????????? Nutrition support ???????????????????????????

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????????? Nutrition support ?????????????????????
??????

• Winai Ungpinitpong, MD. FRCST
• Department of Surgery, Surin Hospital
• 25 September 2008
• winai_ung_at_golfchannelclub.com

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Malnutrition

• The consequence of
• Inadequate intake
• Excessive intake
• Unbalance nutrient intake
• In clinical practice undernutrition and
  malnutrition are often interchanged

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Malnutrition in Hospital

• Common problems 15-50
• Under-recognition and Late detection
• Complications of malnourished patients are 2-20
  times greater than those of well-nourished
  patients
• Increase infection
• Delayed wound healing
• Prolonged hospital stay
• Higher hospital costs
• Increase mortality

Buzby GP et al, Am J Surg 1980 Hickman DM, et al,
1980 Klidjian AM, et al, 1982
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• Nutrition Support

• Nutrition Support

Prevention is better than cure.
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Nutrition Therapy
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Nutrition Support Team Ward NST members

• Physician Dietitian
• - Diagnosis - Calories count
• - Placement of CVC - Enteral Nutrition
• - Team Leader - Transitional Feedings
• Nurse Pharmacist
• - Maintenance of CVC - Admixture
  Preparation
• - Physical Assessment - Admixture
  Formulation
• - Patient Training - Drug-Nutrient
  Interaction

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HA ?????? 3(4.3) ????????????????????

• ??????????????????????????????????????????????????
  ??????? ??????????????? ??????????????????????????
  ??????????????

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Making Awareness
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Development of NSTSurin Hospital

• 2002 SPENT Meetings at Surin hospital
• 2002 NST setting up
• Doctors
• Pharmacists
• Nurses
• Dietitians
• 2003 Clean room for TPN
• 2003 Nutritional Risk Screening program1
• and guideline, manuals2
• 2003 Workshop of nutritional screening
• 1.University of Hospital Nottingham A.
  Mickewright
• 2.Khonkaen University

Dr.Winai Ungpinitpong
Surin Hospital
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Development of NSTSurin Hospital

• 2003 100 Nutritional Risk Screening
• 2003 Incidence of malnutrition in Surgical
  patients at Surin hospital
• 2003 Attend nutrition short course, scientific
  meeting
• 2004 Dietitian award
• 2005 NF care improved by nutritional supporting
• 2006 Wound assessments program
• 2006 Early nutrition support in necrotizing
  fasciitis
• 2006 Lowering incidence of malnutrition in Surin
  hospital
• 2007 Computerized assist nutrition screening
• 2007 Role of IED in necrotizing fasciitis

Dr.Winai Ungpinitpong
Surin Hospital
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Activity

• NST round weekly
• NST joint meeting monthly
• Mini lectures
• Workshops
• Screening of new patients
• Pick up of nutrition risk patients
• Management of nutrition therapy

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NST

• Leader team and active members
• Screening tool Nottingham University Hospital
• SGA
• Guideline of management (Simple)
• Organizational manual
• Report of activities
• Nutrition audit
• Computerized assist

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Department of Surgery, Surin Hospital
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University of Hospital Nottingham A. Mickewright
Nutrition Risk Screening 1 2 3 4
Body mass index (BMI) kg/m2 0gt20 118-20 2lt18
Loss weight over the last 3 months 0no 1lt3kg 2gt3kg
Decrease of food intake over last month 0no 1yes
Stress factors 0none 1moderate 2severe
Total
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Stress Factors / Severity of illness

• 0 none
• 1 Moderate
• Minor surgery
• Chronic disease
• Minor pressure sore
• CVA
• Inflammatory bowel disease, cirrhosis
• Renal failure
• COPD
• DM

• 2 Severe
• Multiple injuries
• Multiple fractures
• Deep pressure sore
• Severe sepsis
• Malignant disease
• Severe dysphagia or pancreatitis
• Major surgery
• Post op complications

