Ahmed MayetAssociate ProfessorKing Saud University
Nutrition
Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein
Malnutrition
Malnutrition—come from extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body
Types of malnutrition
Kwashiorkor: (kwa-shior-kor) is protein malnutrition
Marasmus: (ma-ras-mus) is protein-calorie malnutrition
Kwashiorkor
Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response
Common causes - chronic diarrhea, chronic kidney disease, infection, trauma , burns, hemorrhage, liver cirrhosis and critical illness
Clinical Manifestations
Marked hypoalbuminemia Anemia Edema and ascites Muscle atrophy Delayed wound healing Impaired immune function
Marasmus
The patient with severe malnutrition characterized by calories deficiency
Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation
proteinprotein--caloriecalorie
Clinical Manifestations
Weight loss Reduced basal metabolism Depletion skeletal muscle and
adipose (fat) stores Decrease tissue turgor Bradycardia Hypothermia
Risk factors for malnutrition Medical causes Psychological and social causes
Medical causes(Risk factors for malnutrition)
Recent surgery or trauma Sepsis Chronic illness Gastrointestinal disorders Anorexia, other eating disorders Dysphagia Recurrent nausea, vomiting, or diarrhea Pancreatitis Inflammatory bowel disease Gastrointestinal fistulas
Psychosocial causes
Alcoholism, drug addiction Poverty, isolation Disability Anorexia nervosa Fashion or limited diet
Consequences of Malnutrition Malnutrition places patients at a
greatly increased risk for morbidity and mortality
Longer recovery period from illnesses
Impaired host defenses Impaired wound healing Impaired GI tract function
Cont:
Muscle atrophy Impaired cardiac function Impaired respiratory function Reduced renal function mental dysfunction Delayed bone callus formation Atrophic skin
Results: Of the 5051 study patients, 32.6% were defined as ‘at-risk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients.
International, multicentre study to implement nutritional risk screening and evaluate clinical
outcome
Sorensen J et al ClinicalNutrition(2008)27,340 349
“Not at risk” = good nutrition status
“At risk” = poor nutrition status
Metabolic Rate
60
80
100
120
140
160
180
0 10 20 30 40 50
Days
Re
sti
ng
me
tab
oli
sm
(%
of
no
rma
l)
Major burn Sepsis Trauma Partial starvation Total starvation
Long CL, et al. JPEN 1979;3:452-6
Normal range
Protein Catabolism
0
5
10
15
20
25
30
0 10 20 30 40
Days
Nit
rog
en
ex
cre
tio
n (
g/d
ay
)
Major burn Trauma Sepsis Partial starvation Total starvation
Long CL. Contemp Surg 1980;16:29-42
Normal range
Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein
Height Height Small FrameSmall Frame Medium FrameMedium Frame Large FrameLarge Frame
4'10"4'10" 102-111102-111 109-121109-121 118-131118-131
4'11"4'11" 103-113103-113 111-123111-123 120-134120-134
5'0"5'0" 104-115104-115 113-126113-126 122-137122-137
5'1"5'1" 106-118106-118 115-129115-129 125-140125-140
5'2"5'2" 108-121108-121 118-132118-132 128-143128-143
5'3"5'3" 111-124111-124 121-135121-135 131-147131-147
5'4"5'4" 114-127114-127 124-138124-138 134-151134-151
5'5"5'5" 117-130117-130 127-141127-141 137-155137-155
5'6"5'6" 120-133120-133 130-144130-144 140-159140-159
5'7"5'7" 123-136123-136 133-147133-147 143-163143-163
5'8"5'8" 126-139126-139 136-150136-150 146-167146-167
5'9"5'9" 129-142129-142 139-153139-153 149-170149-170
5'10"5'10" 132-145132-145 142-156142-156 152-173152-173
5'11"5'11" 135-148135-148 145-159145-159 155-176155-176
6'0"6'0" 138-151138-151 148-162148-162 158-179158-179
Standard monogram for Height and Weight in adult-male
Percent weight loss 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20%
Small frame
Medium frame
50kg x 2.2 = 110 50kg x 2.2 = 110 lbslbs
Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein
Classification BMI (kg/m2) Obesity Class
Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity 30.0-34.9 I
Moderate obesity 35.0-39.9 II
Extreme obesity >40.0 III
Average Body Mass Index (BMI) for Adult
Our patient BMI = 16.3 kg/m2
Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein
Fat
Assessment of body fat Triceps skinfold thickness (TSF) Waist-hip circumference ratio Waist circumference Limb fat area Compare the patient TSF to standard
monogram
Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein
Protein (Somatic Protein)
Assessment of the fat-free muscle mass (Somatic Protein)Mid-upper-arm circumference (MAC)Mid-upper-arm muscle circumference Mid-upper-arm muscle area
Compare the patient MAC to standard monogram
Protein (visceral protein)
Assessment of visceral protein depletion
Serum albumin <3.5 g/dL Serum transferrin <200 mg/dL Serum cholesterol <160 mg/dL Serum prealbumin <15 mg/mL Creatinine Height Index (CHI) <75%
Cont;
Our patient has albumin of 2.2 g/dlOur patient has albumin of 2.2 g/dl
Vitamins deficiency
Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin C Vitamin A Vitamin D Vitamin K
Trace Minerals deficiency
Zinc Copper Chromium Manganese Selenium
Iron
BEE
Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy requirements
Total Energy Expenditure
