Malnutrition Flashcards
What is meant by malnutrition?
Too much nutrition or too little nutrition
What is the MUST screening toold?
Malnutrition universal screening test: screening tool that allows us to identifiy adults who are malnourished or at risk of malnutrition.
Every inpatient should have a MUST screening tool completed within 24hrs of admission; true or false?
True
State 3 broad potential causes of under nutrition and if possible provide examples of each
- Poor intake
- Malabsorption
- Coeliac
- Crohn’s
- Chronic pancreatitis
- Short bowel syndrome
- Bacterial overgrowth
- Excessive loss
Describe what the MUST screening tool- including factors it uses to make its assessment
Discuss what investigations you might do if you suspect malnutrition due to malabsorption
- History
- Examination
- Investigations
- Stool samples
- Microscopy: infection
- Faecal elastase: pancreatic insufficiency
- Hydrogen breath test: bacterial overgrowth
- Coeliac screen
- MRI/CT
- Endoscopy:e.g. Crohn’s
- Stool samples
What is refeeding syndrome?
Describes potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally5). These shifts result from hormonal and metabolic changes and may cause serious clinical complications
Discuss the pathophysiology of refeeding syndrome
- In starvation secretion of insulin is decreased because there is a reduced intake of carbohydrates
- In early starvation, body uses fat & protein stores to produce energy
- During prolonged starvation, body makes metabolic changes in attempt to reduce protein breakdown and use fat break down as its sole energy source
- During prolonges starvation, several intracellular minerals become depleted; however, plasma concentrations often remain normal as most of these minerals are intracellular
- When start to refeed, a sudden shift from fat catabolism to carbohydrate catabolism occurs; insulin increases due to glycaemia
- Insulin stimulates glycogen ,fat and protein synthesis; all of which require minerals such as phosphate, magnesium & co-factors such as thiamine
- Phosphate, magnesium & postassium are all taken up by cells; water follows by osmosis
- This leads to decrease in serum levels of phosphate, magnesium & potassium
- Furthermore, changes in carbohydrate metabolism cause an increase in Na+ and water retention- hence if hydrate pt with aim of achieving normal fluid output pt will quickly become fluid overloaded
What two electrolyte/water imbalances suggest refeeding syndrome may be occurring?
- Hypophosphataemia
- Fluid overload
State some factors that could make a pt at:
- Moderate
- High
- Very high
… risk of refeeding syndrome
Mild
- Little/no intake for >5 days
High risk
One of:
- BMI <16kg/m2
- Unitentional weight loss >15% within 3-6 months
- Little/no intake for >10 days
- Low Pi, K+, Mg2+ prior to feeding
Or two of:
- BMI <18.5kg/m2
- Unintentiional weight loss <10% within 3-6 months
- Little/ no intake >5 days
- EtOH abuse history or on certain medications e.g. insulin, chemo, antacids, diuretics
Very high risk
- BMI <14kg/m2
- Little/no intake >15 days
What are the symptoms & signs of refeeding syndrome
- Fatigue
- Weakness
- Confusion
- Difficulty breathing
- Arrhythmias
- Hypertension
Discuss how you can prevent refeeding syndrome
- Identify risk (use MUST)
- Check Pi, Mg2+, K+ prior to feeding
- Slow initial feed rate
- Vitamin replacement
How do you treat refeeding syndrome?
- Slow down rate of feeding
- Replenish electrolytes
State some potential consequences of refeeding syndrome
- Seizures
- Arrhythmias
- Cardiac failure
- Renal failure
- Resp failure
- Death
What is marasmus?
Severe form of malnutritiondue to inadequete intake of all nutrients
What is Kwashiorkor?
- Odematous malnutrition
- Not fully understood- once thought to be due to insufficent protein intake
- Associated wtih TB & HIV
Compare marasmus & kwashiorkor, include whether:
- Oedema present
- Hair changes present
- Skin changes
- Appetite
- Subcutaneous fat
- Fatty liver
- Prognosis
*Ignore bit about protein in Kwashiorkor as mechanism isn’t fully understood
Briefly remind yourself of the role of or consequence of deficiency of the following vitamins in the body:
- A
- B1
- B2
- B12
- C
- D
- E
- K
- Vit A: night blindness, bitot’s spots
- Vit B1: nervous system & cardiovascular function
- Vit B2: dry mucous membranes, corneal ulcers, normochromic normocytica anamia
- Vit B12: megaloblastic anaemia, subacute degeneration of cord
- Vit C: scurvy
- Vit D:rickets/osteomalacia
- Vit E:main role as antioxidant
- Vit K: coagulation
Discuss ways in which you can encourage oral intake
- Keep mealtime interruptions to minimum
- Encourgaement
- Ensuring pt has appropriate aids if necessary
- Finding foods pts like
- Nutrional supplements
If pts are unable to meet their nutrional requirements, have unsafe swallow or non-functioning GI tract what options are availabe? Describe each
NG tube
- Check pH prior to each use. If cannot get aspirtion, e.g. because pt on PPI, do CXR to confirm position
- Decrease risk of aspiration but don’t elimate risk as pts can aspirate on own saliva
PEG/RIG/PEGJ/RIGJ
- Longer term solution
- Tube may feed into:
- Stomach (PEG or RIG)
- Small bowel (PEG-J or RIG-J)
- May be placed endoscopically or radiologically
- All methods require puncture of stomach with trocar so are not without risk
- Pts may still aspirate on own saliva
Describe parenteral nutrition, include:
- What it involves
- Indications
- How it is given
- Risks
- Nutrition & fluid directly into pts veins
- GI tract not accessible (e.g. blocked) or not working (e.g. short bowel syndrome, leaking, diseased)
- Given via central line (PICC or Hickman)
- Risks: line sepsis, liver failure
