Nutrition Support Dr. Ahmed Mayet Associate Professor King Saud University

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

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

Types of malnutrition Kwashiorkor: (kwa-shior-kor) is protein malnutrition Kwashiorkor: (kwa-shior-kor) is protein malnutrition Marasmus: (ma-ras-mus) is protein- calorie malnutrition Marasmus: (ma-ras-mus) is protein- calorie malnutrition

Kwashiorkor Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response Common causes - chronic diarrhea, chronic kidney disease, infection, trauma, burns, hemorrhage, liver cirrhosis and critical illness Common causes - chronic diarrhea, chronic kidney disease, infection, trauma, burns, hemorrhage, liver cirrhosis and critical illness

Clinical Manifestations Marked hypoalbuminemia Marked hypoalbuminemia Anemia Anemia Edema Edema Ascites Ascites Muscle atrophy Muscle atrophy Delayed wound healing Delayed wound healing Impaired immune function Impaired immune function

Marasmus The patient with severe malnutrition characterized by calories deficiency The patient with severe malnutrition characterized by calories deficiency Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation protein-calorie

Clinical Manifestations Weight loss Weight loss lethargy lethargy Depletion skeletal muscle and adipose (fat) stores Depletion skeletal muscle and adipose (fat) stores Bradycardia Bradycardia Hypothermia Hypothermia

Risk factors for malnutrition Medical causes Medical causes Psychological and social causes Psychological and social causes

Medical causes (Risk factors for malnutrition) Recent surgery or trauma Recent surgery or trauma Sepsis Sepsis Chronic illness Chronic illness Gastrointestinal disorders Gastrointestinal disorders Anorexia, other eating disorders Anorexia, other eating disorders Dysphagia Dysphagia Recurrent nausea, vomiting, or diarrhea Recurrent nausea, vomiting, or diarrhea Pancreatitis Pancreatitis Inflammatory bowel disease Inflammatory bowel disease Gastrointestinal fistulas Gastrointestinal fistulas

Psychosocial causes Alcoholism, drug addiction Alcoholism, drug addiction Poverty, isolation Poverty, isolation Disability Disability Anorexia nervosa Anorexia nervosa Fashion or limited diet Fashion or limited diet

Consequences of Malnutrition Malnutrition places patients at a greatly increased risk for morbidity and mortality Malnutrition places patients at a greatly increased risk for morbidity and mortality Longer recovery period from illnesses Longer recovery period from illnesses Impaired host defenses Impaired host defenses Impaired wound healing Impaired wound healing Impaired GI tract function Impaired GI tract function

Cont: Muscle atrophy Muscle atrophy Impaired cardiac function Impaired cardiac function Impaired respiratory function Impaired respiratory function Reduced renal function Reduced renal function Mental dysfunction Mental dysfunction Delayed bone callus formation Delayed bone callus formation Atrophic skin Atrophic 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, “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

Metabolic Rate Long CL, et al. JPEN 1979;3:452-6 Normal range

Protein Catabolism Long CL. Contemp Surg 1980;16:29-42 Normal range

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

Cont: The initial assessment of nutritional status requires a careful The initial assessment of nutritional status requires a careful History History Physical examination Physical examination Laboratory and other tests Laboratory and other tests

Laboratory and other tests Weight Weight BMI BMI Fat storage Fat storage Somatic and visceral protein Somatic and visceral protein

Height Small Frame Medium Frame Large Frame 4'10" '11" '0" '1" '2" '3" '4" '5" '6" '7" '8" '9" '10" '11" '0" Standard monogram for Height and Weight in adult-male

Percent weight loss Percent weight loss 129 lbs – 110 lbs = 19 lbs 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20% 29/139 x 100 = 20% Small frame Medium frame 50kg x 2.2 = 110 lbs Height Small FrameMedium FrameLarge Frame 5'9"

Time Significant Weight Loss (%) Severe Weight Loss (%) 1 week 1-2>2 1 month 5>5 3 months 7.5>7.5 6 months 10>10 Severe weight lost

Laboratory and other tests Weight Weight BMI BMI Fat storage Fat storage Somatic and visceral protein Somatic and visceral protein

ClassificationBMI (kg/m 2 )Obesity Class Underweight<18.5 Normal Overweight Obesity I Moderate obesity II Extreme obesity>40.0III Average Body Mass Index (BMI) for Adult

