Nutrition SupportNutrition Support

Dr. Ahmed MayetDr. Ahmed Mayet

Associate ProfessorAssociate Professor

King Saud UniversityKing Saud University

NutritionNutrition

Nutrition—provides with all basic Nutrition—provides with all basic nutrients and energy required for nutrients and energy required for maintaining or restoring all vital maintaining or restoring all vital body functions from carbohydrate body functions from carbohydrate and fat and for building up body and fat and for building up body mass from amino acid.mass from amino acid.

MalnutritionMalnutrition

Malnutrition—extended Malnutrition—extended inadequate intake of nutrient or inadequate intake of nutrient or severe illness burden on the body severe illness burden on the body composition and function—affect composition and function—affect all systems of the body.all systems of the body.

Types of malnutritionTypes of malnutrition

Kwashiorkor: (kwa-shior-kor) is Kwashiorkor: (kwa-shior-kor) is protein malnutritionprotein malnutrition

Marasmus: Marasmus: (ma-ras-mus) is (ma-ras-mus) is protein-protein-caloriecalorie malnutrition malnutrition

KwashiorkorKwashiorkor Protein malnutrition - caused by Protein malnutrition - caused by

inadequate inadequate proteinprotein intake in the intake in the presence of fair to good calories presence of fair to good calories intake in combination with the stress intake in combination with the stress responseresponse

Common causes - chronic diarrhea, Common causes - chronic diarrhea, chronic kidney disease, infection, chronic kidney disease, infection, trauma , burns, hemorrhage, liver trauma , burns, hemorrhage, liver cirrhosis and critical illness cirrhosis and critical illness

Clinical ManifestationsClinical Manifestations

Marked hypoalbuminemiaMarked hypoalbuminemia AnemiaAnemia EdemaEdema AscitesAscites Muscle atrophyMuscle atrophy Delayed wound healingDelayed wound healing Impaired immune functionImpaired immune function

MarasmusMarasmus The patient with severe The patient with severe

malnutrition characterized by malnutrition characterized by calories deficiency calories deficiency

Common severe burns, injuries, Common severe burns, injuries, systemic infections, cancer etc systemic infections, cancer etc oror conditions where patient does not conditions where patient does not eat like anorexia nervosa and eat like anorexia nervosa and starvationstarvation

proteinprotein--caloriecalorie

Clinical ManifestationsClinical Manifestations

Weight lossWeight loss lethargylethargy Depletion skeletal muscle and Depletion skeletal muscle and

adipose (fat) storesadipose (fat) stores BradycardiaBradycardia HypothermiaHypothermia

Risk factors for malnutritionRisk factors for malnutrition

Medical causesMedical causes Psychological and social causesPsychological and social causes

Medical causesMedical causes((Risk factors for malnutrition)Risk factors for malnutrition)

Recent surgery or traumaRecent surgery or trauma SepsisSepsis Chronic illnessChronic illness Gastrointestinal disordersGastrointestinal disorders Anorexia, other eating disordersAnorexia, other eating disorders DysphagiaDysphagia Recurrent nausea, vomiting, or diarrheaRecurrent nausea, vomiting, or diarrhea PancreatitisPancreatitis Inflammatory bowel diseaseInflammatory bowel disease Gastrointestinal fistulasGastrointestinal fistulas

Psychosocial causesPsychosocial causes

Alcoholism, drug addictionAlcoholism, drug addiction Poverty, isolationPoverty, isolation DisabilityDisability Anorexia nervosaAnorexia nervosa Fashion or limited dietFashion or limited diet

Consequences of Consequences of MalnutritionMalnutrition

Malnutrition places patients at a Malnutrition places patients at a greatly increased risk for morbidity greatly increased risk for morbidity and mortalityand mortality

Longer recovery period from Longer recovery period from illnessesillnesses

Impaired host defensesImpaired host defenses Impaired wound healingImpaired wound healing Impaired GI tract functionImpaired GI tract function

