GI Malnutrition and nutritional assessment Flashcards
definition of malnutrition
state resulting from lack of uptake/intake of nutrition leading to diminished physical and mental function and impaired clinical outcome from disease
rate of malnourishment upon admission to hospital
1 in 3 are manourished
what % of patients have lost weight at discharge
70%
factors that lead to malnutrition in hospitals
co-morbidities e.g. dementia inflexible mealtimes quality of food dysphagia, stomatitis, anaemia, poor dentition, ill fitting dentures inactivity low mood/depression polypharmacy excess nutritional losses repeated NBM status metabolic response to disease/injury
What is the relationship between post-op mortality and weightloss?
loss of >/=20% % of bodyweight preoperatively leads to 10x greater postop mortality
what increases with malnutrition?
mortality septic and post surgical complications length of hospital stay pressure sores readmissions dependency
what decreases with malnutrition?
wound healing
response to treatment
rehabilitation
QoL
what is the cost of malnutrition in England per year.
£19.6 billion -> likely to rise with ageing population
CT good points formal nutrition assessment
provide info about body composition
-> however involves exposing patient to radiation
Why is BMI not used to assess malnutrition?
not representative of difference between fat and fat free mass
skin fold thicknesses used for malnutrition assessment
- triceps skinfold thickness
- mid upper arm circumference use similarly to determine lean body mass (positive association)
anthropometric analysis multifrequency bioelectrical impedance analysis used in which patients?
renal and haematology patients
what type of fat can CT scans distinguish between?
visceral and subcutaneous fat
-> highly accurate for evaluating levels of fat and fat free mass
problems with CT
spenny and expose individuals to small amounts of radiation
- > use for body comp restricted to research normally
- > being used more frequently in specialities where CTs are already part of the clinical treatment pathway
when is CT useful for patients with pancreatic cancer?
in patients which borderline resectable pancreatic cancer -> helps to determine sarcopenia prevalence
what does hand grip respond to quickly?
- nutritional deprivation and nutritional repletion (more so that other parameters like muscle mass/body mass)
why are micronutrient and trace elements tests not undertaken easily?
time consuming
spenny
-> results skewed as a result of the acute inflammatory response
best way of obtaining dietary intake information?
dietary history
what is used to estimate energy requirement,
predictive equations estimating resting BMR
-> generally no more accurate than 70%
requirements to be malnourised
- BMI < 18.5
- unintentional weight loss >10% past 3-6 months
- BMI <20 + unintentional weight loss > 5% past 3-6 months
at risk of malnutrition (2)
eaten little/nothing > 5 days and likely to have the same for the next 5
- poor absorptive capacity/high nutrient losses/increased nutritional needs
what is the provision of enteral or parenteral nutrients to treat or prevent malnutrition called?
artificial nutrition support
Feeding options when oral nutrition isn’t safe
- enteral feeding (GI tract functional + accessible)
2. parenteral feeding (GI tract not functional/accessible)
why is enteral nutritional superior to parentral?
it uses the gut
-> if parenteral used, aim to return to enteral then oral feeding as soon as/where clinically possible
first line route for enteral nutrition?
nasogastric tube
example of when NGT is contraindicated?
gastric outlet obstruction
-> NJT used instead
what is recommended for longer term enteral tube feeding?
When is long term enteral tube given?
> 3 months gastrostomy/jejunostomy
long term enteral tube given >4 wks
what are the complications associated with enteral feeding?
- misplaced NGTs caused 21 deaths + 79 cases of harm from 2005-2011
- mechanical (misplacement, blockage, buried bumper)
- metabolic (hyperglycaemia), deranged electrolytes)
- GI aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea
What should you do if there’s a misplaced NGT?
aspirate of pH <=5.5
- if pH> 5.5, CXR which is interpreted by professional following NPSA guidelines
indication for parenteral nutrition
- inadequate or unsafe oral and/or enteral nutritional intake
OR - non-functioning, inaccessible or perforated GI tract
what type of nutrition is described as delivery of nutrients, electrolytes and fluid directly into venous blood?
parenteral nutrition
access points for CVCs?
tip at superior vena cava and right atrium-> different CVCs for short ad long term use
complications associated with parenteral nutrition?
mechanical (pneumothorax, haemothorax, cardiac arrhythmias, thrombosis, catheter occlusion, extravasion)
metabolic (deranged electrolytes, hyperglycaemia, abnormal liver, enzymes, oedema, hypertriglyceridemia)
catheter-related infection
why is nutrition support offered to malnourished patients?
lower levels of mortality, readmission, ICU admission, major complications and functional status
low levels of what plasma proteins predicts poor prognosis?
albumin
how does the acute phase response affect albumin production?
