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

10
1 1 Donald F. Kirby, MD Chief, Section of Nutrition Division of Gastroenterology M- III III Introduction to Introduction to Clinical Nutrition Clinical Nutrition 2 Things We Take for Granted Things We Take for Granted Air to Breathe Air to Breathe Death Death Taxes Taxes Another Admission Another Admission Our Next Meal ! Our Next Meal ! 3 Though Hard to Believe Though Hard to Believe Malnutrition does occur Malnutrition does occur in the United States in the United States 4 5 Malnutrition is more common Malnutrition is more common in hospitalized patients than is in hospitalized patients than is generally realized generally realized 1/3 1/3- 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 indices nutritional 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 tool tool 6 Millennium Malnutrition Millennium Malnutrition A November 2003 report estimates that A November 2003 report estimates that 842 Million people were malnourished 842 Million people were malnourished from 1999 from 1999- 2001. Their diet supplied 1,400 2001. 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.

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

Page 1: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

1

11

Donald F. Kirby, MD Chief, Section of Nutrition

Division of Gastroenterology

MM--IIIIIIIntroduction to Introduction to

Clinical NutritionClinical Nutrition

22

Things We Take for GrantedThings We Take for Granted

Air to BreatheAir to BreatheDeathDeathTaxesTaxes

Another AdmissionAnother AdmissionOur Next Meal !Our Next Meal !

33

Though Hard to BelieveThough Hard to Believe

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

44 4

55

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

66

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.

Page 2: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

2

77 7 88 8

99

Potential Energy Sources Potential Energy Sources for Fasting Manfor Fasting Man

Glycogen Glycogen –– 2 Days2 DaysProteinProteinFat Fat –– Major SourceMajor Source

1010 10

1111

Malnutrition Affects Every OrganMalnutrition Affects Every Organ

1212

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

Page 3: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

3

1313

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

deathdeath1414

GI TractGI Tract

Mucosal AtrophyMucosal AtrophyMaldigestionMaldigestion occursoccursDecreased Gastric Acid SecretionDecreased Gastric Acid SecretionDecreased Gastric MotilityDecreased Gastric Motility

1515

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

1616

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

1717

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

1818

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

Page 4: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

4

1919

Body Mass IndexBody Mass Index

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

2020

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

2121

AnthropometricMeasurements

2222

Anthropometric MeasurementsAnthropometric Measurements

Triceps Skin Fold Triceps Skin Fold FatFat StoresStoresMidarmMidarm Muscle Circumference Muscle Circumference ProteinProtein storesstores

2323

BiochemicalBiochemical MarkersMarkers

AlbuminAlbuminTransferrinTransferrinPrealbuminPrealbumin

2424

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

Page 5: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

5

2525

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

2626

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

2727

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

2828

2929

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

3030

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.

Page 6: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

6

3131 3232

Free Beer TomorrowFree Beer Tomorrow

3333

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

3434

Reasons for Enteral TherapyReasons for Enteral Therapy

Functional GI TractFunctional GI TractNeurological DisordersNeurological DisordersAnoxic EncephalopathyAnoxic Encephalopathy

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

3535

Multiple Ways to Access

the GI Tract

35 3636

Nasoenteric Tube with a Problem!

36

Page 7: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

7

3737

Colon

37 383838

393939 4040

Peg TubeIn Place

Note: No Sutures

40

414141 4242

PEG Button

42

Page 8: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

8

434343 444444

454545 4646

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

4747

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

484848

Page 9: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

9

4949

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

5050

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?

515151 5252

Three-in-one TPNAll-in-one TPN

52

5353

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

5454

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

Page 10: M-III Things We Take for Granted - VCU School of Medicine · Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next Meal ! 3 Though Hard to Believe Malnutrition

10

555555 5656

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

5757

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

585858

595959