Cont:Cont: Muscle atrophyMuscle atrophy Impaired cardiac functionImpaired cardiac function Impaired respiratory functionImpaired respiratory function Reduced renal functionReduced renal function Mental dysfunctionMental dysfunction Delayed bone callus formationDelayed bone callus formation Atrophic skinAtrophic 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

ClinicalNutrition(2008)27,340e349

International,multicentre study to implement nutritional risk screening and evaluate clinical outcome

Nutritional AssessmentNutritional Assessment

Nutritional assessment (NA) Nutritional assessment (NA) is the first step in the is the first step in the treatment of malnutritiontreatment of malnutrition

Cont:Cont:

The initial assessment of The initial assessment of nutritional status requires a nutritional status requires a careful careful

History History Physical examinationPhysical examination Laboratory and other testsLaboratory and other tests

Laboratory and other Laboratory and other teststests

WeightWeight BMIBMI Fat storage Fat storage Somatic and visceral proteinSomatic 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 lossPercent weight loss

129 lbs – 129 lbs – 110 lbs110 lbs = 19 lbs = 19 lbs

19/129 x 100 = 19/129 x 100 = 15%15%

139 lbs – 139 lbs – 110 lbs110 lbs = 29 lbs = 29 lbs

29/139 x 100 = 29/139 x 100 = 20%20%

Small frame

Medium frame

50kg x 2.2 = 110 50kg x 2.2 = 110 lbslbs

HeightHeight Small FrameSmall Frame Medium FrameMedium FrameLarge FrameLarge Frame

5'9"5'9" 129-142 129-142 139-153 139-153 149-170 149-170

TimeTime Significant Weight Significant Weight Loss (%)Loss (%)

Severe Weight Loss Severe Weight Loss (%)(%)

1 week 1 week 1-2 1-2 >2>2

1 month 1 month 55 >5>5

3 months3 months 7.57.5 >7.5>7.5

6 months 6 months 1010 >10>10

Severe weight lost

Laboratory and other Laboratory and other teststests

WeightWeight BMIBMI Fat storage Fat storage Somatic and visceral proteinSomatic 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

Laboratory and other Laboratory and other teststests

WeightWeight BMIBMI Fat storageFat storage Somatic and visceral proteinSomatic and visceral protein

FatFat

Assessment of body fat Assessment of body fat – Triceps skinfold thickness (TSF)Triceps skinfold thickness (TSF)– Waist-hip circumference ratioWaist-hip circumference ratio– Waist circumferenceWaist circumference– Limb fat areaLimb fat area– Compare the patient TSF to standard Compare the patient TSF to standard

monogrammonogram

Laboratory and other Laboratory and other teststests

WeightWeight BMIBMI Fat storage Fat storage Somatic and visceral proteinSomatic and visceral protein

Protein Protein (Somatic Protein)(Somatic Protein)

Assessment of the fat-free muscle Assessment of the fat-free muscle mass (mass (Somatic ProteinSomatic Protein))Mid-upper-arm circumferenceMid-upper-arm circumference (MAC)(MAC)Mid-upper-arm muscle Mid-upper-arm muscle circumference circumference Mid-upper-arm muscle areaMid-upper-arm muscle area

Compare the patient MAC to Compare the patient MAC to standard monogram standard monogram

Protein Protein (visceral protein)(visceral protein)

Assessment of Assessment of visceral protein visceral protein depletiondepletion

Serum albumin <3.5 g/dL Serum albumin <3.5 g/dL Serum transferrin <200 mg/dL Serum transferrin <200 mg/dL Serum cholesterol <160 mg/dL Serum cholesterol <160 mg/dL Serum prealbumin <15 mg/mL Serum prealbumin <15 mg/mL Creatinine Height Index (CHI) <75%Creatinine Height Index (CHI) <75%

Cont;

Vitamins deficiencyVitamins deficiency

Vitamin Bs (B1,B2, B6, B 9, B12, )Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin CVitamin C Vitamin AVitamin A Vitamin D Vitamin D Vitamin K Vitamin K

