Nutrition Support
Ahmed Mayet, Pharm.D
Associate Professor
King Saud University
Questions


What medical history support that the
patient is “at risk” of malnutrition?
What physical findings support that
the patient is “at risk” of malnutrition?
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.
Malnutrition

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
Marasmus: (ma-ras-mus) is proteincalorie malnutrition
Kwashiorkor


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
Clinical Manifestations

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Marked hypoalbuminemia
Anemia
Edema
Muscle atrophy
Delayed wound healing
Impaired immune function
Marasmus


The patient with severe protein-calorie
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
Marasmus


The patient with severe protein-calorie
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
Clinical Manifestations
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Weight loss
Reduced basal metabolism
Depletion skeletal muscle and adipose
(fat) stores
Decrease tissue turgor
Bradycardia
Hypothermia
Risk factors for malnutrition


Medical causes
Psychological and social causes
Medical causes
(Risk factors for malnutrition)

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Recent surgery or trauma
Sepsis
Chronic illness
Gastrointestinal disorders
Anorexia, other eating disorders
Dysphagia
Recurrent nausea, vomiting, or diarrhea
Pancreatitis
Inflammatory bowel disease
Gastrointestinal fistulas
Psychosocial causes

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Alcoholism, drug addiction
Poverty, isolation
Disability
Anorexia nervosa
Fashion or limited diet
Consequences of Malnutrition

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Malnutrition places patients at a
greatly increased risk for morbidity
and mortality
Longer recovery period from illnesses
Impaired host defenses
Impaired wound healing
Impaired GI tract function
Cont:

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Muscle atrophy
Impaired cardiac function
Impaired respiratory function
Reduced renal function
mental dysfunction
Delayed bone callus formation
Atrophic skin
International, multicentre study to implement nutritional
risk screening and evaluate clinical outcome
“Not at risk” = good nutrition status
“At risk”
= poor nutrition status
Results: Of the 5051 study patients, 32.6% were defined as ‘atrisk’ At-risk’ patients had more complications, higher mortality
and longer lengths of stay than ‘not at-risk’ patients.
Sorensen J et al ClinicalNutrition(2008)27,340 349
International,multicentre study to implement nutritional risk screening and evaluate clinical outcome
ClinicalNutrition(2008)27,340e349
Resting metabolism (% of normal)
Metabolic Rate
Major burn
Sepsis
Trauma
Partial starvation
Total starvation
180
160
140
120
100
Normal range
80
60
0
10
20
30
Days
40
50
Long CL, et al. JPEN 1979;3:452-6
Protein Catabolism
Major burn
Trauma
Sepsis
Partial starvation
Total starvation
Nitrogen excretion
30
25
20
15
10
Normal range
5
0
0
10
20
30
40
Days
Long CL. Contemp Surg 1980;16:29-42
Answer (medical history)
What medical history support that the
patient is “at risk” of malnutrition?
 Nausea
 Abdominal pain
 Diarrhea
 Loss of appetite
 Weight loss
Answer (physical finding)
Cont;
What physical findings support that the patient is “at risk” of
malnutrition?

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Pale
Lethargic
Muscle wasting
cachecxia
Edematous
Hypotensive
Tachycardia
Burses and patichiae on the limbs
Question

What biochemical, anthropometric,
indirect calorimetric, and other testes
are suggesting that your patient is
malnourish?
Cont:
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The initial assessment of nutritional
status requires a careful
History
Physical examination
Laboratory and other tests
Laboratory and other tests
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Weight
BMI
Fat storage
Somatic and visceral protein
Standard monogram for Height and Weight in adult-male
Height
Small Frame
Medium Frame
Large Frame
4'10"
102-111
109-121
118-131
4'11"
103-113
111-123
120-134
5'0"
104-115
113-126
122-137
5'1"
106-118
115-129
125-140
5'2"
108-121
118-132
128-143
5'3"
111-124
121-135
131-147
5'4"
114-127
124-138
134-151
5'5"
117-130
127-141
137-155
5'6"
120-133
130-144
140-159
5'7"
123-136
133-147
143-163
5'8"
126-139
136-150
146-167
5'9"
129-142
139-153
149-170
5'10"
132-145
142-156
152-173
5'11"
135-148
145-159
155-176
6'0"
138-151
148-162
158-179
Percent weight loss
50kg x 2.2 = 110 lbs
Small frame 129 lbs – 110 lbs = 19 lbs
19/129 x 100 = 15%
Medium frame
139 lbs – 110 lbs = 29 lbs
29/139 x 100 = 20%
Severe weight lost
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
Laboratory and other tests
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Weight
BMI
Fat storage
Somatic and visceral protein
Average Body Mass Index (BMI) for Adult
Classification
BMI (kg/m2)
Underweight
Normal
Overweight
Obesity
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
Moderate obesity
Extreme obesity
35.0-39.9
>40.0
Our patient BMI = 16.3 kg/m2
Obesity Class
I
II
III
Laboratory and other tests

