Nutrition During Hospitalization

Nutrition During Hospitalization

• Crystal Bradley wrote the presentation

Objectives

• Identify steps in nutrition care
• Identify components of malnutrition
• Understand role of inflammation in malnutrition
• Understand when each type of nutrition intervention is indicated/contraindicated
• Assess patient scenarios for timing of nutrition intervention
• Identify access for nutrition intervention

Nutrition Screening

• Required by The Joint Commission for most US healthcare facilities, both acute and long-term care
• Systematically identifies individuals at nutrition risk

Malnutrition screening tool (MST)

• A registered nurse screens patients within 24 hours of admission at BJC
• Considers weight loss prior to admission, and appetite prior to admission

Intended Population, Validity, and Reliability

• Oncology patients have 100% sensitivity, 81-92% specificity and ĸ = 0.82 – 0.88 reliability
• Acute Hospitalized Patients have 74-93% sensitivity, 76-93% specificity and ĸ = 0.84 – 0.93 reliability
• Hospitalized Elderly Patients have 90.3% sensitivity and 84.7% specificity

Nutrition Risk in the Critically Ill (NUTRIC) Score

• The ICU RD completes the assessment
• A nutrition risk assessment tool developed and validated specifically for ICU patients, identifies patients most likely to benefit from aggressive nutrition therapy
• Included are: Age, APACHE II, SOFA Score (initial), Number of Comorbidities, Days in hospital to ICU admission and IL-6 (optional, not used at BJH)

MST Score Variables

• Have you lost a weight without trying? (No = 0, Unsure = 2) score
• YES, how much weight have you lost score? (2-13 lb = 1, 14-23 lb = 2, 24-33 lb = 3, 34 lb or more = 4, Unsure = 2) score
• Have you been eating poorly because of a decreased appetite? (NO = 0, YES = 1)
• A score between 0-1 implies not at risk whereas 2+ equals at risk

RD Daily Screening

MST ≥ 2: The Malnutrition Screening Tool (MST) is a quick and effective screening instrument used to identify individuals who are at risk of malnutrition. A score of 2 or higher indicates that the individual may require further assessment by a dietitian or healthcare provider to address potential nutritional deficiencies.

BMI < 18.5: Body Mass Index (BMI) is a critical measure used to determine if an individual is underweight, normal weight, overweight, or obese. A BMI of less than 18.5 categorizes a person as underweight, suggesting that they may need nutritional support and intervention to improve their health and well-being.

Pressure Injury: This refers to localized damage to the skin and/or underlying tissue, typically over a bony prominence, as a result of pressure or pressure in combination with shear. Patients at risk may need dietary intervention to enhance skin health and mobility to prevent such injuries from occurring.

Calorie Count: This process involves tracking the caloric intake of individuals, particularly those who may be at risk for malnutrition. Understanding caloric needs and ensuring adequate nutrition is vital for maintaining health, especially in vulnerable populations.

Follow-up Due: Regular follow-up assessments are crucial for monitoring an individual's nutrition status and making necessary adjustments to their dietary plan. This ensures ongoing support and intervention for individuals identified at risk of malnutrition or other health issues related to their diet.

RD Daily Screening

MST ≥ 2: The Malnutrition Screening Tool (MST) is a quick and effective screening instrument used to identify individuals who are at risk of malnutrition. A score of 2 or higher indicates that the individual may require further assessment by a dietitian or healthcare provider to address potential nutritional deficiencies.

BMI < 18.5: Body Mass Index (BMI) is a critical measure used to determine if an individual is underweight, normal weight, overweight, or obese. A BMI of less than 18.5 categorizes a person as underweight, suggesting that they may need nutritional support and intervention to improve their health and well-being.

Pressure Injury: This refers to localized damage to the skin and/or underlying tissue, typically over a bony prominence, as a result of pressure or pressure in combination with shear. Patients at risk may need dietary intervention to enhance skin health and mobility to prevent such injuries from occurring.

Calorie Count: This process involves tracking the caloric intake of individuals, particularly those who may be at risk for malnutrition. Understanding caloric needs and ensuring adequate nutrition is vital for maintaining health, especially in vulnerable populations.

Follow-up Due: Regular follow-up assessments are crucial for monitoring an individual's nutrition status and making necessary adjustments to their dietary plan. This ensures ongoing support and intervention for individuals identified at risk of malnutrition or other health issues related to their diet.

• LOS
• TF orders
• Diagnosis that would warrant further investigation – example: Type 1 DM, wound, SBO, pancreatitis, cachexia, hepatic failure, high ileostomy output, bariatric surgery, FTT, esophageal, gastric, pancreatic cancer, etc.

