Basic Clinical Nutrition

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Basic Clinical Nutrition

• Pranithi Hongsprabhas MD.

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Objective

• Etiology of PEM
• Classification
• Diagnosis/assessment
• Complication
• Management of PEM
• treatment option
• complication
• monitoring

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References

• 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.

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Malnutrition

• Over nutrition
• obesity
• dietary induced dyslipidemia
• Under nutrition
• protein energy nutrition
• specific nutrient deficiency

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Hospital Malnutrition

• 30-60 malnourished, 10 - 25 severe
• gets worse in hospital
• high morbidity, prolonged hospital stay
• higher mortality

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Cancer 1985 55 258-262
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Diseases and Conditions Predisposing to
Malnutrition
Nutrient utilization
Nutrient intake
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Diseases 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.
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Simple 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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Marasmus 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
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Stress 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

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Stress 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

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Stress 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

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Chronic Stress Starvation

• Mild -moderate stress starvation
• Develops in months

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Functional Redistribution of Body Cell Mass
Liver protein synthesis
Glucose
Visceral protein
Acute phase protein
Extracellular AA pool
Tissue repair
Collagen
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Malnutrition 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

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Complication 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
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Type of Malnutrition

• Response to starvation/ semistarvation Marasmic
  type
• Response to stress starvation protein
  malnutrition, hypoalbuminemic malnutrition,
  Kwashiorkor, Marasmic-kwashiorkor

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Characteristic 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

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Metabolic Response
Nutrition in Critical Care 1994
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How to Detect Patients at Risk?

• Nutritional screening
• Nutritional assessment

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Subjective 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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SGA (cont)
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SGA (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

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Physical Examination

• General
• Specific nutritional examination

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Clinical of Nutritional Deficiency
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General muscle wasting
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Flaky paint dermatosis protein deficiency
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Essential fatty acid deficiency syndromes (EFADs)
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Zinc deficiency
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• dermatitis
• dementia
• diarrhea
• death
• Pellagra
• niacin deficiency

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Vitamin C deficiency
Perifolicullar pitichea
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Vitamin K deficiency
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Anthropometric Study
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Anthropometric 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

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Laboratory Assessment Biochem

• electrolytes

• hepatic secretory protein

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Serum 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

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Distributional Hypoalbuminemia
Lobo et al. Clin Sci 2001
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Prealbumin

• T 1/2 2-3 d
• Decreased in liver failure, acute stress
• response to nutritional support
• increased in renal failure

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Transferrin

• Decreased in liver failure, acute stress
• increased in IDA

Retinol Binding Protein

• Decreased in liver failure, acute stress, vitamin
  A deficiency
• renal failure

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Creatinine 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

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Functional Assessment

• Somatic protein
• handgrip strength
• lung mechanic negative inspiratory pressure,
  maximum ventilatory vol
• muscle stimulation
• Immune response
• Delayed type cutaneous response
• total lymphocyte count

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Immunocompetence

• 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

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Multinutritional 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

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Nutrition Support
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Nutritional 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

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Nutrition 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

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Energy Requirement

• Estimated
• Harris-Benedict equation
• Kcal/kg/d
• Measured
• indirect calorimetry

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Estimated 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
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Protein Requirement
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Nitrogen Balance
N balance N output - N intake

• N output UUNUNUN misc
• UUN (2) (g)
• N intake Protein intake(g)
• 6.25

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Fat Requirement

• Essential fatty acid
• linoleic 4 of total calorie
• linolenic 0.2-0.4 of total calorie
• Source of energy 9kcal/1g
• 20-35

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Mineral Requirement
Vitamin Requirement/ Trace Element Requirement
According to RDA
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Contraindication of Nutrition Support

• Unstable hemodynamics
• Severe fluid, electrolyte, acid- base disorder
  (esp. PN)
• Uncontrolled infection
• Severe GI tract malfunction (mainly EN)

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Enteral Nutrition

• Contraindication
• unstable condition hemodynamics
• intestinal obstruction
• massive GI bleeding
• intestinal ischemia
• severe malabsorption, inflammation

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Enteral Nutrition

• Complication
• tube complication
• aspiration
• diarrhea, vomiting, abdominal discomfort
• metabolic complication

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Parenteral Nutrition

• PPN, TPN
• Indication
• GI tract failure
• Inadequate EN
• Contraindication
• Unstable condition
• Uncontrolled serious condition
• Terminal stage malignancy

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Complication

• line sepsis CRI
• Metabolic derangement/ re-feeding syndrome
• Fluid/ electrolyte/ acid-base imbalance
• Overfeeding syndrome

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Monitoring

• BW
• clinical
• blood chemistry
• BS
• electrolyte
• LFT

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Assessment

• For nutrition response
• monitoring of complication