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Nutritional Risk Score
0-2 Low risk Assessment every week
3-4 Moderate risk Consult to NST
5-7 High risk Consult to NST
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Nutritional screening and Assessment

• Nutrition screening All Patients

• Consult to Nutritional Support Team Mod to High
  Risk

• Nutritional assessments
• SGA
• History (medical, dietary, social)
• Physical examinations
• Anthropometry (weight, height, BMI, muscle
  strength)
• Biochemical test (CBC, Albumin, etc)

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Subjective global assessment (SGA)
A B C
??????? ?????????????? ????????? lt 5 ?? 1 ????? ???? lt 10 ?? 6 ????? ????????? gt 5 ?? 1 ????? ???? gt 10 ?? 6 ????? ???????????????
??????????? ???? ???? ???????????????????
????? ????????????????????????????????????????? ???????????????????? ???? ??????? ??????? ???????? ?????????? ????????????? B gt 2 ???????
???????????????????? ???? ???????????? ??????????????? ???????????
?????????????? ???? ?????????????????????? ???? ???????? ??????? ????? ????????????????????????? ???? ?????? ??????
Nutrition Screening in Ramathibodi Hospital.
Roongpisuthipong C .
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Subjective global assessment (SGA)
A B C
??????? ?????????????? ????????? lt 5 ?? 1 ????? ???? lt 10 ?? 6 ????? ????????? gt 5 ?? 1 ????? ???? gt 10 ?? 6 ????? ???????????????
??????????? ???? ???? ???????????????????
????? ????????????????????????????????????????? ???????????????????? ???? ??????? ??????? ???????? ?????????? ????????????? B gt 2 ???????
???????????????????? ???? ???????????? ??????????????? ???????????
?????????????? ???? ?????????????????????? ???? ???????? ??????? ????? ????????????????????????? ???? ?????? ??????
X
X
X
X
X
Nutrition Screening in Ramathibodi Hospital.
Roongpisuthipong C .
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Nutritional Risk Score
0-2 Low risk 85 Assessment every week
3-4 Moderate risk 10 Consult to NST
5-7 High risk 5 Consult to NST
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• Computerization helps to improve nutrition
  support delivery in Surin hospital, and seem to
  identify the patient at risk at the early phase

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Incidence of malnutrition on admission to
hospital
Study Year Number Malnourished
Willard et al 1980 200 31.5
Bastow et al 1983 744 52.8
Lasson et al 1990 501 28.5
Mc Whirter and Pennington 1994 500 40.0
Kelly 2000 337 13.0
Eddington et al 2000 1611 20.0
Surin Hospital 2004 672 10.8
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Nutrition Depletion in Hospital
Study Patients assessed on admission In Hospital gt 7 days Nutrition Depletion in Hospital
Mc Whirter and Pennington, 1994 500 112 64
Cornish et al, 1998 569 189 62
Surin Hospital, 2004 322 174 54
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Nutrition Management
l
Everything should be made as simple as possible
but not simpler.
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Make it EZ

1. EZ Calculate requirement
2. EZ Appropriate route of administration
3. Monitor the effect objective parameters BW,
   CBC, Electrolyte, albumin, etc
4. Manage complications
5. Modified the regimens if necessary

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Department of Surgery, Surin Hospital
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Nutritional Requirements

• Energy
• Harris-Benedict
• Rule of thumb
• 25 30 kcal/kg BW
• Indirect calorimetry
• Protein
• Stable patients 0.8 1.0 g/kg BW
• Stressed patients 1.2 2.0 g/kg BW

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"If the gut works, use it
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Which Route/Access?