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Weight
BMI
Fat storage
Somatic and visceral protein
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

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Weight
BMI
Fat storage
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
Compare the patient MAC to standard
monogram
Protein (visceral protein)
Cont;
Assessment of visceral protein depletion
 Serum albumin
<3.5 g/dL
 Serum transferrin <200 mg/dL
 Serum cholesterol <160 mg/dL
 Serum prealbumin <15 mg/mL
 Creatinine Height Index (CHI) <75%
Our patient has albumin of 2.2 g/dl
Creatinine-height index (CHI )
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[measured urinary creatinine (24hr)/ Ideal urinary
creatinine for a given height]
Ideal Cr = IBW x 23 mg/kg male
= IBW x 18 mg/kg female
CHI > 80
mild depletion
CHI 60 – 80 moderate
CHI < 60
severe
Assuming that our patient IBW 59 kg (from chart)
990mg/ 59 kg x 23 = 73% (mild depletion)
Vitamins deficiency
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Vitamin
Vitamin
Vitamin
Vitamin
Vitamin
Bs (B1,B2, B6, B 9, B12, )
C
A
D
K
Trace Minerals deficiency

Zinc
Copper
Chromium
Manganese
Selenium

Iron
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-
Clinical Sign or Symptom
Nutrient
General
Wasted, thin
Calorie
-
Loss of appetite
Protein-calorie
Skin
Eczematous scaling
Zinc
-
*Pallor
Folate, iron, vitamin
B12, copper
Follicular hyperkeratosis
Vitamin A
Flaking dermatitis
Protein-calorie, niacin,
riboflavin, zinc
*Bruising
Vitamin C, vitamin K
-
Pigmentation changes
Protein-calorie, niacin
-
Scrotal dermatosis
Riboflavin
*Our patient
Neck
Goiter
Iodine
-
Parotid
enlargement
Protein
Thorax
Thoracic rosary
Vitamin D
Abdomen
Diarrhea
Niacin, folate, vitamin B12
-
Distention
Protein-calorie
-
Hepatomegaly
Protein-calorie
Extremities
*Edema
Protein, thiamine
-
Bone tenderness
Vitamin D
-
Muscle wasting
Protein, vitamin D, selenium
Nails
-
*Hyporeflexia
Ataxia
*Spooning
Transverse
Thiamine
Vitamin B12
Iron
Protein
Estimating Energy/Calorie
BEE

Basal Metabolic Rate (BMR) or Basal
Energy Expenditure (BEE) accounts for
the largest portion of total daily
energy requirements
Total Energy Expenditure

TEE (kcal/day) = BEE x stress/activity
factor
BEE

The Harris-Benedict equation is a
mathematical formula used to
calculate BEE
Harris–Benedict Equations
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Energy calculation
Male
BEE = 66 + (13.7 x actual wt in kg) +
(5x ht in cm) – (6.8 x age in y)
Female
BEE = 655 + (9.6 x actual wt in kg) +
(1.7 x ht in cm) – (4.7 x age in y)
A correlation factor that estimates
the extent of hyper-metabolism
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1.15 for bedridden patients
1.10 for patients on ventilator support
1.25 for normal patients
The stress factors are:
1.3 for low stress
1.5 for moderate stress
2.0 for severe stress
1.9-2.1 for burn
Calculation
Our patient Wt = 50 kg, Age = 45 yrs
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 + ( 685) + (875) – (306)
= 1320 kcal
TEE = 1320 x 1.25 (normal activity)
= 1650 kcal
Calorie sources
Calories


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
Fluid Requirements
Fluid

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The average adult requires
approximately 35-45 ml/kg/d
NRC* recommends 1 to 2 ml of water
for each kcal of energy expenditure
*NRC= National research council
Fluid
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1st 10 kilogram
2nd 10 kilogram
Rest of the weight
100
cc/kg
50
cc/kg
20 to 30 cc/kg
Example: Our patient
1st
10 kg x 100cc = 1000 cc
2nd 10 kg x 50cc = 500cc
Rest 30 kg x 30cc = 900cc
total = 2400 cc
Fluid

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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
Protein Needs
Protein

The average adult requires about 1 to
1.2 gm/kg 0r average of 70-80 grams
of protein per day
Protein

The initial protein goals are estimated
according to the following general
guidelines
Protein
Stress or activity level Initial protein
requirement (g/kg/day)
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Baseline
1.4 g/kg/day
Little stress
1.6 g/kg/day
Mild stress
1.8 g/kg/day
Moderate stress 2.0 g/kg/day
Severe stress
2.2 g/kg/day
Nitrogen Balance Calculation
Nitrogen Balance (NB)
Calculation

