Introduction to clinical nutrition

Hospital Malnutrition in USA
1. 1327 patients surveyed
2. 40-55% among them were malnourished
3. 12% severe malnutrition
4. complication rate 2-3 x >>
5. Length of stay 90%
2
Gallagher-Allred et al: J Am Diet Assoc 1996 Apr; 96(4):361-366

Effect of Single and Combined Observations on
Morbidity and Mortality
Observation Complications Death
Albumin < 3.5 4 x 6 x
TLC < 1500 2 x 4 x
Albumin + TLC 4 x 20 x
3
Seltzer MH. Bastides AJ. Cooper DM et al. Instant Nutritional Assessment.
J. Perenter Enteral Nutr 1979:3:157-159
TLC= total lymphocyte count

4
Energy source
Muscle
protein
75 g
Adipose
Trigly
ceride
160 g
AA
Glycerol
16 g
FA
160 g
Glycogen
Glucose
Hemopoe-
tic sissue
Heart
Kidney
Muscle
Lactate + Pyruvate
40 g
120 g
Keton
60 g
36 g
180 g
144 g
Consumed
Gluconeogenesis
FASTING (1-2 DAYS)
Hill G.L Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone. 1992

5
Sumber energi
Protein
Muscle
20 g
Triglyce-
ride
150 g
AA
Glycerol
15 g
FA
150 g
Glycogen
Glucose
Heart
Kidney
Muscle
Lactate + Pyruvate
36 g
112 g
Keton
57 g
50 g
80 g
44 g
36g
Keton 47 g
Gluconeogenesis
FASTING (5-6 weeks)
Hemopoe-
tic sissue

6
Muscle
protein
180 g
TG
160 g
AA
Glycerol
30 g
GlycogenGlycogen
Glucose
WOUND
Lactate
320 g
114 g
76g
130 g
8 g
104g
Gluconeogenesis
MAJOR TRAUMA
Energy source

7
Sumber energi
Protein
Muscle
250 g
Adipose
Tissue
GluconeogenesisGluconeogenesis
AA
Glycerol
30 g
Glucose
Inflammed
mass
Lactate
360 g
114 g
76g
Consumed
170 g
8 g
136g
Fatty acid
SERIOUS SEPSIS

8
Prolonged administration on iv glucose in the
absence of protein
Growth hormone & glucagon
Insulin
Fat mobilization
Amino acid uptake by skeletal muscle at the
expense of visceral protein synthesis
Hypoalbuminemia and edema
Mizock BA, Troglia Sarah: Nutritional Support of the hospitalized
patient. Disease-a-Month. Mosby Vol 43 No6 June 1997. p.360

Classification of (PEM)
9
PEM
MARASMUSMARASMUS KWASHIORKORKWASHIORKOR MARASMIC
KWASHIORKOR
MARASMIC
KWASHIORKOR

Marasmus
• Severe chronic calorie def
• Wasting appearance
• Body weight < 80%
• TSF < 3 mm
• MAMC < 15 cm
• Associated illness: Cancer,
COPD, anorexia nervosa
• Immune function is less
suppressed as in
Kwashiorkor
10

Kwashiorkor
• Protein intake in stressed
conditions
• May occur within a few weeks
• May appear well-nourished; falling
hair, Edema
• Serum albumin < 2,8 g/dl
• TIBC < 200 g/dl
• TLC < 1500/mm3
• Anergy
• Poor healing wounds
11

Marasmic KwashiorkorWhen acute stress due to surgery, trauma and
infection occurs in already chronically
malnourished
The most severe and life-threatening form
Patients with marasmic kwashiorkor are
hypometabolic and at high risk of overfeeding
12

14
Indirect calorimeter
In vivo neutron
activation
analyser
Scale
Clinical Nutrition Lab
Courtesy of Professor G.L Hill, Auckland University hospital. dept of surgery

Assessment of nutritional status
Anthropometry
Hematology and urine biochemistry
Immunocompetence
Indirrect calorimetry
Measurement of muscle strength
15

Anthropometry Normal
Body mass index ( BB/TB)
Triceps skin fold (TSF)*
Arm Circumference**
AMC=AC - TSF x 3,14
16
18-25
≥ 12,5 mm
≥ 16,5 mm
AMC= Arm Muscle Circumference (lingkar Muscle lengan
atas)
kg/m2

17
Bishop C.W. et al: Norms for Nutritional Assessment of
American adults by upper arm Anthropometry the American
Journal of Clinical Nutrition 34: November 1981 pp 2530-2539.

