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Basic Clinical Nutrition

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Title: Basic Clinical Nutrition


1
Basic Clinical Nutrition
  • Pranithi Hongsprabhas MD.

2
Objective
  • Etiology of PEM
  • Classification
  • Diagnosis/assessment
  • Complication
  • Management of PEM
  • treatment option
  • complication
  • monitoring

3
References
  • Shils M, Olson JA, Shike M, Modern Nutrition in
    Health and Diseases. 2005
  • Rombeau JL, Rolandelli RH. Clinical nutrition
    Parenteral Nutrition. 2001
  • Rombeau JL, Rolandelli RH. Clinical nutrition
    Enteral Nutrition.1997.
  • ?????????????????? ?????????????? 2544.

4
Malnutrition
  • Over nutrition
  • obesity
  • dietary induced dyslipidemia
  • Under nutrition
  • protein energy nutrition
  • specific nutrient deficiency

5
Hospital Malnutrition
  • 30-60 malnourished, 10 - 25 severe
  • gets worse in hospital
  • high morbidity, prolonged hospital stay
  • higher mortality

6
Cancer 1985 55 258-262
7
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8
Diseases and Conditions Predisposing to
Malnutrition
Nutrient utilization
Nutrient intake
9
Diseases and Conditions Predisposing to
Malnutrition
  • Decreased intake
  • Altered metabolism
  • Increased losses
  • Decreased absorption
  • Increased requirement

Hensrud DD. Nutrition screening and assessment.
Med Clin North Am 1999831525-47.
10
Simple Starvation Marasmic Wasting
  • Total or partial cessation of energy intake
  • Short term starvation (lt72 hr)
  • glycogenolysis glucose
  • gluconeogenesis glucose
  • lipolysis FFA, glycerol
  • Prolonged starvation (gt72 hr)
  • decreased RMR, DIT, activity
  • decreased gluconeogenesis from aa, lactate
  • increased tissue utilization of ketone, FFA

11
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12
Marasmus Simple starvation
  • decreased metabolic rate
  • weight loss mainly from fat and also LBM
  • impaired wound healing and immune function
  • Normal albumin level

Bone and skin appearance
13
Stress Starvation
  • Response to starvation and inflammation
  • Days to weeks or months
  • Depend on hormonal and cytokine control
  • Cytokine response
  • catabolic (IL-1, IL-6, TNF-a)
  • increased RMR
  • decreased LBM
  • increased protein breakdown
  • vascular permeability
  • Hormonal response
  • aldosterone/ADH
  • salt/ water retention
  • epinephrine, glucagon, cortisol
  • lipolysis
  • gluconeogenesis
  • severe protein catabolism

14
Stress Starvation
  • Change of body composition
  • ECF expansion / Wt gain
  • body cell mass and ICF decline
  • Loss of body protein functional change
  • respiratory muscle
  • wound healing
  • immune response
  • Catabolic state cannot be reversed by nutrition
    alone nutritional resistance

15
Stress Starvation
  • Kwashiorkor or hypoalbuminemic malnutrition
  • low albumin level/ edema
  • Loss of body protein functional change
  • respiratory muscle
  • wound healing
  • immune response
  • higher morbidity and mortality

16
Chronic Stress Starvation
  • Mild -moderate stress starvation
  • Develops in months

17
Functional Redistribution of Body Cell Mass
Liver protein synthesis
Glucose
Visceral protein
Acute phase protein
Extracellular AA pool
Tissue repair
Collagen
18
Malnutrition Related Complication
  • Impaired immunity
  • CMI, chemotaxis, phagocytosis, complement
  • Impaired wound healing
  • muscle atrophy
  • compromised respiratory function hypoxic
    ventilatory drive, impaired resp muscle, VC, MV
  • compromised cardiac function contractility,
    bradycardia

19
Complication of Malnutrition
  • Reduced renal function reduced GFR and
    concentrating ability
  • inability to handle Na load, acid load
  • polyuria
  • Liver fatty liver
  • GI

