بسم الله الرحمن الرحيم

Nutritional assessment Nutritional assessment in hospitalized patients in hospitalized patients

M. Safarian, MD PhD.M. Safarian, MD PhD.

Nutrition Care Process Nutrition Care Process StepsSteps

Nutrition AssessmentNutrition Assessment

Nutrition DiagnosisNutrition Diagnosis

Nutrition Intervention Nutrition Intervention

Nutrition Monitoring and Nutrition Monitoring and EvaluationEvaluation

Nutritional care process

W t. ch an ge

W e ig h t

H e ig h t

N u trit io n a lsc re en ing

S u b je c tive g lo b a l a sse ssm e nt

S k in fo ld

T ra n s fe rrin

P re -a lb u m in

A lb u m in

B M I

N u trit io n a la sse ssm e nt

N u trit io n a lca re p la n*

Im p le m e n ta tiono f p lan

C o m p lica tio ns

N u tritio n a l s ta tus

P a tie n tm o n ito ring

N u trit ion a l ca rep ro ce ss

Nutritional assessment tools

Anthropometrics

Nutritional AssessmentNutritional Assessment

Anthropometric assessmentAnthropometric assessment

Clinical evaluationClinical evaluation

Biochemical, laboratory Biochemical, laboratory assessmentassessment

Dietary evaluationDietary evaluation

ESPEN guidelinesESPEN guidelines

Questions to be answered:Questions to be answered:

What is the condition now?What is the condition now?

Is the condition stable?Is the condition stable?

Will the condition get worse?Will the condition get worse?

Will the disease process accelerate Will the disease process accelerate nutritional deterioration?nutritional deterioration?

Anthropometric methods in Anthropometric methods in ICUICU

Weight Weight

Height estimationHeight estimation

Mid-arm circumferenceMid-arm circumference

Skin fold thicknessSkin fold thickness

Head circumferenceHead circumference

WeightWeight

Ideal Body Weight (kg)Ideal Body Weight (kg)

Men=48+ 2.3 for each inch over 152 mMen=48+ 2.3 for each inch over 152 m

Women=45.3+2.3 for each inch over Women=45.3+2.3 for each inch over 152 cm152 cm

Correction for skeletal sizeCorrection for skeletal size::

Ideal Body Weight (kg)Ideal Body Weight (kg) Add 10% if SS is largeAdd 10% if SS is large

Subtract 10% if SS is smallSubtract 10% if SS is small

Adjusted body weightAdjusted body weight

Used when actual body weight is Used when actual body weight is more than 120% of IBW:more than 120% of IBW:

ABW=IBW+ 25% of (actual body weight - IBW)

Height in ICU patientsHeight in ICU patients

Alternative measurementsAlternative measurementsEstimating Height from ulna lengthEstimating Height from ulna length

Estimations of heightEstimations of height

Body composition (BIA)Body composition (BIA)

Very popularVery popular SafeSafe NoninvasiveNoninvasive PortablePortable RapidRapid

معرف ميزان چربي زير پوستي و درنتيجه ميزان معرف ميزان چربي زير پوستي و درنتيجه ميزانچاقي خواهد بود.چاقي خواهد بود.

محلهاي اندازه گيري: تريسپس، بايسپس،زير کتف و محلهاي اندازه گيري: تريسپس، بايسپس،زير کتف وباالي تيغه ايلياک .باالي تيغه ايلياک .

:مشکالت عملي:مشکالت عملي

خطاي در اندازه گيري.خطاي در اندازه گيري.1.1.

مشکالت اندازه گيري. مشکالت اندازه گيري. 2.2.

وارياسيون توزيع چربي در افراد مختلف (فردي وارياسيون توزيع چربي در افراد مختلف (فردي 3.3.وجمعيتي).وجمعيتي).

حساسيت کم. حساسيت کم. 4.4.

Skin Fold ThicknessSkin Fold Thickness

Skin Fold ThicknessSkin Fold Thickness

Mid arm circumferenceMid arm circumference

measured with a nonstretch measured with a nonstretch measuring tapemeasuring tape

midway between the acromion and midway between the acromion and olecranon of the nondominant arm olecranon of the nondominant arm

≤ ≤ 15 cm: severe depletion of muscle 15 cm: severe depletion of muscle massmass

16–19 cm: moderate depletion 16–19 cm: moderate depletion 20–22 cm: mild depletion 20–22 cm: mild depletion

Mid arm circumferenceMid arm circumference

If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2

BMI estimation

Clinical assessmentClinical assessment

CLINICAL ASSESSMENTCLINICAL ASSESSMENT

Detectiong of physical signs, (specific & Detectiong of physical signs, (specific & non specific), that may be associated non specific), that may be associated with malnutrition. with malnutrition.