Trace Minerals deficiencyTrace Minerals deficiency

Zinc Zinc CopperCopper ChromiumChromium ManganeseManganese SeleniumSelenium

IronIron

Estimating Estimating Energy/Calorie Energy/Calorie

BEEBEE

Basal Metabolic Rate (BMR) or Basal Metabolic Rate (BMR) or Basal Energy Expenditure (Basal Energy Expenditure (BEEBEE) ) accounts for the largest portion of accounts for the largest portion of total daily energy requirements total daily energy requirements

Harris–Benedict Harris–Benedict EquationsEquations Energy calculationEnergy calculation

MaleMale BEE = 66 + (13.7 x actual wt in kg) + BEE = 66 + (13.7 x actual wt in kg) +

(5x ht in cm) – (6.8 x age in y) (5x ht in cm) – (6.8 x age in y)

FemaleFemale BEE = 655 + (9.6 x actual wt in kg) BEE = 655 + (9.6 x actual wt in kg)

+ (1.7 x ht in cm) – (4.7 x age in y) + (1.7 x ht in cm) – (4.7 x age in y)

Total Energy Total Energy ExpenditureExpenditure

TEE (kcal/day) = BEE x TEE (kcal/day) = BEE x stress/activity factorstress/activity factor

A correlation factor that A correlation factor that estimates the extent of hyper-estimates the extent of hyper-

metabolismmetabolism 1.15 for bedridden patients 1.15 for bedridden patients 1.10 for patients on ventilator support 1.10 for patients on ventilator support 1.25 for normal patients 1.25 for normal patients The stress factors are:The stress factors are: 1.3 for low stress 1.3 for low stress 1.5 for moderate stress 1.5 for moderate stress 2.0 for severe stress2.0 for severe stress 1.9-2.1 for burn1.9-2.1 for burn

Calorie sourcesCalorie sources

CaloriesCalories

60 to 80% of the caloric 60 to 80% of the caloric requirement should be provided requirement should be provided as as glucoseglucose, the remainder 20% to , the remainder 20% to 40% as 40% as fatfat

To include protein calories in the To include protein calories in the provision of energy is provision of energy is controversial controversial

Fluid RequirementsFluid Requirements

FluidFluid

The average adult requires The average adult requires approximately 35-45 ml/kg/dapproximately 35-45 ml/kg/d

NRC* recommends 1 to 2 ml of NRC* recommends 1 to 2 ml of water for each kcal of energy water for each kcal of energy expenditureexpenditure

*NRC= National research council

FluidFluid

11stst 10 kilogram 100 cc/kg 10 kilogram 100 cc/kg 22ndnd 10 kilogram 50 cc/kg 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kgRest of the weight 20 to 30 cc/kg

Example: 50 kg patient Example: 50 kg patient 11stst 10 kg x 100cc = 1000 cc 10 kg x 100cc = 1000 cc 22ndnd 10 kg x 50cc = 500cc 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900ccRest 30 kg x 30cc = 900cc total = 2400 cctotal = 2400 cc

FluidFluid

Fluid needs are altered by the Fluid needs are altered by the patient's functional cardiac, patient's functional cardiac, hepatic, pulmonary, and renal hepatic, pulmonary, and renal status status

Fluid needs increase with fever, Fluid needs increase with fever, diarrhea, hemorrhage, surgical diarrhea, hemorrhage, surgical drains, and loss of skin integrity drains, and loss of skin integrity like burns, open wounds like burns, open wounds

Protein NeedProtein Need

ProteinProtein

The average adult requires about The average adult requires about 1 to 1.2 gm/kg 0r average of 70-1 to 1.2 gm/kg 0r average of 70-80 grams of protein per day80 grams of protein per day

ProteinProtein

Stress or activity level Initial Stress or activity level Initial protein requirement (g/kg/day)protein requirement (g/kg/day)

Baseline 1.4 g/kg/dayBaseline 1.4 g/kg/day Little stress 1.6 g/kg/dayLittle stress 1.6 g/kg/day Mild stress 1.8 g/kg/dayMild stress 1.8 g/kg/day Moderate stress 2.0 g/kg/dayModerate stress 2.0 g/kg/day Severe stress 2.2 g/kg/daySevere stress 2.2 g/kg/day

