Malnutrition and Nutrition Intervention in the Hospitalised Adult Flashcards
define malnutrition
A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome
what percentage of patients will have lost weight on discharge?
70% - mainly loss of muscle mass
what factors increase risk of malnutrition in hospital?
disease related anorexia
metabolic response to injury/ illness
repeated NBM status
quality of food
GI symptoms
inflexibility of mealtimes
inactivity
low mood and depression
poly-pharmacy
co-morbidities
what are some of the impacts of malnutrition?
physical and functional decline and poorer clinical outcomes.
increased mortality, septic and post surgical complications.
what are the two different indications for nutrition support?
Nutrition support should be considered in people who are either:
- Malnourished =
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.
2.At risk of malnutrition =
Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or
Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
what three steps are involved in the diagnosis of malnutrition?
screen - MUST tool
assessment via a dietician - based on: anthropometry, biochemistry, clinical history, diet history, social and physical, nutrition requirements
diagnose
what is anthropometry
measurement system of the size and makeup of the body - weight, BMI, muscle mass, mid upper arm circumference, triceps skin fold thickness, CT for muscle composition and subcutaneous and visceral fat
What is biochemistry used for in malnutrition?
To see nutrient availability
What are some of the disadvantages to using biochemistry in malnutrition?
Can be expensive for micronutrients CRP below 10
Can be skewed due to inflammation - wait until
What is the most reliable way to measure energy expenditure?
Indirect calorimetry
What is indirect calorimetry?
Resting metabolic rate measurement using respirator gas exchange canopy
Can use predictive equations to find estimates too
What are the nutritional options available via the oral route?
Fortification of meals and snacks
•Altered meal patterns
•Practical support
•Oral nutritional supplements (ONS)
•Tailored dietary counselling
When should oral nutrition support be considered?
onsider for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function or if no benefit is anticipated e.g. end of life care.
What is artificial nutrition support?
The provision of enteral or parenteral nutrients to treat or prevent malnutrition
Where parenteral nutrition is used, what is the overall aim?
To return to enteral -> oral feeding as soon as clinically possible
What is enteral nutrition?
What is parenteral nutrition?
Enteral = tube feeding
Parenteral = delivery of nutrients, electrolytes and fluid directly into venous blood.
In enteral nutrition what are the two methods used and what are there uses based on?
Access:
Is gastric feeding possible?
•Yes = Naso-gastric tube (NGT)
•No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)
If a patient has been on enteral feeding for 3+ months, what should they be switched to?
Gastrostomy/ Jejunstomy
Why would you choose to give enteral nutrition through NJT instead of a nasogastric tube?
NGT may be contraindicated in gastric outlet obstruction
What complications are associated with enteral feeding?
Mechanical: misplacement, blockage, buried bumper
•Metabolic: hypergylcaemia, deranged electrolytes
•GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea.
What are the indications for parenteral support?
Indications:
•An inadequate or unsafe oral and/or enteral nutritional intake
OR
•A non-functioning, inaccessible or perforated gastrointestinal tract
What is the access point for parenteral nutrition support?
Central venous catheter (CVC): tip at superior vena cava and right atrium.
•Different CVCs for short / long term use.
Q. What are the complications associated with parenteral nutrition?
Metabolic: deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia
Catheter related infections
Mechanical: pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion
What does hypoalbuminaemia in malnutrition indicate?
A poor prognosis
Where is albumin synthesised?
Liver
How does the acute phase response alter serum albumin?
The acute phase response.
•Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
•Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin.
Degradation and transcapillary loss of albumin increase in inflammatory state
Is albumin a valid marker of malnutrition in the acute hospital setting?
No
What is refeeding syndrome?
A group of biochemical shifts and clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral, or parenteral nutrition
What are the consequences of refeeding syndrome?
Consequences of RFS:
•Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
•Respiratory depression
•Encephalopathy, coma, seizures, rhabdomyolysis,
•Wernicke’s encephalopy
Outline the pathology of refeeding syndrome
During starvation the body aims to utilise energy stores - metabolism switches from carbohydrate to fat, insulin secretion decreases and glucagon increases.
Action of cellular pumps are reduced
Depletion in K+, phosphate and MG2+
Then in refeeding insulin secretion increases in response to blood sugar, increased basal metabolic rate and synthesis which requires phosphates, K+ and Mg2+ which don’t have causing electrolyte and thiamine levels to fall
What categories someone as been at risk of RFS according to NICE guidelines?
Very little or no food intake > 5daysb
According to NICE guidelines, what classes someone as being high risk of RFS?
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)
According to NICE guidelines what criteria is needed for someone to be classed as extremely high risk of RFS?
BMI < 14
Negligible intake > 15days
What is the management plan for RFS?
Start with no more than 10-20 kcal/kg nutrition
40-50% from CHO
Micronutrients given from onset
Correct and monitor electrolytes daily
Thiamine administered from onset of feeding
Monitor fluid shifts and minimise risk of fluid or sodium overload