Nutritional historyNutritional history

General clinical examination, with special General clinical examination, with special attention to organs like hair, angles of the attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland.muscles, bones, & thyroid gland.

Detection of relevant signs helps in Detection of relevant signs helps in establishing the nutritional diagnosisestablishing the nutritional diagnosis

CLINICAL ASSESSMENTCLINICAL ASSESSMENT

General: muscle wasting

Flaky paint dermatosis: protein deficiency

Essential fatty acid deficiency syndromes (EFADs)

Zinc deficiency

Zinc deficiency

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Wasting ClavicleWasting Clavicle

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The Shoulder and ElbowThe Shoulder and Elbow

The shoulderThe shoulder Normal: rounded or Normal: rounded or

slopedsloped Abnormal: square, can Abnormal: square, can

see acromion processsee acromion process The elbow well padded The elbow well padded

and not showing jointand not showing joint

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The ArmThe Arm

Bend arm and pinch at Bend arm and pinch at triceps. Only pinch the triceps. Only pinch the fat, not the muscle. fat, not the muscle.

Normal: fingers donNormal: fingers don’’t t meetmeet

Abnormal: fingers meetAbnormal: fingers meet

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The Legs showing muscle The Legs showing muscle wastingwasting

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Quadriceps and KneesQuadriceps and Knees

Biochemical, Biochemical, laboratory laboratory assessmentassessment

The possibilities of The possibilities of biochemical monitoring biochemical monitoring

On-line monitoring (cardiosurgery On-line monitoring (cardiosurgery –– pH, pH, minerals (K), the electrodes are minerals (K), the electrodes are localized on central cateter, possibility localized on central cateter, possibility to check parameters on-line. to check parameters on-line.

bed side monitoring (glycaemia, bed side monitoring (glycaemia, urine /protein, pH, blood../,oximeter O2 urine /protein, pH, blood../,oximeter O2 saturation, acidobasis, drugs /dg.strips)saturation, acidobasis, drugs /dg.strips)

Biochemical analysis Biochemical analysis

Biochemical parametersBiochemical parameters

Na,K,Cl,Ca,P,Mg, osmolality - blood, urine Na,K,Cl,Ca,P,Mg, osmolality - blood, urine

Acidobasis, lactate Acidobasis, lactate

urea, creatinin, creatinin clearence, Nitrogen urea, creatinin, creatinin clearence, Nitrogen balancebalance

bilirubine, ALT, AST, LDbilirubine, ALT, AST, LDHH, amylase, lipase , amylase, lipase

cholesterol, triglycerides, glucose cholesterol, triglycerides, glucose –– blood, blood, urine urine

Biochemical parametersBiochemical parameters

Total protein, albumine, prealbumineTotal protein, albumine, prealbumine

CRPCRP

TSHTSH

Basic analysis are made at the first,must be Basic analysis are made at the first,must be done within 90minutes done within 90minutes

Other biochemical Other biochemical parametersparameters

Trace elements /Zn,Se../Trace elements /Zn,Se../ VitaminsVitamins Drugs /methotrexate, antiepileptics, Drugs /methotrexate, antiepileptics,

antibiotics.../antibiotics.../ Aminogram /glutamin../Aminogram /glutamin../ Interleucins,TNFInterleucins,TNF…… Hormones /cortisol, glucagone, Hormones /cortisol, glucagone,

adrenaline../.adrenaline../.

Biochemical markers of Biochemical markers of nutrition statusnutrition status::

Plasmatic proteins with short biologic Plasmatic proteins with short biologic half-lifehalf-life

AlbuminAlbumin– -syntetizate in liver, half-life time is 21 days-syntetizate in liver, half-life time is 21 days– Normal: Normal: 35-45g/l.35-45g/l.– Decrease of albDecrease of alb: : malnutrition malnutrition – Trends of changes alb.levels during Trends of changes alb.levels during

realimentation are criterium of succesfull realimentation are criterium of succesfull terapy.terapy.

