LONG-TERM NUTRITIONAL CONSIDERATIONS AFTER SPINAL CORD INJURY AND/OR TRAUMATIC BRAIN INJURY

Transcription

1 LONG-TERM NUTRITIONAL CONSIDERATIONS AFTER SPINAL CORD INJURY AND/OR TRAUMATIC BRAIN INJURY Angela Luciani, RD, LDN Magee Rehabilitation Hospital Philadelphia, PA

2 SPEAKER DISCLOSURE STATEMENT Angela Luciani is a Registered Dietitian with Magee Rehabilitation Hospital No off-label use will be discussed Angela Luciani has no industry relationships to disclose

3 OBJECTIVES 1. Describe nutritional considerations for best practice in SCI/TBI patients at high risk for skin breakdown 2. Explain how changes in body composition can impact health status after SCI 3. Discuss case studies which illustrate the typical nutritional needs/interventions provided by Magee s RD for outpatients with chronic SCI

4 NUTRITION MATTERS Inflammatory Response to Illness, Surgery, Trauma Malnutrition Hospital Acquired Conditions (HACs) Malnutrition is associated with: A % higher risk for Pressure Ulcers among other conditions, Significant increased risk for falls 2-3 times increased risk for developing surgical-site infection or postoperative pneumonia Patients who develop HACs are 60% more likely to be in an ICU, Have increased nutritional needs & higher risk of malnutrition and subsequent increase in HACs

5 A.S.P.E.N CLINICAL CHARACTERISTICS TO IDENTIFY AND DOCUMENT MALNUTRITION Presence of 2 out of the following 6 characteristics are used to diagnose malnutrition Decreased oral intake Weight loss Fat loss Muscle wasting Fluid accumulation Decreased grip strength Consensus statement: Academy of nutrition and dietetics and American society for parenteral and enteral nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition) White J.V., Guenter P., Jensen G., Malone A., Schofield M. (2012) Journal of Parenteral and Enteral Nutrition, 36 (3), pp

6 Acute illness & Malnutrition Making the Connection Obesity, Diabetes, Organ compromise, Multiple co-morbidities Acute Hospitalization Acute with Chronic stress response, hyperglycemia w/increased inflammatory cytokines Delayed wound healing, poor response to standard interventions, need for BG & GI monitoring, & education Altered nutrient utilization & loss of LBM, gastroparesis, vascular complications, infection risk 6

7 NUTRITION STATUS AFTER SEVERE TBI OR SCI 40-50% of patients admitted to hospitals are at risk of nutritional deficiency with 12% severely malnourished TBI 68% of TBI patients are malnourished Weight loss 10-29% - occurs within the first and second month SCI Persons with SCI variable prevalence of obesity from 40 to 66% J Clin Med Res Aug; 4(4): Published online 2012 Jul 20. doi: /jocmr924w Krakau, K., A. Hansson, T. Karlsson, C.N. de Boussard, C. Tengvar, and J. Borg, Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition, (4): p

8 NUTRITIONAL PROBLEMS AND RELATED HEALTH ISSUES Spinal Cord Injury - GI issues - Muscle atrophy with increased muscle spasms until medicated - Altered metabolic and nutritional deficiencies - Loss of LBM - Unwanted weight gain - Risk of obesity, metabolic syndrome, heart disease Traumatic Brain Injury - GI issues - Increased muscular activity - Increased energy requirements - Loss of LBM - Cognitive Deficits - Obesity, metabolic syndrome, heart disease

9 PROTEIN NEEDS AND CRITICAL ILLNESS IMPROVING OUTCOMES Review of the current evidence: Protein supplementation has the potential to improve the recovery of critically ill patients Experts now recommend g PRO/kg/d in critical illness Most critically ill patients receive only.6g/kg/d International studies report protein malnutrition rates in the acute care setting of approximately 40%

10 NUTRITION ASSESSMENT Team communication with nursing liaison before patient arrives Screening of high risk patients within 24 hours Malnutrition assessment performed by an RD Collaboration with Wound Care team Ensuring adequate protein by day 2 of admission