Triceps Skinfold in Adults
18
Morgan Sarah: Fundamentals in Clinical Nutrition. Mosby 1998. p 179
Adequate
Borderline
Severely depleted
Calorie reserves% standard Men
(cm)
Women
(cm)
100 12.5 16.5
90 11.0 15.0
80 10.0 13.0
70 9.0 11.5
60 7.5 10.0
50 6.0 8.0
40 5.0 6.5
30 4.0 5.0
20 2.5 3.0

MAMC in Adults
19
Morgan Sarah: Fundamentals of Clinical Nutrition.Mosby 1998. p 179
Calorie reserves
Adequate
Borderline
Severely depleted
% standard Men
(cm)
Women
(cm)
100 25.5 23.0
90 23.0 21.0
80 20.0 18.5
70 18.0 16.0
60 15.0 14.0
50 12.5 11.5
40 10.0 9.0

Hematology
Albumin
Transferrin
Prealbumin
Retinol binding protein
Serum creatinine
20
Parameter Normal
3.5 - 5 g/dl
200 - 400 mg/dl
22 mg/dl
4.5 - 7 mg/dl
0.6 – 1.6 mg/dl

Other tests
Creatinine-height index comparing patient’s 24-hr
urinary creatinine excretion with reference values from persons of ther
same height and gender
Total lymphocyte count
Delayed Hipersensitivity Skin Test
21

When to suspect PEM?
Weight loss > 10% within 6 months
Organ dysfunction
Body mass index* (BB/TB) < 18 kg/m2
Serum albumin < 3,5 g/dl
NRI (nutritional risk index) < 90
NRI= 1,59 x (serum albumin g/l) + 0,417 (current BW/ usual BW
within the past 6 months) x 100
Bruce Ryan Bistrian.Proceeding 3rd Pensa Congress. Thailand October-1
November 1997
22

Assessment of severity
History and PE
Weight loss (%)
% ideal body weight
5 – 10
80-90
10 – 20
60-80
> 20
< 60
Anthropometry
MAMC (percentile)
Triceps skin fold (percentile)
-
-
5th
– 10th
5th
– 10th
< 5th
< 5th
Serum protein
Albumin (g/dl)
Transferrin (mg/dl)
3.0 – 3.5
150 - 200
2.1- 3
100 - 150
< 2.1
< 100
Immunology
TLC (total lymphocyte count (cell/mm3
)
Delayed hypersensitivty skin testing
1200 – 1500
Reactive
800 – 1200
+/-
< 800
Unreactive
Creatinine height index (%) 80 – 90 60 – 80 < 60
23
Degree of malnutrition
Mild Moderate Severe
Forse R.A.: Diet, Nutrition and Immunity. CRC Press Inc 1994 p 11

Physiological stress
In stress, the inflammed white cells secrete
cytokines
The cytokines (tumor necrosis factor,
interleukin-1 and interleukin-6) stimulates
cathecolamines, Glucagon and cortisol
Promote gluconeogenesis from amino acids
Depressed appetite
Stmulate lipogenesis
Promote the synthesis of acute phase protein in the liver
25

How to examine the presence of
metabolic stress?
Clinical: trauma or major operation, sepsis
Temp> 38 o
C, pulse > 100/min
Respiratory rate > 30/min
Leucocyte > 12000 or < 3000
Positive blood culture
Active IBD (inflammatory bowel disease)
Confirmed focus of infection
26

To measure metabolic stress
Objective:
* RME (indirect calorimeter)
* Catabolic index (CI)
CI= UUN (g) - N diet (g)
27
2
+ 3
If CI < 0 No stress
CI 0-5 Moderate stress
CI > 5 Severe stress
Note: UUN = urinary urea nitrogen
1 g Nitrogen = 6.25 g protein

Protein Catabolic rate
Protein catabolic rate (g/day)=
[24-hr UUN (g) + 4] x 6.25
28

Stress factors
 Malnutrition 0,7
 Chronic renal failure, nondialysis
 Hemodyalisis 1-1,05
 Uncomplicated elective surgery 1,1
 Peritonitis 1,15
 Soft tissue injury 1,15
 Fracture 1,3
 Mild infection 1
 Moderate infection 1,2-1,3
 Severe infectiot 1,4-1,5
 Burn, 0-20% BSA 1-1,5
 Burn, 20-40% BSA 1,5-1,8
 Burn, > 40% BSA 1,8-2
 Head injury 1,6
29

Calorie requirement in children
Age Estimate requirement
Neonates: (kcal/kg/day)
 Low birth weight 150
 Normal birth weight 100-120
Children:
 0-10 kg 100
11-20 kg 1000 kcal + 50 kcal/kg
> 20 kg 1500 kcal + 20 kcal/kg
33
Pitono Suparto, Like S. Djupri, Subijanto MS: Gastroenterologi Anak.
GRAMIK. FK Airlangga. 1997 Adopted from Ament ME.