• Oral 75 of TEE, calculate by Dietician (1800)
• Enteral feeding
• BD
• Commercial products
• Parenteral nutrition all in one/separation
• PPN
• TPN
• Combination of EN and PN

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Monitoring
Every week Every 2 week
NRS /
CBC /
BS /
BUN/Cr /
Electrolyte /
Ca, Mg, Phosphate /
LFT /
Cholesterol /
Triglyceride /
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Possible GI complications

• Regurgitation
• Aspiration
• Diarrhea
• Constipation
• Dehydration
• Abdominal discomfort
• Drug interaction
• Contamination

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Possible Tube-related complications

• Malposition of tube
• Knotting of tube
• Accidental removal perforation of GI tract
• Obstruction, breakage
• Leakage, infection bleeding from insertion site
• Erosion, ulceration necrosis of skin

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Possible metabolic complications

• Electrolyte disturbance
• Hyper/hypoglycemia
• Tube feeding syndrome
• Vitamin/ trace element deficiency

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complications

• Route related
• Catheter sepsis
• Thrombophlebitis
• Catheter occlusion
• Pneumothorax

• Metabolic
• Hyperglycemia
• Abnormal LFTs
• Fluid retension
• Excessive CO2 production

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(No Transcript)
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Parenteral Nutrition
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Combination of EN and PN
TPN PPN
gt14 d lt14 d
Restrict fluid NA
No Sepsis NA
gt900 mOsm/L lt900mOsm/L
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Putting evidence into practice
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Classification Definition
Recommended for practice Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews, and for which expectation of harms is small compared with the benefits
Likely to be effective Interventions for which the evidence is less well established than for those listed under recommended for practice
Benefits balance with harms Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities
Effectiveness not established interventions for which data currently are insufficient of inadequate quality
Effectiveness unlikely Interventions for which lack of effectiveness is less well established than for those listed under not recommended for practice
Not recommended for practice Interventions for which ineffectiveness or harmfulness has been demonstrated by clear evidence, or the cost or burden that is necessary for the intervention exceeds anticipated benefit
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Necrotizing Fasciitis(NF)

• Life-threatening infection affecting the
  superficial fascia and subcutaneous tissue
• Mortality rate 10 to 50.

1.Norton KS, Johnson LW, Am Surg. Aug
200268(8)709-713. 2.Mokoena T, Br J Surg. May
199481(5)772. 3.Mohammedi I, Intensive Care
Med. Aug 199925(8)829-834. 4.Mittermair RP,
Surg Endosc. Apr 200216(4)716.
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Management

• Early diagnosis
• Resuscitation
• Broad-spectrum antibiotics
• Immediate and extended surgical debridement
• Intensive care support
• Appropriate nutritional support
• Reconstruction

• 1. Ward RG. Bmj. Jul 30 1994309(6950)341.
• Wall DB, de Virgilio C, Am J Surg. Jan
  2000179(1)17-21.

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NF Day0
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Day 14
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Day40
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Appropriate nutritional support

• NF
• Increased requirements for nutrients
• Reduced food intake.
• Nutritional status is carefully considered.

1. Ord H. Br J Nurs. Nov 22-Dec 5 200716(21)1346-13
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2. Singh, G., S. K. Sinha, et al. (2002). Eur J Surg
   168(6) 366-71.

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Early nutrition support in necrotizing fasciitis

• Aims To compare the duration before split
  thickness skin graft of necrotizing fasciitis
  between the early nutritional support patients
  and conventional support.
• Setting Surin Hospital
• January December 2005

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Route/Access

• "If the gut works, use it
• Oral 75 of TEE, calculate by Dietician (1800)
• Enteral feeding
• BD
• IED 200 ml x 4 feedings
• Combination of EN and PN

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Assessment by well training nurses
AWM assessment chart
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Results

• 61 patients entered the study
• 6 patients refused to join the trial as unstable
  condition
• 55 patients (35 males, 20 females) were
  randomized,
• 28 to the Early nutritional support
• 27 to the Conventional support.
• Early NS had a shorter mean duration before split
  thickness skin graft (STSG) than the conventional
  support. (meanSD 17.24.5, 21.895, P0.01)