Routes of Nutrition Routes of Nutrition SupportSupport

The nutritional needs of patients The nutritional needs of patients are met through either are met through either parenteralparenteral or or enteralenteral delivery route delivery route

Enteral NutritionEnteral Nutrition

Enteral Enteral

The gastrointestinal tract is always The gastrointestinal tract is always the preferred route of support the preferred route of support (Physiologic)(Physiologic)

““If the gut works, use it”If the gut works, use it” EN is safer, more cost effective, and EN is safer, more cost effective, and

more physiologic that PNmore physiologic that PN

Potential benefits of EN over Potential benefits of EN over

PNPN Nutrients are metabolized and Nutrients are metabolized and

utilized more effectively via the utilized more effectively via the enteral than parenteral routeenteral than parenteral route

Gut and liver process EN before Gut and liver process EN before their release into systemic their release into systemic circulation circulation

Gut and liver help maintain the Gut and liver help maintain the homeostasis of the AA pool and homeostasis of the AA pool and skeletal muscle tissueskeletal muscle tissue

EN EN (Immunologic)(Immunologic)

Gut integrity is maintained by Gut integrity is maintained by enteral feeding and prevent the enteral feeding and prevent the bacterial translocation from the bacterial translocation from the gut and minimize risk of gut gut and minimize risk of gut related sepsisrelated sepsis

Cost (EN)Cost (EN)

Cost of EN formula is less than PNCost of EN formula is less than PN Less labor intensive Less labor intensive

ContraindicationsContraindications

Gastrointestinal obstructionGastrointestinal obstruction Severe acute pancreatitis Severe acute pancreatitis High-output proximal fistulasHigh-output proximal fistulas Intractable nausea and vomiting Intractable nausea and vomiting

or osmotic diarrheaor osmotic diarrhea

Enteral nutrition (EN)Enteral nutrition (EN)

Long-termLong-term nutrition: nutrition: Gastrostomy Gastrostomy Jejunostomy Jejunostomy Short-termShort-term nutrition: nutrition: Nasogastric feedingNasogastric feeding Nasoduodenal feeding Nasoduodenal feeding Nasojejunal feeding Nasojejunal feeding

Intact food

Predigested food

TF = tube feeding

Total Parentral Total Parentral NutritionNutrition

PurposePurpose

To maintain positive nitrogen To maintain positive nitrogen balance through the intravenous balance through the intravenous administration of required administration of required nutrient such as glucose, IL, AA, nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals electrolytes, vitamins, minerals and trace elements and trace elements

PN GoalPN Goal

Provide patients with adequate calories Provide patients with adequate calories and protein to prevent malnutrition and and protein to prevent malnutrition and associated complicationassociated complication

PN therapy must provide:PN therapy must provide: Protein in the form of amino acidsProtein in the form of amino acids Carbohydrates in the form of glucoseCarbohydrates in the form of glucose Fat as a lipid emulsion Fat as a lipid emulsion Electrolytes, vitamin, trace elements, Electrolytes, vitamin, trace elements,

min-min-

Patient SelectionPatient Selection

General Indications General Indications

Requiring NPO > 5 - 7 daysRequiring NPO > 5 - 7 days Unable to meet all daily Unable to meet all daily

requirements through oral or requirements through oral or enteral feedings enteral feedings

Severe gut dysfunction or inability Severe gut dysfunction or inability to tolerate enteral feedingsto tolerate enteral feedings

Can not eat, will not eat, should Can not eat, will not eat, should not eat not eat

Special Indications (can not eat)

Calorie sourcesCalorie sources

60 to 80% of the caloric 60 to 80% of the caloric requirement should be provided requirement should be provided as as glucoseglucose, the remainder 20% to , the remainder 20% to 40% as fat40% as fat

total calculated calorie = 1650 kcaltotal calculated calorie = 1650 kcal

80% from glucose 1650 x 80 80% from glucose 1650 x 80 =1320kcal=1320kcal

20% from fat (IL) 1650 x 20 = 20% from fat (IL) 1650 x 20 = 330kcal330kcal

Protein 1.2gm/kg/dayProtein 1.2gm/kg/day

1.2 x 50 = 60 gm1.2 x 50 = 60 gm

GlucoseGlucose

Maximum oxidized rate for glucose Maximum oxidized rate for glucose is is 4 - 7mg/kg/min 4 - 7mg/kg/min (adult)(adult)

