Ahmed Mayet, Pharm.D Associate Professor King Saud University Nutrition Support Ahmed Mayet, Pharm.D Associate Professor King Saud University

Questions What medical history support that the patient is “at risk” of malnutrition? What physical findings support that the patient is “at risk” of malnutrition?

Nutrition Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

Malnutrition Malnutrition—extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body.

Types of malnutrition Kwashiorkor: (kwa-shior-kor) is protein malnutrition Marasmus: (ma-ras-mus) is protein-calorie malnutrition

Kwashiorkor Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response Common causes - chronic diarrhea, chronic kidney disease, infection, trauma , burns, hemorrhage, liver cirrhosis and critical illness

Clinical Manifestations Marked hypoalbuminemia Anemia Edema Muscle atrophy Delayed wound healing Impaired immune function

Marasmus The patient with severe protein-calorie malnutrition characterized by calories deficiency Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation

Marasmus The patient with severe malnutrition characterized by calories deficiency Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation protein-calorie

Clinical Manifestations Weight loss Reduced basal metabolism Depletion skeletal muscle and adipose (fat) stores Decrease tissue turgor Bradycardia Hypothermia

Risk factors for malnutrition Medical causes Psychological and social causes

Medical causes (Risk factors for malnutrition) Recent surgery or trauma Sepsis Chronic illness Gastrointestinal disorders Anorexia, other eating disorders Dysphagia Recurrent nausea, vomiting, or diarrhea Pancreatitis Inflammatory bowel disease Gastrointestinal fistulas

Psychosocial causes Alcoholism, drug addiction Poverty, isolation Disability Anorexia nervosa Fashion or limited diet

Consequences of Malnutrition Malnutrition places patients at a greatly increased risk for morbidity and mortality Longer recovery period from illnesses Impaired host defenses Impaired wound healing Impaired GI tract function

Cont: Muscle atrophy Impaired cardiac function Impaired respiratory function Reduced renal function mental dysfunction Delayed bone callus formation Atrophic skin

Sorensen J et al ClinicalNutrition(2008)27,340 349 International, multicentre study to implement nutritional risk screening and evaluate clinical outcome “Not at risk” = good nutrition status “At risk” = poor nutrition status Results: Of the 5051 study patients, 32.6% were defined as ‘at-risk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients. Sorensen J et al ClinicalNutrition(2008)27,340 349

ClinicalNutrition(2008)27,340e349 International,multicentre study to implement nutritional risk screening and evaluate clinical outcome ClinicalNutrition(2008)27,340e349

Metabolic Rate Normal range Long CL, et al. JPEN 1979;3:452-6

Protein Catabolism Normal range Long CL. Contemp Surg 1980;16:29-42

Nutritional Assessment Nutritional assessment (NA) is the first step in the treatment of malnutrition

Indications Aggressive nutritional support (enteral or parenteral) should be considered in anyone who: Looks clinically malnourished. Has a low serum albumin <3.5g/dL. Has a recent loss of 10% or greater within Has a history of recent poor intake. Who as a consequence of his illness is going to be or has been NPO for 5-7 days. The term “If gut works, use it” remains the golden rule. However, recently this was changed to: If gut works use it; and if gut works partially, use it partially. 25

Answer (medical history) What medical history support that the patient is “at risk” of malnutrition? Nausea Abdominal pain Diarrhea Loss of appetite Weight loss

Answer (physical finding) Cont; What physical findings support that the patient is “at risk” of malnutrition? Pale Lethargic Muscle wasting cachecxia Edematous Hypotensive Tachycardia Burses and patichiae on the limbs

Question What biochemical, anthropometric, indirect calorimetric, and other testes are suggesting that your patient is malnourish?

Cont: The initial assessment of nutritional status requires a careful History Physical examination Laboratory and other tests

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein

Standard monogram for Height and Weight in adult-male Small Frame Medium Frame Large Frame 4'10" 102-111 109-121 118-131 4'11" 103-113 111-123 120-134 5'0" 104-115 113-126 122-137 5'1" 106-118 115-129 125-140 5'2" 108-121 118-132 128-143 5'3" 111-124 121-135 131-147 5'4" 114-127 124-138 134-151 5'5" 117-130 127-141 137-155 5'6" 120-133 130-144 140-159 5'7" 123-136 133-147 143-163 5'8" 126-139 136-150 146-167 5'9" 129-142 139-153 149-170 5'10" 132-145 142-156 152-173 5'11" 135-148 145-159 155-176 6'0" 138-151 148-162 158-179

Percent weight loss 129 lbs – 110 lbs = 19 lbs 50kg x 2.2 = 110 lbs Small frame Medium frame

Severe weight lost Time Significant Weight Loss (%) Severe Weight Loss (%) 1 week 1-2 >2 1 month 5 >5 3 months 7.5 >7.5 6 months 10 >10

