Malnutrition and Nutritional Assesement (Complete)

Question 1

Define malnutration

Answer 1

State in which lack of uptake or intake of nutrition leads to a altered body compisiton and cell body mass which results in impaired physical and mental function.

Question 2

Malnutrtition tends to be highest in which age groups?

Answer 2

The young and elderly (more common in females)

Question 3

Which 2 hospital specialty wards has the highest prevalence of mulnutrition in patients?

Answer 3

Oncology

Care of the elderly

Question 4

Malnutrition is most common in patients with what group of diseases?

Answer 4

Gastrointestinal diseases

N.B. Also prevalent in patients with chronic diseases such as cancers, diabetes ect

Question 5

70% of patients who have stayed in hospital end up losing weight (muscle mass vs fat). Suggest some hospital related factors that can lead to malnutrition in hospitals.

Answer 5

Question 6

Malnutrition can lead to poorer physical and functional decline, leading to poorer clinical outcomes. List examples of the impact of malnutrition in terms of clinical outcomes.

Answer 6

Increases the risk of:

Mortality

Septic and post surgical complications

Length of hospital-stay

Pressure sores

Re-admissions, dependency

Reduces:

Wound healing

Response to treatment

Rehabilitation potential

Quality of life

Question 7

What is the economic consequence of malnutrition?

Answer 7

Costs the economy £19.6 billion on public health expenditure due to patients requiring more care

Question 8

What is the most common screening tool in the UK for malnutrition?

Answer 8

Malnutrition Universal Screening Tool (MUST)

N.B. It is not a assesment or diagnostic for malnutrition. It only helps to identify risk.

Question 9

What 3 components are assessed in MUST to determine the risk of malnutrition?

Answer 9

BMI

Weight loss (unexplained weight loss)

Acute disease effect score (looks at whether acute disease is reducing or will reduce food intake)

Question 10

What is the next step of action if a MUST score shows a patient is at high risk of malnutrition and may benefit from treatment (e.g. are not at imminent death)?

Answer 10

Refer to a dietician

Question 11

What is the role of a dietician when dealing with malnourished patients?

Answer 11

Able to carry of an extensive nutritional assesment and diagnose malnutrition.

Question 12

List the 3 components of a systematically approached nutritional assesement

Answer 12

Anthropology (to measure different compartments of the body and how they have been affected by malnutrition)

Biochemistry (Tests can be used to estimate nutritent availability in fluids and tissues)

Clinical history (provide insight into nutrient related problems) [E.g. clinical conditions, dietary constrictions, socioeconomic statuses]

Question 13

What is the most reliable way to estimate energy expenditure and guide energy prescriptions in a nutritional assesment?

Answer 13

Indirect caliometry

N.B. However has many restrictions which limits its use in clincal setting. Therefore predictive equations are done instead.

Question 14

According to NICE guidelines, providing nutrition support should be considered in people who are either? (2)

Answer 14

Malnourished

At risk of malnourishment

Question 15

List 3 ways a patient can be considered malnourished according to NICE guidelines

Answer 15

BMI < 18.5 kg/m2 or

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

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

Question 16

List 2 ways a patient can be considered at risk of being malnourished according to NICE guidelines

Answer 16

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.

Question 17

Define artificial nutritional support

Answer 17

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

Question 18

According to the algorithm by Stratton and Elia for malnutrition support, when should a patient be considered for enteral tube feeding?

Answer 18

Oral nutrition is not possible and GI tract is functional and accesible

Or oral nutrition is possible but regularly monitored intake shows inadequate nutrition after receiving oral nutritional support

Question 19

According to the algorithm by Stratton and Elia for malnutrition support, when should a patient be considered for parenteral tube feeding?

Answer 19

Oral nutrition not possible or safe

GI tract is not functional and inaccesible

Question 20

Give 2 examples of artificial nutritional support routes and state which of the two is superior?

Answer 20

Enteral nutrition (Superior as it involves the GI tract) [EN]

Parenteral nutrition [PN]

Question 21

What is the aim of parenteral nutrition? (PN)

Answer 21

Aim is to return to enteral nutrition as soon as possible and oral nutrtion of clinically possible

Question 22

What are the different types of enteral feeding methods depending on access points?

Answer 22

Put a tube down the nose and the tube can end up in different access points:

Nasogastric tube (Stomach) [NGT]

Nasoduodenal tube [NDT]

Naso-jejunal tube [NJT]

Or for long term (>3 months) of enteral nutrition is required, may require a gastrostomy or jejunostomy (Directly into stomach or jejunum)

Question 23

For a patient requiring long-term enteral nutrition (> 3 months), what type of enteral nutrition method would be most suitable?

Answer 23

A gastrostomy (if gastric feeding possible)

Jejunstomy (If gastric feeding not possible)

Question 24

For a patient in which gastric feeding is not possible, what is the most suitable enteral nutrition feeding methods? (2)

Answer 24

NDT (Naso-duodenal tube)

NJT (Naso-jejunal tube)

Question 25

Give an example of a condition which can prevent gastric feeding as a possibility for enteral nutrition and suggest what the next step of action should be in these patients.

