Week 3 - H - Malnutrition (MUST score/management, Re-feeding syndrome) and Intestinal failure (Types, Short bowel, H.P.N)

Question 1

What does NICE define malnutrition as?

Answer 1

NICE defines malnutrition as * BMI OR * >10% unplanned weight loss in the last 3-6 months OR * a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months

Question 2

Screening for malnutrition if mostly done using MUST (Malnutrition Universal Screen Tool). When should a MUST score be calculated? What three factors does a MUST score take into account?

Answer 2

A MUST score should be done on admission to care/nursing homes and hospital, or if there is concern. For example an elderly, thin patient with pressure sores A MUST score takes into account a patients BMI, recent weight loss and evidence of acute disease effect It then categorises the patients into low, medium and high risk

Question 3

What are the 5 MUST steps?

Answer 3

* Step 1 - measure height and weight of patient to calculate Body Mass Index * Step 2 - Note percentage of unplanned weight loss in the past 3-6 months * Step 3 - Establish acute disease effect (are they acutely ill and when did they last eat) * Step 4 - Add scores from steps 1,2,3 together to obtain overall risk of malnutrition * Step 5 - Manage patient based on their risk category

Question 4

What are the different scores given for Steps 1-3 in calculating the MUS score?

Answer 4

Step 1 BMI * >20 (>30 obese) = 0 * 18.5-20 = 1 * Step 2 Unplanned weight loss score (last 3-6 months) * 10% = 2 Step 3 - Acute disease effect * Acutely ill and no nutritional intake >5 days = 2

Question 5

What score is required form combining steps 1,2,3 to classify as Low risk Medium Risk Overall Risk What is the management of the different sections?

Answer 5

Low risk = 0 - routine clinical care Medium risk = 1 - observe, document dietary intake for 3 days High risk = 2 or more - Treat - refer to dietitian, nutritional support steam or local policy within 24 hours

Question 6

Who does NICE state requires nutritional support?

Answer 6

Nutritional support should be given to anybody who is considered malnourished * BMI 10% unplanned weight loss in last 3-6 months * BMI 5% unplanned weight loss in last 3-6 mths Nutritional support should also be given to anybody at risk of malnutrtion * Acutely ill and has been or is likely to be no nutritional intake for >5days * Poor absorptive capacity and/or high nutrient loss and/or increase nutrtional needs

Question 7

Nutritional support What are the different steps in providing nutritional support (ie how is food given to the patient)?

Answer 7

Food first Oral nutrition supplements eg additional snacks between meals, NOT instead of meals Enteral tube feeding - the delivery of a nutritionally complete feed directly into the gut via a tube Parenteral nutrition - the delivery of nutrition intravenously

Question 8

What are the different types of enteral tube feeding?

Answer 8

Nasogastric tube Nastoduodenal tube Nasojejunal tube Gastotomy or jejunostomy tubes - these may be placed endoscopically, radiologically or surgically

Question 9

What are the different indications for enteral tube feeding? What are the indications for parenteral nutrition?

Answer 9

Enteral tube feeding * Inadequate or unsafe oral intake in a patient with a functional, accessible GI tract * Unconscious patients * Neuromuscular swallowing disorder * Upper GI obstruction Parenteral feeding Inadequate or unsafe oral intake in a patient with a non-functional, or inaccessible GI tract

Question 10

Refeeding syndrome is a potentially fatal medical condition that may affect malnourished and/or ill patients in response to an inappropriately high protein-calorie intake via any route. Why does refeeding sydnrome occur?

Answer 10

As the body turns to fat and protein metabolism in a starved state, there is a drop in circulating insulin (due to decreased carbohydrate levels). The catabolic state also depletes intracellular stores of phosphate, potassium and magnesium although serum levels may remain normal. When refeeding begins, the level of insulin rises in response to carbohydrate load, and one consequence is to increase cellular uptake of phosphate, magnesium and potassium causing hypophosphataemia, hpomagnesiumia, hypokaelaemia to develop usually within 4 days - responsible for most features

Question 11

How may refeeding manifest due to both * Metabolic changes? * Physiological changes?

Answer 11

Refeeding syndrome can manifest as either * Metabolic changes * Hypokalaemia, Hypophosphataemia, Hypomagnesaemia, * Altered glucose metabolism and * Fluid balance abnormalities Physiological changes (ie arrhythmias, altered level of conciousness, seizures) and potentially death

Question 12

Patients at risk of refeeding syndrome can either be moderate, high or extremely high risk Which patients are at moderate risk of refeeding syndrome? Which patients are at extremely high risk of refeeding syndrome?

Answer 12

Moderate risk - patients who have had little or no nutritional for >5 days Extremely high risk – BMI 15 days

Question 13

What can be given immediately before and during the first 10 days of feeding to a patient at risk of re-feeding syndrome? It is hoped to prevent the development of the condition

Answer 13

Give the patient high dose Pabrinex (contains vitamin C and vitamin B1 (thiamine), B2 (riboflavin), B3 (nicotinamide aka niacin) and B6 (pyroxidine) before and during the refeeding window

Question 14

What is given for the treatment of refeeding syndrome?