inflammatory stimulus -> activation of monocytes and macrophages -> release of cytokines
cytokines act on the liver to stimulate production of some proteins whilst downregulating production of others like albumin
is albumin a valid marker of malnutrition in the acute hospital setting?
no
- though decreased in repsonse to inflammation, not marker of nutrition status nor indication for nutrition intervention in the acute setting
- best evidence - hypoalbuminaemia in obese trauma patients
- dietitian focused on the etiology/impact of the inflammatory state on nutrition status
what is refeeding syndrome?
a group of biochemical shifts and clinical symptoms that can occur in the malnourished/starved individual on the reintroduction of oral, enteral or parenteral nutrition
stages of body response to starvation
- body aims to utilize energy stores
- reduction insulin secretion and increased in glucagon to increase glucose
- glycogen stores in liver and AA in skeletal muscle metabolised -> glucose
- stores depleted (within 24/72 hours) leads to derivation of energy from ketone production due to free fatty acids released from fat stores (used instead of AA to spare skeletal muscle) - decreased BMR and brain uses ketone bodies instead of glucose -> loss of fat mass
- action cellular pumps reduced (to save energy) so electrolytes leak across cell membrane
- increased extracellular water, Na and total body water and depletion of Mg, K and phosphate.
- Serum electrolyte conc. maintained whilst intracellular stores are depleted
- Na and fluid leak into cells -> sodium and fluid intolerance
- micronutrients depleted
- thiamine deficiency likely- water soluble and body has limited stores
how does introduction of carbohydrate affect the response to starvation?
stimulates insulin production -> Na/K ATPase working
- > Mg is a cofactor
- > drives K into cells and Na out of cells
- > carbohydrate and insulin drives PO4 into cells
- increased cellular uptake of glucose, K, Mg and phosphate (hypokalaemia, hypophosphatemia, hypomagnesaemia)
- thiamine is coenzyme for carb digestion -> deficiency occur in refeeding of vit B depleted patient
what can low concentrations of electrolytes from giving a starving person carbs cause?
- less Na and fluid excretion = expansion extracellular fluid compartment –> this leads to refeeding oedema and fluid overload
consequences of RFS?
- arrhythmia
- CHF -> cardiac arrest + sudden death
- tachycardia
- respiratory depression
- encephalopathy, coma, seizures, rhabdomyolysis
- Wernickes encephalopathy
According to NICE, what are the the criteria for defining at risk of refeeding syndrome/
very little or no food intake for > 5 days
According to NICE, what are the the criteria for defining at high risk of refeeding syndrome/
>=1 of these: - BMI < 16 - unintentional weight loss > 15% 3-6/12 - very little/no nutrition > 10 days - Low K+, Mg2+, PO4 prior to feeding >=2 of these: - BMI < 18.5 - unintentional weight loss > 10% 3-6/12 - very little/no nutrition > 5 days - PMHx alcohol abuse or drug (insulin, chemo, antacids, diuretics)
According to NICE, what are the the criteria for defining at extremely high risk of refeeding syndrome/
- BMI < 14
- Negligible intake > 15 days
stages of RFS management
- start with 10/20kcal/kg
40-50% energy from carbs
Micronutrients given from onset of feeding - correct + monitor electrolytes daily following trust policy
- Administer thiamine 30 min from the onset of feeding following Trust policy
- Monitor fluid shifts + minimise risk of fluids + Na overload
Who is at highest risk of malnutrition?
>65 Long-term condition e.g. diabetes Chronic progressive disease GI dysfunction Drug abuse
Which wards have highest rates of malnutrition?
Care of Elderly
Oncology
In which ages is malnutrition highest in?
In order of most to least:
90+
80-89
18-19
What is the cost of malnourished patients in healthcare?
Cost is 3x greater
When asking about dietary history, what do we have to ask about?
Allergies
Intolerances
Aversions
Cultural, religious, ethical dietary restrictions
What are different ways a dietician asses nutrition?
Anthropometry: Weight, tricep skinfold thickness, CT, hand grip
Biochemistry
Clinical: signs, PHx, symptoms, medications
Dietary
Social and physical assessment
Nutrition requirements: indirect calorimetry
What are pros and cons of biochemistry investigation is assessing nutrition?
Expensive and time-consuming
Shows inflammatory response
What tube would we use for short term enteral feeding (2-4wks)?
Fine bore naso-enteral tube
For a malnourished patient where oral nutrition is possible what are treatment options?
Oral nutritional support: counselling, supplements, dietary fortification
Require texture modification- consider thickeners and additional support (oral tube)
What kind of nutritional feeds are there?
Renal Low sodium Respiratory Immune Elemental Peptide
