Malnutrition Overview

Significance of malnutrition relative to morbidity and mortality;

  • 25-50% of hospitalized patients are malnourished usually caused by an imbalance between (deficient) intake and (excessive) utilization
  • Consequences of malnutrition:
    • Increases morbidity and mortality
    • Takes wounds a longer time to heal
    • Increased incidence of infection
    • Greater frequency of complications
    • Increased length of hospitalization and associated costs

Factors leading to malnutrition

  • Imbalance between Intake & utilization
    • Inadequate intake
      • anorexia (may be due to a drug–digoxin, ADHD meds, etc)
      • N/V
      • Mechanical obstruction (tumor, adhesions, etc0
      • Swallowing dysfunction (alzheimer’s)
      • Trauma (altered level of consciousness)
    • Excessive utilization
      • Trauma
      • Burns
      • Sepsis
      • Tumor
  • Risk factors:
    • 20% above/below usual body weight
    • Recent weight loss of 10% or more
    • History of poor nutritional intake
    • NPO for 7 days or longer
    • Serum albumin of less than 3gm/dL
    • Cancer, surgery, burns, elderly, drug abusers, low income, etc. common sense stuff
  • Diseases associated with malnutrition
    • Marasmus (dying away state)
      • Deficient in both proteins & calories
      • Develops over months to years and results in losses (over 10%) of both fat & skeletal muscle
    • Kwashiorkor
      • Deficiency in proteins  (normal fats & carbs)
      • Develops rapidly over weeks and is common in patients w/ high catabolic rates, trauma, burns, sepsis, cancer resulting in hypoalbumenia and edema)
    • Mixed
      • Results in a loss of both visceral protein & adipose tissue
      • Common in chronically ill patients
  • Malnutrition can be determined by:
    • Triceps skin fold measurement, mid arm muscle circumference
    • BMI (Body Mass Index) – <16 = severe, 16-17 = moderate, 17-18.5 = mild
    •  Actual body weight verses ideal – <84% considered malnourished
  • Fluid needs for a patient for who is indicated for enteral or parenteral nutrition:
    • adult (> 20 kg):  basal requirement = 1500 mL + 20 mL for each kg over 20kg
  • 1 L of fluid = 1 kg of weight
  • Protein therapy:  you want nitrogen intake > output
  • Enteral nutrition should be used if the patient is unable to get adequate nutrition via the oral route and if the patient has a functional GI tract
    • contraindications:  GI obstructions/bleeds/severe malabsorption or an ilieus
    • If possible you would rather do enteral vs. parenteral nutrition b/c it helps to maintain normal GI structure/function, is lower cost and has fewer complications compared to TPNs
    • Given either continuously, continuous-cyclic, intermittent or via bolus dosing
  • Parenteral nutrition is indicated for patients who can’t/won’t/shouldn’t eat or who can’t eat enough
  • Dextrose = 3.4 Kcal/g
    • Can’t give greater than 10% dextrose via a peripheral line  (give central)
  • Protein = 4 kcal/g
  • Fat:  10% = 1.1 Kcal/mL           20% = 2 Kcal/mL               30% = 3Kcal/mL due to elmusifiers
  • 3 in 1 TPN solutions contain (AAs, dextrose, 30% lipids)
Daily

2-3 Times/Week

Weekly

Weight

CBC

Albumin

Vital signs

Calcium

Total protein

Fluid intake/output

Magnesium

Transthyretin

Na, K, Cl, CO2, BUN, Creatinine

Phosphorus

AST, ALT, Alkaline phosphatase, Bilirubin

Blood glucose Q 6 hours until stable, then BID

 

PT and PTT

 

 

Nitrogen balance (always want positive)

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