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Nutritional Assessment and Support PowerPoint Presentation

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This medical PowerPoint presentation talks about Nutritional Assessment and Support critical care medicine.

Nutritional assessment and support are critical components of care for patients in the intensive care unit (ICU). Malnutrition is common among critically ill patients, and it can lead to prolonged hospital stays, increased morbidity, and mortality. Therefore, it is essential to identify patients who are at risk for malnutrition and provide them with appropriate nutritional support.

Nutritional assessment in critical care medicine involves a comprehensive evaluation of the patients nutritional status, including anthropometric measurements, biochemical markers, and clinical evaluation. Anthropometric measurements include weight, height, body mass index (BMI), and skinfold thickness. Biochemical markers include serum albumin, prealbumin, transferrin, and total lymphocyte count. Clinical evaluation includes assessment of muscle and fat wasting, presence of edema, and other physical signs of malnutrition.

Once the patients nutritional status has been assessed, appropriate nutritional support can be provided. Nutritional support can be delivered either orally or via enteral or parenteral routes. Enteral nutrition involves feeding the patient through a feeding tube that is inserted into the stomach or small intestine. Parenteral nutrition involves providing nutrients through an intravenous line.

Enteral nutrition is preferred over parenteral nutrition because it is associated with fewer complications, including infections and metabolic abnormalities. However, in some cases, such as when the patient is unable to tolerate enteral feeding or has a gastrointestinal obstruction, parenteral nutrition may be necessary.

The amount of nutritional support required for each patient varies depending on their individual needs. Factors such as the patients underlying condition, degree of malnutrition, and metabolic rate should be taken into consideration when determining the appropriate amount of nutritional support.

In summary, nutritional assessment and support are critical components of care for critically ill patients. Early identification of patients at risk for malnutrition and appropriate nutritional support can improve outcomes, reduce morbidity, and mortality in the ICU.

Tags : Nutritional Assessment, Nutrition in Critical Care, Critical illness, malnutrition, enteral nutrition, parenteral nutrition, oral nutrition, critical care medicine, critical care medicine PowerPoint presentation

Published on : Mar 28, 2023 | Views : 1872 | Downloads : 3

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Slide 1-

Nutritional AssessmentandSupport
Slide 2-

Outline Malnutrition definition types Physiology fasting starvation effects of stress & trauma Nutritional Assessment presence & degree of malnutrition Nutritional Support who benefits proper timing enteral vs. parenteral simple calculations
Slide 3-

Nutrition intake of nutrients to provide energy for… performance of mechanical work maintenance of organ/tissue function heat production maintenance of metabolic homeostasis TEE (total energy expenditure) REE or BEE (fasting resting or basal energy expenditure) ~ 70%(~1 kcal/kg/hr) activity expenditure ~ 20% avg. but very variable thermic effect of feeding ~ 10% (intake increases the metabolic rate)
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Malnutrition estimated that >50% of hospitalized patients exhibit malnutrition results in the catabolism of energy stores adipose (oxidation of triglycerides) ~ 13kg in average person glycogen (glucose) ~ 0.5kg, mostly in muscle protein (not stored - in use by the body) skeletal muscle ~ 6-12 kg other protein stores (organs, visceral proteins, nerve tissue) ~ few hundred grams
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Types of Malnutrition Marasmus cachexia chronic calorie malnutrition – relatively balanced diet, but too little for too long usually the result of a longstanding problem (months) see wasting of fat, skeletal muscle (weakness) visceral protein stores less affected Kwashiorkor (West African term – “disease of the displaced child”) “malnourished African child” (after weaning) with edema and protuberant abdomen more rapid development and worse prognosis chronic protein malnutrition (unbalanced diet) and the presence of physiologic stress fat & skeletal muscle reserves are less depleted (carbohydrates drive insulin) visceral protein stores & immunity are affected early Marasmic kwashiorkor combined features – usually what is seen in ICU / ill patients malnurished person with stress of illness (hypermetabolic state) worst prognosis – nutritional support tends to only increase fat mass unless the underlying stressors are reversed
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Adipose&circulatingFFA & TG amino acids glycerol fatty acids Liver gluconeogenesis Early Fasting Human(Day One) FFA oxidationin mitochondria ketones glucose CNS MuscleHeartKidney lactatepyruvate glycogen fuelsupply consumption PNSMedulla Marrow Eyes Circulatingglucose Muscle glycogen & protein
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Adipose amino acids glycerol fatty acids Liver gluconeogenesis Early Fasting Human(Days 2-14) FFA oxidationin mitochondria ketones glucose CNS MuscleHeartKidney lactatepyruvate fuelsupply consumption * lose 5% body protein stores per week Renal Marrow PNSEyes Muscle75 g/d
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Adipose amino acids glycerol fatty acids Liver gluconeogenesis Adapted Fasting Human(2 to 6 weeks) FFA oxidation in mitochondria ketones glucose CNS MuscleHeartKidney lactatepyruvate fuelsupply consumption Muscle20 g/d Renal Marrow PNSEyes
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Adipose amino acids glycerol fatty acids Liver gluconeogenesis Traumatized Human FFA oxidation in mitochondria ketones glucose CNS MuscleHeartKidney lactatepyruvate glycogen fuelsupply consumption ReparativeProcess Renal Marrow PNSEyes Visceral& MuscleProtein250 g/d
Slide 10-

