Scott A. Lynch, MD, MPH,FAAFP Assistant Professor

Transcription

1 Scott A. Lynch, MD, MPH,FAAFP Assistant Professor 2015 MFMER

2 Nutrition in the Hospital Mayo School of Continuous Professional Development 2nd Annual Inpatient Medicine for NPs & PAs: Hospital Care from Admission to Discharge Wednesday-Saturday, October 19-22, 2016 Sawgrass Marriott Hotel Ponte Vedra Beach, Florida 2015 MFMER

3 Disclosures None 2016 MFMER

4 Objectives Describe the importance of nutrition in the inpatient setting. List tools used to screen nutritional status. Understand the interplay between nutrition and inflammation. Describe how the SGA is used to assess nutritional status. Describe important considerations for enteral and parenteral nutrition 2016 MFMER

5 Why Inpatient Nutrition Matters Incidence 1/3 admitted patients are malnourished 2/3 will worsen without intervention Adverse outcomes are preventable Reduces costs J Parenter Enteral Nutr. 2013;37: MFMER

6 Why Inpatient Nutrition Matters Adverse Outcomes Impaired wound healing Increased infection rate Increased risk of falls Longer length of stay Higher readmission rate Increased mortality J Parenter Enteral Nutr. 2013;37: MFMER

7 Defining Malnutrition Two or more of: Insufficient calorie intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation Decreased functional status J Acad Nutr Diet. 2012;112: MFMER

8 Nutrition Screening Sensitivity Malnutrition Screening Tool 92-93% Mini-Nutritional Assessment-Short Form 89-98% Malnutrition Universal Screening Tool 61-75% Nutritional Risk Screening % Short Nutritional Assessment Questionnaire 79-86% J Parenter Enteral Nutr. 2013;37: MFMER

9 Assessing Nutritional Status Labs No reliable labs to assess nutritional status Albumin limited nutrition assessment utility Negative acute phase protein Affected by volume status Good risk indicator for morbidity and mortality Prealbumin similar limitations as albumin Decreased in liver failure JPEN 2006;30(5): Increased in kidney failure Semin Dial. 2004;17(6): MFMER

10 Assessing Nutritional Status Labs Indicators of inflammation Elevated CRP Leukocytosis Hyperglycemia 2016 MFMER

11 Acute-phase Proteins Positive Haptoglobin Fibrinogen C-reactive protein alpha-antitrypsin Negative Albumin Prealbumin Transferring Fibronectin Retinol binding protein JPEN 2006;30(5): MFMER

12 Inflammatory Conditions Affecting Nutrition Bowel injury Inflammatory bowel disease Wounds/trauma Sepsis HIV/AIDS Cancer Organ failure Obesity Metabolic Syndrome Cardiovascular disease Diabetes JPEN 2006;30(5): MFMER

13 Assessing Nutritional Status SGA Subjective Global Assessment History Exam Score 2016 MFMER

14 SGA: History Weight change: <5%, 5-10%, >10% Dietary intake: change from baseline, adequacy GI symptoms: symptoms, frequency and duration Functional capacity: presence and change past 2 weeks 2016 MFMER

15 SGA Exam Subcutaneous fat eyes, triceps, biceps Muscle wasting scapula, shoulders, interosseus Edema Ascites 2016 MFMER

16 SGA Score A no malnutrition/at risk B mild to moderate malnutrition C severe 2016 MFMER

17 Nutrition Delivery Options Oral Enteral Parenteral 2016 MFMER

18 Enteral Nutrition Indications Oral intake unable to be utilized Functional GI tract No ethical contraindications Meuller, MFMER

19 Enteral Nutrition Contraindications Short duration Malnourished patient: < 5-7 days Well nourished patient: < 7-9 days Severe nausea and vomiting GI obstruction or ileus Severe GI bleed Significant GI malabsorption Distal high-output fistula Meuller, MFMER

20 Enteral Nutrition Benefits Maintains functional integrity of the gut/gut barrier First pass for optimal nutrient utilization Maintains gallbladder function through CCK secretion Maintains gut lymphoid tissues Prevents bacterial translocation Reduces infectious complications of pneumonia, sepsis, IV line sepsis, intra-abdominal abscess Less expensive than TPN Meuller, MFMER

21 Enteral Nutrition Tube Selection <4 weeks: nasal or oral tube >4 weeks: percutaneous tube Meuller, MFMER

22 Enteral Nutrition Delivery Continuous: critically ill, respiratory failure, risk of refeeding, jejunostomy tube Cyclic: decrease time demands, 8-<24 hours Intermittent: gastric tubes, larger volumes, feedings last less then 1 hour, amenable to waking hour feedings Bolus & Gravity: larger volumes, feedings last 4-10 min, mimic normal feedings Meuller, MFMER

23 Parenteral Nutrition Indications Unable to use EN Perioperative support in moderate to severe malnutrition Crohn s disease acute exacerbation GI fistulas Significant short bowel Critical care with prolonged NPO Severe acute necrotizing pancreatitis Bowel obstruction Meuller, MFMER

24 Parenteral Nutrition Delivery Peripheral (PPN) Mild-moderate malnutrition Lower osmolality ( mosm/l) Short duration (<2 weeks) Meuller, MFMER

25 Parenteral Nutrition Delivery Central (CPN/TPN) Significant malnutrition Can be concentrated ( mosm/l) Longer duration (>7-14 days) Can meet full nutritional need Meuller, MFMER

26 Parenteral Nutrition Cautions Prior to starting Stabilize electrolytes Normalize phosphorus Control glucose Meuller, MFMER

27 Nutrition Discharge Planning Insurance coverage requirements Confirm managing physician Document Indications Expected duration Requesting physician/service 2016 MFMER

28 Additional Work Cited Mueller CM, ed. The A.S.P.E.N. Adult Nutrition Support Core Curriculum (2 nd Edition). Silver Spring, MD:A.S.P.E.N.; MFMER

29 Questions & Discussion 2016 MFMER