Title: Basic Clinical Nutrition
1Basic Clinical Nutrition
- Pranithi Hongsprabhas MD.
2Objective
- Etiology of PEM
- Classification
- Diagnosis/assessment
- Complication
- Management of PEM
- treatment option
- complication
- monitoring
3References
- 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.
4Malnutrition
- Over nutrition
- obesity
- dietary induced dyslipidemia
- Under nutrition
- protein energy nutrition
- specific nutrient deficiency
5Hospital Malnutrition
- 30-60 malnourished, 10 - 25 severe
- gets worse in hospital
- high morbidity, prolonged hospital stay
- higher mortality
6Cancer 1985 55 258-262
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8Diseases and Conditions Predisposing to
Malnutrition
Nutrient utilization
Nutrient intake
9Diseases 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.
10Simple 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
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12Marasmus 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
13Stress 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
14Stress 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
15Stress 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
16Chronic Stress Starvation
- Mild -moderate stress starvation
- Develops in months
17Functional Redistribution of Body Cell Mass
Liver protein synthesis
Glucose
Visceral protein
Acute phase protein
Extracellular AA pool
Tissue repair
Collagen
18Malnutrition 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
19Complication 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
20Type of Malnutrition
- Response to starvation/ semistarvation Marasmic
type - Response to stress starvation protein
malnutrition, hypoalbuminemic malnutrition,
Kwashiorkor, Marasmic-kwashiorkor
21Characteristic 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
22Metabolic Response
Nutrition in Critical Care 1994
23How to Detect Patients at Risk?
- Nutritional screening
- Nutritional assessment
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25Subjective 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
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27SGA (cont)
28SGA (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
29Physical Examination
- General
- Specific nutritional examination
30Clinical of Nutritional Deficiency
31General muscle wasting
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34Flaky paint dermatosis protein deficiency
35Essential fatty acid deficiency syndromes (EFADs)
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37Zinc deficiency
38- dermatitis
- dementia
- diarrhea
- death
- Pellagra
- niacin deficiency
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40Vitamin C deficiency
Perifolicullar pitichea
41Vitamin K deficiency
42Anthropometric Study
43Anthropometric 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
44Laboratory Assessment Biochem
- hepatic secretory protein
45Serum 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
46Distributional Hypoalbuminemia
Lobo et al. Clin Sci 2001
47Prealbumin
- T 1/2 2-3 d
- Decreased in liver failure, acute stress
- response to nutritional support
- increased in renal failure
48Transferrin
- Decreased in liver failure, acute stress
- increased in IDA
Retinol Binding Protein
- Decreased in liver failure, acute stress, vitamin
A deficiency - renal failure
49Creatinine 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
50Functional Assessment
- Somatic protein
- handgrip strength
- lung mechanic negative inspiratory pressure,
maximum ventilatory vol - muscle stimulation
- Immune response
- Delayed type cutaneous response
- total lymphocyte count
51Immunocompetence
- 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
52Multinutritional 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 -
53Nutrition Support
54Nutritional 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
55Nutrition 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
56Energy Requirement
- Estimated
- Harris-Benedict equation
- Kcal/kg/d
- Measured
- indirect calorimetry
57Estimated 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
58Protein Requirement
59Nitrogen Balance
N balance N output - N intake
- N output UUNUNUN misc
- UUN (2) (g)
- N intake Protein intake(g)
- 6.25
60Fat Requirement
- Essential fatty acid
- linoleic 4 of total calorie
- linolenic 0.2-0.4 of total calorie
- Source of energy 9kcal/1g
- 20-35
61Mineral Requirement
Vitamin Requirement/ Trace Element Requirement
According to RDA
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63Contraindication of Nutrition Support
- Unstable hemodynamics
- Severe fluid, electrolyte, acid- base disorder
(esp. PN) - Uncontrolled infection
- Severe GI tract malfunction (mainly EN)
64Enteral Nutrition
- Contraindication
- unstable condition hemodynamics
- intestinal obstruction
- massive GI bleeding
- intestinal ischemia
- severe malabsorption, inflammation
65Enteral Nutrition
- Complication
- tube complication
- aspiration
- diarrhea, vomiting, abdominal discomfort
- metabolic complication
66Parenteral Nutrition
- PPN, TPN
- Indication
- GI tract failure
- Inadequate EN
- Contraindication
- Unstable condition
- Uncontrolled serious condition
- Terminal stage malignancy
67Complication
- line sepsis CRI
- Metabolic derangement/ re-feeding syndrome
- Fluid/ electrolyte/ acid-base imbalance
- Overfeeding syndrome
68Monitoring
- BW
- clinical
- blood chemistry
- BS
- electrolyte
- LFT
69Assessment
- For nutrition response
- monitoring of complication