malnutrition

Question 1

define malnutrition

Answer 1

deficiency, excess or imbalance nutrients, results in a measurable adverse effect on body function and clinical outcome

Question 2

cause of malnutrition in hospital

Answer 2

reduced intake
-NBM
-depression

maldigestion/malabsorption
-function
-length

altered metabolism
1. injury
2.catabolism- cover metabolic need
3.anabolism- muscle recovery

Question 3

impact on malnutrition

Answer 3

-poorer clinical outcome- increase mortality/decrease wound healing

-NHS cost

Question 4

how to diagnose malnutrition

Answer 4

1. screen: MUST (malnutrition universal screening tool)
2. assess- dietitian
   3.diagnose

Question 5

nutritional support should be considered in people who are either:

Answer 5

malnourished//

at risk of malnutrition

Question 6

what is considered malnourished

Answer 6

BMI < 18.5 kg/m2 or

Unintentional weight loss >10 % past 3-6/12 or

BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 –6/12 month.

Question 7

what is considered at risk of malnutrition

Answer 7

Have eaten little/nothing for > 5 days +/- are likely to eat little or nothing for the next 5 days+ or

poor absorptive capacity, +/- high nutrient losses +/- increased nutritional needs ie. catabolism.

Question 8

Oral Nutrition Support- examples and who is it for

Answer 8

-Tailored dietary counselling,
-Oral nutritional supplements (ONS)
-Fortification of meals and snacks

any patient with inadequate food and fluid intakes,
unless they cannot swallow safely, impaired GI function or if no benefit is anticipated e.g. end of life care.

Question 9

Q. What is artificial nutrition support?

Answer 9

The provision of enteral or parenteral nutrients to treat or prevent malnutrition.

Question 10

what are the 2 types of artificial nutrition support

Answer 10

enteral

parenteral

Question 11

order of feeding preferences and to return to preferred ones as soon as clinically possible

Answer 11

1. oral nutrition support
2. enteral nutrition support
3. parenteral nutrition support

Question 12

enteral nutrition access: is gastric feeding possible? yes/no- what tube is used?

long term: 3 months+ access?

Answer 12

yes= naso-gastric tube (NGT)

no= naso-duodenal (NDT)/naso-jejunal tube(NJT)

LT= gastrostomy/ jejunostomy

Question 13

what to do if there is Gastric outlet obstruction? In terms of access using enteral feeding

Answer 13

cannot use NGT feeding.
use NJT

Question 14

What are the complications associated with enteral feeding? Mechanical, metabolic and GI

Answer 14

Mechanical: misplacement, blockage

Metabolic: hypergylcaemia, electrolytes imbalance

GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, V+D

Question 15

what to do when NGT is misplaced

Answer 15

-Aspirate pH ≤5.5
-pH > 5.5 → chest x-ray

Question 16

Artificial Nutrition Support: Parenteral- how are the nutrients delivered

Answer 16

The delivery of nutrient directly into venous blood.

Question 17

when to use parenteral nutrition support

Answer 17

inadequate/ unsafe oral +/- enteral nutritional intake

OR

impaired gastrointestinal tract

Question 18

parenteral feed access:

Answer 18

Central venous catheter (CVC): tip at superior vena cava and right atrium.

Question 19

What are the complications associated with parenteral nutrition?

Answer 19

-catheter related infections

-metabolic: electrolyte imbalance, hyperglycaemia

-mechanical- pneumothorax, thrombosis, catheter occlusion

Question 20

Albumin- where it’s synthesised, what does hypoalbuminaemia mean?

Answer 20

-liver
-poor prognosis
-negative acute phase protein -> low albumin= high inflammation

Question 21

albumin-what is the acute phase response

Answer 21

Inflammatory stimulus → activation of monocytes → release cytokines.

Cytokines act on liver -> proteins synthesis e.g. CRP, whilst downregulating production of others e.g. albumin.

Question 22

Is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 22

No. Albumin synthesis ↓es in response to inflammation ∴ poor predictor of malnutrition during acute phase.

Question 23

what is refeeding syndrome

Answer 23

biochemical shifts & clinical symptoms occurring in malnourished/starved individual on the reintroduction of oral, enteral or parenteral nutrition

Question 24

Consequences of RFS:

Answer 24

-Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death

-Respiratory depression
-Encephalopathy, coma, seizures
-Wernicke’s encephalopy

Question 25

RFS: what are the criteria for: at risk, high risk and extremely high risk

Answer 25

At risk:
Very little or no food intake for > 5 days

High risk: ≥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)

Extremely high risk:
-BMI < 14 kg/m2
-Negligible intake > 15 days

Question 26

RFS management

Answer 26

refer to dietitians
1. administer thiamine 30 mins before + first 10 days of feeding

2.correct and monitor electrolyte

3. start 10-20kcal/kg
   carb-40-50%
   micronutrients from feeding
4. monitor fluid shifts and minimise risk of fluid and Na+ Overload