Nutritional Support In Hospital And Community Care Settings And Organisation Of Nutrition Support Teams

Question 1

Why is nutrition important?

Answer 1

• impaired wound healing, immune response
• inactivity leads to pressure sores
• reduced muscle strength
• increased risk of post-operative complications
• depression and self-neglect

Question 2

Intestinal failure definition and the 3 types

Answer 2

• comprises a group of disorders with many different causes, all of which are characterised by an inability to maintain adequate nutrition via the intestines (obstruction, abnormal motility, major surgical resection, congenital defect or disease-associated loss of absorption)
• type I: short term, self-limiting and peri-operative
• type II: metabolically unstable (sepsis) patient in hospital requiring PN for >28 days
• type III: metabolically stable, chronic condition requiring long term HPN

Question 3

Management of IF/fistulae using SNAP approach

Answer 3

S= sepsis (surgical or radiological intervention) 
N= nutrition (control of fluid balance and electrolyte levels, EN if possible) 
A= anatomy (how much bowel do they have left?) 
P= planned intervention (if no spontaneous closure at 3-6 months)

Question 4

Management of short bowel syndome

Answer 4

1) determine the location of intestine resected and amount so can assess the likelihood of diarrhea, malabsorption and malnutrition
2) replace fluid losses and manage diarrhea i.e oral rehydration solution with 90 mmol/L Na. Need to replace fluids on the basis of WHERE the fluid is lost from
3) select appropriate oral nutrition (max energy from fat and CHO and N content)
4) replace specific vitamin and mineral deficiencies

Question 5

Screening and assessment of nutrition

Answer 5

• screening: using the MUST tool, fluid charts, bloods, weight history, diet history
• calculating nutritional requirements: henry equations to get BMR + stress factor + DIT/PA (for high BMI use calculation for BMI 25 unless severely stressed)
• nutritional support: oral diet + oral supplements, NGT, jejunostomy feeding, fistuloclysis, PN

Question 6

Parenteral nutrition: energy, glucose infusion rates, fluid requirements, electrolyte requirements

Answer 6

• energy: provide 40-60% of non-protein energy as fat
• glucose max infusion rates (5 mg/kg/min for non-septic patient, 3 mg/kg/min for septic patient)
• underestimating better than over-estimating
• fluid: 30-35 ml/kg (but need to be aware of losses)
• fluid for restricted or tiny patent (1500-2000 mL), 50-70kg patient (2500 mL), big patient or large losses (3000 mL)
• recommended electrolyte levels: Na and K (1-1.5 mmol/kg), Ca (0.1-0.15 mmol/kg), Mg (0.1-0.2 mmol/kg), phosphate (0.5-0.7 mmol/kg)
• consider a lipid-free bag if poor liver function, extremely malnourished, upcoming surgery or if diabetic

Question 7

Refeeding syndrome: who is at risk and how to manage

Answer 7

• risk factors: at least one of the following (BMI <16, WL >15% in 3-6 months, little nutrition for 10+ days, low levels of K, Mg, phosphate prior to feeding) OR at least two of the following (BMI <18.5, WL >10% in 3-6 months, little nutrition for 5+ days, history of alcohol abuse/insulin, chemo, antacids or diuretics)
• management: oral (100 mg thiamine, vitamin B TDS, multivitamin and mineral supplement (forceval)), enteral (as previous), parental (2 ampules Pabrinex OD for 3-5 days)

Question 8

What is central access and risks associated

Answer 8

• used for PN, and can take an osmolarity of 1500-2500 mosmol/kg
• risks: infection, thrombosis, occlusion, fracture

Question 9

What is clinical homecare and why is it important?

Answer 9

• allows patient to receive consultant-level care at home with homecare nurses, sometimes up to twice a day
• allows patients to foster independence and be free of the hospital, to be around their own family
• growing 20% YOY
• also has potential cost saving capacity