Exp: our patient is 50 kgExp: our patient is 50 kg

5mg x 50kg x 60min x 24 hr =360 5mg x 50kg x 60min x 24 hr =360 gmgm

360gm x 3.4 kcal/gm = 1224 kcal360gm x 3.4 kcal/gm = 1224 kcal

Maximum cal from glucose = Maximum cal from glucose = 1224kcal1224kcal

Cont;

Fat emulsionFat emulsion

Maximum recommended allowance Maximum recommended allowance 2.5 grams/kg/day2.5 grams/kg/day

Exp: 2.5 x 50 kg = 125 gm Exp: 2.5 x 50 kg = 125 gm

125gm x 9 kcal/gm = 1125 125gm x 9 kcal/gm = 1125 kcalkcal

Intralipid Intralipid contraindications:contraindications: HyperlipdemiaHyperlipdemia Acute pancreatitis Acute pancreatitis Previous history of fat embolismPrevious history of fat embolism Severe liver diseaseSevere liver disease Allergies to egg, soybean oil or Allergies to egg, soybean oil or

safflower oilsafflower oil

DiabeticDiabetic

DM is not contraindication to TPNDM is not contraindication to TPN Use sliding-scale insulin to avoid Use sliding-scale insulin to avoid

hyperglycemiahyperglycemia

AdministrationAdministration

Central PN (TPN)Central PN (TPN)

Central PN (TPN) is a Central PN (TPN) is a concentrated formula and it can concentrated formula and it can delivered large quantity of delivered large quantity of calories via subclavian or jugular calories via subclavian or jugular vein onlyvein only

Peripheral PN (PPN)Peripheral PN (PPN)

PPN is a semi-concentrated PPN is a semi-concentrated formula and it can delivered formula and it can delivered reasonable quantity of calories reasonable quantity of calories via peripheral vein (10% dextrose via peripheral vein (10% dextrose and 2.8% AA)and 2.8% AA)

MonitoringMonitoring

Complications of TPNComplications of TPN

Complications Associated with Complications Associated with PNPN

Mechanical complicationMechanical complication Septic complicationSeptic complication Metabolic complicationMetabolic complication

Mechanical Mechanical ComplicationComplication Improper placement of catheter Improper placement of catheter

may cause pneumothorax, may cause pneumothorax, vascular injury with hemothorax, vascular injury with hemothorax, brachial plexus injury or cardiac brachial plexus injury or cardiac arrhythmiaarrhythmia

Venous thrombosis after central Venous thrombosis after central venous accessvenous access

Infectious Infectious ComplicationsComplications

The mortality rate from catheter The mortality rate from catheter sepsis as high as 15%sepsis as high as 15%

Inserting the venous catheterInserting the venous catheter Compounding the solutionCompounding the solution Care-giver hanging the bagCare-giver hanging the bag Changing the site dressingChanging the site dressing

Metabolic Metabolic ComplicationsComplications Early complicationEarly complication -early in the -early in the

process of feeding and may be process of feeding and may be anticipatedanticipated

Late complicationLate complication - - caused by not caused by not supplying an adequate amount of supplying an adequate amount of required nutrients or cause required nutrients or cause adverse effect by solution adverse effect by solution compositioncomposition

IronIron

Iron is not included in TPN Iron is not included in TPN solution and it can cause iron solution and it can cause iron deficiency anemiadeficiency anemia

Add 100mg of iron 3 x weekly to Add 100mg of iron 3 x weekly to PN solution or give separatelyPN solution or give separately

Vitamin KVitamin K

TPN solution does not contain TPN solution does not contain vitamin K and it can predispose vitamin K and it can predispose patient to deficiencypatient to deficiency

Vitamin K 10 mg should be given Vitamin K 10 mg should be given weekly IV or IM if patient is on weekly IV or IM if patient is on long-term TPN long-term TPN

Thank youThank you