Introduction to Clinical Nutrition

Dr.Fachrul Jamal, Intensivis.

Objectives
Hospital Malnutrition prevalence Malnutrition and its Consequences Screening and Nutritional Assessment Energy Metabolism and Normal Nutritional Requirements Metabolic Response to Starvation and stress response : Nutritional Requirements

Hospital Malnutrition prevalence

A Problem of Physician Awareness Up to 50% of hospitalized patients may be malnourished on admission Before nutritional assessment training: Only 12.5% of malnourished patients are identified

Prevalence of Malnutrition in Hospitalized Patients In a published British study: 46% of general medicine patients 45% of patients with respiratory problems 27% of surgical patients 43% of elderly patients Percentage of malnourished patients at time of admission
McWhirter et al. Br Med J 1994

Malnutrition and its Consequences

Changes in intestinal barrier Reduction in glomerular filtration Alterations in cardiac function Altered drug pharmacokinetics

Roediger 1994; Green 1999; Zarowitz 1990

Malnutrition and its Consequences

Loss of weight Slow wound healing Impaired immunity Increase in length of hospital stays Increased treatment costs Increase in mortality

Screening and Nutritional Assessment

Nutritional Screening Nutritional Assessment

Nutritional Screening

Identify the characteristics associated with nutritional problems Identify patients at nutritional risk

Nutritional Assessment

Collect and evaluate clinical conditions, diet, body composition and biochemical data, among others Classify patients by nutritional state: wellnourished or malnourished

Screening and Nutritional Asessment: Common Objectives

Identify at-risk patients to reduce:

Complications Treatment failures Physiological problems Health care costs

Difference Between Screening and Nutritional Assessment

Type and scope of information Training and skills of those collecting information Time required by the process Expense of the process

Nutritional Screening

Involuntary increase or decrease in weight > 10% of usual weight over 6 months or > 5% of usual weight over 1 month Inadequate oral intake

Barrocas et al. J Am Diet Assoc 1995;95:647-648.

Nutritional Assessment

Body composition Biochemical data Clinical Assessment

Subjective Global Assessm ent of Nutritional Status

A. History
1. W eight change Overall loss in past 6 months: ________ kg Change in past 2 weeks: increase Percent loss ________ no change decrease

2. Dietary intake change relative to norm al No change ________ Change: duration ________ weeks ___ ____ m onths

Type: sub-optimal solid diet ________ full liquid diet ________ hypocaloric liquid diet _______ starvation ______ 3. Gastrointestinal sym ptom s (persisting more than 2 weeks) None Nausea ________ Vomiting Diarrhea ________ Anorexia _______

Subjective Global
Assessment (SGA)

4. Functional capacity No dysfunction ___________ Dysfunction: duration _______ week s _______ m onths am bulatory _________ bedridden _________

Type: working sub-optimally ________

5. Disease and its relationship to nutritional requirements Prim ary diagnosis: ____________________________ Metabolic demand / Stress: none _ _______ low ________ m oderate ________ high ________

B. Physical Exam ination

(for each specify: 0 = norm al, 1+ = m ild, 2+ = m oderate, 3+ = severe) Loss of subcutaneous fat (triceps, chest) ______________ Muscle wasting (quadriceps, deltoids) __ _______________ Ankle edem a ________ Sacral edem a ________ Ascites ________

C. Subjective Global Assessm ent Rating

W ell nourished Moderately (or suspected) of being) m alnourished Severely m alnourished A B C

Nutritional Assessment: Body Composition Parameter

Weight and height BMI = weight / height2 Triceps or subscapular thickness of skin fold Mid-arm muscle circumference and mid-arm muscle area

Nutritional Assessment: Biochemical Parameters

At Risk Level Serum albumin Total lymphocyte count cell/mm3 Serum transferrin Serum pre-albumin Total iron-binding capacity Serum cholesterol

< 3.5 g/dL < 1500

<140 mg/dL < 17 mg/dL < 250 mcg/dL < 150 mg/dL

Heymsfield SB, et al. In: Modern Nutrition in Health and Disease. Philadelphia, PA: Lea & Febiger;1994:812-841.