Nutritional Assessment
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Normal Nutrition Calories US standard diet for 70kg active man contains ~2700 kcal protein ~325 kcal (81 grams) fat ~1125 kcal (125 grams) carbohydrates ~1250 kcal (312 grams) amount needs to be decreased for inactivity Protein US standard diet ~80 grams/d (12% of caloric intake) protein-free diets result in negative nitrogen balance lose .34 grams protein/kg/d (nitrogen in urine, feces, skin, breath, sputum, etc.) titrate dietary protein to just keep a positive nitrogen balance need .38 to .52 grams protein/kg/d (higher estimate b/o inefficiency in utilization) most use .43 as a minimum and 0.5 - 0.8 gm/kg/d as average amount needs to be increased for stress (hypercatabolic)
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Nutritional Assessment Every patient should prompt three questions Does pre-existing malnutrition exist? Is malnutrition likely to occur? When and how to correct the situation?
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Does malnutrition exist? poor intake weight loss last 6 months (25% false positive, 33% false negative) <5% considered mild malnutrition; 10% is a useful cut-off in nutritional support decisions >20% considered severe malnutrition GI symptoms of anorexia, N/V, diarrhea, malabsorption, obstruction hypercatabolic pre-admission infection, sepsis trauma, burns major surgery or pulmonary disease anthropometric changes loss of SQ fat, muscle wasting, BMI < 18 functional changes muscle weakness, respiratory effort, daily activity performance lab studies albumin, transferrin, prealbumin, RBP, cholesterol, immune function affected by by critical illness and become less useful in stressed pts
Slide 14-

Does malnutrition exist? Subjective Global Assessment Scale (SGA Scale) graded on 6 features weight change intake GI symptoms functional capacity physiologic stress physical alterations each feature is rated A = no deficit B = mild deficit C = severe deficit scored overall A = well nourished = 16% septic complications B = mild to moderate malnutrition = 43% septic complications C = severe malnutrition = 69% septic complications
Slide 15-

Is Malnutrition Likely to Occur? poor intake NPO for more than 5 days GI symptoms of anorexia, N/V, diarrhea, malabsorption, obstruction hypercatabolic infection, sepsis trauma, burns major surgery or pulmonary disease
Slide 16-

Nutritional Support Theoretical goals of improving the nutritional status of hospitalized patients improve wound healing decrease infectious complications (in the severely malnourished) decrease non-septic complications decrease ventilator weaning time shorten hospital stays decrease mortality rate
Slide 17-

Enteral vs Parenteral Nutritional Support Acute critical illness see catabolism>>anabolism, fat mobilization is impaired. Enteral and parenteral support confer DIFFERENT clinical outcomes in critically ill patients. Enteral nutrition: when started early in the disease (first 48 hrs) may decrease risk of infection compared to delayed initiation (day 8 or >). Barely reaches statistical significance in meta-analyses. Mortality reduction trends lower, but never reaches significance in meta-analyses. Benefit > harm, but positive trials mostly in SICU, not MICU, pts. Parenteral nutrition: no evidence of benefit by early initiation vs late. There is good evidence of harm 69 trial meta-analysis with 3750 pts comparing early TPN vs none found higher infection rates and no diff in other outcomes or mortality. 2 studies adding TPN (1 early and 1 late) to enteral nutrition (hyperalimentation) found increased infection rates, days on vent, days in hosp, and mortality in 1 trial. Head to head studies, mostly SICU (TPN vs enteral): lower infection rate (RR 0.61) and no mortality difference with enteral support. Studies are needed to define roles of each in medical pts (more pre-existing malnutrition) vs surgical (acute illness with less pre-existing malnutrition).
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Simplified Approach severe burn or trauma  early enteral NS within 24-36 hours severe physiologic stress and diet will be compromised  early enteral well-nourished on admit, no hurry malnourished (remember wt loss, BMI <18.5, alb < 3.2, TLC < 1500 can be from catabolism) use decision chart
Slide 19-

