1. Ahmed Mayet Associate Professor King Saud University
Nutrition Support

2. Nutrition
Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein

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

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

5. 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

6. Clinical Manifestations
Marked hypoalbuminemia
Anemia
Edema and ascites
Muscle atrophy
Delayed wound healing
Impaired immune function

8. 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

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

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

12. 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

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

14. 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

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

16. 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,

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

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

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

20. 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"

21. Percent weight loss 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20%
50kg x 2.2 = 110 lbs
Small frame
Medium frame

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

23. 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

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

25. 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

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

27. 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

28. 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

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

30. Trace Minerals deficiency
Zinc
Copper
Chromium
Manganese
Selenium
Iron

31. Estimating Energy/Calorie

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

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

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

35. 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)

36. 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

37. 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

38. Calorie sources

39. 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

40. Fluid Requirements

41. 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

42. 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

43. Protein Needs

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

45. 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

46. Routes of Nutrition Support

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

49. Enteral Nutrition

50. 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

51. 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

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

53. Safety Catheter sepsis Pneumothorax Catheter embolism
Arterial laceration

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

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

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

58. Intact food
Predigested food

59. TF = tube feeding

60. Total Parentral Nutrition

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

62. 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-

63. Patient Selection

64. 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

65. Special Indications (can not eat)

66. 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)

67. 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

69. Fat Emulsion Concentrated source of calories
Source of essential fatty acids (EFAs)
Substitute for carbohydrate in diabetic & fluid restricted patients

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

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

74. Administration

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

76. Parenteral Nutrition Central Nutrition Peripheral nutrition
Subclavian line
Long period
Hyperosmolar solution
Full requirement
Minimum volume
Expensive
More side effect
Peripheral nutrition
Peripheral line
Short period < 14days
Low osmolality
< 900 mOsm/L
Min. requirement
Large volume
Thrombophlebitis

77. Note PPN can infuse through central line but
central TPN can NOT infuse through
the peripheral line

80. Complications of TPN

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

82. 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

83. 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

84. 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

86. 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

87. 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

88. Thank you