Malnutrition Tutorial Flashcards
What can you use to estimate height and weight if the patients is unable to tell you?
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
What do you have to be mindful of when giving propofol?
Contributes additional energy of 1 kcal/mL
Risk of fat overload
What do pro-kinetics do?
Promote gastric emptying
What must be monitored when feeding?
Bowel frequency
Bristol stool chart
What can be used when bowel frequency is high?
Pancreatic enzymes to help with absorption
What is PICC?
Peripherally inserted central catheter
What are the two main nutritional goals for all patients?
Prevent dehydration
Improve nutritional status
What are some of the implications nutritionally of commonly prescribed ICU medications?
Slow gut motility
Reduce blood flow to gut increasing risk of gut ischaemia
What often happens during ICU admission?
Many become insulin resistant even if they do not have diabetes, showing hyperglycaemia
Give insulin but must be mindful of hypoglycaemia
What medication must you be mindful of when feeding nutrition to a patient?
(Hint: why is the symptom of diarrhoea post-op confusing?)
Use of laxatives - need to distinguish whether feeding is causing diarrhoea or the medication
What needs to happen if a patients it taking the anticonvulsant phenytoin?
If given via the enteral route requires a break from feed for drug absorption
Do we start to feed our patient with severe acute necrotising pancreatitis? If so, using which route?
Yes, start enternal nutrition within the gut via NGT feed
Enteral VS parenteral? In patients, which do you start and why?
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
What does the Penn State equation for feeding take into account?
Gender Age Height Temperature Ventilation settings
What do you take into account when preparing a nutritional feed for a patient?
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
How can you feed into the gut if there is stenosis in the duodenum?
Naso-jejunal tube
Can be place via endoscopy or also at the bedside
What is ‘trophic’ NG feeding?
Minimal amount
Why do you always want to prioritise enteral feeding?
Used alongside parenteral
To challenge the gut, stop gut becoming leaky, high risk of bacterial translocation - maintain integrity
What is an early indicator of adequate nutritional support?
Hand grip
Indicative of muscle function improving
What is short bowel syndrome?
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
Which part of the bowel is important for nutrient absorption?
Most nutrients absorbed within first 120cm (2m) of jejunum - should be mindful of this during bowel resection
What does the nutritional consequences for a patient after resection depend on?
Type of bowel remaining
Length
Quality of bowel
or remnant small bowel
Colon present or not?
In what resection is there no colon present?
End-Jejunostomy
Ends in stoma at abdomen
In which resections is the colon preserved?
Ileocolonic anastaomosis
Jejunocolonic anastamosis
What are the benefits of preserving the colon?
Allows for the reabsorption of sodium, fluid and fatty acids
Slows intestinal transit
Allows for intestinal readaption
What defines short bowel syndrome?
Less than 2 metres from duodenojejunal flexure
What are the critical lengths in short bowel syndrome?
< 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-
What happens to fluid after a resection?
Daily secretions 4L a day arriving at the upper jejunum for reabsorption
Fluid reabsorbed if colon is present
If not high fluid losses
What is the target stoma output 6 weeks post op?
1.5L a day
What oral fluid advice would you give to prevent further dehydration and electrolyte balance?
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
What should patients have when they are dehydrated?
Oral rehydration solution
1L of electrolyte mix
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
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
What is the dietetic intervention for jejunostomy?
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
What do you do if appetite in a jejunostomy patient decreases?
Food fortification
Oral nutritional supplements
What is a common symptom after bowel resection?
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
What strategies can be used to overcome thirst?
Strategies to overcome thirst: Ice chips, smaller cup, drink between rather than with meals
What urinary sodium value indicates dehydration?
> 20mmol/L
What are the two main nutrition goals?
Prevent dehydration
Improve nutritional status
How can dehydration be prevented?
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
How is nutritional status improvement measured?
By showing an increase in lean body mass
Evidenced by increased mid-arm muscle circumference & handgrip strength over next 4 weeks