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Characteristic Early NS 28 Control 27 P
Sex M/F 16/12 19/8 0.403
Age - year 5321.2 5717.7 0.271
Comorbidiy - 0.365
1. No comorbid 32.1 29.6
2. Diabetes 21.4 7.4
3. CRF 7.1 14.8
4. Streroid use 7.1 14.8
5. Cirrhosis 25.0 37.0
Albumin 2.70.9 2.90.8 0.811
BUN 27.511.6 25.4814.05 0.582
Creatinine 1.891.65 2.071.61 0.883
Duration STSG 17.24.5 21.85.1 0.010
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Day0
Day0
Day0
Day3
Day10
Day13
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DRGs system
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Unit Cost IPD (2006)
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Thai DRGs
Version Version Refined Diagnosis code Procedure code Groups Implement
1 1 No ICD-10 (WHO) 1992 ICD-9-CM 2000 511 ??.2541
2 2 No ICD-10 (WHO) 1992 ICD-9-CM 2000 511 ??.2544
3 3.0 5 levels ICD-10 (WHO) 1992 ICD-9-CM 2000 1,283 ??.2546
3 3.1 5 levels ICD-10 (WHO) 1992 ICD-9-CM 2000 1,283 ???.2548
3 3.3 5 levels ICD-10 (WHO) 2005 ICD-9-CM 2005 1,283 ??.2549
3 3.5 5 levels ICD-10 (WHO) 2005 ICD-9-CM 2005 1,467 -
4 4 5 levels ICD-10 (WHO) 2007 ICD-10-TM ICD-9-CM 2007 with extension 1,920 ??.2551
For data entry only (not for new
classification)
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???????????? DRG
opened cholecystectomy, w mild to mod CC
0 7 0 5 2
?????????????????? CC ?????? 0, 1, 2, 3, 4 ??? 9
MDC????????????????????????
DC (Disease Cluster)
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Possible ICD-10 codesMalnutrition
E40-E46 Malnutrition
E43 Severe degree malnutrition
E44.0 Moderate degree malnutrition
E44.1 Mild degree malnutrition
E46 Not specified PEM
E64.0 Consequences of PEM
E77.8 Hypoproteinemia
E88.0 Hypoalbuminemia
R63.3 Nutrition problems and improper nutrition
R64 Cachexy
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ICD-10 codesMetabolic disorders
E87.5, E87.6 Hyper-, Hypo-kalemia
E87.0, E87.1 Hyper-, Hypo-natremia
E83.4 Hypomagnesemia
E83.5 Hypocalcemia
E68 Sequelae of hyper-alimentation
E87.2, E87.3 Acidosis, Alkalosis
E87.8 Other Electrolyte imbalance
E61 Deficiency of other nutrient elements
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DRG Nutrition issues

• Provide financial incentive to provider
• Encourage efficiency cost effectiveness

