Malnutrition Flashcards
Malnutrition
State resulting from lack of uptake or intake of nutrition leading altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease
Fraction malnourished in hospital
1 in 3
Weight loss after discharge
70% - mainly muscle mass
Reasons for malnutrition in hospital
Dysphagia
Quality of food
Inflexibility of mealtime
Depression
Impact of malnutrition
Physical and functional decline and poorer clinical outcome
Diagnose malnutrition
Screen - within 6 hours of admission and weekly - identify risk, not assessment or diagnosis
Assess - dietitian - systemic process of collecting and interpreting information to determine nature and cause of nutrition imbalance
Diagnose - nutrition diagnosis
Plan, implement, monitor evaluate
Nutrition support for those who are
Either malnourished or at risk of malnutrition
Malnourished
BMI less than 18.5kg/m2 or
Unintentional weight loss more than 10% past 3-6 months or
BMI less than 20kg/m2 and unintentional weight loss more than 5% past 3-6 months
At risk of malnutrition
Eaten little or nothing for more than 5 days and or likely to eat little or nothing for next 5 days or longer or
Poor absorptive capacity and or have high nutrient losses and or have increase nutritional needs from causes such as catabolism
Nutritional support algorithm
Oral nutrition possible and safe?
- yes for oral nutritional support
- no for GI tract functional and accessible?
—yes for enteral tube feeding
—no for parenteral nutrition until tube feeding possible
Enteral tube feeding
Superior to parenteral
When parenteral is used, aim is to return to enteral and then oral feeding asap
Gastric feeding possible?
-yes - nasogastric tube
-no - nasoduodenal - nasojejunal if contraindicated
Long term - more than 3 months - gastrostomy or jejunstomy
Complications of enteral feeding
Mechanical - misplacement, blockage, buried bumper
Metabolic - hypergylcaemia, deranged electrolytes
GI - aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea
Parenteral
Delivery of nutrients to venous blood
Parenteral indications
Inadequate or unsafe oral and or enteral nutritional intake
Or
Non functioning, inaccessible or perforated GI tract
Parenteral access
Central venous catheter - tip at superior vena cava and right atrium
Parenteral complications
Metabolic - deranged electrolytes, hyperglycaemia, oedema
Mechanical - pheumothorax, haemothorax, thrombosis, cardiac arrhythmias
Catheter related infections
Albumin
Synthesised in liver
Low plasma albumin - poor prognosis
Decreased plasma albumin when increases inflammation
Acute phase response
Inflammatory stimulus - activation of monocytes and macrophages - release cytokines - act on liver to stimulate production of some proteins while downgrading production of other (albumin)
Albumin as marker of malnutrition
Albumin decrease in inflammation
Hypoalbuminaemia in obese trauma
Refeeding syndrome
Biochemical shifts and clinical symptoms that can occur in malnourished or starved individual on reintroduction of oral, enteral or parenteral nutrition
Consequences of RFS
Arrhythmia, tachy, cardiac arrest
Respiratory depression
Encephalopathy, coma, seizures
Wernicke’s encephalopy
RFS risk
At risk - little or no food intake for more than 5 days
High risk - more than one of following
-BMI less than 16
-unintentional weight loss more than 15% 3-6 months
-little to no nutrition more than 10 days
-low potassium, magnesium, phosphate prior to feeding
OR more than 2 of following
-BMI less than 18.5
-unintentional weight loss more than 10% 3-6 months
-little to no nutrition more than 5 days
-past history of alcohol abuse or drugs
Extremely high risk - BMI less than 14 or negligible intake for more than 15 days
RFS management
Start 10-20kcal/kg
Carbohydrates 40-50% energy
Micronutrients from onset of feeding
Correct and monitor electrolytes daily
Administer thiamine from onset of feeding
Monitor fluid shift and minimise risk of fluid and sodium overload