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NB is an important calculation for
assessing nutritional response
NB is used to evaluate the adequacy
of protein intake as well as to estimate
current protein requirements
Calculations
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NB = N intake – N losses
N intake = Protein intake (g/day) / 6.25gm
N losses = UUN (g/day) + 4g*
UUN is determined from a 24 hour urine
collection
*4g is a "fudge factor" to account for
miscellaneous nitrogen losses
Cont:
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Positive NB indicates an anabolic state, with
a net gain in body protein
Negative NB indicates a catabolic state, with
a net loss of protein
With adequate feeding
NB 0 –5 g/day indicates moderate stress
NB > –5 g/day indicates severe stress
Routes of Nutrition Support

The nutritional needs of patients are
met through either parenteral or
enteral delivery route
Enteral Nutrition
Enteral

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The gastrointestinal tract is always the
preferred route of support (Physiologic)
“If the gut works, use it”
EN is safer, more cost effective, and
more physiologic that PN
Potential benefits of EN over PN
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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 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
Safety
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Catheter sepsis
Pneumothorax
Catheter embolism
Arterial laceration
Cost (EN)
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Cost of EN formula is less than PN
Less labor intensive
Contraindications
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Gastrointestinal obstruction
Severe acute pancreatitis
High-output proximal fistulas
Intractable nausea and vomiting or
osmotic diarrhea
Enteral nutrition (EN)
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Long-term nutrition:
Gastrostomy
Jejunostomy
Short-term nutrition:
Nasogastric feeding
Nasoduodenal feeding
Nasojejunal feeding
Parenteral nutrition (PN)
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Peripheral Parenteral Nutrition (PPN)
Total Parenteral Nutrition (TPN)
Cautious use of PN:
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Azotemia
Congestive heart failure
Diabetes Mellitus
Electrolyte disorders
Pulmonary disease
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
Patient Selection
General Indications

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Requiring NPO > 5 - 7 days
Unable to meet all daily requirements
through oral or enteral feedings
Severe gut dysfunction or inability to
tolerate enteral feedings.
Can not eat, will not eat, should not
eat
Special Indications (can not eat)
Cont:
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When enteral feeding can’t be
established
After major surgery
Pt with hyperemesis gravidarum
Pt with small bowel obstruction
Pt with enterocutaneous fistulas (high
and low)
Cont:
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Hyper-metabolic states:
Burns, sepsis, trauma, long bone fractures
Adjunct to chemotherapy
Nutritional deprivation
Multiple organ failure:
Renal, hepatic, respiratory, cardiac failure
Neuro-trauma
Immaturity
Calorie sources

60 to 80% of the caloric requirement
should be provided as glucose, the
remainder 20% to 40% as fat
Calculation
Our patient Wt = 50 kg, Age = 45 yrs
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 + ( 685) + (875) – (306)
= 1320 kcal
TEE = 1320 x 1.25 (normal activity)
= 1650 kcal
total calculated calorie = 1650 kcal
80% from glucose 1650 x 80 =1320kcal
20% from fat (IL) 1650 x 20 = 330kcal
Protein 1.2gm/kg/day
1.2 x 50 = 60 gm
Protein requirement
150 kcal to 6.25 gm of protein
1650 kcal/150 x 6.25 gm = 68.8 or 70gm
Glucose

Cont;
Maximum oxidized rate for glucose is
4 - 7mg/kg/min (adult)
Exp: our patient is 50 kg
5mg x 50kg x 60min x 24 hr =360 gm
360gm x 3.4 kcal/gm = 1224 kcal
Maximum cal from glucose = 1224kcal
Fat emulsion
Maximum recommended allowance
 2.5 grams/kg/day
Exp: 2.5 x 50 kg = 125 gm
125gm x 9 kcal/gm = 1125 kcal
Calorie calculation
Total calorie requirement = 1650 kcal
calorie from glucose
= 1224 kcal
_______
form lipid
436 kcal
Intralipid contraindications:

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Hyperlipdemia
Acute pancreatitis
Previous history of fat embolism
Severe liver disease
Allergies to egg, soybean oil or
safflower oil
Diabetic

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DM is not contraindication to TPN
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
Continuous vs Cyclic Administration
Continuous vs Cyclic administration


It is given overnight and the patient is
free during the day from the PN
solution and associated administration
paraphernalia (long-term care)
Continuous administration is preferred
in hospitalized patients as they often
have fluid and electrolyte disturbances
Monitoring
Complications of TPN
Complications Associated with PN


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Mechanical complication
Septic complication
Metabolic complication
Mechanical Complication


Improper placement of catheter may
cause pneumothorax, vascular injury
with hemothorax, brachial plexus
injury or cardiac arrhythmia
Venous thrombosis after central
venous access
Infectious Complications
PN imposes a chronic breech in the
body's barrier system
 The mortality rate from catheter sepsis
as high as 15%
 Inserting the venous catheter
 Compounding the solution
 Care-giver hanging the bag
 Changing the site dressing
Metabolic Complications

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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
Iron


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
Vitamin K


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 longterm TPN
Thank you