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