malnutrition

Question 1

when is oral feeding not advised

Answer 1

cognitive impairment

Dysphasia

Question 2

Types of oral feeeing

Answer 2

By mouth

Normal food, softened food, thickened foods, puréed, fluids etc

Question 3

What is first line enteral feeding

Answer 3

nasogastric tube

Question 4

Complications of NG tubes

Answer 4

Tube misplacement
Obstruction 
Electrolyte imbalance 
Hyperglycaemia 
Aspiration pneumonia!
Larynx ulceration, pharyngeal pain
Vomiting and diarrhoea
Line infections
Refeeding syndrome

Question 5

How is parenteral nutrition done

Answer 5

Via central venous catheter

Question 6

Difference between feeding or parenteral and enteral

Answer 6

Enteral made for patients needs

Parenteral from scratch bag

Question 7

Indications for parenteral feeding

Answer 7

Where oral enteral unsafe

Or GI inaccessible or cannot function

Question 8

How to testif enteral feed misplaced

Answer 8

pH shouldn’t be over 5.5

If over, immediate imaging to find it

Question 9

What is refeeding syndrome

Answer 9

starvation for long time
if reintroduced to nutrients, surge in insulin
Encourages cells to take up potassium magnesium and phosphate which are already low in serum (and get lower) causing electrolyte imbalances
A causes arrhythmias, respiratory arrest, multi organ failure

Question 10

definition of malnutrition

Answer 10

state resulting from lack of uptake/intake of nutrition leading to diminished physical and mental function and impaired clinical outcome from disease

Question 11

rate of malnourishment upon admission to hospital

Answer 11

1 in 3 are manourished

Question 12

what % of patients have lost weight at discharge

Answer 12

70%

Question 13

factors that lead to malnutrition in hospitals

Answer 13

co-morbidities e.g. dementia
inflexible mealtimes
quality of food
dysphagia, stomatitis, anaemia, poor dentition, ill fitting dentures
inactivity
low mood/depression
polypharmacy
excess nutritional losses
repeated NBM status
metabolic response to disease/injury

Question 14

loss of what % of bodyweight preoperatively leads to 10x greater postop mortality?

Answer 14

> =20%

Question 15

what increases with malnutrition?

Answer 15

mortality
septic and post surgical complications
length of hospital stay
pressure sores
readmissions
dependency

Question 16

what decreases with malnutrition?

Answer 16

wound healing
response to treatment
rehabilitation
QoL

Question 17

CT advantages in formal nutrition assessment

Answer 17

provide info about body composition

-> however involves exposing patient to radiation

Question 18

Why is BMI not used to assess malnutrition?

Answer 18

not representative of difference between fat and fat free mass

Question 19

skin fold thicknesses used for malnutrition assessment

Answer 19

• triceps skinfold thickness

- mid upper arm circumference use similarly to determine lean body mass (positive association)

Question 20

anthropometric analysis multifrequency bioelectrical impedance analysis used in which patients?

Answer 20

renal and haematology patients

Question 21

what type of fat can CT scans distinguish between?

Answer 21

visceral and subcutaneous fat

-> highly accurate for evaluating levels of fat and fat free mass

Question 22

problems with CT for nutritional assessment

Answer 22

expensive, expose individuals to small amounts of radiation
-> use for body comp restricted to research normally

-> being used more frequently in specialities where CTs are already part of the clinical treatment pathway

Question 23

why are micronutrient and trace elements tests not undertaken easily?

Answer 23

time consuming
expensive
results skewed as a result of the acute inflammatory response

Question 24

best way of obtaining dietary intake information

Answer 24

dietary history

Question 25

what is used to estimate energy requirement

Answer 25

predictive equations estimating resting MBR | -> generally no more accurate than 70%

Question 26

requirements to be malnourised

Answer 26

- BMI < 18.5 - unintentional weight loss >10% past 3-6/`1 - BMI <20 + unintentional weight loss > 5% past 3-6/12

Question 27

people at risk of malnutrition

Answer 27

eaten little/nothing > 5 days and likely to have the same for the next 5 - poor absorptive capacity/high nutrient losses/increased nutritional needs

Question 28

Feeding options when oral nutrition isn't safe

Answer 28

``` enteral feeding (GI tract functional + accessible) parenteral feeding (GI tract not functional/accessible) ```

Question 29

why is enteral nutritional superior to parentral?

Answer 29

it uses the gut | -> if parenteral used, aim to return to enteral then oral feeding as soon as/where clinically possible

Question 30

what is recommended from longer term enteral tube feeding (>3 months)

Answer 30

gastrostomy/jejunostomy

Question 31

what are the complications associated with enteral feeding?

Answer 31

- misplaced NGTs cause death - mechanical (misplacement, blockage, buried bumper) - metabolic (hyperglycaemia), deranged electrolytes) - aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Question 32

indication for parenteral nutrition

Answer 32

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

Question 33

access points for CVCs?

Answer 33

tip at superior vena cava and right atrium-> different CVCs for short ad long term use

Question 34

complications associated with parenteral nutrition?

Answer 34

mechanical (pneumothorax, haemothorax, cardiac arrhythmias, thrombosis, catheter occlusion, extravasion) metabolic (deranged electrolytes, hyperglycaemia, abnormal liver, enzymes, oedema, hypertriglyceridemia) catheter-related infection

Question 35

low levels of what plasma proteins predicts poor prognosis?

Answer 35

albumin

Question 36

how does the acute phase response affect albumin production?

Answer 36

inflammatory stimulus -> activation of monocytes and macrophages -> release of cytokines cytokines act on the liver to stimulate production of some proteins whilst downregulating production of others like albumin

Question 37

is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 37

no - though decreased in repsonse to inflammation, not marker of nutrition status nor indication for nutrition intervention in the acute setting - best evidence - hypoalbuminaemia in obese trauma patients - dietitian focused on the etiology/impact of the inflammatory state on nutrition status

Question 38

how does introduction of carbohydrate affect the response to starvation? refeeding

Answer 38

stimulates insulin production -> Na/K ATPase (Mg cofactor) drives K into cells and Na out of cells carbohydrate and insulin drives PO4 into cells - increased cellular uptake of glucose, K, Mg and phosphate - thiamine is coenzyme for carb digestion -> deficiency occur in refeeding of vit B depleted patient

Question 39

what can low concentrations of electrolytes from giving a starving person carbs cause?

Answer 39

- less Na and fluid excretion = expansion extracellular fluid compartment --> this leads to refeeding oedema

Question 40

consequences of RFS?

Answer 40

- arrhythmia - CHF -> cardiac arrest + sudden death - tachycardia - respiratory depression - encephalopathy, coma, seizures, rhabdomyolysis - Wernickes encephalopathy

Question 41

what are the the criteria for defining at risk of refeeding syndrome

Answer 41

very little or no food intake for > 5 days

Question 42

stages of RFS management

Answer 42

1. start with 10/20kcal/kg CHO 40-50% energy and micronutrients 2. correct + monitor electrolytes daily 3. Administer thiamine from the onset of feeding 4. Monitor fluid shifts + minimise risk of fluid/Na overload

Question 43

whole process of nutrition in hospital

Answer 43

screening assessment diagnosis plan - implement, monitor, evaluate

Question 44

example of when NGT is contraindicated?

Answer 44

gastric outlet obstruction | go straight to ND/NJT

Question 45

composition of paraenteral nutrition feeds

Answer 45

ready made scratch bags

Question 46

what is short bowel syndrome

Answer 46

surgical resection or congenital defect/loss of absorption in bowel characterised by inability to maintain energy, fluid, electrolyte or micronutrient balances when on a normal diet