Nutrition in Sick PatientsNutrition in Sick Patients
Why it is important?Why it is important? What is the evidence?What is the evidence? How to treat and prevent How to treat and prevent
malnutritionmalnutrition Which route to chooseWhich route to choose What sort of tubes are there?What sort of tubes are there? Calculations and refeeding syndromeCalculations and refeeding syndrome
Hippocrates 400 B.C.Hippocrates 400 B.C.
‘‘A slender and restricted diet is A slender and restricted diet is always dangerous in chronic and in always dangerous in chronic and in
acute diseases’acute diseases’
‘ ‘Do not let your patients starve and when Do not let your patients starve and when you offer them nutrition support, do so by you offer them nutrition support, do so by the safest, simplest, most effective route.’the safest, simplest, most effective route.’
Dr Mike Stroud Feb 2006Dr Mike Stroud Feb 2006 Chair of NICE committeeChair of NICE committee
Why is it important?Why is it important?
McWhirter and Pennington 1994:McWhirter and Pennington 1994: 40% of hospital patients malnourished 40% of hospital patients malnourished
on admission and nutritional state on admission and nutritional state usually deteriorates in hospital. Costs usually deteriorates in hospital. Costs £3.8bn/yr£3.8bn/yr
Critically ill are often malnourished: Critically ill are often malnourished: admitted after major surgery, following admitted after major surgery, following extended illness or hospital stay, high extended illness or hospital stay, high rate of alcohol/drug misuse, poor self rate of alcohol/drug misuse, poor self care, elderly, co-existing disease etccare, elderly, co-existing disease etc
Effects of malnutritionEffects of malnutrition
Effects of Undernutrition
Immunity – Increased risk of infection
HypothermiaImpaired gutintegrity andimmunity
Renal function - loss of ability to excrete Na & H2O
Decreased Cardiac output
Ventilation - loss ofmuscle & hypoxic responses
Psychology –depression & apathy
Anorexia ? Micronutrient deficiency
Loss of strength
liver fatty change, functional declinenecrosis, fibrosis
Impaired wound healing
Nutritional State and ComplicationsNutritional State and Complications
0
5
10
15
20
25
Complications No Complications
Poor Intermediate Good
HDU
Metabolic response to starvationMetabolic response to starvation Aims to minimize impact on vital Aims to minimize impact on vital
organs and conserve energyorgans and conserve energy Reduction in tissue metabolismReduction in tissue metabolism Decreased metabolic rate Decreased metabolic rate Decreased temperatureDecreased temperature Reduction in physical activityReduction in physical activity Protein lossProtein loss
StarvationStarvation
Bobby Sands – lost 7 kg in first 17 daysBobby Sands – lost 7 kg in first 17 days Approx 0.5kg/dayApprox 0.5kg/day Died at 65 days (9 weeks)Died at 65 days (9 weeks) Not expending excess energy, not in Not expending excess energy, not in
ICUICU ICU patients – often have increased ICU patients – often have increased
metabolic demands AND starvationmetabolic demands AND starvation Complex metabolic changesComplex metabolic changes
Critical illness: Metabolic demandCritical illness: Metabolic demand sympathetic nervous system stimulationsympathetic nervous system stimulation acute phase response: cytokinesacute phase response: cytokines severe catabolismsevere catabolism organ failure, poor gut functionorgan failure, poor gut function increased oxygen requirementsincreased oxygen requirements poor wound healing poor wound healing insulin resistance: hyperglycaemiainsulin resistance: hyperglycaemia Wasting Wasting iatrogenic problems – drugs/HAI iatrogenic problems – drugs/HAI
Starvation and ICUStarvation and ICU
Complex metabolic changesComplex metabolic changes Weight loss is high if sick patients are Weight loss is high if sick patients are
not fednot fed But nutrients are not always But nutrients are not always
adequately absorbed or metabolisedadequately absorbed or metabolised Weight loss occurs despite feedingWeight loss occurs despite feeding Important to feed patients but with Important to feed patients but with
regard to their individual needs and regard to their individual needs and complexities.complexities.