Dosage of amino acid for children
Newborn : initially 0,5 g/kg/day
Infant and young children: initial dose
1 g/kg/day
34
increased to 2 g/kg/day
Sakiio Suita, Tomoru Sakaguki: Amino Acids in Pediatric Nutrition
AMINO ACIDS VIDEO SERIES No. 9

36
Nutritional assessment
Decision to initiate Specialized Nutrition Support
Functional GI Tract
Yes No
NUTRISI ENTERAL PARENTERAL
GI Function Short-term Long-term (> 7 days)
Intact
Nutrient
Defined
Formula
GI function returns
Adequate Inadequate Adequate
Nutrient
tolerance
Normal Compromised
Long-term
Gastrostomy
Jejunostomy
Short-term
Nasogastric
Nasoduodenal
Nasojejunal
(obstruction, peritonitis, intractable
vomiting, acute pancreatitis, short
bowel sindrome, ileus)
Progress to
oral feeding
PN Supplementation Progress to more complex Diet and oral feeding
Yes No
PPN TPN

38
• Economical
• Promotes secretion of digestive hormones
• Prevents villous atrophy
• Inhibits bacterial overgrowth and translocation
• No risk of catheter-related sepsis and phlebitis

39
• Nasogastric, nasoduodenal
• Jejunostomy
• Gastrostomy
• PEG (percutaneous endoscopic
gastrostomy)
Hill G.L: Disorders of Nutrition and Metabolism in Clinical Surgery.
Churchill Livingstone 1992.

40
Intact
Hydrolysate
Crystalline
Special
Modular

Intact protein
Intact protein: Caseinate-based or soya-based
products; lactose-free and low residue.
Generally contain oligosaccdaydes and LCT
(MCT)
Calorie content 1 kcal/ml
Additional: fibres
41
Examples: Proten , Pan Enteral, Ensure, Isocal, Osmolite

Protein hydrolysate
Also called chemically defined formulas
Partially predigested; low-residue and free-lactose
Protein may take form as peptides or free amino
acids
Carbohydrate: oligo or dissacdaydes
Low fat content
42
Examples: Pepti-2000, Criticare HM, Tolorex

Protein hydrolysate
Useful for patients with GIT dysfunction and
impaired absorption of protein, such as catabolic
states associated with Hypoalbuminemia and
Crohn’s disease.
Expensive, not palatable
43

Crystalline Protein
Also named elemental formula
Protein source is free amino acids
Most products contain oligosaccharides/ Glucose as
NPC source with low LCT
44
Patients with GIT dysfunction
Examples: Tolorex, Vivonex

Sepcialized formula
For specialized conditions (eg, metabolic stress, liver
disease, renal disease, glucose intolerance)
May contain immunonutrients (eg. glutamine,
arginine, etc)
45
Examples:Kidmin, Aminoleban, Neomune Pulmocare, Traumacal

Modular Formula
Contains solely one nutrient, eg: : calcium
caseinate, whey protein, maltodextrin, glucose
polimers
46
Examples: Casec, Polycose liquid, Sumacal

Entry sites of CV Catheters
V. subclavia infraclavicular (most commonly used)
V. subclavia supraclavicular
V. jugularis interna
48

Procedure
Right sided is preferred owing to
absence of throacic duct
Trendelenburg position
Cleanse the area and apply povidone
iodine.
Select a point at midclavicular line for
insertion and inject local anesthetics as
fas as clavocular peiosteum
In fossa supraclavicular space, using
fore finger press down to first rib. Insert
needle (22-G ) toward the rib pointed by
fore finger
49
Tsugushiko Tashiro MD, Head of Surgical Metabolism Unit
The First Department of Surgery Chiba University Medical School
Site of puncture for
subclavicular approach
Direction of puncture

Procedure (cont’d)
Insert 14-G until 2 mm deep and
aspirate the blood. Patient is instructed
to hold breathing, release the syringe
nad insert catheter via needle access site
into subclavian vein. Caution:
hypovolemia may cause air emboli.
Withdraw catheter until only 15 cm
remaining inside. Fix the cataheter with
silk suture.
Connect the catheter to infusion line
50