Perspect Crit Care 1989 21
20
Type of Malnutrition
  • Response to starvation/ semistarvation Marasmic
    type
  • Response to stress starvation protein
    malnutrition, hypoalbuminemic malnutrition,
    Kwashiorkor, Marasmic-kwashiorkor

21
Characteristic Differentiating of Starvation and
Stress Starvation Related Malnutrition
  • Marasmus
  • develops over mo-yr
  • principally from low intake
  • usually emaciated
  • edema not prominent
  • usually normal albumin
  • lower mortality than kwashiorkor
  • Marasmic kwashiorkor
  • develops over weeks
  • usually from low intake and stress
  • appear well nourished
  • edema is characteristic
  • may be no wt loss
  • usually low serum protein
  • higher mortality

22
Metabolic Response
Nutrition in Critical Care 1994
23
How to Detect Patients at Risk?
  • Nutritional screening
  • Nutritional assessment

24
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25
Subjective Global Assessment
  • History
  • wt loss
  • dietary change
  • significant GI symptoms
  • functional ability
  • degree of stress
  • PE
  • degree of fat loss
  • muscle wasting
  • edema/ ascites
  • clinical signs of nutritional deficiency

26
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SGA (cont)
28
SGA (cont)
  • Class A
  • no change in BW, normal intake,
  • lt 5 wt loss, or gt 5 wt loss but recent gain
    and improve appetite
  • Class B
  • 5-10 wt loss without recent stabilization or
    gain, poor dietary intake and mild loss of
    subcutaneous tissue
  • Class C
  • ongoing wt loss of gt 10 with severe subcutaneous
    tissue loss and muscle wasting often with edema

29
Physical Examination
  • General
  • Specific nutritional examination

30
Clinical of Nutritional Deficiency
31
General muscle wasting
32
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34
Flaky paint dermatosis protein deficiency
35
Essential fatty acid deficiency syndromes (EFADs)
36
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37
Zinc deficiency
38
  • dermatitis
  • dementia
  • diarrhea
  • death
  • Pellagra
  • niacin deficiency

39
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40
Vitamin C deficiency
Perifolicullar pitichea
41
Vitamin K deficiency
42
Anthropometric Study
43
Anthropometric Measurement
  • BW/HT, BMI
  • Skinfold thickness
  • Mid arm cir (MAC), Mid arm muscle cir. (MAMC),
    mid arm muscle area
  • limitation
  • fluid
  • technique reproducibility
  • do not reflect variation in bone size, skin
    compressibility

44
Laboratory Assessment Biochem
  • electrolytes
  • hepatic secretory protein

45
Serum Albumin
  • Low alb correlated with poor clinical outcome
    prognosticator
  • Low alb lt 2.5 associates with hypooncotic effects
  • affected by non nutritional factors
  • fluid
  • stress
  • prioritization
  • leakage

46
Distributional Hypoalbuminemia
Lobo et al. Clin Sci 2001
47
Prealbumin
  • T 1/2 2-3 d
  • Decreased in liver failure, acute stress
  • response to nutritional support
  • increased in renal failure

48
Transferrin
  • Decreased in liver failure, acute stress
  • increased in IDA

Retinol Binding Protein
  • Decreased in liver failure, acute stress, vitamin
    A deficiency
  • renal failure

49
Creatinine Height Index
  • Factors affecting CHI reliability
  • renal insufficiency
  • rhabdomyolysis
  • bed rest
  • catabolic state
  • incomplete collection
  • Correlates with lean body mass
  • CHI actual 24-hr Cr excretion
  • expected Cr excretion
  • estimated 18-20 kg muscle produce 1 g Cr
  • expected Cr excretion
  • female 18 mg/kg
  • male 23 mg/kg
  • interpretation
  • gt 80 0-mild depletion
  • 60-80 moderate depletion
  • lt 60 severe depletion

50
Functional Assessment
  • Somatic protein
  • handgrip strength
  • lung mechanic negative inspiratory pressure,
    maximum ventilatory vol
  • muscle stimulation
  • Immune response
  • Delayed type cutaneous response
  • total lymphocyte count