Nutritional Parameters: Change Per Type of Malnutrition

Chronic Acute Malnutrition Malnutrition Weight Mid-arm Circumference

Mixed

Albumin
Lymphocyte Count

Immune Function

Subjective Global Assessment (SGA)

1. Weight changes 2 Changes in dietary intake 3. Gastrointestinal symptoms 4. Functional capacity 5. Link between disease and nutritional requirements 6. Physical exam focused on nutritional aspects
Detsky AS, et al. JPEN 1987;11:8-15.

Subjective Global Assessment: Diagnosis

Well-nourished Moderately malnourished or suspected malnutrition Severely malnourished

Energy Substrate Utilization

Fasting state:

Depends on nutrient availability

In stress:

Depends on hormonal environment and inflammatory response

Malnutrition

Ideal Weight Actual Weight

In malnutrition, energy expenditure must be calculated based on actual body weight.

Obesity

Ideal Weight Actual Weight

In obesity, energy expenditure must be calculated on ideal weight.

Calculating Basal Energy Expenditure Variables gender, weight (kg), height (cm), age (years)
Men: 66.47 + (13.75 x weight) + (5 x height) (6.76 x age) Women: 655.1 + (9.56 x weight) + (1.85 x height) (4.67 x age)

Harris-Benedict Equation

Calorie requirement = BEE x activity factor x stress factor

Calorie Calculation

Rule of Thumb

Calorie requirement = 25 to 30 kcal/kg/day

Carbohydrates
Provide 50% to 60% of total calories Necessary to maintain protein anabolism Produces 4 kcal/g by mouth or enterally and 3.4 kcal/g intravenously

Fat Recommendations

Source of energy and essential fatty acids Linoleic acid: 2 to 7 g/day Provide 20% to 30% of total calories 1 g/kg/day In special disease management 45+% of total calories from fat may be beneficial

Glycemic control Reduction of CO2 production

Vitamins
Fat Soluble Vitamins Vitamin A Vitamin E Vitamin D Vitamin K Water Soluble Vitamins Folic Acid Thiamin Pantothenic Acid Vitamin B6 Biotin Vitamin B12 Niacin Vitamin C Riboflavin

Minerals
Sodium Potassium Chloride Calcium Phosphorus Magnesium
Zinc Copper Chromium Manganese Selenium Iodine Iron

Penggunaan substrat nutrisi pada normal dan pada status katabolisme

NORMAL
15% 25%

CATABOLIC
25%

Protein Fat

30%

Fat

Protein

CHO
60%

CHO
45%

Stress Response
Surgery Hypoxemia Pneumonia Severe infection sepsis Trauma Burn Pain

Stress Response ( neuroendocrine response )

A. Afferent stimuli
(Hypovolemia, trauma, hypoxemia,pain, anesthesia, MODS, sepsis,toxins &bacteria )

B. Transmitters

( Blood and lymphatics, peripheral nerves, CNS)

C. Effector site Sympathetic nerv syst
Adrenal medula

Hypothalamus

Kidney islets
Renin, angiotens

Pancr

Ant pituitary Post pituitary Adr cortex

Epinephrn
norepinephr Cortison, aldostr, G.H

ADH
Aldostrn

Glukagon
Insulin

Perjalanan penyakit pada pasien-pasien dengan stres respons

Burns, trauma, Sepsis, Pancreatitis, Peritonotis Surgery, Radiation Th/
Respons Stres

Ebb phase

Syok, hipoksi, dll

Resusitasi
Kondisi katabolisme / hiperkatabolisme

Respons akut
Respons Maladaptif

Flow phase
Recovery (anabolic phase)

Adaptive response

Metabolic Response to Stress

Ebb Phase
Energy Expenditure

Flow Phase

Time

Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

Pasien Sakit Kritis hipermelabolik, katabolik, imun respons bifasik ( meningkat/menurun)