Laboratory and other tests Weight Weight BMI BMI Fat storage Fat storage Somatic and visceral protein Somatic and visceral protein

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

Laboratory and other tests Weight Weight BMI BMI Fat storage Fat storage Somatic and visceral protein Somatic and visceral protein

Protein (Somatic Protein) Assessment of the fat-free muscle mass (Somatic Protein) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Assessment of the fat-free muscle mass (Somatic Protein) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram Compare the patient MAC to standard monogram

Protein (visceral protein) Assessment of visceral protein depletion Assessment of visceral protein depletion 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 deficiency Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin Bs (B1,B2, B6, B 9, B12, ) Vitamin C Vitamin C Vitamin A Vitamin A Vitamin D Vitamin D Vitamin K Vitamin K

Trace Minerals deficiency Zinc Zinc Copper Copper Chromium Chromium Manganese Manganese Selenium Selenium Iron Iron

Estimating Energy/Calorie

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

Harris–Benedict Equations Energy calculation Energy calculation Male Male BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) Female Female BEE = (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y) BEE = (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y)

Total Energy Expenditure TEE (kcal/day) = BEE x stress/activity factor TEE (kcal/day) = BEE x stress/activity factor

A correlation factor that estimates the extent of hyper-metabolism 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 stress 2.0 for severe stress for burn for burn

Calculation Our patient Wt = 50 kg, Age = 45 yrs Height = 5 feet 9 inches (175 cm) Height = 5 feet 9 inches (175 cm) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) = 66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) = 66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) =66 + ( 685) + (875) – (306) =66 + ( 685) + (875) – (306) = 1320 kcal = 1320 kcal TEE = 1320 x 1.25 (normal activity) = 1650 kcal = 1650 kcal

Calorie sources

Calories 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat To include protein calories in the provision of energy is controversial To include protein calories in the provision of energy is controversial

Fluid Requirements

Fluid The average adult requires approximately ml/kg/d The average adult requires approximately ml/kg/d NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council

Fluid 1 st 10 kilogram 100 cc/kg 1 st 10 kilogram 100 cc/kg 2 nd 10 kilogram 50 cc/kg 2 nd 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kg Rest of the weight 20 to 30 cc/kg Example: 50 kg patient 1 st 10 kg x 100cc = 1000 cc 1 st 10 kg x 100cc = 1000 cc 2 nd 10 kg x 50cc = 500cc 2 nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc Rest 30 kg x 30cc = 900cc total = 2400 cc total = 2400 cc

Fluid Fluid needs are altered by the patient's functional cardiac, hepatic, pulmonary, and renal status Fluid needs are altered by the patient's functional cardiac, hepatic, pulmonary, and renal status Fluid needs increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin integrity like burns, open wounds Fluid needs increase with fever, diarrhea, hemorrhage, surgical drains, and loss of skin integrity like burns, open wounds

Protein Need

Protein The average adult requires about 1 to 1.2 gm/kg 0r average of grams of protein per day The average adult requires about 1 to 1.2 gm/kg 0r average of grams of protein per day

Protein Stress or activity level Initial protein requirement (g/kg/day) Stress or activity level Initial protein requirement (g/kg/day) Baseline 1.4 g/kg/day Baseline 1.4 g/kg/day Little stress 1.6 g/kg/day Little stress 1.6 g/kg/day Mild stress 1.8 g/kg/day Mild stress 1.8 g/kg/day Moderate stress 2.0 g/kg/day Moderate stress 2.0 g/kg/day Severe stress 2.2 g/kg/day Severe stress 2.2 g/kg/day

Routes of Nutrition Support

The nutritional needs of patients are met through either parenteral or enteral delivery route The nutritional needs of patients are met through either parenteral or enteral delivery route

Enteral Nutrition

Enteral The gastrointestinal tract is always the preferred route of support (Physiologic) The gastrointestinal tract is always the preferred route of support (Physiologic) “If the gut works, use it” “If the gut works, use it” EN is safer, more cost effective, and more physiologic that PN EN is safer, more cost effective, and more physiologic that PN

Potential benefits of EN over PN Nutrients are metabolized and utilized more effectively via the enteral than parenteral route Nutrients are metabolized and utilized more effectively via the enteral than parenteral route Gut and liver process EN before their release into systemic circulation Gut and liver process EN before their release into systemic circulation Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue

EN (Immunologic) Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis

Cost (EN) Cost of EN formula is less than PN Cost of EN formula is less than PN Less labor intensive Less labor intensive

Contraindications Gastrointestinal obstruction Gastrointestinal obstruction Severe acute pancreatitis Severe acute pancreatitis High-output proximal fistulas High-output proximal fistulas Intractable nausea and vomiting or osmotic diarrhea Intractable nausea and vomiting or osmotic diarrhea

Enteral nutrition (EN) Long-term nutrition: Long-term nutrition: Gastrostomy Gastrostomy Jejunostomy Jejunostomy Short-term nutrition: Short-term nutrition: Nasogastric feeding Nasogastric feeding Nasoduodenal feeding Nasoduodenal feeding Nasojejunal feeding Nasojejunal feeding

Intact food Predigested food

TF = tube feeding

Total Parentral Nutrition

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

PN Goal Provide patients with adequate calories and protein to prevent malnutrition and associated complication Provide patients with adequate calories and protein to prevent malnutrition and associated complication PN therapy must provide: PN therapy must provide: Protein in the form of amino acids Protein in the form of amino acids Carbohydrates in the form of glucose Carbohydrates in the form of glucose Fat as a lipid emulsion Fat as a lipid emulsion Electrolytes, vitamin, trace elements, min- Electrolytes, vitamin, trace elements, min-

Patient Selection

General Indications Requiring NPO > days Requiring NPO > days Unable to meet all daily requirements through oral or enteral feedings Unable to meet all daily requirements through oral or enteral feedings Severe gut dysfunction or inability to tolerate enteral feedings Severe gut dysfunction or inability to tolerate enteral feedings Can not eat, will not eat, should not eat Can not eat, will not eat, should not eat

Special Indications (can not eat)

Calorie sources 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat

total calculated calorie = 1650 kcal total calculated calorie = 1650 kcal 80% from glucose 1650 x 80 =1320kcal 80% from glucose 1650 x 80 =1320kcal 20% from fat (IL) 1650 x 20 = 330kcal 20% from fat (IL) 1650 x 20 = 330kcal Protein 1.2gm/kg/day Protein 1.2gm/kg/day 1.2 x 50 = 60 gm 1.2 x 50 = 60 gm

Glucose Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult) Maximum oxidized rate for glucose is 4 - 7mg/kg/min (adult) Exp: our patient is 50 kg Exp: our patient is 50 kg 5mg x 50kg x 60min x 24 hr =360 gm 5mg x 50kg x 60min x 24 hr =360 gm 360gm x 3.4 kcal/gm = 1224 kcal 360gm x 3.4 kcal/gm = 1224 kcal Maximum cal from glucose = 1224kcal Maximum cal from glucose = 1224kcal Cont;

Fat emulsion Maximum recommended allowance 2.5 grams/kg/day 2.5 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 kcal 125gm x 9 kcal/gm = 1125 kcal

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

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

Administration

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

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

Monitoring

Complications of TPN

Complications Associated with PN Mechanical complication Mechanical complication Septic complication Septic complication Metabolic complication Metabolic complication

Mechanical Complication Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia Venous thrombosis after central venous access Venous thrombosis after central venous access

Infectious Complications The mortality rate from catheter sepsis as high as 15% The mortality rate from catheter sepsis as high as 15% Inserting the venous catheter Inserting the venous catheter Compounding the solution Compounding the solution Care-giver hanging the bag Care-giver hanging the bag Changing the site dressing Changing the site dressing

Metabolic Complications Early complication -early in the process of feeding and may be anticipated Early complication -early in the process of feeding and may be anticipated Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition

Iron Iron is not included in TPN solution and it can cause iron deficiency anemia Iron is not included in TPN solution and it can cause iron deficiency anemia Add 100mg of iron 3 x weekly to PN solution or give separately Add 100mg of iron 3 x weekly to PN solution or give separately

Vitamin K TPN solution does not contain vitamin K and it can predispose patient to deficiency TPN solution does not contain vitamin K and it can predispose patient to deficiency Vitamin K 10 mg should be given weekly IV or IM if patient is on long- term TPN Vitamin K 10 mg should be given weekly IV or IM if patient is on long- term TPN

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