M-III Things We Take for Granted - VCU School of Medicine Things We Take for Granted Air to Breathe

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Transcript of M-III Things We Take for Granted - VCU School of Medicine Things We Take for Granted Air to Breathe

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    Donald F. Kirby, MD Chief, Section of Nutrition

    Division of Gastroenterology

    MM--IIIIII Introduction to Introduction to

    Clinical NutritionClinical Nutrition

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    Things We Take for GrantedThings We Take for Granted

    Air to BreatheAir to Breathe DeathDeath TaxesTaxes

    Another AdmissionAnother Admission Our Next Meal !Our Next Meal !

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    Though Hard to BelieveThough Hard to Believe

    Malnutrition does occur Malnutrition does occur in the United Statesin the United States

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    Malnutrition is more common Malnutrition is more common in hospitalized patients than is in hospitalized patients than is

    generally realizedgenerally realized

    1/31/3--1/2 of patients have significant deficits 1/2 of patients have significant deficits in one or more of the commonly accepted in one or more of the commonly accepted nutritional indicesnutritional indices Physical examination is not specific Physical examination is not specific enough when used as the sole diagnostic enough when used as the sole diagnostic tooltool

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    Millennium MalnutritionMillennium Malnutrition A November 2003 report estimates that A November 2003 report estimates that 842 Million people were malnourished 842 Million people were malnourished from 1999from 1999--2001. Their diet supplied 1,4002001. Their diet supplied 1,400-- 1,700 Kcal when most diets should supply 1,700 Kcal when most diets should supply about 2,300 Kcal.about 2,300 Kcal. In 26 countries the number of hungry In 26 countries the number of hungry people went up people went up –– Afghanistan, Congo, Afghanistan, Congo, Yemen, the Philippines, Liberia, Kenya, Yemen, the Philippines, Liberia, Kenya, and Iraq.and Iraq.

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    77 7 88 8

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    Potential Energy Sources Potential Energy Sources for Fasting Manfor Fasting Man

    Glycogen Glycogen –– 2 Days2 Days ProteinProtein Fat Fat –– Major SourceMajor Source

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    Malnutrition Affects Every OrganMalnutrition Affects Every Organ

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    Severe Malnutrition and the Severe Malnutrition and the HeartHeart

    BradycardiaBradycardia Mild Arterial HypotensionMild Arterial Hypotension

    Reduced Venous PressureReduced Venous Pressure Decreased Oxygen ConsumptionDecreased Oxygen Consumption

    Low Stroke Volume Low Stroke Volume Reduced Cardiac OutputReduced Cardiac Output

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    LungsLungs

    Weakness and atrophy of the Weakness and atrophy of the muscles of respirationmuscles of respiration Decreased clearance of secretionsDecreased clearance of secretions Impaired host defensesImpaired host defenses Pneumonia Pneumonia –– Common cause of Common cause of

    deathdeath 1414

    GI TractGI Tract

    Mucosal AtrophyMucosal Atrophy MaldigestionMaldigestion occursoccurs Decreased Gastric Acid SecretionDecreased Gastric Acid Secretion Decreased Gastric MotilityDecreased Gastric Motility

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    Immune SystemImmune System CellCell--mediated immunitymediated immunity –– T Cell T Cell –– important against intracellular important against intracellular

    parasitesparasites AntibodyAntibody--mediated immunitymediated immunity –– B Cells B Cells –– specific antibodiesspecific antibodies

    Complement Complement –– Decreased total serum complementDecreased total serum complement –– Decreased individual components except CDecreased individual components except C44

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    Ideal Test for Nutritional StatusIdeal Test for Nutritional Status

    1.1. Specific for deficits of nutritional originSpecific for deficits of nutritional origin 2.2. Changes Changes –– good or bad good or bad –– should be should be

    reflected promptlyreflected promptly 3.3. Deviations from normal should have Deviations from normal should have

    clinical or prognostic significanceclinical or prognostic significance 4.4. Readily availableReadily available 5.5. Reasonable costReasonable cost

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    Nutritional AssessmentNutritional Assessment

    1.1. History & Physical History & Physical –– Weight historyWeight history 2.2. Diet HistoryDiet History 3.3. Anthropometric MeasurementsAnthropometric Measurements 4.4. Plasma ProteinPlasma Protein

    a. Albumin/a. Albumin/TransferrinTransferrin/ / PrealbuminPrealbumin b. b. CreatinineCreatinine--Height IndexHeight Index

    5.5. Immunologic StatusImmunologic Status a.a. Total Lymphocyte CountTotal Lymphocyte Count b.b. Skin TestsSkin Tests

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    Weight DataWeight Data Usual Body WeightUsual Body Weight Ideal Body WeightIdeal Body Weight

    Present Body WeightPresent Body Weight

    Weight EquationsWeight Equations

    %UBW = %UBW = Present Body WeightPresent Body Weight x 100x 100 Usual Body WeightUsual Body Weight