ICU nutritionICU nutrition
Used to be everything mixed up and Used to be everything mixed up and given via NG tubegiven via NG tube
Risk of infectionRisk of infection Now specialised feeds are used in Now specialised feeds are used in
sterile packagingsterile packaging
What is the evidence in HDU?What is the evidence in HDU? Early nutrition is important Early nutrition is important Bowel function may recover within 12 Bowel function may recover within 12
hours hours Use the gut if you canUse the gut if you can Bowel sounds are not a good indication of Bowel sounds are not a good indication of
bowel functionbowel function Ileus is commonIleus is common Giving pre-op sugary drinks can speed Giving pre-op sugary drinks can speed
bowel function (ERAS)bowel function (ERAS) Use EN + TPN to achieve goalsUse EN + TPN to achieve goals
How do we treat/prevent How do we treat/prevent malnutrition?malnutrition?
Whose role is it?Whose role is it?
How do we treat/prevent How do we treat/prevent malnutrition?malnutrition?
Think about itThink about it Identify it – history – weight loss, intake, Identify it – history – weight loss, intake,
vomiting, diarrhoea, IBD, cancer etc: vomiting, diarrhoea, IBD, cancer etc: doctors and nursesdoctors and nurses
Weight- nursesWeight- nurses Optimise intake – Optimise intake –
oral/enteral/parenteral: oral/enteral/parenteral: doctors/dietitians/nursesdoctors/dietitians/nurses
Monitor – nurses/dietitians/doctorsMonitor – nurses/dietitians/doctors
Organisation of Nutrition SupportOrganisation of Nutrition Support
3. NICE Guidelines for Nutrition Support in Adults 2006
Screen
Recognise
Treat
Oral Enteral Parenteral
Monitor & Review
Step 1: ScreenStep 1: Screen
MUST MUST Malnutrition Universal Screening Tool from BAPEN
BMI score, weight loss score, acute disease effect score together
gives low, medium and high risk of malnutrition: if high, patient must be treated early
At risk of malnutritionAt risk of malnutrition
Eaten little or nothing for 5 days and Eaten little or nothing for 5 days and unlikely to do so for at least next 5 unlikely to do so for at least next 5 daysdays
Poor absorptive capacity and/or high Poor absorptive capacity and/or high nutrient losses and/or increased nutrient losses and/or increased nutritional needs due to catabolism nutritional needs due to catabolism etcetc
3. NICE Guidelines for Nutrition Support in Adults 2006
Patient at risk of becoming
malnourished
MalnourishedMalnourished
BMI less than 18.5 Kg/mBMI less than 18.5 Kg/m22
Weight loss > 10% within last 3-6 Weight loss > 10% within last 3-6 monthsmonths
BMI < 20Kg/mBMI < 20Kg/m22 and unintentional and unintentional weight loss > 5% in last 3-6 monthsweight loss > 5% in last 3-6 months
3. NICE Guidelines for Nutrition Support in Adults 2006
Patient already malnourished
Weighing PatientsWeighing Patients
Important for nutrition Important for nutrition screening/dosagescreening/dosage
Drug dosagesDrug dosages Cardiac output monitoring Cardiac output monitoring Fluid balanceFluid balance CT scanningCT scanning
Estimation?Estimation?
Routes: Enteral
Preserves intestinal mucosal structure and function
More physiological Reduced risk of infectious
complications £6 vs £66
RoutesOf feeding
Naso-gastric FeedingNaso-gastric Feeding
Risk of aspiration in ICU: HOB 30 Risk of aspiration in ICU: HOB 30 degreesdegrees
Don’t start feed at nightDon’t start feed at night Risk of displacement Risk of displacement High aspirates and inadequate High aspirates and inadequate
calories common in ICUcalories common in ICU PEG/gastrostomy feeding for long-PEG/gastrostomy feeding for long-
termterm
Jejunal FeedingJejunal Feeding
Jejunal feed: via a tube placed Trans-nasally by endoscopy, radiologically, at the bedside. Into the jejunum either at laparotomy
or laparoscopy May reduce incidence of aspiration Often increases dose of EN given
over NG
Why do we use TPN?Why do we use TPN?