Tujuan dukungan nutrisi : Menyesuaikan asupan dengan perubahan metabolisme yang terjadi Mempertahankan masa sel tubuh (otot, usus. mukosa dan organ2 lain) Mencegah dan mengatasi kekurangan zat2 nutrisi yang spesifik Mempertahankan fungsi sistim imun untuk mengatasi infeksi Mencegah komplikasi yang dapat timbul sehubungan dg tehnik pemberian nutrisi

Substrat nutrisi
Kebutuhan energi, cairan dan elektrolit

Jumlah
25 30 (kritis) 30 50 25 30 (kritis) 30 50 1,2 1,5 1 -2 1 3:1 - 1;1

Air cc/kgBB/hari Energi Kcal/kgBB/hari As.Amino/prot Gr/kgBB/hari Na meq/kgBB/hari K meq/kgBB/hari Glukosa : lemak

Metabolic Response to Starvation and Stress Nutritional Requirements

Injury Minor surgery Long bone fracture Cancer Peritonitis/sepsis Severe infection/multiple trauma Multi-organ failure syndrome Burns Activity Confined to bed Out of bed Stress Factor 1.00 1.10 1.15 1.30 1.10 1.30 1.10 1.30 1.20 1.40 1.20 1.40 1.20 2.00 Activity Factor 1.2 1.3 Example: Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2

ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456

Catabolic Response in Critically ill Patients

28 24 20 Nitrogen 16 excretion gm/day 12 8 4 0
Elective surgery Major burns Skeletal trauma Severe sepsis Infection

Normal range Partial starvation

Total starvation

10

20 Day

30

40
Long CL. Contemp Surg 16:29-42

Metabolic Response to Overfeeding

Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia

Barton RG. Nutr Clin Pract 1994;9:127-139

DANGERS OF OVERFEEDING
Secretory diarrhea (with EN) Hyperglycemia, glycosuria, dehydration, lipogenesis, fatty liver, liver dysfunction Electrolyte abnormalities: Volume overload, CHF CO2 production- ventilatory demand PO4 , K, Mg

O2 consumption

Increased mortality (in adult studies)

MONITORING Prevent Overfeeding

Carbohydrate: High RQ indicates CHO excess, stool reducing substances Protein: Nitrogen balance Fat: triglyceride Visceral protein monitoring Electrolytes, vitamin levels Caloric requirement assessment by metabolic cart

Macronutrientes during Stress

Fat

Provide 20%-35% of total calories Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Macronutrients during Stress

Carbohydrate

At least 100 g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30%-40% of total calories Glucose intake should not exceed 5 mg/kg/min

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

Macronutrients during Stress

Protein

Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Determining Protein Requirements for Hospitalized Patients

No Stress
> 150:1 < 15% protein 0.8 g/kg/day
Moderate Stress

Stress Level Calorie:Nitrogen Ratio Percent Potein / Total Calories Protein / kg Body Weight

Severe Stress
< 100:1 > 20% protein

150-100:1 15-20% protein 1.0-1.2 g/kg/day

1.5-2.0 g/kg/day

Summary
Malnutrition Extensive prevalence & linked to:
Increased complications Increased length of hospital stay Higher costs Increased mortality

Defined nutritional screening and assessment Nutrients are necessary to maintain life
Described techniques for assessing nutritional status and explanation of the Subjective Global Assessment Nutrient utilization depends on availability (fasting) and inflammatory response (stress) Energy requirements vary according to patients clinical condition Metabolic response to starvation is an adaptive mechanism Nutritional requirements increase during stress response

Indications for use:

patient unable to meet nutrient needs by oral food intake > 5 days and PEM; <50% requirements 5-10 days lower GIT functional, but upper GIT not functional examples: inadequate oral intake / dysphagia esophageal cancer maldigestion malabsorption

Contraindications for use: non-functional GIT bowel obstruction (physical or paralytic ileus) bowel rest (controversial)

Steps for Delivery of EN

Nutrition assessment indicates nutrition support (need) Based on nutrition assessment, select appropriate formula Method of delivery
continuous drip deliver over specified time low complications