Answer 25

Gastric outlet obstruction NGT is contraindicted in these cases so should give patient a NJT

Question 26

List some complications associated with enteral feeding. (10)

Answer 26

**Mechanical**: Misplacement Blockage Buried bumper (Bumber erodes abdominal wall and gets stuck between gastric wall and skin) **Metabolic:** Hypergylcaemia, Deranged electrolytes **GI:** Aspiration (Food enters lung) Nasopharyngeal pain Laryngeal ulceration Vomiting Diarrhoea

Question 27

What is a serious complication associated with enteral feeding and how can this be avoided?

Answer 27

Misplaced NG tube Must take an aspirate sample from the NG tube and measure the pH Aspirate should be pH _\<_ 5.5 (indicates GI acidic content) if aspirate pH \> 5.5 then they need an X-ray interpreted by trained professional following NPSA guidelines

Question 28

A regular aspirate sample has been taken from a patients NGT. The sample has shown a pH of 6.8. What is the next course of action?

Answer 28

pH \> 5.5 so will need a CXR Imaging should be interpretted by a proffesional following National Patient Safety Agency (NPSA) safety guidelines

Question 29

Define parental nutrition

Answer 29

The delivery of nutrients, electrolytes and fluid directly into venous blood.

Question 30

What are 2 indications which suggest that a patient may benefit from perental feeding as the method of artifical nutritional support?

Answer 30

An inadequate or unsafe oral and/or enteral nutritional intake OR A non-functioning, inaccessible or perforated gastrointestinal tract

Question 31

What is the most common access point for parenteral nutrition?

Answer 31

•Central venous catheter (CVC): tip at superior vena cava and right atrium. N.B. Different centra venous catheters for short/long-term use

Question 32

How is parenteral nutrition composition determined for individual patients?

Answer 32

Can administer ready made or 'scratch' bags The dietician also liases with the MDT to determine the electrolyte/fluid targets for the day

Question 33

List some complications associated with parenteral feeding

Answer 33

**Catheter related infections** **Mechancal complications:** Pneumothorax Haemothorax Thrombosis Cardiac arrythmias **Metabolic:** Deranged electrolyttes Hyperglycaemia Hypertriglycerideamia

Question 34

What is the most abundant circulating protein in the plasma of healthy individuals? What can it be useful in predicting?

Answer 34

Albumin Low levels are useful in predicting poor progonosis

Question 35

Albumin is considered a negative acute phase protein. State what this means

Answer 35

Negative acute phase proteins are proteins that lower in levels in response to acute inflammatory response

Question 36

Explain the acute phase resposne which results in lower albumin levels

Answer 36

When there is an inflammatory stimulus (e.g. muscle breakdown), it triggers the activation of **macrophages** and **monocytes** which release cytokines such as **IL-6** and **TNF**. Cytokines then act on the liver and upregulate some proteins whilst downregulating others such as albumin

Question 37

Can low albumin levels be a viable indication for malnutrition?

Answer 37

No as albumin levels lower in response to inflammatory stress which can be due to multiple things such as tissue injury, infection, muscle breakdown, stress ect. E.g. hypoalbuminaemia in obese **trauma** patients

Question 37

What is refeeding syndrome? (RFS)

Answer 37

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.

Question 38

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.

Answer 38

Refeeding syndrome

Question 39

What are some of the symptoms and consequences of refeeding syndrome? (7)

Answer 39

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death Respiratory depression Encephalopathy (Damage to brain) Coma Seizures Rhabdomyolysis (breakdown of muscle tissue leading to muscle fibres circulating in blood and can lead to kidney damage) Wernicke’s encephalopy (brain complications due to lactic acid in brain due to thiamine deficiency needed for glucose to not be metabolised anerobically)

Question 40

Summarise the pathogenesis of refreeding syndrome

Answer 40

When malnourished, the body switches to a catabolic state (gluconeogeneis, glycogenolysis, increased glucagon, proteinolysis) Protein, fat, mineral and elctrolyte depeltion results in salt and water intolerance (low concentration in plasma) Refeeding then triggers a anabolic state resulting in insulin secretion This promotes increased protein and glycogen synthesis, increased electrolyte uptake, glucose uptake and utilization of thiamine. This consequently depletes plasma stores as they are already low, resulting in many complications such as hypokalaemia, thiamine deficiency, hypomagnesia, salt and water retention (e.g. oedema). These depletions can result in the clinical manifestations of refeeding syndrome (e.g. arrythmia, werknickes encephalopathy due ti thiamine deficiency)

Question 41

According to the NICE guidlines, RFS (refeeding syndrome) risk can be categorised as at risk, high risk, extremely high risk. What would place a patient at risk of RFS?

Answer 41

Very little food or no food intake for \> 5 days

Question 42

According to the NICE guidlines, RFS (refeeding syndrome) risk can be categorised as at risk, high risk, extremely high risk. What would place a patient at **high** risk of RFS?

Answer 42

_\>_ 1 or more 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 or more 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)

Question 43

According to the NICE guidlines, RFS (refeeding syndrome) risk can be categorised as at risk, high risk, extremely high risk. What would place a patient at **extremely high** risk of RFS?

Answer 43

BMI \< 14 kg/m2 Negligible intake \> 15 days

Question 44

What is the management plan for a patient at risk of refeeding syndrome?

Answer 44

**Micronutrients** from onset of feeding (e.g. 10-20kcal/kg with 40-50% of the energy coming from carbohydrates [CHO]) Correct and monitor electrolytes **daily** **Administer thiamine** from onset of feeding Monitor **fluid shifts** and minimise risk of fluid and Na+ overload