The top 5 things all doctors should know about nutrition. Dr Peter Mooney Consultant Gastroenterologist Leeds Teaching Hospitals NHS Trust

Transcription

1 The top 5 things all doctors should know about nutrition Dr Peter Mooney Consultant Gastroenterologist Leeds Teaching Hospitals NHS Trust

2 ONE NUTRITION IS EVERYONE S PROBLEM

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4 Mortality and malnutrition Elia M et al Nutrients 2012;28(5):477 Office for national statistics 2018

5 1st study in UK to report prevalence of malnutritionon admission to hospital. 40% patients were malnourished on admission 78% deteriorated during hospital stay. <50% malnourished patients had any nutritional information documented

6 Malnutrition Incidence 30% of adults on admission to hospital and about 34% of those in hospital wards 15% or more of adults attending hospital outpatients Children: 5% to 15% among those accessing healthcare services in routine practice in hospital and community settings BAPEN 2012 Malnutrition pre-disposes to disease and adversely affects its outcome: Adverse effects on mortality, morbidity and quality of life Delayed recovery from illness Impaired body function affecting well being and activities of daily living

7 Malnutrition causes adverse effects on functional and/or clinical outcomes (NICE, 2006)

8 Malnutrition costs money!

9 Two ASSESSING NUTRITIONAL STATUS

10 MUST Screening Tool Step 1: BMI (can use alternatives such as ulna length for height or mid-upper arm circumference (MUAC) as approximation for BMI: MUAC <23 cm = BMI 20kg/m2, MUAC >32cm = BMI >30 kg/m2) Step 2: Percentage weight loss Step 3: Establish Acute Disease Effect and score Step 4: Add scores step 1,2,3 together to obtain overall risk of malnutrition Step 5: Develop care plan

11 Anthropometry and body composition

12 When should nutrition support be considered and referral to the dietitian made? In people who are malnourished, as defined by any of the following: BMI <18.5 kg/m 2 Unintentional weight loss >10% within the last 3 6 months BMI less than 20 kg/m 2 and unintentional weight loss greater than 5% within the last 3 6 months. In people at risk of malnutrition, as defined by any of the following: Eaten little or nothing for 5 days and/or likely to have poor intake for next 5 days or longer Poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism Any patient with Grade 2 pressure ulcer

13 Three ALBUMIN ALONE IS NOT A MARKER OF MALNUTRITION

14 Albumin Albumin is not a marker of malnutrition

15 Biochemical markers of malnutrition Electrolytes may become deplete but serum levels normal Vit A/D/E (K INR), B12/folate/ferritin Zn/Se/Cu prone to assay error particularly in inflammatory states Albumin Loss nephrotic syndrome/protein losing enteropathy Inflammation sepsis, autoimmunity, IBD etc Malignancy Liver disease Rarely pure protein calorie malnutrition (bariatric surgery)

16 Management of intestinal failure SEPSIS NUTRITION ANATOMY PLAN Resolving Sepsis is vital before intestinal function and Nutritional status can be restored. Nutritional repletion is vital before considering reconstructive surgery. Intestinal Anatomy must be defined so that we can formulate a definitive management Plan. Lal et al., Alimen Pharm Ther 2006; 24: 19-31

17 Key messages Good nutrition is linked to clinical outcome, recovery from illness and shorter hospital stay Nutrition is a fundamental part of every patient s care and should be a part of every patient s care pathway Think about nutrition on every ward round Obtain guidance and support from Dietetic colleagues Support Protected Mealtimes

18 Four RE-FEEDING SYNDROME

19 Pathophysiology

20 Consequences Monitor LFTs ECG Consider HDU/cardiac monitoring

21 Who is at risk? High risk groups alcohol, eating disorders Beware ALL Glucose calories 1L 5% dextrose contains 200kCal BAPEN 2012

22 Management Dietitian Thiamine replacement prior to commencing nutrition Pabrinex Start nutrition no faster than 5-10kCal/kg Daily (or 2x daily) K/PO 4 /Ca/Mg Replace prior to commencing nutrition if significantly low ECG consider HDU

