Nutritional assessment and provision

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Nutritional assessment and provision

• Yousif .A Qari MD, FRCPC, ABIM
• Consultant Gastroenterologist
• KAUH ,Jeddah

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Selection of patients for nutritional support

• Aim
• To decrease mortality and morbidity related to
  defecate of energy, protein and other nutrients
• To provide nutrition support only to those
  patients in whom the benefits will exceed risks.

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Indications for nutrition support
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4 Traditional Indicators Of Nutritional Status

• 1. Body Composition
• Body weight
• Anthropometry
• Urinary cratenine excretion
• 2. Plasma Proteins
• Albumin
• Prealbumin
• Retinol-binding protein
• Tranferrin
• 3. Immune System Function
• Total lymphocyte count
• Delayed cutaneous hypersensitivity
• 4. Multivariate Analyses
• Prognostic nutritional index
• Nutrition risk index

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Body Composition

• Body weight
• 10 or greater unintentional loss in body weight
  is associated with an adverse clinical outcome.
• lt70 of Ideal body weight (IBW)
• Anthropometry
• Triceps and sub scapular skin fold thicknesses
• provides an index of body fat and muscle mass,
  which is compared with standard tables.
• markedly abnormal values (below the fifth
  percentile) usually predict a poor clinical
  outcome.
• urinary creatinine excretion
• Assessment of body muscle mass
• Values can be compared with tables providing an
  expected amount of creatinine excretion in
  relationship to height in subjects consuming a
  meat-free diet.

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Plasma Proteins

• Albumin (lt 2.1g/dl )
• correlate with clinical outcome
• increased incidence of medical complications
• Other causes of Hypoalbuminemia
• Inflammation and injury
• Decreases albumin synthesis
• Increases albumin degradation
• Increases albumin transcapillary losses
• Losses through the gut or kidney
• GI
• renal,
• cardiac diseases
• Losses from surface tissues.
• Wounds
• Burns
• Peritonitis

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Immune system function

• Measured by
• Total lymphocyte count (lt 800/mm³ )
• delayed cutaneous hypersensitivity
• Associated with a poor clinical outcome.

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Multivariate Analyses

• Prognostic nutritional index
• Correlated with postoperative mortality and
  complications
• 4 variables
• Alb serum albumin (g/dl)
• TSF triceps skin fold thickness ( mm )
• TFN serum (transferrin (mg/dL)
• DH delayed hypersensitivity
• 0nonreactive
• 1lt5mm induration
• 2gt5mm induration
• 158 16.6 (Alb) 0.78 (TSF) 0.2( TFN) 5.8
  (DH)
• When gt 50 ------ increased risk
• Subjective Global assessment

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Subjective Global Assessment (SGA)

• TABLE 51-5 Subjective Global Assessment (SGA) Of
  Nutritional Status
• A. History
• 1. Weight change
• Overall loss in past 6 months amount
  _________________ kg
• Change in past wk ____________ increase
• ____________ no change
• ____________ decrease
• 2. Dietary intake change (relative to normal)
• ______________ No change
• ______________ Change duration __________ wk
• type ______ suboptimal solid diet ________ full
  liquid diet
• ______ hypocaloric liquids ________ starvation
• 3. Gastrointestinal symptoms (that persisted gt2
  wk)
• _________ none __________ anorexia ___________
  nausea ___________ vomiting ___________ diarrhea
• 4. Functional capacity
• ______________ No dysfunction (e.g. full
  capacity)
• ______________ Dysfunction duration
  ___________ wk
• ___________ working sub optimally

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Summery of indications of malnutrition

• Weight loss gt 10 in 6 months
• Minimal subcutaneous fat in non-athletes (
  measure or estimate by pinching)
• Muscle wasting in the absence of neurological
  cause(estimate visually and by palpation)
• Serum albumin less than 3 g/dl not resulting from
  overhydration,liver disease,or chronic excessive
  loss from the intestinal tract or kidneys

