Acute management of severe malnutrition

Dr Simon Gabe St Mark’s Hospital, London

Malnutrition definition

A state resulting from lack of uptake or intake of nutrition leading to altered

body composition (decreased fat free mass), and

body cell mass

leading to diminished physical and mental function and impaired clinical outcome from disease

Although this definition is well-accepted, the condition lacks clear and generally accepted diagnostic criteria.

Incidence & recognition of malnutrition in hospital

Nutrition state General surgery (n=100)

General medicine (n=100)

Respiratory medicine (n=100)

Orthopaedic surgery (n=100)

Medicine for elderly (n=100)

Undernourished 27 46 45 39 43

Normal 25 30 17 30 27

Overweight 48 24 38 31 30

Weight change

Overweight (n=29)

Normal (n=28)

Undernourished

Mild (n=19) Moderate (n=19) Severe (n=17)

Mean weight loss (%)

5.4 5.3 5.3 9.7 6.4

McWhirter & Pennington, BMJ 1994

Under & overnutrition

Underweight Obesity

Community 4-5% 28%

Care homes 30-35%% 9%

Hospitals 30-34% 12.5%*

*HSCIC data for 2011/12

Malnutrition is a common problem

35% 34%

30%

18%

15% 13%

10%

5%

Care homeresident

On a hospitalward

Admission tohospital

Admission tomental health

unit

Hospitaloutpatients

Shelteredhousing

Visiting the GP Adultpopulation in

England

Distribution of malnutrition

Medium & high risk MUST Estimated costs

Cost of malnutrition in England 2011–12

Public expenditure on malnutrition • £19.6 billion • >15% of total expenditure on health & social care Calculated from • the proportion of healthcare activity due to

malnutrition and the cost for this activity • In some cases costs were uplifted to take into account

additional known effects of malnutrition (eg increased LOS)

Most of the cost of malnutrition was due to healthcare (78%) rather than social care (22%).

Cost of malnutrition per person

Saunders et al.

Medicine 2015;43(2): 112–118

Causes of malnutrition

Causes of malnutrition in hospital in-patients

Medical causes of inadequate and/or poor quality oral intake

Anorexia of disease

Nausea and vomiting

Gastrointestinal dysfunction

Reduced absorption of macro- and/or micronutrients

Increased nutrient loses

‘Nil by mouth’ for investigation or medical reasons

Physical disability & inability to feed self

Environmental causes of inadequate and/or poor quality oral intake

Inadequate food quality

Inadequate food availability

No protected meal times

Missed meals when going for investigations

Inadequate training and knowledge of medical and nursing staff

Altered requirements

In critical illness there are altered substrate demands and several sub-groups of patients have a increased energy expenditure

Severe malnutrition

WHO, 1999: Management of severe malnutrition: a manual for physicians & health workers (ISBN 92 4 154511 9)

Refeeding Syndrome

Severe fluid & electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding

1st described in prisoners of war after 2nd World War

Also classic experiments of Keys on conscientious objectors during the war

The fasted state

Fasting

insulin, glucagon, cortisol

Gluconegenesis, glycogenolysis protein catabolism

Depletion of electrolytes, proteins, fats, minerals, vitamins

Adjustments to new metabolic state

Na/K Pump

Na+

K+ (Mg2+)

Cell

Glucose

Phosphate

Thiamine

CHO

Insulin

Glycolysis

TCA cycle

ATP synthesis

Refeeding syndrome

Fasting Refeeding

insulin, glucagon, cortisol

Gluconegenesis, glycogenolysis protein catabolism

Depletion of electrolytes, proteins, fats, minerals, vitamins

insulin, glucagon, cortisol

Glucose, PO4, Mg & K uptake thiamine use

PO4, K, Mg, Thiamine deficiency

Respiratory / cardiac failure / sudden death Adjustments to new metabolic state

Refeeding syndrome

May cause serious clinical complications

Hallmark biochemical feature: hypophosphataemia

Other features:

Abnormal sodium & fluid balance

Changes in glucose, protein & fat metabolism

Thiamine deficiency

Hypokalaemia

Hypomagnesaemia

Main problems of refeeding

Problem Result

Low phosphate Death

Thiamine deficiency Wernicke’s encephalopathy Loss of short term memory

Re-activation of Na+/K+ pump

Oedema LVF

NICE 2006 High risk of developing refeeding problems

One or more BMI <16 kg/m2

Weight loss >15% in 3-6/12 Little or no intake >10 days Low K, PO4 or Mg

Two or more BMI <18.5 kg/m2

Weight loss >10% in 3-6/12 Little or no intake >5 days Alcohol or drug abuse Insulin, chemotherapy, antacids, diuretics