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein

Average Body Mass Index (BMI) for Adult Classification BMI (kg/m2) Obesity Class Underweight <18.5   Normal 18.5-24.9 Overweight 25.0-29.9 Obesity 30.0-34.9 I Moderate obesity 35.0-39.9 II Extreme obesity >40.0 III Our patient BMI = 16.3 kg/m2

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein

Fat Assessment of body fat Triceps skinfold thickness (TSF) Waist-hip circumference ratio Waist circumference Limb fat area Compare the patient TSF to standard monogram

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein

Protein (Somatic Protein) Assessment of the fat-free muscle mass (Somatic Protein) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram

Protein (visceral protein) Cont; Assessment of visceral protein depletion Serum albumin <3.5 g/dL Serum transferrin <200 mg/dL Serum cholesterol <160 mg/dL Serum prealbumin <15 mg/mL Creatinine Height Index (CHI) <75% Our patient has albumin of 2.2 g/dl

Creatinine-height index (CHI ) [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height] Ideal Cr = IBW x 23 mg/kg male = IBW x 18 mg/kg female CHI > 80 mild depletion CHI 60 – 80 moderate CHI < 60 severe Assuming that our patient IBW 59 kg (from chart) 990mg/ 59 kg x 23 = 73% (mild depletion)

Vitamins deficiency Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin C Vitamin A Vitamin D Vitamin K

Trace Minerals deficiency Zinc Copper Chromium Manganese Selenium Iron

*Our patient Clinical Sign or Symptom Nutrient General Wasted, thin - Clinical Sign or Symptom Nutrient General Wasted, thin Calorie Loss of appetite Protein-calorie Skin Eczematous scaling Zinc Follicular hyperkeratosis Vitamin A Flaking dermatitis Protein-calorie, niacin, riboflavin, zinc Pigmentation changes Protein-calorie, niacin Scrotal dermatosis Riboflavin Folate, iron, vitamin B12, copper *Pallor *Bruising Vitamin C, vitamin K *Our patient

Neck Goiter Iodine - Parotid enlargement Protein Thorax Thoracic rosary Vitamin D Abdomen Diarrhea Niacin, folate, vitamin B12 Distention Protein-calorie Hepatomegaly Extremities Bone tenderness Muscle wasting Protein, vitamin D, selenium Ataxia Vitamin B12 Nails Transverse *Edema Protein, thiamine *Hyporeflexia Thiamine *Spooning Iron

Estimating Energy/Calorie

BEE Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy requirements

Total Energy Expenditure TEE (kcal/day) = BEE x stress/activity factor

BEE The Harris-Benedict equation is a mathematical formula used to calculate BEE

Harris–Benedict Equations Energy calculation Male BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) Female BEE = 655 + (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y)

A correlation factor that estimates the extent of hyper-metabolism 1.15 for bedridden patients 1.10 for patients on ventilator support 1.25 for normal patients The stress factors are: 1.3 for low stress 1.5 for moderate stress 2.0 for severe stress 1.9-2.1 for burn

Calculation =66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) Our patient Wt = 50 kg, Age = 45 yrs Height = 5 feet 9 inches (175 cm) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) =66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) =66 + ( 685) + (875) – (306) = 1320 kcal TEE = 1320 x 1.25 (normal activity) = 1650 kcal

Calorie sources

Calories 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat To include protein calories in the provision of energy is controversial

Fluid Requirements

Fluid The average adult requires approximately 35-45 ml/kg/d NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council

Fluid 1st 10 kilogram 100 cc/kg 2nd 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kg Example: Our patient 1st 10 kg x 100cc = 1000 cc 2nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc

Fluid Fluid needs are altered by the patient's functional cardiac, hepatic, pulmonary, and renal status Fluid needs increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin integrity like burns, open wounds

Protein Needs

Protein The average adult requires about 1 to 1.2 gm/kg 0r average of 70-80 grams of protein per day

Protein The initial protein goals are estimated according to the following general guidelines

Protein Stress or activity level Initial protein requirement (g/kg/day) Baseline 1.4 g/kg/day Little stress 1.6 g/kg/day Mild stress 1.8 g/kg/day Moderate stress 2.0 g/kg/day Severe stress 2.2 g/kg/day

Nitrogen Balance Calculation

Nitrogen Balance (NB) Calculation NB is an important calculation for assessing nutritional response NB is used to evaluate the adequacy of protein intake as well as to estimate current protein requirements

Calculations NB = N intake – N losses N intake = Protein intake (g/day) / 6.25gm N losses = UUN (g/day) + 4g* UUN is determined from a 24 hour urine collection *4g is a "fudge factor" to account for miscellaneous nitrogen losses

Cont: Positive NB indicates an anabolic state, with a net gain in body protein Negative NB indicates a catabolic state, with a net loss of protein With adequate feeding NB 0 –5 g/day indicates moderate stress NB > –5 g/day indicates severe stress