Nutrition Care Process

• Nutrition Assessment
• Nutrition Diagnosis
• Monitoring
• Evaluation

Nutrition Assessment Elements

• In depth systematic process to integrate and interpret various data forms about a patient to identify nutrition related problems
• Includes anthropometrics, patient history, current clinical presentation, biochemical data, nutrient intake data, nutrition focused physical exam findings and functional status

Nutrition Assessment - Anthropometrics

• Includes height and weight
• Characteristic for diagnosis of malnutrition Includes actual body weight, usual body weight, dry body weight, ideal body weight, weight loss (unintentional); skewness, trends, weight can be skewed by many things including, source, fluid status, disease state. The trends are compared with standards (same age and gender) and / or with previous measurements

Body Mass Index (BMI)

• BMI = Weight (kg) / Height (m)² which is the ratio of body weight to height
• Practical measure of body size and an indirect measure of body adiposity
• Does not account for sex, age, race, fitness levels, or variations in abdominal adiposity

BMI Classification

• <18.5 suggests underweight
• 18.5 – 24.9 means normal weight
• 25 – 29.9 means overweight
• 30-34.9 suggests Class 1 Obesity
• 35 – 39.9 suggests Class II Obesity
• ≥ 40 means Class III Obesity
• American Society of Enteral and Parenteral Nutrition (ASPEN) and Academy of Nutrition and Dietetics (AND) did not include BMI as a malnutrition clinical characteristic because malnutrition can occur at any BMI

Obesity in Hospitalized Patients

• Associated with increased all-cause mortality
• 60 associated comorbid medical conditions
• 12 different types of cancer
• Complicates management in the hospital
• Can be present with: Type 2 Diabetes, Hypertension, Coronary Artery Disease, Nonalcoholic fatty liver disease, Obstructive sleep apnea

Bariatric Surgery

• Patients admitted for bariatric surgery, have complications of bariatric surgery, or admission for a non-related condition that may be complicated by history of bariatric surgery
• Restrictive - laparoscopic banding, sleeve gastrectomy reduces intake by limiting gastric volume. The alimentary canal remains intact limiting metabolic complications
• Restrictive and Malabsorptive - Roux-en-Y gastric bypass, Biliopancreatic Diversion (BPD): increases malabsorption as the roux limb length increases
• Roux-en-Y transects the upper portion of the stomach., and creates small proximal gastric pouch is created and connected to a proximal jejunum segments (Roux limb), bypassing the rest of the stomach, duodenum and portion of the jejunum
• Subtotal gastrectomy and a proximal gastric pouch is used for Biliopancreatic Diversion (BPD). A common channel is created using the distal small intestine and is anastomosed to the gastric remnant and ileum and also requires BPD Duodenal Switch – stomach is partially removed, creating a sleeve (pylorus intact) with the food bypass limb anastomosed to the duodenum, in order to avoid dumping syndrome

Obesity Challenges

• One third of critically ill patients are obese, and physical challenges include difficult airway, positioning and difficult IV access
• Non-physical challenges include ICU drug dosing and the “Obesity Paradox" where obesity is associated with improved ICU outcomes, the reason is unknown but could be nutrition “reserves” or inflammatory preconditioning?

Energy Needs

• Indirect Calorimetry provides the best estimation, but has many limiting factors

Relative Indications for Indirect Calorimetry

• BMI < 20.5, BMI > 80 Unexplained weight loss that is not a result of excessive volume status in a patient who regularly receives close to 100% of target feeding Massive tissue loss from amputation where preadmission fluid overload without a clear body weight reported with accurate hydration is unknown

Contraindications for Indirect Calorimetry

• Air leak (chest tubes, cuff leak, any other leak in ventilator circuit, leaks around face masks, canopies, etc) is a contraindication for indirect calorimetry
• Spontaneously breathing patients that rely on any supplemental oxygen that also feature an inability to cooperate with the measurement or have claustrophobia are not recommended

Estimated Energy Equations

• Calories/kg are simple, but not the most accurate way to predict RMR in critically ill patients
• Simple, but not the most accurate way to predict RMR in critically ill patients
• The effect of obesity is captured in the ASPEN method by changing the kcal / kg range or the mass used for the calculation (IBW, rather than actual body weight, is used for patients with BMI > 50)
• Academy of Nutrition and Dietetics (AND) systemic review found more favorable evidence for the Mifflin-St. Jeor equations than for any other. The accuracy rate falls somewhat when applied to obese people

Penn State Equation

• AND EAL: Resting Metabolic Rate Predictive Equations for Non-Obese Critically Ill Adults
• If indirect calorimetry is not available, RD should use Penn State University. Research indicates that this equation has the best prediction accuracy in non-obese patients
• AND EAL: Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults - If indirect calorimetry is not available, RD should use the Penn State University [for obese patients less than 60 years of age and for obese patients 60 years or older. Research indicates that these equations have the best prediction accuracy.

