🍔Gastro🍔 - Malnutrition & Nutrition Intervention

Question 1

What is the definition of malnutrition?

Answer 1

A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome

Question 2

What are the causes of malnutrition in hospitals?

Answer 2

Reduced intake
Maldigestion/malabsorption
Altered metabolism

Question 3

What is meant by altered metabolism?

Answer 3

Question 4

What are the reasons for reduced food intake in hospital?

Answer 4

Contraindicated
Disease related anorexia
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue

Question 5

What are the causes of maldigestion/malabsorption?

Answer 5

Function
Length - reduced GI tract length
Losses - fluid, blood, through urine etc…
Drug-nutrient interactions

Question 6

Give some context as to the impact of malnutrition

Answer 6

Surgery for perforated duodenal ulcer.
Postoperative mortality 10 x greater in those who had lost  20% bodyweight preoperatively, compared with those who had lost less

Malnutrition:
Direct cause 77 hospital deaths
Contributory factor 436 hospital deaths

Question 7

What is the impact of malnutrition in a hospital setting?

Answer 7

Physical and functional decline
Poorer clinical outcomes

Question 8

What are the indications that someone is malnourished?

Answer 8

BMI < 18.5 kg/m2
or
Unintentional weight loss >10 % past 3 - 6 / 12
or
BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12

Question 9

What are the indications that someone is at risk of malnutrition?

Answer 9

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer
or
Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism

Question 10

What are the oral nutritional support options?

Answer 10

Fortification of meals and snacks
Altered meal patterns
Practical support
Oral nutritional supplements (ONS)
Tailored dietary counselling

Question 11

What is artificial nutrition support?

Answer 11

Provision of enteral or parenteral nutrients to treat or prevent malnutrition

Question 12

What is the superior form of artificial nutrition support?

Answer 12

Enteral nutrition (EN) is superior to parenteral nutrition (PN)

Question 13

What is the overall aim of parenteral nutrition?

Answer 13

Where parenteral nutrition is used, the aim is to return to enteral → oral feeding as soon as (or where) clinically possible

Question 14

What should be used if gastric feeding is possible?

Answer 14

Naso-gastric tube (NGT)

Question 15

What should be used if gastric feeding is not possible?

Answer 15

Naso-duodenal tube (NDT)
or
Naso-jejunal tube (NJT)

Question 16

When might gastric feeding not be possible?

Answer 16

Gastric outlet obstruction
Gastroparesis
Upper GI strictures or fistulas
High aspiration risk

Question 17

What are the mechanical complications associated with enteral feeding?

Answer 17

Misplacement, blockage, buried bumper

Question 18

What are the metabolic complications associated with enteral feeding?

Answer 18

Hyperglycaemia, deranged electrolytes

Question 19

What are the GI complications associated with enteral feeding?

Answer 19

Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Question 20

What is an iatrogenic complication of enteral feeding?

Answer 20

Misplaced NGT

Question 21

What is parenteral nutrition?

Answer 21

The delivery of nutrients, electrolytes and fluid directly into venous blood

Question 22

What are the indications for parenteral nutrition support?

Answer 22

inadequate or unsafe oral and/or enteral nutritional intake
or
A non-functioning, inaccessible or perforated gastrointestinal tract

Question 23

Where is parenteral nutrition support accessed?

Answer 23

Central venous catheter (CVC): tip at superior vena cava and right atrium

Question 24

What are the mechanical complications with parenteral nutrition support?

Answer 24

Pneumo/haemothorax
Thrombosis/thrombus
Cardiac Arrythmias
Catheter related infections

Question 25

What are the metabolic complications with parenteral nutrition support?

Answer 25

Deranged electrolytes Hyperglycaemia Abnormal liver enzymes Oedema Hypertriglyceridaemia

Question 26

Outline albumin and its significance in acute inflammation

Answer 26

Albumin synthesised in the liver. Hypoalbuminaemia = poor prognosis. A negative acute phase protein = ↓ plasma albumin when ↑ inflammation

Question 27

What is meant by a "negative acute phase protein?

Answer 27

A protein whose levels decrease during periods of inflammation, infection, or trauma During inflammation, the liver shifts its protein production to prioritize acute phase reactants (positive acute phase proteins like CRP, fibrinogen, and haptoglobin). Albumin production decreases because: The liver reallocates resources to synthesizing proteins involved in the immune response

Question 28

What causes the acute decrease of albumin synthesis?

Answer 28

Inflammatory stimulus → activation of monocytes & macrophages → release cytokines Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin

Question 29

Is albumin a valid marker of malnutrition?

Answer 29

No Albumin synthesis decrease is a response to inflammation - not a valid marker of nutrition status

Question 30

What is refeeding syndrome (RFS)?

Answer 30

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition

Question 31

What are the consequences of refeeding syndrome?

Answer 31

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death Respiratory depression Encephalopathy, coma, seizures, rhabdomyolysis Wernicke’s encephalopathy

Question 32

Outline the pathogenesis of RFS

Answer 32

Prolonged fasting leads to depletion of electrolytes The body shifts to fat and protein metabolism Sudden carbohydrate intake causes a surge in insulin release - stimulates a huge intracellular shift of electrolytes Leads to huge electrolyte disturbances

Question 33

What are the electrolyte imbalances seen in RFS?

Answer 33

Hypophosphataemia → Weakness, confusion, seizures, heart failure Hypokalaemia → Arrhythmias, muscle weakness, ileus Hypomagnesaemia → Neuromuscular irritability, tetany, arrhythmias

Question 34

How does RFS lead to Wernicke's encephalopathy?

Answer 34

Thiamine deficiency → Increased glucose metabolism without sufficient thiamine can precipitate Wernicke’s encephalopathy

Question 35

Who is at risk of developing RFS?

Answer 35

Very little/no food intake for >5 days

Question 36

Who is at high risk of developing RFS?

Answer 36

1+ of the following: BMI<16 Unintentional weight loss >15% Very little/no nutrition >10days Low K+, Mg2+, PO4 prior to feeding 2+ of the following: BMI<18.5 Unintentional weight loss >10% Very little/no nutrition >5days PMHx alcohol abuse or drugs (insulin, chemo, antacids, diuretics)

Question 37

Who is at extremely high risk of developing RFS?

Answer 37

BMI <14 Negligible intake >15days

Question 38

What is the first step of management of RFS?

Answer 38

Administer thiamine 30 minutes before and for the first 10 days of feeding

Question 39

How should patients be monitored to avoid development of RFS?

Answer 39

Correct and monitor electrolytes daily Start 10-20kcal/kg CHO 40-50% of energy Micronutrients from onset of feeding Monitor fluid shifts and minimise risk of fluid and Na+ overload

Question 40

How is RFS treated?

Answer 40

Electrolyte Monitoring and Replacement Phosphate: Oral or IV phosphate supplements if levels drop <0.3 mmol/L. Potassium: Replace if <3.0 mmol/L to prevent arrhythmias. Magnesium: IV magnesium sulfate if <0.5 mmol/L or symptomatic# **most important is prevention**