– Acute decreaseAcute decrease: acute phase response.: acute phase response.

Biochemical markers of nutrition status :

TransferinTransferin: : syntesyntesized sized in in liver,liver, – biologbiolog HL: HL: 8days.Fysiolog. 8days.Fysiolog.– ValueValue 2-4g/l,2-4g/l,

RBPRBP: : syntesyntesized sized in in liverliver– BiologBiolog half-life half-life : : 12h.,12h.,– Normal Normal valuevalue:: 0,03-0,006g/l. 0,03-0,006g/l.– Acute phase reactant (negative)Acute phase reactant (negative)

Biochemical markers of nutrition status :

PPrealbuminrealbumin-synte-syntesizedsized in liver, in liver, – biolog.half-lifebiolog.half-life::1,5 days.1,5 days.– Normal Normal Value 0,15-0,4g/l.Value 0,15-0,4g/l.– Decrease in failure of proteosyntesis-Decrease in failure of proteosyntesis-

indicator of acute protein malnutrition.indicator of acute protein malnutrition.

NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT

Urine urea nitrogen (UUN): to Urine urea nitrogen (UUN): to evaluate degree of hypermetabolism evaluate degree of hypermetabolism (stress level):(stress level):– 0 0 ––5 g/d= normometabolism5 g/d= normometabolism– 5 5 –– 10 g/d = mild hypermetabolism 10 g/d = mild hypermetabolism

(level 1 stress)(level 1 stress)– 10 10 –– 15 = moderate (level 2 stress) 15 = moderate (level 2 stress)– >15 = severe (level 3 stress)>15 = severe (level 3 stress)

Nutrition Monitoring and Nutrition Monitoring and EvaluationEvaluation

Monitor progress and determine if Monitor progress and determine if goals are metgoals are met

Identifies patient/client outcomes Identifies patient/client outcomes relevant to the nutrition diagnosis relevant to the nutrition diagnosis and intervention plans and goalsand intervention plans and goals

Measure and compare to clientMeasure and compare to client’’s s previous status, nutrition goals, or previous status, nutrition goals, or reference standardsreference standards

Other OutcomesOther Outcomes

Food and Nutrient Food and Nutrient Intake (FI)Intake (FI)

Energy intakeEnergy intake Food and Beverage Food and Beverage Enteral and Enteral and

parenteralparenteral Bioactive Bioactive

substancessubstances Macronutrients Macronutrients Micronutrients Micronutrients

Physical Physical Signs/Symptoms Signs/Symptoms

AnthropometricAnthropometric Biochemical and Biochemical and

medical tests medical tests Physical Physical

examination examination

MonitoringMonitoring

Enteral Nutrition Monitoring: Enteral Nutrition Monitoring: Gastric ResidualsGastric Residuals

Clinically assess the patient for abdominal Clinically assess the patient for abdominal distension, fullness, bloating, discomfortdistension, fullness, bloating, discomfort

Place the pt on his/her right side for 15-20 Place the pt on his/her right side for 15-20 minutes before checking a RV to avoid minutes before checking a RV to avoid cascade effectcascade effect

Seek transpyloric access of feeding tubeSeek transpyloric access of feeding tube Raise threshold for RV to 200-300 mLRaise threshold for RV to 200-300 mL Consider stopping RV checks in stable ptsConsider stopping RV checks in stable pts

Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.

Some Lab testsSome Lab tests

NaNa serum levelsserum levels

HypernatremiaHypernatremia:: Na Na over 150 mmol/lover 150 mmol/l hyperaldosteronism hyperaldosteronism hhypovolemiaypovolemia

renin-angiot-aldost. renin-angiot-aldost. Hypothalamic damage Hypothalamic damage Hypertonic hyperhydration Hypertonic hyperhydration Diabetes insipidusDiabetes insipidus Brain death Brain death

Na serum Na serum levelslevels((136-145136-145mEq/L))

HyponatremiaHyponatremia: Na : Na under 130 under 130 mEq/L

Na in the third space - ascites, Na in the third space - ascites, hydrothoraxhydrothorax

Cardiac failure Cardiac failure –– increase of increase of extracellular volume extracellular volume

Application of solutions without Application of solutions without electrolytes electrolytes

Hypersecretion of ADH Hypersecretion of ADH –– water water retention retention

K serum levels K serum levels (3.5-5.3(3.5-5.3mEq/L))

