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

4. 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?

5. 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.

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

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

8. 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

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

11. 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

12. 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

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

15. Risk factors for malnutrition
Medical causes
Psychological and social causes

16. 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

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

18. 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

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

20. 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,

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

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

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

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

25. 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

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

27. 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

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

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

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

33. Standard monogram for Height and Weight in adult-male
Small Frame
Medium Frame
Large Frame
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"

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

35. 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

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

37. Average Body Mass Index (BMI) for Adult Classification BMI (kg/m2)
Obesity Class
Underweight
<18.5
Normal
Overweight
Obesity I
Moderate obesity II
Extreme obesity
>40.0
III
Our patient BMI = 16.3 kg/m2

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

39. 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

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

41. 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

42. 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

43. 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 > mild depletion
CHI – 80 moderate
CHI < severe
Assuming that our patient IBW 59 kg (from chart)
990mg/ 59 kg x 23 = 73% (mild depletion)

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

45. Trace Minerals deficiency
Zinc
Copper
Chromium
Manganese
Selenium
Iron

46. *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

47. 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

48. Estimating Energy/Calorie

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

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

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

52. 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 = (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y)

53. 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
for burn

54. 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

55. Calorie sources

56. 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

57. Fluid Requirements

58. 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

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

60. 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

61. Protein Needs

62. Protein
The average adult requires about 1 to 1.2 gm/kg 0r average of grams of protein per day

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

64. Protein
Stress or activity level Initial protein requirement (g/kg/day)
Baseline g/kg/day
Little stress g/kg/day
Mild stress g/kg/day
Moderate stress g/kg/day
Severe stress g/kg/day

65. Nitrogen Balance Calculation

66. 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

67. 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

68. 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

69. Routes of Nutrition Support

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

72. Enteral Nutrition

73. 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

74. 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

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

76. Safety Catheter sepsis Pneumothorax Catheter embolism
Arterial laceration

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

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

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

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

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

83. Intact food
Predigested food

85. TF= tube feeding
TF = tube feeding

86. TF = tube feeding

88. Total Parentral Nutrition

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

90. 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-

91. Patient Selection

92. 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

93. Special Indications (can not eat)

94. 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)

95. 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

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

97. 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

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

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

100. Glucose Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult)
Cont;
Maximum oxidized rate for glucose is mg/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

101. 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

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

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

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

108. Administration

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

111. Continuous vs Cyclic Administration

112. 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

113. Monitoring

116. Complications of TPN

117. Complications Associated with PN
Mechanical complication
Septic complication
Metabolic complication

118. 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

119. 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

120. 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

122. 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

123. 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

124. Thank you