51
Insertion of Arrow CVC set
Courtesy of Dr Irwan Amin,SpAn KIC

52
Central Venous Catheterization Set (ARROW)
Indwelling Catheter: 14 Ga. x 6" (16 cm) Radiopaque
Polyurethane with Blue FlexTip™, Integral Extension Line,
Extension Line Clamp, Side Holes, Integral Suture Wing
One: Spring-Wire Guide, Marked: .032" (.81 mm) dia. x 17-13/16"
(45 cm) (Straight Soft Tip on One End - "J" Tip on Other) with
Arrow Advancer®
One: Fastener: Catheter Clamp
One: Introducer Needle: 18 Ga. x 2-1/2" (6.35 cm) XTW
One: Pressure Transduction Probe
One: Arrow Raulerson Spring-Wire Introduction Syringe*: 5 cc
One: Clamp: Catheter
One: Vessel Dilator

54
Introduction syringe
Vessel dilator
Catheter
Guide wire
Catheter clamp

55
Apply antiseptic on the right chest

56
Povisone iodine wiped with alcohol gauze

57
Supraclavicular method
External jugular vein
Internal jugular vein
Subclavian vein
First rib
NeedleClavicle
V. innominata
John Windsor. Total Parenteral Nutrition. New Ethicals October
1988. (Modified by Irwan Amin)

58
Operating area covered with sterile cloth

59
2 ml Lidocain HCL withdrawn from ampule

60
Lidocaine HCL injected to skin surrounding access site

61
Once Lidocaine HCl has been injected out, the same needle
is directed toward vena innominata and pushed deeper, blood
is then aspirated

62
Introduction syringe is passed through entry site of local
anesthetics blood is aspurated from central vein
Note: Introduction syringe is not syringe of Lidocain HCl

63
Guide wire is inserted into central vein. The tip is hooked
to avoid injury)

66
Entry site of guide wire is dilated by vessel dilator

67
Catheter is inserted along the guide wire

68
Catheter passed down the guide wire

69
Catheter length is almost inside

71
Blood is aspirated to ensure the catheter is correctly
located in central vein

72
Syringe is left in situ before disconnected and preparation
of infusion set

73
Catheter is already connected to infusion line

74
Catheter clamp is not sutured to the skin because patient
was agitated

76
John A Windsor. Total Parenteral Nutrition. New Ethicals October 1988.
A patient on TPN with catheter
insertion via subclavian vein to
superior vena cava

77
Tsugushiko Tashiro MD, Head of Surgical Metabolism Unit
The First Department of Surgery Chiba University Medical School
Water 2000 ml/day
Protein 1-2 g/kg/day
TEE 30-40 kcal/kg/day
Na 1-2 mEq/kg/day
K 1-2 mEq/Kg/day
Mg 0.2-0.5 mEq/kg/day
Ca 0.2-0.3 mEq/kg/day
P 0.5-1 mEq/kg/day
Cl 1.0-2.0 mEq/kg/day
Vitamints & trace
elements

To determine nutrient requirement
Water: Maintenance 25-35 ml/kg/day or
approx. 2000-2500 ml/day
Patients with intestinal obstruction, fistulae
and fever are dehydrated and may require
more water.
79

Dosage of Nutrients
Energy : 30 kcal/kg/day in nonstressed and 40
kcal/kg/day in stressed conditions. (Note: the whole
requirement cannot be fulfilled instantly. Titration is
mandatory)
Fat emusion 20% of total NPC to alleviate metabolic
load of the liver. Yet, sole glucose is sufficient for TPN
of 2-4 weeks. When TPN > 4 weeks: 200 ml of 10% fat
emulsion is recommended
High BCAA is recommended in metabolic stress
80

82
• Supply calory of less than 1000 kcal/day
• Generally < 7 day in patients whose gut
function has not resumed to normal or as
supplement to oral/enteral route
• Osmolarity should be less than 900
mOsm/L

Assessment of Nutritional Status
Clinical: General appearance: skinny face, promonent
cheek bone, flat buttock, pointed shoulder bone
Body fat stores (pinch triceps/biceps) positive finger-
thumb test
Body protein stores (prominent tendon of scapula)
positive tendon-bone test
Hypoalbuminemia
Physiological function: poor wound healing, weak hand
grip; inability to blow a sheet of paper; dyspnea
84
Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery. Churchill
Livingstone. 1992.