    %IBW = %IBW = Present Body WeightPresent Body Weight x 100x 100 Ideal Body WeightIdeal Body Weight

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    Body Mass IndexBody Mass Index

    BMI = BMI = Weight (Kg)Weight (Kg) Height (M)Height (M)22

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    Classification Based on BMIClassification Based on BMI Morbid Obesity > 40Morbid Obesity > 40 Obese > 30Obese > 30 Overweight > 27 Overweight > 27 –– 29.929.9 Normal 19Normal 19--26.926.9 Underweight

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    Causes of Causes of HypoalbuminemiaHypoalbuminemia 1.1. Decreased SynthesisDecreased Synthesis

    -- CatabolizedCatabolized at 4%/dayat 4%/day -- Status of liver synthesisStatus of liver synthesis -- Amino Acid DeficiencyAmino Acid Deficiency

    2.2. Increased LossesIncreased Losses -- NephroticNephrotic SyndromeSyndrome -- BurnsBurns -- ProteinProtein--losing losing EnteropathiesEnteropathies

    3.3. Rapid Rapid RehydrationRehydration 4.4. NonspecificNonspecific

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    Beneficial Effects Attributable to Beneficial Effects Attributable to Interleukin 1 & 6Interleukin 1 & 6

    FeverFever WBC WBC –– left shiftleft shift

    Redistribution of trace metalsRedistribution of trace metals Albumin Albumin SynthesisSynthesis of acute phase proteinsof acute phase proteins ProcoagulantProcoagulant activityactivity

    Alterations in Intermediary MetabolismAlterations in Intermediary Metabolism

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    Total Lymphocyte CountTotal Lymphocyte Count Determined as follows:Determined as follows:

    WBC x % lymphocytes = TLCWBC x % lymphocytes = TLC e.g., WBC = 6,000mme.g., WBC = 6,000mm33

    % lymphocytes = 30%% lymphocytes = 30% TLC = 6000 x .30 = 1,800mmTLC = 6000 x .30 = 1,800mm33

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    Screening for MalnutritionScreening for Malnutrition

    Daily dietary intake

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    3131 3232

    Free Beer TomorrowFree Beer Tomorrow

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    Consider Patients for Nutrition Consider Patients for Nutrition Support with any of the Following:Support with any of the Following:

    Impaired ability to maintain adequate oral Impaired ability to maintain adequate oral nutrient intake. e.g., radiation nutrient intake. e.g., radiation esophagitisesophagitis Loss of 10% or more of preLoss of 10% or more of pre--illness weightillness weight A preA pre-- or postoperative course requiring or postoperative course requiring more than 5more than 5--7 days without adequate 7 days without adequate nutrient intakenutrient intake Somatic wasting, e.g. pressure sores or Somatic wasting, e.g. pressure sores or cachexiacachexia

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    Reasons for Enteral TherapyReasons for Enteral Therapy

    Functional GI TractFunctional GI Tract Neurological DisordersNeurological Disorders Anoxic EncephalopathyAnoxic Encephalopathy

    OropharyngealOropharyngeal--Esophageal DiseaseEsophageal Disease Tumor, Trauma, Tumor, Trauma, NeoplasmsNeoplasms

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    Multiple Ways to Access

    the GI Tract

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    Nasoenteric Tube with a Problem!

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    Colon

    37 383838

    393939 4040

    Peg Tube In Place

    Note: No Sutures

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    414141 4242

    PEG Button

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    434343 444444

    454545 4646

    Types of Enteral DietsTypes of Enteral Diets 1.1. BlenderizedBlenderized –– more bulk and fibermore bulk and fiber 2.2. Intact NutrientsIntact Nutrients 3.3. Chemically DefinedChemically Defined 4.4. Special FormulasSpecial Formulas

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    Complications of Enteral NutritionComplications of Enteral Nutrition

    1.1. Gastric DistentionGastric Distention 2.2. Gastric AspirationGastric Aspiration 3.3. DiarrheaDiarrhea 4.4. ConstipationConstipation 5.5. Obstruction of Feeding TubeObstruction of Feeding Tube 6.6. Displacement of the Feeding TubeDisplacement of the Feeding Tube 7.7. HyperglycemiaHyperglycemia 8.8. Fluid and Electrolyte DisordersFluid and Electrolyte Disorders

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    Indications for Parenteral NutritionIndications for Parenteral Nutrition

    Have had no nutrition for 5 days and not Have had no nutrition for 5 days and not expected to eat for 7expected to eat for 7--10 more days10 more days Exception would be someone who is Exception would be someone who is already at nutritional risk after having been already at nutritional risk after having been assessedassessed

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    Parenteral Nutrition OverviewParenteral Nutrition Overview Can the gut be utilized?Can the gut be utilized? What is the estimated time before normal GI What is the estimated time before normal GI function is expected to return?function is expected to return? Are th