M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to...
Transcript of M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to...
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Donald F. Kirby, MD Chief, Section of Nutrition
Division of Gastroenterology
MM--IIIIIIIntroduction to Introduction to
Clinical NutritionClinical Nutrition
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Things We Take for GrantedThings We Take for Granted
Air to BreatheAir to BreatheDeathDeathTaxesTaxes
Another AdmissionAnother AdmissionOur 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 indicesPhysical 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 MalnutritionA 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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Potential Energy Sources Potential Energy Sources for Fasting Manfor Fasting Man
Glycogen Glycogen –– 2 Days2 DaysProteinProteinFat 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
BradycardiaBradycardiaMild Arterial HypotensionMild Arterial Hypotension
Reduced Venous PressureReduced Venous PressureDecreased 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 respirationDecreased clearance of secretionsDecreased clearance of secretionsImpaired host defensesImpaired host defensesPneumonia Pneumonia –– Common cause of Common cause of
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GI TractGI Tract
Mucosal AtrophyMucosal AtrophyMaldigestionMaldigestion occursoccursDecreased Gastric Acid SecretionDecreased Gastric Acid SecretionDecreased Gastric MotilityDecreased Gastric Motility
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Immune SystemImmune SystemCellCell--mediated immunitymediated immunity–– T Cell T Cell –– important against intracellular important against intracellular
parasitesparasitesAntibodyAntibody--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 origin2.2. Changes Changes –– good or bad good or bad –– should be should be
reflected promptlyreflected promptly3.3. Deviations from normal should have Deviations from normal should have
clinical or prognostic significanceclinical or prognostic significance4.4. Readily availableReadily available5.5. Reasonable costReasonable cost
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Nutritional AssessmentNutritional Assessment
1.1. History & Physical History & Physical –– Weight historyWeight history2.2. Diet HistoryDiet History3.3. Anthropometric MeasurementsAnthropometric Measurements4.4. Plasma ProteinPlasma Protein
a. Albumin/a. Albumin/TransferrinTransferrin/ / PrealbuminPrealbuminb. b. CreatinineCreatinine--Height IndexHeight Index
5.5. Immunologic StatusImmunologic Statusa.a. Total Lymphocyte CountTotal Lymphocyte Countb.b. Skin TestsSkin Tests
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Weight DataWeight DataUsual Body WeightUsual Body WeightIdeal Body WeightIdeal Body Weight
Present Body WeightPresent Body Weight
Weight EquationsWeight Equations
%UBW = %UBW = Present Body WeightPresent Body Weight x 100x 100Usual Body WeightUsual Body Weight
%IBW = %IBW = Present Body WeightPresent Body Weight x 100x 100Ideal 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 BMIMorbid Obesity > 40Morbid Obesity > 40Obese > 30Obese > 30Overweight > 27 Overweight > 27 –– 29.929.9Normal 19Normal 19--26.926.9Underweight <18.5Underweight <18.5Severe Malnutrition < 16Severe Malnutrition < 16
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AnthropometricMeasurements
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Anthropometric MeasurementsAnthropometric Measurements
Triceps Skin Fold Triceps Skin Fold FatFat StoresStoresMidarmMidarm Muscle Circumference Muscle Circumference ProteinProtein storesstores
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BiochemicalBiochemical MarkersMarkers
AlbuminAlbuminTransferrinTransferrinPrealbuminPrealbumin
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Plasma ProteinsPlasma ProteinsAlbumin Albumin –– 2 Main Functions2 Main Functions
1)1) Binding and transport of small molecules Binding and transport of small molecules (e.g., drugs, vitamin B6, etc.)(e.g., drugs, vitamin B6, etc.)
2)2) Accounts for 70% of the Colloid Osmotic Accounts for 70% of the Colloid Osmotic Pressure of PlasmaPressure of Plasma
Advantage Advantage –– Readily availabilityReadily availabilityNormal ranges are variable with age and Normal ranges are variable with age and
general health of the patientgeneral health of the patient
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Causes of Causes of HypoalbuminemiaHypoalbuminemia1.1. 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 RehydrationRehydration4.4. NonspecificNonspecific
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Beneficial Effects Attributable to Beneficial Effects Attributable to Interleukin 1 & 6Interleukin 1 & 6
FeverFeverWBC WBC –– left shiftleft shift
Redistribution of trace metalsRedistribution of trace metalsAlbumin Albumin SynthesisSynthesis of acute phase proteinsof acute phase proteins
ProcoagulantProcoagulant activityactivityAlterations in Intermediary MetabolismAlterations in Intermediary Metabolism
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Total Lymphocyte CountTotal Lymphocyte CountDetermined as follows:Determined as follows:
WBC x % lymphocytes = TLCWBC x % lymphocytes = TLCe.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 <1000kcal or 50gm of Daily dietary intake <1000kcal or 50gm of proteinproteinGreater than 10% weight lossGreater than 10% weight lossSerum albumin <3.0 on admissionSerum albumin <3.0 on admissionAnergyAnergy
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RoubenoffRoubenoff R, et al. Malnutrition among hospitalized R, et al. Malnutrition among hospitalized patients: A problem of physician awareness. patients: A problem of physician awareness.