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Time for beginning nutrition support
Patient nutrition status Begin tube feeding if possible Begin TPN
Neither hypercatabolic or malnourished 7 days 14 days
Either hypercatabolic or malnourished 1 - 5 days 6 -1 0 days
Patient both hyper- catabolic and malnourished 1 - 3 days 1 - 7 days
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Calculating calorie and protein goals

• Non protein calorie goal
• 25-35 kcal/kg/d
• Protein goal
• 1 -2 kcal/kg/d

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• Basal energy expenditure (BEE)
• Is the energy used for normal body functions when
  well, awake, in a thermoneutral environment, and
  in a basal fasting state after overnight bed rest
• On average 20 kcal/kg/d
• More accurately calculated by Harris-Benedict
  equations
• Women (kcal/d) 655 9.6 wt(cm) 1.7
  hight(cm) 4.7 age(years)
• Men (kcal/d) 66 13.7 wt (kg) 5
  hight(cm) 6.8 age (years)

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Components of daily energy expenditure (DEE)

• Harris-Benedict equations(contd)
• These formulas will overestimate energy
  expenditure for obese patients. To improve the
  estimate , we should use the mean of actual body
  weight (ABW) desirable body weight ( DBW)
• DBW
• Males 106 pounds 6 pounds for each inch above
  5 feet.
• Females 100 pounds 5 pounds for each inch
  above 5 feet.
• 1 foot 12 inches 20 cm
• 1 inch 2.5 cm
• 1 kg 2.2 pounds

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• Stress hypermetabolism
• Calculated by
• BEE Stress factor according to medical
  condition (special tables values vary from 0.5 to
  2.0) Resting Energy Expenditure (REE)

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• 3. Non shivering thermogenesis
• The energy required to maintain body temperature
  above ambient temperature
• It is minimal for intact patients with intact
  skin in temperature-controlled environments
• Can be ignored.

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• 4. Diet-induced thermogenesis
• The energy required to digest, absorb, transport,
  metabolize, and store nutrients.
• About 10 - 15 of energy administered

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• 5. Abnormal energy loss in urine, stool, and
  drainage from fistulae ad wounds .
• Seldom significant
• can be ignored

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• 6. Energy expenditure of activity
• Ranges from 10 - 30 for most hospitalized
  patients

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Components of daily energy expenditure (DEE)

1. Basal energy expenditure (BEE)
2. Stress hyermetabolism
3. Non shivering thermogenesis
4. Diet induced thermogenesis
5. Abnormal energy loss in urine, stool, and
   drainage from fistulae and wounds
6. Energy expenditure from activity
7. Energy expenditure for weight gain

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Components of daily energy expenditure (DEE)

• 7. Energy expenditure for weight gain
• For 1 pound weight gain we need 3500 kcal
• When weight gain is required
• 500 kcal /day can be added to the energy
  goal
• 1pound/week weight gain
• Should not be attempted in patients with stress
  factor above 1.2.
• Can be set at 20 of BEE.

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General recommendations for calculating
nonprotein calorie intake

• Estimate BEE (Harris-benedict formula or 20
  kcal/d
• Stress hypermetabolism BEE stress factor
• Add for activity 10 to 30 of BEE
• Add for weight gain if indicated 500 to 1000
  kcal/d
• N.B
• REE BEE stress hypermetabolism
  non-shivering thermogenesis

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Indirect Calorimetry

• The standard method
• By measuring carbon dioxide (CO2) production and
  oxygen (O2) consumption
• the amount of heat produced during substrate
  oxidation is proportional to the amount of CO2
  produced and O2 consumed.
• Indications
• Severely malnourished
• Patients in heart failure, or respiratory failure
• Diabetics
• Morbid obesity
• Closed head trauma
• Paralysis

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Protein goal

• The reason for giving protein is to provide
  nitrogen, not energy
• Excessive protein administration to patients may
  result in
• Azotemia
• Osmotic diuresis
• Hyperammonemia
• Hepatic encephalopathy
• Respiratory muscle fatigue
• When energy intake is adequate, optimum protein
  intake for hospitalized patients ranges from 0.8
  to 2.0 g/kg/d

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Access for Nutritional Support

• Oral
• Enteral
• Parenteral (Intravenous)
• Peripheral
• Central

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Peripheral TPN

• Consists of mixture of
• 5 to 10 glucose
• 2 to 5 amino acid
• Electrolytes
• 10 to 20 iv fat emulsion
• Low rate of blood flow ( 10 50 mls/min) High
  osmolality of peripheral TPN fluid (600-900
  mosm/kg) large volume of fluids ( 2-3 L/d) ?
  raises osmolality in the vein ? Phlebitis.