Nutritional Support
Slide 20-

Route of Administration Enteral more physiologic (doesn’t bypass gut mucosa and liver) less complicated (supplements, NG tube, PEG, DHT, naso-jejunal tube) less costly (especially cyclic, intermittent, or bolus feeding) fewer infectious and other complications better at preserving gut mucosal integrity and preventing microbial translocation Parenteral use only if you cannot use the gut bowel leak (not just bowel surgery; enteral feeding may help fresh anastomosis) bowel obstruction prolonged ileus short bowel / severe malabsorption mesenteric ischemia no gut access
Slide 21-

Estimate Needs (weight based) If malnourished (BMI <18.5), use actual body weight to avoid refeeding syndrome Devine formula, 1974 males IBW = 50 kg + 2.3 kg for each inch over 5 feet females IBW = 45.5 kg + 2.3 kg for each inch over 5 feet underestimates IBW for short women Robinson formula, 1983 males IBW = 52 kg + 1.9 kg for each inch over 5 feet females IBW = 49 kg + 1.7 kg for each inch over 5 feet better estimate for females Obesity correction (BMI ≥ 30) adjusted IBW = IBW + (ABW - IBW)/4 for pts with BMI between 18.5 and 29,most useABW – edema weight
Slide 22-

Estimate Needs calories basal or resting energy expenditure (BEE or REE) men: 66 + (13.7 x kg wt) + (5 x cm ht) – (6.8 x age) or 879 + (10.2 x kg wt) women: 665 + (9.6 x kg wt) + (1.7 x cm ht) – (4.7 x age) or 795 + (7.18 x kg wt) activity factor bed rest: +5-10% light activity: +50% ambulatory: +20-30% moderate activity: +75% stress factor minor surgery: +10% appendicitis, long bone fracture: +20% major infection: +30-40% multiple trauma: +60% burns: +30-70% special cases (unstable sepsis, hypotension) reduce or hold caloric support to avoid hyperglycemia (<110, NEJM 2001) and immune suppression protein basal 0.5 - 0.8 gm/kg/d adjust for stress/illness
Slide 23-

Estimate Needs(Practical Method) calories per kg/day critically ill: 15-20 (18) bed rest/mod ill: 25 mild stress or activity: 30 for weight gain: 35 burn patient: 40 protein grams per kg/day no stress: 0.8 mild stress: 1.0 dialysis 1.3 moderate stress: 1.2 severe stress: 1.5 burn patient: 2.0+ 80 kg patient 2400 kcal 100 grams protein
Slide 24-

TPN Calculations dextrose=3.45 kcal/gram D70=70 grams/dl D70=241 kcal/dl D70=2.4 kcal/cc carbo=D70 lipid=F20 protein=AA10 fat=9 kcal/gram F20=20 grams/dl F20=180 kcal/dl F20=1.8 kcal/cc protein=4 kcal/gram AA10=10 grams/dl AA10 =40 kcal/dl AA10 =0.4 kcal/cc 80 kg patient 2400 kcal 100 grams protein protein 100x4=400 kcal 480/0.4=1000 cc lipid 2400x30%=720 kcal 720/1.8=400 cc 2400-400=2000 kcal 2000-720=1280 kcal carbo 1280/2.4=530 cc *propofol is ~F10 = 1 kcal/cc
Slide 25-

Monitoring Nutritional Status/Support correct osmolality, volume, glucose and electrolyte abnormalities first watch for refeeding syndrome (fluid retention/CHF, low phos, K, Mg, high glucose) if serum glucose is hard to control, increase lipid ratio (up to 50-66% of calories), but remember that lipid is less nitrogen preserving than dextrose (below 150 g/d dextrose) if triglycerides are hard to control, lower the lipid ratio (can be removed for periods) follow weights daily, consider prealbumin weekly, and UUN occasionally (rare) N balance = (grams protein intake/6.25) - (grams UUN + 4) grams N deficit x 6.25 = extra grams protein needed