Malnutrition

Question 1

A 43-year-old male patient is admitted to intensive care following an emergency laparotomy for a ruptured infected appendix. He is a smoker and drinks 40 units of alcohol a day. He is intubated and ventilated.

Why is this patient at high risk of malnutrition?

Answer 1

• Likely abdominal sepsis with poor oral intake prior to his recent illness.
• Major abdominal surgery is associated with a postoperative ileus.
• This is a high-risk patient that has had a major procedure and will
  likely need a prolonged stay in intensive care and hospital.
• Alcohol excess suggests possible poor long-term nutritional status and possible chronic liver disease (causing decreased absorption of essential nutrients).

Question 2

What are the systemic complications associated with malnutrition?

Answer 2

• Overall increase in morbidity and mortality.
• Decreased muscle mass, leading to poor mobility and increased risk of venous thromboembolism.
• Low respiratory drive and function associated with respiratory failure and pneumonia.
• Increased time on the ventilator and difficult weaning.
• Poor wound healing and increased risk of wound infection.
• Refeeding syndrome.

Question 3

What is your plan for nutrition in this patient?

Answer 3

Assessment:
* This patient is at high risk of malnutrition and refeeding syndrome given his surgical and social history, therefore an urgent dietician assessment is needed to determine the best regimen.

• The patient should be examined for signs of malnutrition e.g. body mass index, muscle mass, dentition, skin and hair health.
• Investigations should include regular electrolytes to monitor for signs of refeeding syndrome. A low serum creatinine reflects low muscle mass, and low urea is often associated with prolonged malnutrition.
• Carry out a multidisciplinary discussion with the surgical team to ensure an appropriate method of feeding is instigated.

Question 4

What are the standard daily nutritional requirements for a 70 kg adult?

Answer 4

See page 142

Question 5

What is your plan for nutrition in this patient?

Continued…

Answer 5

Treatment:
* Insert a nasogastric tube and check for correct positioning according to recognised standard clinical guidelines as advised by NICE.

• Estimate the appropriate feed composition based on the patient’s weight.
• Ensure an appropriately restricted dose of feed initially to minimise the risk of refeeding syndrome.
• Monitor the patient for signs of malabsorption and consider interventions as necessary.

Question 6

Two days after enteral feeding is started, the patient has high aspirate volumes.

How would you manage this?

Answer 6

• Review the patient and documentation of aspirate volumes since the feed was started. Discuss the regimen options with the dietician and a senior intensivist. Enteral feeding may still be continued, perhaps at a lower rate depending on the gastric residual volumes.
• Consider pharmacological prokinetic agents e.g. metoclopramide and erythromycin.
• Review the position of the nasogastric tube and consider nasojejunal positioning.
• Consider parenteral nutrition if the above measures fail.

Question 7

What are the complications of parenteral nutrition?

Answer 7

Line-related complications:
* Infection.
* Bleeding/haematoma.
* Pneumothorax.
* Thrombosis.

Feed-related complications:
* Electrolyte disturbances.
* Refeeding syndrome.
* Fluid overload.
* Poor blood glucose control.
* Stress ulcers.

Question 8

How can the risk of stress ulcers be minimised?

Answer 8

• Pharmacological agents e.g. histamine receptor antagonists, proton pump inhibitors, sucralfate (rarely used due to difficulty in administration).
• Nasogastric (enteral) feeding.
• Optimal oxygenation.