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Central TPN

• Access
• Rt subclavian
• High blood flow (1.5- 2.0 L/min)

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Optimal nutritional support

• KCALS

Lists of components
Keep patient nourished
Access
FACE-MTV
Special monitoring
Calculate energy and nonprotein goal
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Designing TPN formula

• In addition to energy and protein content of a
  TPN formula, the following are important to
  remember
• ( FACE- MTV )
• (F) Fluids
• (A) Amino acids
• (C) Calories
• (E) Electrolytes
• (M) Miscellaneous Additives
• (T) Trace elements
• (V) Vitamins

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Designing TPN formula

• ( FACE- MTV )
• 1. (F) Fluids
• When fluid restriction is needed ( patient
  can not take more than 1000 1500 ml of fluids)
  use
• 70 dextrose
• 15 A.A solution
• 20 fat emulsion

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Designing TPN formula

• ( FACE- MTV )
• 2. (A) Amino acids
• A typical standard A.A mixture contains
  approximately 15 amino acids
• 45 are essential
• 20 branched chain (leucine, isoleucine, valine)
• 12 methionine plus aromatic amino
  acids(phenylalanine, tyrosine, tryptophan)
• Spetial formulas
• Renal Failure
• Higher proportion of essential amino acids
• Liver failure
• More branched chain A.A
• Less methionine and aromatic amines

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Designing TPN formula

• ( FACE- MTV )
• 3.(C)Calories
• Non protein calories
• TPN
• Fat
• 10 - 70 is well tolerated by most patients
• 20 - 30
• gt 50 appropriate for

Fat (10 - 45)
Carbohydrate
Fewer complication
Greater efficacy
Diabetics
Pulmonary failure
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Designing TPN formula

• ( FACE- MTV )
• 3.(C)Calories
• Non protein calories
• TPN
• Fat
• Lipid emulsions
• In sepsis avoid gt 1g/kg of lipid emulsions per
  day( 30g/d )
• Other iv lipids Fish oil, MCT, and Structured
  lipids.

Fat (10 - 45)
Carbohydrate
Impaired macrophage function
? bacterial clearance
Alter immunocompetance
Impaired pulmonary function
Blocks reticuloendothelial system
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Designing TPN formula

• ( FACE- MTV )
• 4. (E) Electrolytes
• Standard electrolyte mixtures are suitable for 50
  80 of patients receiving TPN.
• Specifically adjusted mixtures are needed for
  Patients with
• Electrolyte disturbances
• Renal failure
• Hepatic failure
• Heart failure
• Multi organ failure

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Designing TPN formula

• ( FACE- MTV )
• 4. (E) Electrolytes
• Phosphorous
• 15 mmol/800 glucose calories
• ? 2 4 days after starting TPN
• Potassium
• 30 40 mEq/800 glucose calories
• ? 6 12 hours after starting TPN
• Sodium
• 30 50 mEq/liter of formula
• Most cases of hyponatremia are dilutional
• True hyponatremia may occur in
• Ileostomies
• Fitulae
• Diarrhea

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Designing TPN formula

• ( FACE- MTV )
• 4. (E) Electrolytes
• Magnesium
• 5 10 mEq/mlof TPN
• Chloride/Acetate
• Small amount of chloride and larger amount of
  acetate is provided by manufacturer in virtually
  all amino acid mixtures to prevent acidosis
  resulting from metabolism of Lysine and Arginine.
• Added to standard electrolyte mixtures to prevent
  metabolic acidosis in patients with large gastric
  fluid losses who are not receiving a histamine
  receptor antagonists