Arch Intern Med 1987;147:1462.Arch Intern Med 1987;147:1462.
Points out that we are still failing to teach Points out that we are still failing to teach our our housestaffhousestaff and medical students and medical students
about nutrition.about nutrition.
However, there is hope! They showed that a However, there is hope! They showed that a brief nutrition review coupled with a brief nutrition review coupled with a database could significantly improve database could significantly improve
physician awareness and change nutrition physician awareness and change nutrition practices in a large teaching hospital.practices in a large teaching hospital.
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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 esophagitisesophagitisLoss of 10% or more of preLoss of 10% or more of pre--illness weightillness weightA 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 intakeSomatic 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 TractNeurological DisordersNeurological DisordersAnoxic EncephalopathyAnoxic Encephalopathy
OropharyngealOropharyngeal--Esophageal DiseaseEsophageal DiseaseTumor, 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
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Peg TubeIn Place
Note: No Sutures
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PEG Button
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Types of Enteral DietsTypes of Enteral Diets1.1. BlenderizedBlenderized –– more bulk and fibermore bulk and fiber2.2. Intact NutrientsIntact Nutrients3.3. Chemically DefinedChemically Defined4.4. Special FormulasSpecial Formulas
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Complications of Enteral NutritionComplications of Enteral Nutrition
1.1. Gastric DistentionGastric Distention2.2. Gastric AspirationGastric Aspiration3.3. DiarrheaDiarrhea4.4. ConstipationConstipation5.5. Obstruction of Feeding TubeObstruction of Feeding Tube6.6. Displacement of the Feeding TubeDisplacement of the Feeding Tube7.7. HyperglycemiaHyperglycemia8.8. 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 daysException 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 OverviewCan 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 there difficulties with venous access?Are there difficulties with venous access?Is Peripheral Vein (PPN) or central vein nutrition Is Peripheral Vein (PPN) or central vein nutrition (TPN) most appropriate?(TPN) most appropriate?Are there preAre there pre--existing electrolyte abnormalities?existing electrolyte abnormalities?What are the caloric requirements?What are the caloric requirements?Are there any special physiologic Are there any special physiologic considerations?considerations?
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Three-in-one TPNAll-in-one TPN
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Glucose PreparationsGlucose PreparationsGlucose Glucose Caloric ContentCaloric Content OsmolalityOsmolality
ConcentrationConcentration (Kcal/liter)(Kcal/liter) ((mOsmmOsm/liter)/liter)5 170 252
10 340 50520 680 101040 1360 202050 1700 252560 2040 303070 2380 3535
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TPN Standard SolutionTPN Standard SolutionAmino Acids 4.25%Amino Acids 4.25% 500ml500mlDextrose 25%Dextrose 25% 500ml500mlSodiumSodium 35mEq35mEqPotassiumPotassium 30mEq30mEqChlorideChloride 35mEq35mEqAcetateAcetate 50mEq50mEqMagnesium Magnesium 5mEq5mEqPhosphorusPhosphorus 15mM15mMMVIMVI 4ml4mlTrace ElementsTrace Elements 1ml1mlNonProteinNonProtein CaloriesCalories 850 Kcal/liter850 Kcal/literOsmolalityOsmolality 1160 1160 mOsmmOsm/liter/liter
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TPN ComplicationsTPN Complications1.1. Technical problems with line insertionTechnical problems with line insertion
-- PneumothoraxPneumothorax-- Air embolismAir embolism-- Arterial punctureArterial puncture-- Cardiac perforation & Cardiac perforation & tamponadetamponade-- Brachial plexus injuryBrachial plexus injury-- Catheter fragment embolismCatheter fragment embolism
2.2. PostPost--insertion catheter problemsinsertion catheter problems3.3. Metabolic complicationsMetabolic complications
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Metabolic Complications during Metabolic Complications during Parenteral NutritionParenteral Nutrition
1.1. General electrolyte disorders General electrolyte disorders ––hypo/hyper hypo/hyper –– Sodium, Potassium …Sodium, Potassium …
2.2. Glucose abnormalitiesGlucose abnormalities3.3. Phosphorus abnormalitiesPhosphorus abnormalities4.4. Calcium abnormalitiesCalcium abnormalities5.5. Magnesium abnormalitiesMagnesium abnormalities6.6. Vitamin & Trace element abnormalitiesVitamin & Trace element abnormalities
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