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Acute Cholecystitis
summary1 summary2
Pricipal diagnosis Acute Cholecystitis (K810) Acute Cholecystitis (K810)
SDx1 Moderatemalnutrition (E44.0)
SDx2
SDx3
Procedure Opened Cholecystetomy (5122) Opened Cholecystetomy (5122)
DRG 07050 No CC 07052 Moderate CC
RW 2.2817 3.0947
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Cellulitis gt 17 yr
summary1 summary2 summary4
Pricipal diagnosis NF (L088) NF (L088) Pancreatitis (K859)
SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0)
SDx2
SDx3
Procedure Debridement (8660) Debridement (8660) Debridement (8660)
DRG 09060 No CC 09060 No CC 09063 Severe CC
RW 1.5044 1.5044 3.2367
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Acute Pancreatitis
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis Pancreatitis (K859) Pancreatitis (K859) Pancreatitis (K859) Pancreatitis (K859) Pancreatitis (K859)
SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0) Severe malnutrition (E43) Severe malnutrition (E43)
SDx2 Hypokalemia (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) PPN (9915)
DRG 07530 No CC 07530 No CC 07532 Moderate CC 07532 Moderate CC 07533 Severe CC
RW 1.0068 1.0068 1.4107 1.4107 2.3798
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Enterocutaneous Fistula
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis Enterocutaneous Fistula (K632) Enterocutaneous Fistula (K632) Enterocutaneous Fistula (K632) Enterocutaneous Fistula (K632) Enterocutaneous Fistula (K632)
SDx1 Mild malnutrition (E44.1) Moderatemalnutrition (E44.0) Severe malnutrition (E43) Severe malnutrition (E43)
SDx2 Hypokalemia (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) TPN (9915)
DRG 06600 No CC 06600 No CC 06603 Moderate CC 06603 Moderate CC 06604 Severe CC
RW 1.7043 1.7043 2.1178 2.1178 2.3798
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CA Esophagus
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis CA Esophagus (C15.9) CA Esophagus (C15.9) CA Esophagus (C15.9) CA Esophagus (C15.9) CA Esophagus (C15.9)
SDx1 Moderatemalnutrition (E44.0) Severe malnutrition (E43) Severe malnutrition (E43) Severe malnutrition (E43)
SDx2 Hypo K (E87.6) Hypo K (E87.6) Hypo K (E87.6)
SDx3
Procedure PPN (9915) PPN (9915) SEMS Stent (4281) Gastrostomy (43.19)
DRG 06550 No CC 06503 Severe CC 06504 CatastrophicCC 06164 06014
RW 1.5334 2.5773 3.7863 6.8600 9.0348
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CA Stomach
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis CA Stomach (C16.9) CA Stomach (C16.9) CA Stomach (C16.9) CA Stomach (C16.9) CA Stomach (C16.9)
SDx1 malnutrition (E44.0) malnutrition (E43) malnutrition (E43) malnutrition (E43)
SDx2 Hypo K (E87.6) Hypo K (E87.6) Hypo K (E87.6)
SDx3
Procedure TPN (9915) Gastrostomy (43.19) Gastrectomy (43.89)
DRG 06500 No CC 06503 Severe CC 06504 CatastrophicCC 06014 06304
RW 1.5334 2.5773 3.7863 9.0348 12.6030
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Trauma
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis Injury to large bowel (S36.5) Injury to large bowel (S36.5) Injury to large bowel (S36.5) Injury to large bowel (S36.5) Injury to large bowel (S36.5)
SDx1 malnutrition (E43) Fx Femur (S72.9) Fx Femur (S72.9) Fx Femur (S72.9)
SDx2 Hypo K (E87.6) malnutrition (E43) Malnutrition (E43) Hypo K (87.6)
Procedure ORIF (79.35) ORIF (79.35) ORIF (79.35)
Procedure Repair large bowel (46.75) Repair large bowel (46.75) Repair large bowel (46.75) Repair large bowel (46.75) Repair large bowel (46.75)
DRG 06030 No CC 06034 24100 24103 24104
RW 3.8865 9.8118 6.1573 8.1515 12.0640
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Burns
summary1 summary2 summary3 summary4 summary5
Pricipal diagnosis Burns (T300) Burns (T300) Burns (T300) Burns (T300) Burns (T300)
SDx1 malnutrition (E43) malnutrition (E43) malnutrition (E43) malnutrition (E43)
SDx2 Hypo K (E87.6) Hypo K (E87.6) Hypo K (E87.6)
SDx3 Anemia (D649) Septicemia (A419)
Procedure PPN (9915) PPN (9915) Debridement (8622)
DRG 22520 No CC 22522 22523 22523 22524
RW 0.8565 1.5278 3.5348 3.5348 4.8587
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Conclusion

• Policy of Nutrition support
• Standard of care
• Appropriate reimbursement
• Alliance
• Support each other
• Encourage a team with success
• Continuous development
• Sharing experience
• Smile Thank you

Department of Surgery, Surin Hospital
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• To be born as a Human
• Is to serve Humanity
• TO CARE FOR THE ONES FOLLOWING YOU
• The Underprivileged and the Weak
• The Poor and the Sick
• T. Uttaravichien 1977

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Thank you for your attention