Determination of metabolic stress
Clinic and catabolic index
Objective (indirect calorimetry):
RME (kcal/24 hour) = 13.6 x FFM (fat-free
mass) + 550
Mean (+ SD) ratio of measured RME to
calculated RME. Normal subject :1,00 + 0,09
Ratio of > 1,18 is considered metabolic stress
85
Hill G.L. Disorders of Nutrition and Metabolism in Clinical
Surgery. Churchill Livingstone. 1992.

Goal of nutrition support
Marasmus Recovery of fat and protein store and
normalisation of body hydration
Major trauma or serious sepsis (kwashiorkor)
limit protein loss , partially normalize hydration and
improvement of physiological function
Marasmic kwashiorkor: replete protein. In the
presence of sepsis, focus of sepsis must be eliminated first.
86

Total Energy Requirement
.
87
25 kcal/kg/day
Saito H. Perioperative Nutritional Support. In Tienboon P.,
Chuntrasakul C. Nutrition and Metabolic Support in Clinical Practice.
Pensa 1998. pp 159-174.

Protein requirement
Maintenance : 1,0 - 1,5 g/kg/day
Replacement : 1,5 - 2,0 g/kg/day
Repletion of massive loss : 2,0 - 2,5 g/kg/day
88
Hill G.L. Disorders of Nutrition and Metabolism in Clinical Surgery.
Churchill Livingstone. 1992.

Water and mineral requirements in
adults
Patient group (16-25 th) (25-55 th) (56-65 th) (> 65 th)
Water 40 ml/kg 35 ml/kg 30 ml/kg 25 ml/kg
Natrium 60-100 mmol 60-100 mmol 60+ mmol 50+ mmol
Kalium 60+ mmol 60+ mmol 60+ mmol 50+ mmol
Calcium 15 mEq 15 mEq 20-50 mEq 20-50 mEq
Phosphate 20-50 mmol 20-50 mmol 20-50 mmol 20-50 mmol
Magnesium 8-20 mEq 8-20 mEq 8-20 mEq 8-20 mEq
89
Hill G.L. Disorders of Nutrition and Metabolism in Clinical
Surgery. Churchill Livingstone. 1992.

Indications of enteral nutrition support of
surgical patients
Moderate to severe PEMwhere oral intake is
impossible in preceeding 3 days
Mild PEM where less than 50% of dietary
requirement is met since the preceeding 7-10 days
Disphagia to all nutrients but fluid
Massive enterectomy in recovery period
Distal enterocutaneous fistulas
Major trauma
Prolonged postoperative care
IBD (inflammatory bowel disease)
90

Contraindications of enteral nutrition
Total small intestinal obstruction
Ileus
Severe diarrhea
Proximal small bowel fistula
Severe pancreatitis
Shock
91

Metabolic response
Hypermetabolism
Proteolysis and nitrogen loss
Accelerated gluconeogenesis and utilization of
glucose
93

94
180
160
140
120
100
80
60
10 20 30 40 50 60 70
Restingmetabolism(%normal)
day
Major burn
Peritonitis
Fracture
Partial starvation
Total starvationl
Kisaran normal
Long CL, Schaffel N. Geiger JW, et al: Metabolic response to injury and illness:
estimation of energy and protein needs from indirect calorimeter
and nitrogen balance, JPEN 3:452.1979.)
Changes in metabolic rate and nitrogen excretion
with physiological stress

95
Nitrogenexcretion(g/day)
28
24
20
16
12
8
4
0
10 20 30 40
Major burn
Skeletal trauma
Severe Sepsis
Infection
Elective surgery
Partial starvation
Total starvation
day
Changes in metabolic rate and nitrogen excretion
with physiological stress
Long CL, Schaffel N. Geiger JW, et al: Metabolic response to injury and illness:
estimation of energy and protein needs from indirect calorimeter and nitrogen
balance, JPEN 3:452.1979.)
Normal range

Definition of Sepsis Syndrome
one of the following:
Temp > 38,3o
C
RR > 20/minute or mechanical ventilation
Heart rate > 90 /minute
Clinical evidence of infection
Positive blood culture after 48 hours
97
Screening criteria

Calorie and protein requirement in
sepsis
Total energy requirement 25 kcal/kg/day
Protein : 1,5-2 g/kg/day
98
The Journal of Critical Care Nutrition/Volume 5 No 1 1998

Introduction to clinical nutrition

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