Answer 14

Re-introduce food slowly Monitor the potassium, phosphate and magneisum levels - if blood levels become low provide oral, enteral or intravenous supplements

Question 15

INTESTINAL FAILURE What is intestinal failure? What is it characterized by?

Answer 15

Intestinal failure is the result of an inability to maintain adequate nutrition or fluid status via the intestines It is characterised by the inability to maintain protein-energy, fluid, electrolytre or micro-nutrient (vitamins and minerals) balance

Question 16

Simply put, intestinal failure is where the gut is no longer able to supply the hydration and nutritional needs of the body What are different causes of intestinal failure?

Answer 16

Intestinal failure can occur due to * Obstuction * Dysmotility * Surgical resection * Congenital defect * Disease associated loss absorption

Question 17

When a patient experiences intestinal failure resulting in function below the minimum necessary for the absorption of nutrients and water/electrolytes, what is required?

Answer 17

The reduction in function below the minimum necessary for the absorption of macronutrients and / or water and electrolytes is such that intravenous supplementation is required to maintain health and / or growth Parenteral nutrition is required

Question 18

Intestinal failure can be classified as Type 1, 2 or 3 Where type does acute short term /chronic long term fall into?

Answer 18

Acute intestinal failure is can be either type 1 or 2 intestinal failure Chronic intestinal failure lasts longer and is type 3 intestinal failure

Question 19

What is the difference in type 1, 2 and 3 intestinal failure? In terms of duration, nutritional support and where treatment takes place?

Answer 19

Treatment in Wards Type 1 IF-short term (2 wks) - self limiting intestinal failure (parenteral nutriton is short term) Type 2 IF- is medium term- significant and prolonged parenteral nutritonal supports >28 days Treatment - wards to home Type 3 IF - Chronic - long term parenteral support

Question 20

What are different causes of type 1, 2 and 3 intestinal failure?

Answer 20

Type 1 * Usually the result of minor gastrointestinal surgery (Ileus is a temporary arrest of intestinal peristalsis. It occurs most commonly after abdominal surgery, particularly when the intestines have been manipulated) * Can occr due to GI problems - vomting, dysphagia etc Type 2 * Usually the result of extensive bowel resection Type 3 * Short bowel syndrome +/- other pathology

Question 21

Type 1 intestinal failure is common and short term (days/week) How is it treated?

Answer 21

Treated by replacing fluid and correcting electrolyte abnormalities Parenteral nutrition if unable to tolerate food/fluids >/= 7 days post-op Acid suppression - PPI

Question 22

Type 2 intestinal failure was usually in patients with extensive bowel resection What complications is it associated with? What is the treatment?

Answer 22

Associated with septic, metabolic, and complex nutritional complications. Usually requires weeks/months of care in ICU/HDU - pareneteral +/- some enteral feeding

Question 23

Type 3 intestinal failure is chronic and usually requires hospital parenteral nutrition that is transferred to home parenteral nutrition Home parenteral nutrition remains the treatment of choice Short bowel syndrome and/or other pathologies cause this condition What are other causes of type 3 intestinal failure?

Answer 23

Crohn’s disease Neoplasia - inoperable obstruction Vascular Mechanical - dysmotility Radiation

Question 24

The most common indication for home parenteral nutiriton is intestinal failure caused by short bowel syndrome What is the average length of small bowel? What length is known as short bowel syndrome? Why is nutritional support needed?

Answer 24

Average length of small bowel is approx 7m (700cm) (ranges from 250cm-1050cm) <200cm = short bowel Nutritonal support required as there is Insufficient length of small bowel to meet nutritional needs without artificial nutritional support

Question 25

Short bowel syndrome is a small bowel <200cm What length of small bowel usually indicates the need for HPN?

Answer 25

<50cm of small bowel indicates a need for HPN

Question 26

What are the different types of parenteral nutrition therapy?

Answer 26

Peripheral venous line - use of peripheral veins, can lead to phlebitis Central venous line * Hickman line - tunnel catheter - long term * PICC line - peripheral incerted venous catheter - short term

Question 27

Parenteral nutrition is high risk and should only be condiered if the patient is likely to become malnoruished (>7 days post op for Type 2 IF) without it What are different complications of parenteral nutrition?

Answer 27

Sepsis Thrombosis - SVCO or Pulmonary embolus Metabolic imbalance Liver disturbance

Question 28

What are the different causes of short bowel syndrome?

Answer 28

Short bowel syndrome in adults and children is usually caused by surgery. This surgery may be done for: * Crohn’s disease * Mesenterc infarct * Radiation * Volvulus * Trauma Some children are also born with an abnormally short small intestine -> congenital short bowel

Question 29

What are two different surgical options that are involved in attempting to lengthen the small bowel?

Answer 29

Longitudinal lengthening - Biacnhi procedure (bowel is cut in half and one end is sewn to the other) Serial transverse enteroplasty (STEP) (bowel is cut and stapled in a zigzag pattern)

Question 30

What is the last resort treatment for type 3 intestinal failure? What is the main indication for this?

Answer 30

Small bowel transplantation - lower 5 year survival than HPN * (Transplantation - 50-60% 5 year survival * (60% 5y survival home PN) The main indication for this is loss of venous access / liver disease and therefore is usually combined with a liver transplant