Malnutrition

Question 1

Malnutrition

Answer 1

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

Question 2

Fraction malnourished in hospital

Answer 2

1 in 3

Question 3

Weight loss after discharge

Answer 3

70% - mainly muscle mass

Question 4

Reasons for malnutrition in hospital

Answer 4

Dysphagia
Quality of food
Inflexibility of mealtime
Depression

Question 5

Impact of malnutrition

Answer 5

Physical and functional decline and poorer clinical outcome

Question 6

Diagnose malnutrition

Answer 6

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

Question 7

Nutrition support for those who are

Answer 7

Either malnourished or at risk of malnutrition

Question 8

Malnourished

Answer 8

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

Question 9

At risk of malnutrition

Answer 9

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

Question 10

Nutritional support algorithm

Answer 10

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

Question 11

Enteral tube feeding

Answer 11

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

Question 12

Complications of enteral feeding

Answer 12

Mechanical - misplacement, blockage, buried bumper
Metabolic - hypergylcaemia, deranged electrolytes
GI - aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Question 13

Parenteral

Answer 13

Delivery of nutrients to venous blood

Question 14

Parenteral indications

Answer 14

Inadequate or unsafe oral and or enteral nutritional intake
Or
Non functioning, inaccessible or perforated GI tract

Question 15

Parenteral access

Answer 15

Central venous catheter - tip at superior vena cava and right atrium

Question 16

Parenteral complications

Answer 16

Metabolic - deranged electrolytes, hyperglycaemia, oedema
Mechanical - pheumothorax, haemothorax, thrombosis, cardiac arrhythmias
Catheter related infections

Question 17

Albumin

Answer 17

Synthesised in liver
Low plasma albumin - poor prognosis
Decreased plasma albumin when increases inflammation

Question 18

Acute phase response

Answer 18

Inflammatory stimulus - activation of monocytes and macrophages - release cytokines - act on liver to stimulate production of some proteins while downgrading production of other (albumin)

Question 19

Albumin as marker of malnutrition

Answer 19

Albumin decrease in inflammation

Hypoalbuminaemia in obese trauma

Question 20

Refeeding syndrome

Answer 20

Biochemical shifts and clinical symptoms that can occur in malnourished or starved individual on reintroduction of oral, enteral or parenteral nutrition

Question 21

Consequences of RFS

Answer 21

Arrhythmia, tachy, cardiac arrest
Respiratory depression
Encephalopathy, coma, seizures
Wernicke’s encephalopy

Question 22

RFS risk

Answer 22

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

Question 23

RFS management

Answer 23

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