Energy Requirements

• BMI is inversely related to energy requirements
• High BMI requires less kcal / kg/day
• *Kg - use actual body weight or estimated actual dry weight unless otherwise specified.

Overfeeding

• Overfeeding results in Hyperglycemia, increased BUN, GI upset, increased CO2 production, weight gain involving an increase in fat mass out of proportion of LBM and lipogenesis with fatty liver

Underfeeding in morbidly obese patients

• High protein/hypocaloric feeding helps maintain nitrogen balance and LBM while facilitating the mobilization of adipose tissue
• Goal feeding should not exceed 65-70% of energy requirements (ASPEN / SCCM Critical Care Guidelines)

Increased Energy Needs

• Healthy Individual is less than Acutely III ↑ than Critically ill with mechanical ventilation
• Also Pregnancy or Critical Illness all increase the inflammation

Decreased Energy Needs

• Spinal Cord Injuries including paraplegia and tetraplegia are characterised by Lower levels of physical activity, Lower RMR and lower thermogenic effect of food

Nutrition Assessment

• Understand how diseases, medical conditions, and surgical interventions can alter digestion, absorption, ingestion, and metabolism of micro- and macronutrients
• Use to determine malnutrition etiology
• Medical History (ex: DM, Crohn's Disease), Surgical History (example: gastric bypass), Family History (ex: familial hypertriglyceridemia), Psychosocial History (ex: Alcohol abuse, Eating disorder), Current clinical status (ex: adm for small bowel obstruction), Current medications (drug-nutrient interactions, side-effects that impact nutrition intake)

Biochemical assessment

• Provides insight into organ/system function like Liver Function Tests, creatinine or BUN
• Shows metabolic consequences of disease state or nutrition intake like blood glucose or vitamin or mineral deficiency
• Supportive data for nutrient deficiency - use in context of other information - can be impacted by inflammatory response, volume status, blood products
• No lab marker for overall nutrition status

Albumin and Prealbumin

• Influenced by non-nutrition related factors
• Negative acute-phase reactants like Surgery, Stress, Injury, Organ failure and Infection
• Serum concentrations do not change until the stress metabolism subsides

Nutrition Assessment- Nutrient Intake Data

• Includes energy intake as a characteristic of malnutrition, Oral food/beverages/supplements, Enteral and Parenteral Nutrition (TF)
• Stool output for GI symptoms, with frequency, appearance and volume and with or withour intake, frequency, apperance, volume

Nutrition Focused Physical Exam

• Focuses primarily on changes to muscle, fat stores, fluid retention, and / or other physical signs that can result from malnutrition, deficiencies
• Limited by injuries, medical devices, Patient ability to participate and Positioning
• Can be difficult in Elderly and obese populations

Focused physical exam in muscle loss: *Characteristic for Diagnosis of Malnutrition

• Upper body has smaller muscle groups than lower body
• Upper body is more sensitive to muscle wasting but is less effected by edema
• Upper body focused on the Temple Region (temporalis muscle, Clavicle Bone Region (Pectoralis Major, Deltoid, Trapezius Muscle), Clavicle and Acromion Bone Region (Deltoid Muscle), Scapular Bone Region (Trapezius, Supraspinus, Infraspinus Muscles) and Dorsal Hand (Interosseous Muscle)

More Focused physical exam in muscle loss: *Characteristic for Diagnosis of Malnutrition

• Includes muscle loss in the larger groups of the lower body that are less sensitive to change and are effected by edema
• Includes Anterior Thigh/Patellar Region (Quadriceps Muscles) and Posterior Calf Region (Gastrocnemius)

Fat Loss *Characteristic for Diagnosis of Malnutrition

• Includes Orbital Region (surrounding the eye), Cheek Region (Buccal Fat), Upper Arm Region (Triceps / Biceps) and Thoracic and Lumbar Region (Ribs, Lower Back, Midaxillary Line)

Micronturient Assessent

• Areas of the body of the body with high cell turnover like Hair, skin, mouth and tongue are among those that likely show nutrient deficency signs and are be able to show evidence of vitamin and mineral deficiency/toxicity, Generalized protein-calorie malnutrition, Essential faty acid deficiency and Anemia