51
Immunocompetence
  • Malnutrition immunocompromized
  • DHR, total L count detect malnutrition related
    immuno-suppression
  • DHR affected by hepatic failure, elyte imbalance
    infection, renal insufficiency
  • TLC lt1500mm3 affected by infection, stress,
    chronic diseases
  • in most hospitalized patient DHR, TLC not
    useful in nutrition assessment

52
Multinutritional Indices
  • PNI () 158-16.6 alb-0.78 TSF-0.2TFN-5.8 DH
  • alb, TFN g/dl, TSF mm, DH 0 NR, 1 lt5mm, 2
    gt5mm

53
Nutrition Support
54
Nutritional Support
  • Indication
  • NPO gt 10-14 day
  • PEM or at nutritional risk
  • Inadequate oral intake
  • Maldigestion, malabsorption
  • Nutrient loss fistula, dialysis, drainage
  • Hypercatabolic state sepsis, burn, multiple
    trauma
  • Perioperative severely malnorished
  • Undergoing BMT

55
Nutrition Aim/ Goal
  • Improve nutritional depletion
  • malnourished/ low catabolism
  • Maintain nutritional status/ prevent malnutrition
  • malabsorption
  • unable to eat
  • Minimized nutritional related complication
  • critically illness
  • moderate hypercatabolic state
  • Improve clinical outcome
  • perioperative nutrition
  • nutrition in BMT
  • trauma

56
Energy Requirement
  • Estimated
  • Harris-Benedict equation
  • Kcal/kg/d
  • Measured
  • indirect calorimetry

57
Estimated Energy Requirement
  • 1. Requirement BEE x AF x SF
  • Activity factor 1.2 (low), 1.3 ( moderate ) ,
    1.5 ( high )
  • Stress factor mild 1-1.1, moderate 1.2-1.4,
    severe 1.5-2
  • 2. Kcal/kg
  • 25-35 kcal/kg/d

Harris Benedict Equation BEE m 6613.7 wt5
ht-6.3 age f 6559.6wt17ht-4.7age
58
Protein Requirement
59
Nitrogen Balance
N balance N output - N intake
  • N output UUNUNUN misc
  • UUN (2) (g)
  • N intake Protein intake(g)
  • 6.25

60
Fat Requirement
  • Essential fatty acid
  • linoleic 4 of total calorie
  • linolenic 0.2-0.4 of total calorie
  • Source of energy 9kcal/1g
  • 20-35

61
Mineral Requirement
Vitamin Requirement/ Trace Element Requirement
According to RDA
62
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  • ?????????????????????????????????????????? GI
    function ???????
  • ?????????? GI function ??????????????
  • ?????????? GI tract failure

63
Contraindication of Nutrition Support
  • Unstable hemodynamics
  • Severe fluid, electrolyte, acid- base disorder
    (esp. PN)
  • Uncontrolled infection
  • Severe GI tract malfunction (mainly EN)

64
Enteral Nutrition
  • Contraindication
  • unstable condition hemodynamics
  • intestinal obstruction
  • massive GI bleeding
  • intestinal ischemia
  • severe malabsorption, inflammation

65
Enteral Nutrition
  • Complication
  • tube complication
  • aspiration
  • diarrhea, vomiting, abdominal discomfort
  • metabolic complication

66
Parenteral Nutrition
  • PPN, TPN
  • Indication
  • GI tract failure
  • Inadequate EN
  • Contraindication
  • Unstable condition
  • Uncontrolled serious condition
  • Terminal stage malignancy

67
Complication
  • line sepsis CRI
  • Metabolic derangement/ re-feeding syndrome
  • Fluid/ electrolyte/ acid-base imbalance
  • Overfeeding syndrome

68
Monitoring
  • BW
  • clinical
  • blood chemistry
  • BS
  • electrolyte
  • LFT

69
Assessment
  • For nutrition response
  • monitoring of complication
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