutrients, etc.
How are nutritional requirements assessed?
usually uses predictive equations but you can also use:
→ indirect calorimetry
→ measures the energy expenditure of a person
What happens after a nutritional assessment?
→ diagnosis
→ plan
→ implementation
→ monitor
→ evaluate
When should nutritional support be considered for a patient?
→ malnourished
→ at risk of malnutrition
What is the criteria for a patient to be considered malnourished?
→ BMI < 18.5 kg/m^2 or
→ unintentional weight loss > 10% past 3-6 / 12 or
→ BMI < 20 kg/m^2 + unintentional weight loss > 5% past 3-6 / 12
What makes a patient at risk of malnutrition?
→ have eaten little or nothing > 5days and / or are likely to eat little to nothing for the next 5 days or longer
→ have poor absorptive capacity and/or high nutrient losses and/or have increased nutritional needs from causes such as catabolism
What is artificial nutritional support?
provision of enteral or parenteral nutrients to treat of prevent malnutrition
What is the algorithm for treatment for malnutrition?
When in enteral tube feeding considered for a patient?
→ when oral nutrition is NOT possible + safe
→ when GI tract is functional + accessible
When in parenteral tube feeding considered for a patient?
→ when oral nutrition is NOT possible + safe
→ when GI tract is NOT functional + accessible
What else is important when considering treatment of malnutrition?
→ consent
→ law + ethics
What is the route of access for enteral feeding if gastric feeding is possible?
if gastric feeding is possible, naso-gastric tube (NGT)
What is the route of access for enteral feeding if gastric feeding is NOT possible?
if gastric feeding is not possible, nano-duodenal (NDT) or nano-jejunal tube (NJT)
What is the route of access for enteral feeding if it is long-term (over 3 months)?
if long-term (over 3 months), gastrostomy or jejunostomy
When is NGT feeding contraindicated?
e.g. when there is gastric outlet obstruction
What is the nutritional feed contents dependent on?
→ renal
→ low sodium
→ respiratory
→ immune
→ elemental
→ peptide
*What are the types of complications associated with enteral feeding?
→ mechanical
→ metabolic
→ GI
How do you prevent misplaced NGTs?
when NGT is placed, take an aspirate and measure pH
→ pH needs to be lower than 5.5
→ pH higher than 5.5 indicates chest x-ray, interpreted by trained professional following NPSA guidelines
What are the mechanical complications of enteral feeding?
→ misplaced NGTs (21 deaths + 79 cases of harm between 2005-2011)
→ blockage
→ buried bumper
What are the metabolic complications of enteral feeding?
→ hyperglycaemia
→ deranged electrolytes
What are the GI complications of enteral feeding?
→ aspiration
→ nasopharyngeal pain
→ laryngeal ulceration
→ vomiting
→ diarrhoea
What is parenteral nutrition?
delivery of nutrients, electrolytes, and fluid directly into venous blood
What are the indications for PN?
→ inadequate or unsafe oral route or enteral intake
→ non-functioning, inaccessible, perforated GI tract
What are access points for PN?
→ CVC (central venous catheter) : tip at superior vena cava and right atrium
→ other CVCs can be used (at subclavian, jugular or femoral veins, or inserted peripherally) with tip still at SVC
→ different CVCs are used for short term + long term use
What are the PN feeds composed of?
→ ready-made bag or bespoke “scratch” bag
→ MDT - fluid + electrolyte targets
What are the types complications of PN?
→ mechanical
→ metabolic
→ catheter related infections
What are the mechanical complications of PN?
→ pneumothorax
→ haemothorax
→ thrombosis
→ cardiac arrhythmias
→ thrombus
→ catheter occlusion
→ thrombophlebitis
→ extravasion
What are the metabolic complications of PN?
→ deranged electrolytes
→ hypoglycaemia
→ abnormal liver enzymes
→ oedema
→ hypertriglyceridaemia
*Does nutritional support benefit the malnourished patient?
reduces mortality for sure
(shown in systematic studies)
What is albumin?
→ most abundant circulating protein in plasma
→ synthesised in liver
What is the trend between health and albumin?
→ low plasma albumin = poor prognosis
→ negative acute phase protein = decrease in plasma albumin when there’s increase in inflammation
What happens in the acute inflammatory phase response?
→ inflammatory stimulus cause activation of monocytes + macrophages, causing release of cytokines
→ cytokines act on liver to stimulate production of some proteins whilst down regulating production of other e.g. albumin
Is albumin a valid marker of malnutrition in the hospital setting?
→ no
→ only reduces in response to inflammation
→ not a good indication of malnutrition
→ e.g. increase in trauma patients
What is refeeding syndrome?
group of biochemical shifts + clinical symptoms that can occur in the malnourished or starved individuals on the reintroduction of oral, enteral or PN
What is the pathogenesis of RFS?
What are some of the consequences of RFS?
→ arrhythmias, tachycardia, CHF, cardiac arrest, sudden death
→ respiratory depression
→ encephalopathy
→ coma, seizures, rhabdomyolysis
→ Wernicke’s encephalopathy
What criteria defines the risk of RFS?
v
How is RFS managed?
v
