Malnutrition Screening and Assessment Flashcards
How does the onset of an inflammatory process begin?
With an insult to the body from pathogens, trauma, or other disease-causing agents
The inflammatory response increases cytokine production which in turn does what?
Signals hepatocytes to suppress the production of negative acute-phase proteins in favor of freeing amino acids for production of positive acute-phase proteins
What are the 5 components of the SGA that consider medical history, and the 3 components that focus on physical examination?
Medical history: weight changes, dietary intake, GI symptoms, functional capacity, metabolic stress from disease
Physical: muscle wasting, fat depletion, nutrition-related edema
According to Subjective Global Assessment (SGA) criteria, what severity of malnutrition best describes a patient who presents with cirrhosis complicated by portal hypertension, ascites, and edema?
Scenario: 52 y/o M h/o cirrhosis and portal hypertension r/t etoh abuse, 10 lb gain in 2 weeks with massive ascites, mild encephalopathy, asterixis, scleral ictus. Normal temp, low albumin, low prealbumin, normal WBC, elevated bilirubin and LFTs. Poor intake for at least 1 month (<50% of usual intakes), chronic early satiety, loss of appetite, diarrhea from lactulose. 150 lb usual weight, present weight 161 lb. 3-4+ LLE edema. severe fat loss in triceps and chest, severe muscle wasting in deltoids
Patient’s SGA ranging is C severely malnourished, as defined by his poor nutrition intake, muscle wasting, and loss of subcutaneous fat; supported by data showing his decreased functional capacity, persistent GI symptoms for >2 weeks, and increased metabolic demand. Nutrition intervention aimed at promoting adequate energy intake with balanced macronutrients, sodium restriction, replacement of appropriate micronutrients. May benefit from protein-energy supplements and vitamin/mineral replacement
Common medical/surgical diagnoses associated with heightened and intense inflammatory response with an acute injury/illness etiology of malnutrition
Critical illness, major infection/sepsis, adult respiratory distress syndrome, systemic inflammatory response syndrome, severe burns, major abdominal surgery, multitrauma, closed head injury, severe acute pancreatitis, post-op ileus
Common medical/surgical diagnoses associated with mild to moderate inflammatory response with a chronic illness (>3 months) etiology of malnutrition
Cardiovascular disease, CHF, cystic fibrosis, inflammatory bowel disease, celiac disease, chronic pancreatitis, rheumatoid arthritis, solid tumors, hematologic malignancies, sarcopenic obesity, DM, metabolic syndrome, CVA, neuromuscular disease, dementia, organ failure/transplant of kidney liver heart lung or gut, periodontal disease, pressure wounds, COPD, HIV, lupus, SBO, prolonged ileus
Common medical/surgical diagnoses associated with no inflammatory response with a social/behavioral/environmental circumstance etiology of malnutrition
Starvation, anorexia nervosa, compromised food intake in the setting of financial disparity, dementia, alcohol/drug abuse, pain, SBO
Suggested biochemical data parameters to assess for the presence of inflammation
Depleted albumin, prealbumin, transferring; elevated CRP, ferritin; hyperglycemia; leukocytosis, leukopenia, thrombocytopenia
Suggested microbiological data parameters to assess for the presence of inflammation
Urine cultures (UTI), blood cultures (bloodstream infections), fecal cultures (GI infections), bodily fluid cultures (infected abscess, pleural fluid, sputum, ascites)
Suggested imaging parameters to assess for the presence of inflammation
Chest xray (pneumonia, infiltrations, inflammation); CT, MRI, PET scan, abdominal/pelvic xray (abscess, pancreatitis, cancer, inflammatory process, bowel obstruction); gastric emptying study/small bowel follow-through (gastroparesis, dysmotility); EGD/colonoscopy (IBD, radiation enteritis, GVHD, gastritis, ulcers, fistula, strictures); ECHO (vegetation, endocarditis)
Suggested clinical manifestation parameters to assess for the presence of inflammation
Fever, hypothermia, chills, night sweats
Tachycardia, low BP
Rashes, skin redness, swelling, tenderness
Discharge from eyes or nose
Swelling or redness of mouth/gums
Pain with urination, productive cough, burns
What kind of factors can skew measures of weight?
Dehydration, excessive fluid accumulation, tumors
List the time frame and percentage of meaningful weight loss for moderate and severe acute illness/injury malnutrition
Moderate: 1-2% in 1 week, 5% in 1 week, 7.5% in 3 months
Severe: >2% in 1 week, >5% in 1 month, >7.5% in 3 months
List the time frame and percentage of meaningful weight loss for moderate and severe chronic illness malnutrition
Moderate: 5% in 1 month, 7.5% in 3 months, 10% in 6 months, 20% in 1 year
Severe: >5% in 1 month, >7.5% in 3 months, >10% in 6 months, >20% in 1 year
List the time frame and percentage of meaningful weight loss for moderate and severe social/environmental circumstance malnutrition
Moderate: 5% in 1 month, 7.5% in 3 months, 10% in 6 months, 20% in 1 year
Severe: >5% in 1 month, >7.5% in 3 months, >10% in 6 months, >20% in 1 year
What is the NUTRIC score?
Nutrition Risk in Critically Ill. Focuses on severity of illness using APACHE II, SOFA (with or without IL-6), number of comorbidities, days from hospital to ICU admission. Predictive of 28-day mortality. Recommended to assist with identification of critically ill patients most likely to gain from aggressive nutrition interventions
Describe the effect of starvation on lean muscle mass and adipose stores?
Preservation of LBM is the ultimate goal. Glycogen is initially used as the primary energy source, but reserves are quickly depleted forcing the body to use amino acids to make glucose and support energy requirements. Eventually, further adaptation occurs and resting energy expenditure decreases as fat becomes the main energy source providing ketones as fuel as a means to preserve muscle mass
Describe the effects of the metabolic pathway of inflammation/stress response on lean muscle mass and adipose stores?
Characterized by extreme catabolism and negative nitrogen balance, driven by a storm of hormones and cell mediators to mount an immune defense and repair tissue during injury and illness. All these reactions accelerate muscle breakdown to generate energy. Amino acids are displaced from muscles and used for gluconeogenesis. Additionally, cytokines act to inhibit repair and synthesis of new muscle tissue, promote muscle breakdown, and affect muscle function. Muscle degradation continues unabated while the condition persists, creating a much faster rate of skeletal and lean muscle loss than seen in starvation. The stress response mechanisms also work against nutrition intervention aimed at preservation.
What is muscle atrophy?
Loss of bulk and tone that is detectable by palpation
Define sarcopenia and its etiology
The age-related loss of muscle mass and has been associated with a decline in function. Various etiologies such as inflammatory and cytokine-driven oxidative stress as well as protein synthesis and neuromuscular integrity
Name conditions that affect sarcopenia
Lack of muscle use, chronic disease, insulin resistance, and poor nutrition
Define cachexia
Loss of muscle mass, irrespective of adipose tissue changes, which accompanies underlying illnesses and is often associated with inflammation, insulin resistance, decreased appetite and intake, and protein catabolism
Is cachexia responsive to nutrition support?
No because of its multifaceted and profound inflammatory state. Symptom management is imperative