HyperkalemiaHyperkalemia: K : K over 5,0 - 5,5 over 5,0 - 5,5 mEq/L

– pH dependent /acidosis increases K levepH dependent /acidosis increases K levell– Bigger intake, low output or bothBigger intake, low output or both– Acute renal failure Acute renal failure – Acute metabolic acidosisAcute metabolic acidosis– Infusion with K Infusion with K

KK serum levels serum levels

HypokalemiaHypokalemia: K : K under 3,5under 3,5mEq/L

– Low intake, bigger uptake, or bothLow intake, bigger uptake, or both

– Emesis, diarrhoe / intestinal loss/ Emesis, diarrhoe / intestinal loss/

– Diuretics Diuretics

– Chemotherapy, antimycotics /renal tubules Chemotherapy, antimycotics /renal tubules failure/ failure/

– Anabolic phasis Anabolic phasis

– HyperaldosteronismHyperaldosteronism

– Acute metabolic alcalosis Acute metabolic alcalosis

BUN (5-20 BUN (5-20 mg/dlmg/dl))

Consider hydration and Nutrition. High level of urea

– high intake of N, – increase catabolism– polytrauma-muscele loss– GIT bleeding – dehydration – low output- renal failure,

Low level – malnutrition,serious hepatic failure- ureosyntetic cycle and gluconeogenesis dysfunction, pregnancy- increase ECF

BUN (5-20 BUN (5-20 mg/dlmg/dl))

Low level – – malnutrition,– serious hepatic failure- – ureosyntetic cycle and gluconeogenesis

dysfunction, – pregnancy- – increase ECF

UreaUrea

Urea in urine Urea in urine Increase Increase –– catabolism, prerenal catabolism, prerenal

failure failure Decrease Decrease –– chronic malnutrition, chronic malnutrition,

acute renal failure acute renal failure

Creatinine(0.5-1.1Creatinine(0.5-1.1 mg/dl)) Serum levels of creatinine evaluation together with Serum levels of creatinine evaluation together with

muscle mass, age, gender muscle mass, age, gender IncreaseIncrease

– bigger offer- destruction of muscle mass,bigger offer- destruction of muscle mass,– low output-renal failurelow output-renal failure

Decrease- Decrease- – low offer-low muscle masslow offer-low muscle mass– malnutrition malnutrition

Creatinine clearence, excretion fraction -renal Creatinine clearence, excretion fraction -renal functionfunction

N-balance N-balance –– catabolism catabolism –– the need of nitrogen the need of nitrogen Uratic acid Uratic acid –– cell damage, arthritis uratica cell damage, arthritis uratica

ALTALT(SGPT)(SGPT)

N V: M: 7-46 F:4-35 U/LN V: M: 7-46 F:4-35 U/L HighHigh level level ––

– hepatopathhepatopathologiaologia, , – steatosis, steatosis, – hepatitis, hepatitis, – cell damage, cell damage,

ASTAST(SGOT)(SGOT)

HighHigh level level –– – hypoperfusion, hypoperfusion, – hepatitis, hepatitis, – cell necrosis, cell necrosis, – muscles damage muscles damage

both aminotransferases increase both aminotransferases increase during damage of hepatic cells during damage of hepatic cells during inf.hepatitis. during inf.hepatitis.

TGTG(10-190 (10-190 mg/dl))

TG-increase TG-increase – during sepsis, mainly on the begining,during sepsis, mainly on the begining,– monitorate during parentermonitorate during parenteráál nutrition with l nutrition with

lipidlipid emulsionemulsion

Glycemia, serum, urine,Glycemia, serum, urine, Hypoglycemia below 2,5mmol/l-vital Hypoglycemia below 2,5mmol/l-vital

dangerdanger hyperglycemia- insulin.rezistence, hyperglycemia- insulin.rezistence,

recomendation level of glycemia 4,5-recomendation level of glycemia 4,5-8,2 /2006/ better survive in ICU patient8,2 /2006/ better survive in ICU patient

Glucose Glucose

Glycemia, serum, urine,Glycemia, serum, urine, Hypoglycemia below 2,5Hypoglycemia below 2,5mmol/l--(45 (45

mg/dl) ) vital dangervital danger hyperglycemia- insulin.rezistencehyperglycemia- insulin.rezistence

RecomendationRecomendation level of glycemia level of glycemia 4,5-8,24,5-8,2 (80-150 (80-150 mg/dlmg/dl))

PP–– serum levels serum levels(2.7-4.5 (2.7-4.5 mg/dl))

HypophosphataemiaHypophosphataemia:: under 1,9 under 1,9 mg/dl

– Acute wastage of energy after Acute wastage of energy after succesfully resuscitation, overfeeding succesfully resuscitation, overfeeding sy, anabolism (energetic substrates sy, anabolism (energetic substrates without K,Mg,P)without K,Mg,P)..