Screening for malnutrition

MUST tool

Most widely used in the UK

Detects Malnourished patients

Patients at risk of malnutrition

Obese with significant wt loss

Widely used but variably performed correctly

Full dose daily IV vitamin B preparation, or

Oral thiamine 200–300 mg daily & vit B comp 1-2 tab TDS

Balanced multivitamin/trace element supplement OD

Immediately

Extreme undernutrition

In most patients Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs

Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs

Cardiac monitor

NICE recommendations Management of patients at risk of refeeding

1g glucose = 4 kcal 1L 5% dextrose = 50g glucose = 200 kcal

Full dose daily IV vitamin B preparation, or

Oral thiamine 200–300 mg daily & vit B comp 1-2 tab TDS

Balanced multivitamin/trace element supplement OD

Immediately

Extreme undernutrition

In most patients Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs

Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs

Cardiac monitor

NICE recommendations Management of patients at risk of refeeding

50 kg patient 10 kcal/kg/day glucose

= 500 kcal

2.5L dextrose/day

40 kg patient 5 kcal/kg/day glucose

= 200 kcal

1L dextrose/day

Full dose daily IV vitamin B preparation, or

Oral thiamine 200–300 mg daily & vit B comp 1-2 tab TDS

Balanced multivitamin/trace element supplement OD

Immediately

Provide

Restore

Extreme undernutrition

In most patients Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs

Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs

Cardiac monitor

Restore circulatory volume & monitor fluid balance closely

Potassium (2–4 mmol/kg/day)

Phosphate (0.3–0.6 mmol/kg/day)

Magnesium (0.2 mmol/kg/day IV, 0.4 mmol/kg/day oral)

NICE recommendations Management of patients at risk of refeeding

http://www.rcpsych.ac.uk/files/pdfversion/CR189.pdf

Initial driver for the guidance

12 cases of young people with severe anorexia nervosa who had died on medical units owing to

re-feeding syndrome

underfeeding syndrome

other complications of anorexia nervosa and its treatment

Recommendations

Adult patients with anorexia nervosa being admitted to a medical ward are often at high risk

• Risk assessment should include BMI, physical exam, blood tests & ECG

• Most adults with severe anorexia nervosa should be treated on specialist eating disorders units (SEDUs)

• Medical admission required for patients needing treatments not available on a psychiatric ward (eg IV infusion)

Recommendations Medical ward admission

In-patient medical team

• Should be supported by a senior psychiatrist

• Expertise in eating disorders

• Liaison psychiatrist

• Adult general psychiatrist

• Should contain a physician & dietician

• With specialist knowledge in eating disorders

• Work within a nutrition support team

Key tasks

• Safely re-feed the patient

• Avoid re-feeding & underfeeding syndromes

• Manage common behavioural problems eg sabotaging nutrition (with the help of psychiatric staff)

• Manage family concerns

• Treat under Section 3 if required (psychiatric support)

• Arrange transfer to a SEDU as soon as safely possible

Nutrition support

Oral

Enteral Parenteral

Misplaced NGs

NG placement often by an experienced nurse, but when they fail it is the most inexperienced doctor

How often does the NG go into the trachea?

Often quoted as 2-2.5% knowing it is an underestimation1

35% using Iris NG tube (CCD chip on the end of the NG)2

1Sorokin R & Gottlieb JE JPEN 2006;30:440–5 2Carrera G et al, Clin Nutr 2015;34(S1)S117–S118

Undetected misplaced NGs

20

16

10

35

2012-13 2013-14 2014-15 2015-16

*

NCEPOD: a mixed bag An enquiry into the care of hospital patients receiving PN

877 adult, 270 neonatal and 70 paediatric notes assessed

2010

NCEPOD: quality of care

19%

Good practice: A standard that you would accept from yourself, your trainee and your institution

Monitoring

Inadequate monitoring in 43% patients

CVC Complications

Complications

26% CVC related

54% thought to be avoidable

2% managed inappropriately

Summary

Prevalence & cost

• Obesity common in the community

• Malnutrition common in hospitals (34%) & care homes (35%)

• Cost of malnutrition in 2011/12: 19.6 billion

Refeeding

• Hallmark biochemical feature: hypophosphataemia

• High risk patients & management discussed

MARSIPAN

• Guidance for combined management of high risk anorexic patients

NG placement issues very common & do lead to deaths

PN administration needs to improve in the UK