Nutrition

Question 1

Malnutrition

Answer 1

BMI < 18
Unintentional weight loss >10% 3-6 months
BMI < 20 and Unintentional weight loss >5% within 3-6 months

Risk if poor oral intake for 5 days
Poor absorptive capacity

Question 2

Metabolic response to starvation

Answer 2

Use ATP via citric acid cycle and oxidative phosphorylation

Insulin down
Glucagon up
Hepatic glycogenolysis up
Protein catabolism up
Lipolysis and ketogenesis up
Basal metabolic rate down

Fatty acids under go beta oxidation to form acetyl co-A

This can combine with oxaloacetate –> but these re depleted in starvation (used for gluconeogenesis)

Thus converted into ketone bodies
Brain can use this for 30% of requirements

Question 3

Stress response to surgery/trauma

Answer 3

Sympathetic stimulation –> catecholamine release
RAAS –> sodium and water retention
ACTH –> glucocorticoids

Question 4

Sepsis

Answer 4

Hypermetabolic state and increased protein breakdown
Marked glucose intolerance with development of diabetes like state
Can consume 250g protein a day

Question 5

Screening

Answer 5

Ascites
2.2, 6, 14

Oedema
1, 5, 10.4

Question 6

NG

Answer 6

Better than parenteral for hyperglycaemia, cholestasis and hypertriglyceridaemia

But complications
aspiration
Discomfort
Pressure necrosis
Diarrhoea
Misplacement
Difficulty

Need head up during feeding

Pro kinetics

Metoclopramide
Erythromycin
Domperidone

Question 7

Enterostomy

Answer 7

Contraindications
Coagulopathy
Distal mechanical bowel obstruction
Peritonitis over insertion site

Malignancy, massive ascites, hepatosplenomegaly, gastric varies, and peritoneal dialysis are relative contraindications

Question 8

Parenteral

Answer 8

Non-functional, inaccessible or perforated GIT

SBO
Intestinal fistulae
Short bowel syndrome
Refractory IBD

High osmolality so must be in central vein otherwise thrombophlebitis

PPN can be given to peripheral temporarily

PICC line is best to avoid

Question 9

Complications

Answer 9

Tube displacement
Pressure necrosis
Fistulae
Wound infection
Tube blockage
Pulmonary aspiration

TPN:
Infection 
Line blockage
CV thrombosis
Fluid overload
Hyperglycaemia
Hypertriglyceridaemia

Question 10

Refeeding

Answer 10

Hypophosphataemia
Intracellular mineral stores severely depleted
Insulin release stimulates processes requiring minerals
Serum levels fall quickly –> marked fluid shifts
ATP depletion leads to inhibited cellular oxygen utilisation

SLOW re-introduction of food

Arrhythmias 
Cardiac failure
SOB
Resp weakness
Ventilator depndence
Wernicke's 
Seizures
Tetany
Pain
N+V
Ileus
Myalgia
Osteomalacia
Rhabdo
Blood cell dysfunction
2,3 DPG depletion
Haemolysis