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Designing TPN formula

• ( FACE- MTV )
• 5. (M) Miscellaneous additives
• Heparin
• 1 unit/ml is added to central TPN mixtures.
• Minimize clotting in the catheter
• Decrease fibrin sheath formation on the surface
  of the
• Insulin
• Only to manage documented hyperglycemia
• Should not exceed 10 units/800 glucose calories
• Albumin
• To patients with serum level below 2.5 g/dL in
  conditions like
• Capillary leak ( sepsis burns)
• Proteinurea
• Protein-losing enteropathy
• Should be stopped when serum level reach 3.0 g/dL

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Designing TPN formula

• ( FACE- MTV )
• 6. (T) Trace elements
• A typical trace element cocktail the is added to
  daily TPN provides the following
• Zinc 5.0 mg
• Copper 1.0 mg
• Manganese 500 µg
• Chromium 10 µg
• Selenium 60 µg
• No practical way to asses trace element status
  clinically
• Serum levels are difficult to measure accurately
• Zinc is the only element likely to be required in
  larger amounts in
• Diarrheal illnesses
• Ileostomy output

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Designing TPN formula

• ( FACE- MTV )
• 7. Vitamins

Vitamins Amount
Vitamin A 3300 IU
Vitamin D 200 IU
Ascorbic acid (Vitamin C) 100 mg
Folic acid 400 µg
Niacin 40 mg
Riboflavin (VitaminB2) 3.6 mg
Thiamine (VitaminB1) 3.0 mg
Pyridoxine (VitaminB6) 4.0 mg
Cyanocobalamin (Vitaminb12) 5.0 µg
Pantothenic acid 15 mg
Biotin 60 µg
Vitamin E 10 IU
Vitamin K 1 mg
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Central TPN

• Special monitoring
• Nitrogen balance is the most practical and
  effective way to estimate the adequacy of
  nitrogen and energy administration
• Patient should be on constant calorie and
  nitrogen intake
• The test requires 24 h urine collection for
  urinary urea nitrogen (UUN)
• Calculate total urea nitrogen (TUN) by the
  equation.
• TUN UUN/0.8
• Nitrogen balance N in N out
• N in g amino acids administered /6.25
• N out TUN (g) 1 g

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Central TPNRisks and complications

• Mechanical
• Septic
• Metabolic

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Central TPNMetabolic complications

• Hyperglycemia
• Hypoglycemia
• Hypophosphatemia
• Hypokalemia
• Hypomagnesemia
• Hyponatremia
• Fluid overload/dehydration
• Fat intolerance
• Hypercalcemia
• Liver test abnormality

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Central TPNMetabolic complications

• Hyperglycemia
• Serum glucose gt200 mg/dL
• May lead to dehydration, coma and death
• Administration rate of TPN should be reduced if
  serum glucose concentration exceeds 350 mg/dL
• In a previously stable patient it usually
  indicates a new metabolic stress, most often
  infection

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Central TPNMetabolic complications

• Hypophosphatemia
• Intracellular shift caused by glucose
• Patients at increased risks
• Chronic alcoholics
• Severely malnourished
• Patients taking anti acids
• When severe May result in
• Hemolysis
• Serious effects on Cardio respiratory system
• Affects on WBC function

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Central TPNMetabolic complications

• Hypokalemia
• May be caused by
• Glucose
• Alkalosis
• Hypomagnesemia
• Occasionally as much as 150 to 200 mEq may be
  given per 24 hours.

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Central TPNMetabolic complications

• Hypomagnesemia
• Most likely occurs in
• Chronic alcoholics
• Severely malnourished
• Patients receiving diuretics
• When severe (lt1.0 mEq/L) should be treated with
  up to 100 mEq of magnesium sulfate/24 hours via a
  separate line.

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Central TPNMetabolic complications

• Hyponatremia
• Most often dilutional
• Should be treated by fluid restriction

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THANK YOU