Routes of Nutrition Support

The nutritional needs of patients are met through either parenteral or enteral delivery route

Enteral Nutrition

Enteral The gastrointestinal tract is always the preferred route of support (Physiologic) “If the gut works, use it” EN is safer, more cost effective, and more physiologic that PN

Potential benefits of EN over PN Nutrients are metabolized and utilized more effectively via the enteral than parenteral route Gut and liver process EN before their release into systemic circulation Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue

EN (Immunologic) Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis

Safety Catheter sepsis Pneumothorax Catheter embolism Arterial laceration

Cost (EN) Cost of EN formula is less than PN Less labor intensive

Contraindications Gastrointestinal obstruction Severe acute pancreatitis High-output proximal fistulas Intractable nausea and vomiting or osmotic diarrhea

Enteral nutrition (EN) Long-term nutrition: Gastrostomy Jejunostomy Short-term nutrition: Nasogastric feeding Nasoduodenal feeding Nasojejunal feeding

Parenteral nutrition (PN) Peripheral Parenteral Nutrition (PPN) Total Parenteral Nutrition (TPN)

Cautious use of PN: Azotemia Congestive heart failure Diabetes Mellitus Electrolyte disorders Pulmonary disease

Intact food Predigested food

TF= tube feeding TF = tube feeding

TF = tube feeding

Total Parentral Nutrition

Purpose To maintain positive nitrogen balance through the intravenous administration of required nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals and trace elements

PN Goal Provide patients with adequate calories and protein to prevent malnutrition and associated complication PN therapy must provide: Protein in the form of amino acids Carbohydrates in the form of glucose Fat as a lipid emulsion Electrolytes, vitamin, trace elements, min-

Patient Selection

General Indications Requiring NPO > 5 - 7 days Unable to meet all daily requirements through oral or enteral feedings Severe gut dysfunction or inability to tolerate enteral feedings. Can not eat, will not eat, should not eat

Special Indications (can not eat)

Cont: When enteral feeding can’t be established After major surgery Pt with hyperemesis gravidarum Pt with small bowel obstruction Pt with enterocutaneous fistulas (high and low)

Cont: Hyper-metabolic states: Burns, sepsis, trauma, long bone fractures Adjunct to chemotherapy Nutritional deprivation Multiple organ failure: Renal, hepatic, respiratory, cardiac failure Neuro-trauma Immaturity

Calorie sources 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat

Calculation =66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) Our patient Wt = 50 kg, Age = 45 yrs Height = 5 feet 9 inches (175 cm) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) =66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) =66 + ( 685) + (875) – (306) = 1320 kcal TEE = 1320 x 1.25 (normal activity) = 1650 kcal

total calculated calorie = 1650 kcal 80% from glucose 1650 x 80 =1320kcal 20% from fat (IL) 1650 x 20 = 330kcal Protein 1.2gm/kg/day 1.2 x 50 = 60 gm

Protein requirement 150 kcal to 6.25 gm of protein 1650 kcal/150 x 6.25 gm = 68.8 or 70gm

Glucose Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult) Cont; Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult) Exp: our patient is 50 kg 5mg x 50kg x 60min x 24 hr =360 gm 360gm x 3.4 kcal/gm = 1224 kcal Maximum cal from glucose = 1224kcal

Fat emulsion Maximum recommended allowance 2.5 grams/kg/day Exp: 2.5 x 50 kg = 125 gm 125gm x 9 kcal/gm = 1125 kcal

Calorie calculation Total calorie requirement = 1650 kcal calorie from glucose = 1224 kcal _______ form lipid 436 kcal

Intralipid contraindications: Hyperlipdemia Acute pancreatitis Previous history of fat embolism Severe liver disease Allergies to egg, soybean oil or safflower oil

Diabetic DM is not contraindication to TPN Use sliding-scale insulin to avoid hyperglycemia

Administration

Central PN (TPN) Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only

Continuous vs Cyclic Administration

Continuous vs Cyclic administration It is given overnight and the patient is free during the day from the PN solution and associated administration paraphernalia (long-term care) Continuous administration is preferred in hospitalized patients as they often have fluid and electrolyte disturbances

Monitoring

Complications of TPN

Complications Associated with PN Mechanical complication Septic complication Metabolic complication

Mechanical Complication Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia Venous thrombosis after central venous access

Infectious Complications PN imposes a chronic breech in the body's barrier system The mortality rate from catheter sepsis as high as 15% Inserting the venous catheter Compounding the solution Care-giver hanging the bag Changing the site dressing

Metabolic Complications Early complication -early in the process of feeding and may be anticipated Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition

Iron Iron is not included in TPN solution and it can cause iron deficiency anemia Add 100mg of iron 3 x weekly to PN solution or give separately

Vitamin K TPN solution does not contain vitamin K and it can predispose patient to deficiency Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN

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