TEE (kcal/day) = BEE x stress/activity factor
BEE
The Harris-Benedict equation is a mathematical formula used to calculate BEE
Harris–Benedict Equations Energy calculation Male BEE = 66 + (13.7 x actual wt in kg)
+ (5x ht in cm) – (6.8 x age in y) Female BEE = 655 + (9.6 x actual wt in kg)
+ (1.7 x ht in cm) – (4.7 x age in y)
A correlation factor that estimates the extent of hyper-metabolism 1.15 for bedridden patients 1.10 for patients on ventilator support 1.25 for normal patients The stress factors are: 1.3 for low stress 1.5 for moderate stress 2.0 for severe stress 1.9-2.1 for burn
Calculation
Our patient Wt = 50 kg Age = 45 yrs Height = 5 feet 9 inches (175 cm)
BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y)
=66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45)
=66 + ( 685) + (875) – (306)
= 1320 kcal
TEE = 1320 x 1.25 (normal activity)
= 1650 kcal
Calories
60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat
To include protein calories in the provision of energy is controversial
Fluid
The average adult requires approximately 35-45 ml/kg/d
NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure
*NRC= National research council
Fluid
1st 10 kilogram 100 cc/kg 2nd 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kg
Example: Our patient 1st 10 kg x 100cc = 1000 cc 2nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc
Protein
The average adult requires about 1 to 1.2 gm/kg 0r average of 70-80 grams of protein per day
Protein
Stress or activity level Initial protein requirement (g/kg/day)
Baseline 1.4 g/kg/day Little stress 1.6 g/kg/day Mild stress 1.8 g/kg/day Moderate stress 2.0 g/kg/day Severe stress 2.2 g/kg/day
The nutritional needs of patients are met through either parenteral or enteral delivery route
Enteral
The gastrointestinal tract is always the preferred route of support (Physiologic)
“If the gut works, use it” EN is safer, more cost effective, and
more physiologic that PN
EN (Immunologic)
Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis
Safety
Catheter sepsis Pneumothorax Catheter embolism Arterial laceration
Cost (EN)
Cost of EN formula is less than PN Less labor intensive
Contraindications
Gastrointestinal obstruction Severe acute pancreatitis High-output proximal fistulas Intractable nausea and vomiting or
osmotic diarrhea
Enteral nutrition (EN)
Long-term nutrition: Gastrostomy Jejunostomy Short-term nutrition: Nasogastric feeding Nasoduodenal feeding Nasojejunal feeding
Intact food
Predigested food
TF = tube feeding
PN Goal
Provide patients with adequate calories and protein to prevent malnutrition and associated complication
PN therapy must provide: Protein in the form of amino acids Carbohydrates in the form of glucose Fat as a lipid emulsion Electrolytes, vitamin, trace elements,
min-
General Indications
Requiring NPO > 5 - 7 days Unable to meet all daily
requirements through oral or enteral feedings
Severe gut dysfunction or inability to tolerate enteral feedings.
Can not eat, will not eat, should not eat
Special Indications (can not eat)
Cont:
When enteral feeding can’t be established
After major surgery Pt with hyperemesis gravidarum Pt with small bowel obstruction Pt with enterocutaneous fistulas
(high and low)
Cont:
Hyper-metabolic states: Burns, sepsis, trauma, long bone
fractures Adjunct to chemotherapy Nutritional deprivation Multiple organ failure: Renal, hepatic, respiratory, cardiac failure Neuro-trauma Immaturity
Fat Emulsion
Concentrated source of calories Source of essential fatty acids
(EFAs) Substitute for carbohydrate in
diabetic & fluid restricted patients
Fat (Intralipid) contraindications: Hyperlipdemia Acute pancreatitis Previous history of fat embolism Severe liver disease Allergies to egg, soybean oil or
safflower oil
Central PN (TPN)
Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only
Peripheral PN provides limited calories
Parenteral Nutrition
Central Nutrition Subclavian line Long period Hyperosmolar solution Full requirement Minimum volume Expensive More side effect
Peripheral nutrition
Peripheral line Short period < 14days Low osmolality
< 900 mOsm/L Min. requirement Large volume Thrombophlebitis
Note
PPN can infuse through central line but
central TPN can NOT infuse through
the peripheral line
Complications Associated with PN
Mechanical complication Septic complication Metabolic complication
Mechanical Complication
Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia
Venous thrombosis after central venous access
Infectious Complications
PN imposes a chronic breech in the body's barrier system
The mortality rate from catheter sepsis as high as 15%
Inserting the venous catheter Compounding the solution Care-giver hanging the bag Changing the site dressing
Metabolic Complications
Early complication -early in the process of feeding and may be anticipated
Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition
Iron
Iron is not included in TPN solution and it can cause iron deficiency anemia
Add 100mg of iron 3 x weekly to PN solution or give separately
Vitamin K
TPN solution does not contain vitamin K and it can predispose patient to deficiency
Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN