Malnutrition Tutorial

Question 1

What can you use to estimate height and weight if the patients is unable to tell you?

Answer 1

Ulnar length
Mid arm circumference

e.g.
Ulna length: 27 cm = height 1.71m

Mid upper arm circumference 21cm = BMI 18 kg / m2.
Weight est. 60 kg

Question 2

What do you have to be mindful of when giving propofol?

Answer 2

Contributes additional energy of 1 kcal/mL

Risk of fat overload

Question 3

What do pro-kinetics do?

Answer 3

Promote gastric emptying

Question 4

What must be monitored when feeding?

Answer 4

Bowel frequency

Bristol stool chart

Question 5

What can be used when bowel frequency is high?

Answer 5

Pancreatic enzymes to help with absorption

Question 6

What is PICC?

Answer 6

Peripherally inserted central catheter

Question 7

What are the two main nutritional goals for all patients?

Answer 7

Prevent dehydration

Improve nutritional status

Question 8

What are some of the implications nutritionally of commonly prescribed ICU medications?

Answer 8

Slow gut motility

Reduce blood flow to gut increasing risk of gut ischaemia

Question 9

What often happens during ICU admission?

Answer 9

Many become insulin resistant even if they do not have diabetes, showing hyperglycaemia

Give insulin but must be mindful of hypoglycaemia

Question 10

What medication must you be mindful of when feeding nutrition to a patient?
(Hint: why is the symptom of diarrhoea post-op confusing?)

Answer 10

Use of laxatives - need to distinguish whether feeding is causing diarrhoea or the medication

Question 11

What needs to happen if a patients it taking the anticonvulsant phenytoin?

Answer 11

If given via the enteral route requires a break from feed for drug absorption

Question 12

Do we start to feed our patient with severe acute necrotising pancreatitis? If so, using which route?

Answer 12

Yes, start enternal nutrition within the gut via NGT feed

Question 13

Enteral VS parenteral? In patients, which do you start and why?

Answer 13

Used to be thought that during pancreatitis, the gut and pancreas need to be ‘rested’

Recent research shows this is not true, ‘resting’ the gut provides no benefit and may actually be detrimental

Need to keep using gut and its motility

Parenteral nutrition (PN) is a method to provide nutrition without ‘stimulating’ the pancreas, this is detrimental as it can make the gut leaky, bacterial translocation etc., which may exacerbate pancreatitis

Question 14

What does the Penn State equation for feeding take into account?

Answer 14

Gender
Age
Height
Temperature
Ventilation settings

Question 15

What do you take into account when preparing a nutritional feed for a patient?

Answer 15

IV pabrinex = thiamine
Must be given alongside nutritional feed each time, and must be starts 30 mins prior to feeding

If patient has a strong alcohol misuse history - nutritional feed needs to prepared in consideration that ethanol may inhibit absorption of thiamine = perhaps need a higher dose than normal

Question 16

How can you feed into the gut if there is stenosis in the duodenum?

Answer 16

Naso-jejunal tube

Can be place via endoscopy or also at the bedside

Question 17

What is ‘trophic’ NG feeding?

Answer 17

Minimal amount

Question 18

Why do you always want to prioritise enteral feeding?

Answer 18

Used alongside parenteral

To challenge the gut, stop gut becoming leaky, high risk of bacterial translocation - maintain integrity

Question 19

What is an early indicator of adequate nutritional support?

Answer 19

Hand grip

Indicative of muscle function improving

Question 20

What is short bowel syndrome?

Answer 20

Short-bowel syndrome-intestinal failure results from surgical resection, congenital defect or disease-associated loss of absorption

Characterised by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balances when on a conventionally accepted, normal diet

Question 21

Which part of the bowel is important for nutrient absorption?

Answer 21

Most nutrients absorbed within first 120cm (2m) of jejunum - should be mindful of this during bowel resection

Question 22

What does the nutritional consequences for a patient after resection depend on?

Answer 22

Type of bowel remaining
Length
Quality of bowel
or remnant small bowel

Colon present or not?

Question 23

In what resection is there no colon present?

Answer 23

End-Jejunostomy

Ends in stoma at abdomen

Question 24

In which resections is the colon preserved?

Answer 24

Ileocolonic anastaomosis

Jejunocolonic anastamosis

Question 25

What are the benefits of preserving the colon?

Answer 25

Allows for the reabsorption of sodium, fluid and fatty acids

Slows intestinal transit

Allows for intestinal readaption

Question 26

What defines short bowel syndrome?

Answer 26

Less than 2 metres from duodenojejunal flexure

Question 27

What are the critical lengths in short bowel syndrome?

Answer 27

< 100cm of jejunum = long term intravenous fluid + e-
< 75 cm of jejunum = long term PN, fluid + e-
< 50 cm of jejunum + colon = long term PN, fluid + e-

Question 28

What happens to fluid after a resection?

Answer 28

Daily secretions 4L a day arriving at the upper jejunum for reabsorption

Fluid reabsorbed if colon is present

If not high fluid losses

Question 29

What is the target stoma output 6 weeks post op?

Answer 29

1.5L a day

Question 30

What oral fluid advice would you give to prevent further dehydration and electrolyte balance?

Answer 30

Decrease oral fluids

Misconception that it should be increased

Drinking hypotonic fluids (Na 90mmol or less) results in high stoma output as sodium is dragged into gut lumen

Anything very concentrated as the same impact e.g. fruit juice - fluid dragged into lumen to balance solute

Question 31

What should patients have when they are dehydrated?

Answer 31

Oral rehydration solution

1L of electrolyte mix

Question 32

What is the recipe for ORS?
20g (6 teaspoons) glucose
3.5g (1 level 5ml teaspoon) salt
2.5g (1 heaped 2.5ml spoon) sodium bicarbonate
1L water
Add cordial, chill, sip through straw

Answer 32

20g (6 teaspoons) glucose
3.5g (1 level 5ml teaspoon) salt
2.5g (1 heaped 2.5ml spoon) sodium bicarbonate
1L water
Add cordial, chill, sip through straw

Question 33

What is the dietetic intervention for jejunostomy?

Answer 33

Hyperphagic diet
Absorb half of food they eat
Calories requirements and nitrogen doubled
High fat- for energy and essential fatty acids
Low fibre - lowers intestinal gut transit
Additional NaCl given
Additional selenium and magnesium

Question 34

What do you do if appetite in a jejunostomy patient decreases?

Answer 34

Food fortification

Oral nutritional supplements

Question 35

What is a common symptom after bowel resection?

Answer 35

Feeling of dehydration -

Feel thirsty but they acc need to restrict / decrease fluid intake

Drinking hypotonic fluids = net influx of sodium into the bowel lumen until 100 mmol/L conc reached = more water excreted out in the urine exacerbating the dehydration feeling

Question 36

What strategies can be used to overcome thirst?

Answer 36

Strategies to overcome thirst: Ice chips, smaller cup, drink between rather than with meals

Question 37

What urinary sodium value indicates dehydration?

Answer 37

> 20mmol/L

Question 38

What are the two main nutrition goals?

Answer 38

Prevent dehydration

Improve nutritional status

Question 39

How can dehydration be prevented?

Answer 39

Aiming for urine sodium >20 mmol/L
by encouraging adherence to fluid restriction
and consumption of an oral rehydration solution over the next 2 wks

Question 40

How is nutritional status improvement measured?

Answer 40

By showing an increase in lean body mass

Evidenced by increased mid-arm muscle circumference & handgrip strength over next 4 weeks