Parenteral NutritionParenteral Nutrition
GI tract is not functional GI tract is not functional GI tract cannot be accessed GI tract cannot be accessed Inadequate GI feeding:Inadequate GI feeding: Optimise enteral first if possible; if Optimise enteral first if possible; if
not absorbing start TPN on day 3-7 not absorbing start TPN on day 3-7 depending on nutritional statedepending on nutritional state
TPNTPN
Doctors decide patient needs itDoctors decide patient needs it Dietitian sees patientDietitian sees patient Decides best regimeDecides best regime Orders bag from pharmacyOrders bag from pharmacy Made up aseptically to requirementsMade up aseptically to requirements Start low and build upStart low and build up Monitor bloodsMonitor bloods
Access for PNAccess for PN
Usually central line in ICU – keep a Usually central line in ICU – keep a clean port if PN may be needed. 5 clean port if PN may be needed. 5 lumenlumen
Short term PN – can have PIC (need a Short term PN – can have PIC (need a different formula) or PICCdifferent formula) or PICC
Long-term TPN – tunnelled subclavian Long-term TPN – tunnelled subclavian catheter (Hickman) or subcutaneous catheter (Hickman) or subcutaneous port is usually inserted – OBSERVE port is usually inserted – OBSERVE STRICT ASEPSIS if handling these lines.STRICT ASEPSIS if handling these lines.
-------------------
Tubes and LinesTubes and Lines
ComplicationsComplications ConstipationConstipation Diarrhoea – important points?Diarrhoea – important points? Intolerance: ? SepsisIntolerance: ? Sepsis
Use pro-kinetics, NJ feeding, drugsUse pro-kinetics, NJ feeding, drugs Line sepsisLine sepsis Ileus – Ileus – Avoid opioids, optimise fluid Avoid opioids, optimise fluid
balance and electrolytes, ?trickle of balance and electrolytes, ?trickle of feedfeed
OverfeedingOverfeeding Lactic acidosisLactic acidosis HyperglycaemiaHyperglycaemia Increased infectionsIncreased infections Liver impairment (Alk phos, ALT, Liver impairment (Alk phos, ALT,
GGT, acalculous cholecystitis)GGT, acalculous cholecystitis) Persistent pyrexiaPersistent pyrexia
How much to give – general How much to give – general recommendationsrecommendations
Prescription calculated by dietitian Schofield equation e.g. for 60-74 year old
woman: BMR = (9.2x weight in kg) + 687, (tables available)=requirement in Kcal/24hr
Add Activity factor and stress factor e.g. 10% for bedbound + 20-60% for sepsis – burns
i.e for 65kg woman ventilated woman with sepsis this works out as 1670 Kcal = approx 25 Kcal/kg/24hr
Rough guide to start: 25 Kcal/kg/day total energy. Increase to 30 as patient improves
How much to give – general How much to give – general recommendationsrecommendations
1.25g/kg/day protein more just gets excreted
30ml fluid/kg/24 hours. Add 100-200ml/day for each degree of temperature
Account for excess losses
Adequate electrolytes, micronutrients etc Avoid overfeeding Obesity: feed to BMR no stress factor
unless stress is severe e.g. burns/trauma
Refeeding SyndromeRefeeding Syndrome 1944 conscientious objectors/concentration 1944 conscientious objectors/concentration
camps – CCF when fed camps – CCF when fed Starvation 1Starvation 1stst 24-72 hours – body uses 24-72 hours – body uses
glycogen stores for gluconeogenesis, 72+ glycogen stores for gluconeogenesis, 72+ hours – FFA oxidation to ketones, sparing hours – FFA oxidation to ketones, sparing protein.protein.