Steps for Delivery of EN

Intermittent feedings delivery of EN over >30 min mobility Bolus Orders for EN Start all acute patients with continuous feeds 10 ml/hr isotonic strength increase the dose by titration to optimal dose dilute formula if needed (not necessary)

Steps for Delivery of EN

Increase rate or concentration one at a time - rate 25 ml/hr at one time - concentration 25-50% every 824 hr - both patient specific - each institute has its preference - decrease either if complications

Monitoring
Use of pump less complications Gastric residuals (naso/orogastric/PEG) Weight (weekly), height if growing Bowel function (sounds/symptoms/abdominal distension) Fluid balance Initial, follow-up (72 hr) and weekly chart notes Biochemistry

Biochemistry to consider:
Blood Biochemistry BUN, glucose albumin (25-30 moderate, <25 g/L severe protein depletion) electrolytes (Na, K, Cl, CO2, Mg, Ca, P) Urine values to consider: urine glucose, urine specific gravity Additional blood values to consider: liver function tests and creatinine

Complications
Mechanical Nutritional/Metabolic

Types and Selection of EN formulae

Blenderized Milk based protein isolates (complete) Non-milk based protein isolates (complete) Hydrolysed-protein-based (elemental) Special-purpose formulae Modular Components

Types and Selection of EN formulae

Modular Components protein whole amino acids carbohydrates simple oligosaccharides polysaccharides (glucose polymers) fat LCT MCT List examples from site visit to VGH.

Selection of EN Formulae
Need to consider Position of tube GIT functions needed for digestion/absorption list where all nutrients are absorbed along the GIT Need to consider individual needs malabsorption syndromes fats (MCT) lactose intolerance/ lactase deficiency peptides Vs amino acids

Selection of EN Formulae
Risk of contamination Costs- formula and nursing time etc.

How to Determine the Type of Nutrition Support

Can the patient's nutritional requirements be met with regular food? Will the patient consume their nutritional requirements from regular food or do they need a supplement? Can the patient tolerate a milk-based supplement? Does the patient need a tube feeding to meet their nutritional needs?

How to Determine the Type of Nutrition Support

Is the patient's GIT functioning? Will a standard, whole-protein, 1.0 kcal/Ml formula meet their needs?

Does the patient have elevated calorie

requirements, volume intolerance, or a fluid restriction that may require a high-calorie

formula?

How to Determine the Type of Nutrition Support

Does the patient have elevated protein requirements? Would the patient benefit from a fibre-containing formula for bowel management? If the GIT is not fully functioning, would an elemental diet be the best choice?

How to Determine the Type of Nutrition Support

Does the patient have a specific metabolic problem or organ failure that would suggest a special or condition specific nutritional requirements? burns, liver disease Does the patient need extra CHO, fat or protein, from a modular, added to their formula? Does the patient need parenteral nutrition because they are unable to use their GIT?

Product available in the market

Peptisol high protein and calorie ( CH ) Enterasol Hepatosol BCAA enriched Usually 1cc contain 1 kcal complete with vitamin, electrolyte and trace element

ENTERAL or PARENTERAL?
Enteral Nutrition: Superior to Parenteral Trophic effects on intestinal villus Reduces bacterial translocation Supports Gut-associated Lymphoid Tissue Promotes secretory IgA secretion and function Lower cost Parenteral Nutrition IV access Infectious risk

PARENTERAL NUTRITION (PN)

The PN formulation is based on: Fluid Requirements Energy Requirements Vitamins Trace elements Other additives-Heparin, H2 blocker etc

PN-suggested guidelines for Initiation and Maintenance

Substrate

Initiation

Advancement

Goals

Comments

Dextrose

10%

2-5%/day

25%

Increase as tolerated. Consider insulin if hyperglycemic Maintain calorie:nitrogen ratio at approximately 200:1 Only use 20%

Amino acids
20% Lipids

1 g/kg/day

0.5-1 g/kg/day 0.5-1 g/kg/day

2-3 g/kg/day 2-3 g/kg/day

1 g/kg/day