Hyperphosphataemia Hyperphosphataemia –– over over 5,85,8 mg/dl

– Renal failure Renal failure – Cell damageCell damage

Mg Mg –– serum levels serum levels (1,3-2,5 (1,3-2,5 mEq/LmEq/L))

Mg Mg –– together with potassium together with potassium Hypomagnesaemia Hypomagnesaemia –– under under 1,2 1,2

mEq/LmEq/L / / – renal failurerenal failure– low intake.low intake.

Monitoring of ENMonitoring of EN

For formula intolerance,For formula intolerance,

Hydration status,Hydration status,

Electrolyte status,Electrolyte status,

Nutritional status,Nutritional status,

MonitoringMonitoring

Monitoring in PN therapy

Weight(on a daily basis,initialy and )

BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases

Monitoring in PN therapy

Variable to be monitoredInitial Later period

Clinical statusDailyDaily

Catetheter siteDailyDaily

Temperature DailyDaily

Intake &OutputDailyDaily

Monitoring in PN therapy

Variable to be monitoredInitial Later period

Weight Daily Weekly

serum glucoseDaily3/wk

Electrolytes (Na+, K+, Cl-)Daily1-2//wk

BUN3/wkWeekly

Ca+, P,mg3/wkWeekly

Liver function Enzymes3/wkWeekly

Serum triglycerides weeklyweekly

CBCweeklyweekly

Problems

1. Catheter sepsis

2. Placement problems

3. Metabolic complications

Complications

Dehydration Possible cause:

Inadequate fluid support;Unaccounted fluid loss (e.g. diarrhea, fistulae, persistent high fever).

Management: Start second infusion of appropriate fluid, such as D5W, 1/2NS, NS.

Estimate fluid requirement and adjust PN accordingly.

Complications

OverhydrationPossible cause:

Excess fluid administration;Compromised renal or cardiac function.

Management: Consider D70 (can’t use with PPN) or 20% lipid as calorie sourceInitiate diuretics.Limit volume.

Complications

Alkalosis Possible cause:

Inadequate K to compensate for cellular uptake during glucose transport

Excessive GI or renal K losses.Inadequate Cl- in patients undergoing gastric decompression.

Management: KCl to PN. Assure adequate hydration.Discontinue acetate.

Complications

AcidosisPossible cause:

Excessive renal or GI losses of baseExcessive Cl- in PN.

Management: Rule out DKA and sepsis.Add acetate to PN.

Complications

HypercarbiaPossible cause:

Excessive calorie or carbohydrate load.Management:

Decrease total calories orCHO load.

Complications

HypocalcemiaPossible cause:

Excessive PO4 saltsLow serum albumin.Inadequate Ca in PN.

Management: Slowly increase calcium in PN prescription.

Complications

Hypercalcemia Possible cause:

Excessive Ca in PNAdministration of vitamin A in patients with renal failure. Can lead to pancreatitis.

Management: Decrease calcium in PN.Ensure adequate hydration.Limit vitamin supplements in patients with renal failure to vitamin C and B vitamins.

Complications

Hyperglycemia

Possible cause:Stress response. Occurs approximately 25% of cases.

Management: Rule out infection. Decrease carbohydrate in PN. Provide adequate insulin.

Complications

Hypoglycemia

Possible cause:Sudden withdrawal of concentrated glucose. More common in children.

Management: Taper PN. Start D10.

Complications

Cholestasis

Possible cause:Lack of GI stimulation.Sludge present in 50% of patients on PN for 4-6 weeks; resolves with resumption of enteral feeding.

Management: Promote enteral feeding.

Complications

Hepatic tissue damage and fat infiltration Possible cause:

Unclear etiology. May be related to excessive glucose or energy administration;

L-carnitine deficiency.

Management: Rule out all other causes of liver failure.Increase fat intake relative to CHO.Enteral feeding.

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