Edema *Characteristic for Diagnosis of Malnutrition

• Caused by a vareity of disease, conditions and medications
• Edema is rarely as a direct result of mulnutrition
• Be sure to rule out other edema causes at a dry patient weight Includes peripheral edema which is characterized in the lower extremitites with a tendency to accumulate dependendant areas
• Also includes, pulmonary edema with more serious than pulmonary edema so check characterization of primary swollen, also be sure to test pitting edema

Nutrition Focused Physical Exam

• Assessment of the hair include inspeting Hair for hair color, pigmentation, distribution pattern, shine, texture, and quantity.
• Temoralis muscle is assessed by palpating the muscles over the bone around

Obesity in Hospitalized Patients

• Associated fluid accumulation, anorexia and ascites

Pathophysiological Changes of Muscle and Fat

• Stress response and starvation both affect nutrition utilization and breakdown, as well as fat stores and muscle mass at different rates and to varying degrees of severity due to different metabolic pathways

Goal/Preserve

• Starvation has the body's goal to preserve lean body mass and use glycogen as the primary energy source
• Adaption: To resting energy expenditure decrease fat becomes the key energy source, also for ketones to fuel lean body mass.
• Starvation is much faster rate of skeletal and lean muscle loss than seen in starvation

Role of Inflammation in Malnutrition

• Insult from pathogens, trauma, or other disease-causing agents and promotes cytokine-driven protein catabolism of skeletal muscle
• inflammation production ↑ cytokine production ↑ hepatocytes to suppress production of negative.
  • Acute-phase proteins that alter function levels for malnutrition are present
  • Identification of acute or chronic inflammation necessary

Additional Parameters to Asses

• Biochemical data, and microbiological data.
• Includes imaging, clinical manifestations

Aspen Criteria for Malnutrition

• To suspect, two or more critera may need to be identified
• Includes malnutrition charateristics, inflamation

Chronic

• Chronic > 3months for (organ, Mild/Moderate), failure + RA/ Sarcopenic

Related

• More Acute / marked: for Short / ICU Related from Infection.

Starving

• Pure Chronic: Like Anorexia.

Nationwide

• <10% patients only are screened.
• So is the importnance to ID.

Malnutrition in the ICU

Prevalence of Malnutrition according to patient type

– Heterogeneous group = 37.8-78.1% – Elderly groups = 37.8-78.1% – Cardiac surgery = 5.0%-20.0% – Liver transplantation = 52.6% – Acute kidney injury = 82%

Nutrition Intervention Types

• Oral Nutitrion, Enteral Nutrition or Parenteral Nutrition

Oral Nutrition

• Its the most ideal way to provide nutrition but, patients may have increased needs and lower appetite due to disease state, medications, side effects of treatment and interventions, etc
• Diet as needed, nutrition supplements, shakes and other methods may be more useful

Enteral Nutrition- indications

• Patients with functional GI tracts show generalized inability to meet energy and protein requirments, and benefit Patients are more at benefit if experiencing; mechanical ventilation, dysphagia, AMS / delirium, Poor intake due to lack of appetite and tastiness
• Beneficials for lumenal Proximal obstruction, head and neck, esophagus, or Gastric issues

Enteral Nutrition

• Maintain functional integrity
• Maintain normal gallbladder function
• Support immune Function
• EN is preferrable: It is cheaper, maintains integrity and is better for patient

Timing for EN

• High risks pts = Earlier
• With other PO = Later
• Depends on ICU stay, and oral assessments

Pre and post opp timing of E N

• Severely Malnourished = Give Before Opp
• Wait 1-2 Days After opp in cases

Enteral Access

• Short Use = Nose route
• Long Use = Percutaneous.
  • Nasogastric tube - allows use of a stomach -Orogastric tube - allows use of a stomach and is preferred in cases of mechanical ventilation cases -Small bowel feeding tube is preferred when needing small bowel feeds

Routes to Acess

• Temporary tube needed for are needed in 4-6 cases in NGTs & OGTs
• G tube / PEGS or longer uses
• GJ to Decompress and feed other areas.

Parenteral Indications- PT is no longer working

• Due to non function -
• generalized
• short or complete bowel,

PT is a viable alternative

• Pts are NPO for multiple days.
• 3-1- pt gets 3 elements at same time
• 2-1 pt gets 2 elements and must supplement the lacking element

Muscle Loss in Critically ill + Elders

Maintainence is dependent on Protien intake. But bed rest may affect horomones. A well balanced diet alongside a PT / Ot session is important

Working Together with pts.

• If a patient is not in the best shape to be worked with, give pts more time
• Get the appropriate intakes, if eating isn't best ask to make it easier to work together with all involved