Feeding – metabolism shifts back to glucose –Feeding – metabolism shifts back to glucose –ATP and 2-3DPG produced. Phosphate drops ATP and 2-3DPG produced. Phosphate drops and K and Mg shift into cells due to anabolism and K and Mg shift into cells due to anabolism and insulin release. and insulin release.
Extra-cellular fluid expansion and thiamine B1 Extra-cellular fluid expansion and thiamine B1 deficiency occur (co-factor in CH metabolism).deficiency occur (co-factor in CH metabolism).
Refeeding Syndrome Refeeding Syndrome
Unlikely to be a clear diagnosisUnlikely to be a clear diagnosis Contributes to fluid imbalances, Contributes to fluid imbalances,
arrhythmias, muscle weakness, failure arrhythmias, muscle weakness, failure to wean, cardiac failureto wean, cardiac failure
Awareness of the possibility is Awareness of the possibility is important: nutritional history and important: nutritional history and electrolyteselectrolytes
Remember in HDU patients too – may Remember in HDU patients too – may not be fed for a long timenot be fed for a long time
Risk of re-feeding syndromeRisk of re-feeding syndrome
OneOne or more of the following: or more of the following: BMI less than 16 kg/mBMI less than 16 kg/m22
unintentional weight loss greater than 15% unintentional weight loss greater than 15% within the last 3-6 monthswithin the last 3-6 months
little or no nutritional intake for more than little or no nutritional intake for more than 10 days10 days
Very low levels of potassium, phosphate or Very low levels of potassium, phosphate or magnesium prior to feedingmagnesium prior to feeding
NICE Guidelines for Nutrition Support in Adults 2006
Risk of re-feeding syndromeRisk of re-feeding syndrome
TwoTwo or more of the following: or more of the following: BMI less than 18.5 kg/mBMI less than 18.5 kg/m22
unintentional weight loss greater unintentional weight loss greater than 10% within the last 3-6 monthsthan 10% within the last 3-6 months
little or no nutritional intake for more little or no nutritional intake for more than 5 daysthan 5 days
a history of alcohol abuse or drugs a history of alcohol abuse or drugs including insulin, chemotherapy, including insulin, chemotherapy, antacids or diureticsantacids or diuretics
Managing refeeding problemsManaging refeeding problems start nutrition support at 10 start nutrition support at 10
kcal/kg/day maximumkcal/kg/day maximum increase levels slowlyincrease levels slowly restore circulatory volume and restore circulatory volume and
monitor fluid balance and clinical monitor fluid balance and clinical status status
provide multivitamin/trace element provide multivitamin/trace element supplementation: Pabrinex (B1,B2,C) supplementation: Pabrinex (B1,B2,C) o.d. or thiamine B1 +Vigranon B o.d. or thiamine B1 +Vigranon B beforebefore feed feed
provide extra Phosphate, Kprovide extra Phosphate, K++ and Mg and Mg2+2+NICE Guidelines for Nutrition Support in Adults 2006
Complex nutrition: MonitoringComplex nutrition: Monitoring
U & Es, phosphate, calcium, U & Es, phosphate, calcium, magnesiummagnesium
GlucoseGlucose LFTsLFTs Fluid balanceFluid balance HaematologyHaematology WeightWeight Trace elements if long-termTrace elements if long-term
ConclusionConclusion
Do not forget about feedingDo not forget about feeding Keep an eye on whether nutritional Keep an eye on whether nutritional
targets are being mettargets are being met Speak to the surgeons and dietitian Speak to the surgeons and dietitian Remember refeeding syndromeRemember refeeding syndrome Do not be reluctant to start PN in a Do not be reluctant to start PN in a
supplemental capacitysupplemental capacity Avoid hyperglycaemiaAvoid hyperglycaemia Nutrition is often neglectedNutrition is often neglected