23 Five SHORT BOWEL SYNDROME

24 Short Bowel Syndrome Phrase first used in 1960 s Intractable diarrhoea with impaired absorption of fats, vitamins and other nutrients, ultimately leading to malnutrition, anaemia and continued weight loss Intestinal Failure, Ed. Nightingale

25 Short Bowel Syndrome Consensus definition, 2006 Short-bowel syndrome results from surgical resection, congenital defect, or diseaseassociated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balances when on a conventionally accepted, normal diet O Keefe et al. Gastro Hepatol 2006

26 Short bowel syndrome Females < Males Shorter < Taller Nightingale et al. Gut 2006

27 Short Bowel Syndrome Increasing risk

28 Short Bowel Syndrome Jejunostomy EARLY fluid balance problems Leaky Sensitive to Na content Aim mmol/l Poor adaptation

29 Short Bowel Syndrome Jejuno-colon SLOW malnutrition Hyperphagia Compensation if > 1/3 energy absorbed Need for PN if <50cm Low oxalate diet (25% stone risk)

30 Short Bowel Syndrome Jejuno-ileum-colon Usually no problems Tight junctions Active Na/water absorption Good adaptation

31 SBS assessment Doesn t account for Crohn s/increasing age BSG

32 Clinical assessment Symptoms Thirst, dizziness, lethargy, nausea Fluid balance crucial Input Output Electrolytes (Mg) Urinary Na Anthropometry BMI (Daily weights) TSF, MAMC, MAC, Hand grip

33 SBS Management Investigate reversible causes Active Crohn s Sepsis Coeliac disease Pancreatic insufficiency Bacterial overgrowth Manage SBS simultaneously

34 SBS management Fluid balance Reduce motility Acid suppression Bile salt binder if colon intact Dietary measures

35 Fluid balance Aim: Urine output > 800 mls/day Urinary Na > 20 mmol/l Use oral glucose-electrolyte solution Dioralyte Na 60 mmol/l 10 sachets in 1 litre, sipped throughout day Or St. Mark s Or Glucodrate Restrict hypotonic fluids to mls per day

36 Reduce motility Loperamide Typically 4 mg QDS Maximum 64 mg per day Melts may be better absorbed Codeine Maximum tolerated Synergistic effect Nightingale et al. Clin Nutr, 1992

37 Acid suppression Resection hypergastrinaemia High doses of PPIs E.g. omeprazole 40 mg BD MUPS may be better absorbed Test ph of stoma to assess effect (Aim ph > 5.5)? Stop at 6-12 months? Low Mg

38 What about octreotide? May be effective if large volume jejunostomy and significant salt losses Gradually increase to 200 mcg TDS BUT No effect on energy/nitrogen absorption Inhibits adaptation Risk of hypo/perglycaemia and gallstones O Keefe et al. JPEN 1994

39 Low magnesium Correct dehydration Options: Mg oxide Mg glycerophosphate Mg aspartate Ensure adequate levels of vitamin D Cholecalciferol 40,000 weekly x 7 (<30) or monthly x 3 (>30), then reassess If no response, consider im Vit D

40 Other measures If intact colon and TI resection: high likelihood of bile acid diarrhoea Cholestyramine Colestipol Colesevelam No evidence to advise: Separation of fluids and solids Low fat diet

41 GLP-2 analogue (teduglutide) STEPS 3 83 patients Placebo vs mg/kg/day vs mg/kg/day 20% reduction in PN 6% vs. 43% vs. 25% TPN TPN + GLP2 STEPS patients TED vs. Plac vs. New 89% vs. 46% vs. 50% 3 Jeppesen et al. Gut Schwartz et al. Clinical and Translational Gastroenterology 2016

42 Intestinal Transplantation IF on PN plus Progressive IFALD Severe sepsis Limited venous access Patients with indications for major evisceration Transplantation of other organs Rutter CS et al Trans Proc 2016;48:468

43 Summary Ensure no reversible cause Structured approach Fluid balance paramount Urinary Na most useful test Mg red flag electrolyte Beware the patient admitted with recurrent AKI/low Mg

44 THANKS ANY QUESTIONS?