11 TEAM APPROACH TO ASSESSMENT Clinical Nutrition is under the Department of Nursing, separate from the Department of Food Service RD screens within hours upon admission to Magee Rehab with a WOCN team approach Anthropometrics PIAG (bowel rounds using Bristol Stool Chart) Co-treat with SLP On-sight video swallow studies Specialty supplements and products for dysphagia Adjust diet to the patient not force patient to fit the diet Experience based strategies to increase intake

12 BARRIERS TO ADEQUATE NUTRITION Age Skin breakdown Dependent for feeding Adjustment to disability Malnutrition

13 I CAN SWALLOW BUT CAN I EAT?

14 TRANSITION THROUGH REHAB TO OUTPATIENT Tube feeding recommendations and speech therapy Coordinating with case managers and collaboration with team for discharge recommendations Free care supplements to bridge from inpatient to outpatient for transitioning home Nutrition education classes Referrals to dietitian in outpatient setting

15 LONG-TERM NUTRITION CONSIDERATIONS IN SCI / TBI Increased risk for cardiovascular disease due to inactivity and immobilization (metabolic syndrome) Changes in weight Calorie, protein, fluid needs Education

16 FOLLOW-UP Magee s lifetime follow-up Weight Tube feeding management Dietary recommendations Supplements PEG placement Referrals to community services for food security

17 CASE STUDY #1 TOO FATIGUED TO MEET INCREASED METABOLIC NEEDS 21 YO AA M presents with C4 Incomplete Quad w/ Trach No PMH DOO: Admission to MRH: 9/12 18 days later Anthropometrics: BMI: 19.9 % wt loss: 16% Skin issues on admit: No Diet IV fluids on admit: RD assessment: Transfer: Ground and thins 4 days prior to transfer: Cleared for P.O. diet and NG tube removed No Pt with inadequate PO intake, increased calorie and protein needs

18 NUTRITIONAL CONCERNS AND INTERVENTIONS Intervention during Rehab PEG placement Various modulars to Rehab meet special needs Nutrition education Rehab-SLP agrees with classes transfer diet recommendations Acute CWOCN skin breakdown noted on admit Passed swallow RD inadequate intake, study >1 hour to consume <25% Skin intact per of meals transfer NG tube removed. Discharge plans Discharged with PEG in place Education regarding weight and smart eating choices PEG care

19 CASE STUDY #2 DELAYED PEG PLACEMENT WITH HYPERMETABOLIC NEEDS DOO: Admission to MRH: 58 YO W M presents with C5 Tetra (Vent/Trach/PEG) No PMH prior to injury 10/15 18 days later Anthropometrics: BMI: 21.4 % wt loss: 3.7% Skin issues on admit: Diet Sacral Unstageable Transfer: NPO PEG placed: 10/23 (9 days after onset of injury) IV fluids on admit: RD assessment: No Dry oral cavity, loss of LBM, loss of fat mass

20 NUTRITIONAL CONCERNS AND INTERVENTIONS Discharge Acute Delayed PEG placement High calorie and protein needs Rehab Unstageable sacral on admit Multiple issues with enteral nutrition administration Above average / recommended calorie needs Intervention Providing above estimated needs Clinical judgment and collaboration with wound care Enteral nutrition insurance coverage Communicating with case manager and vendors regarding supplies

21 CASE STUDY #3 INCREASED PROTEIN AND CALORIE NEEDS WITH NG REMOVED PRIOR TO REHAB 57 YO W M presents with T2-T6 Fx Tetra (Vent/Trach/PEG) No PMH prior to injury DOO: Admission to MRH: Anthropometrics : Skin issues on admit: Diet IV fluids on admit: RD assessment: 8/22 30 days later BMI: 31 % wt loss: 7.5% Surgical incisions Transfer: Nectars and Puree Dobhoff Tube in acute pulled before admission No Dry oral cavity, loss of LBM, loss of fat mass

22 NUTRITIONAL CONCERNS AND INTERVENTIONS Discharge Acute DHT in place Communication with nursing liaison High calorie and protein needs Rehab Admitted without DHT Seen by SLP, VFSS completed, upgraded to regular Intervention Provided protein modulars, snacks and calorie-dense supplements for meeting estimated needs Clinical judgment and collaboration with speech therapy Education regarding healthy weight and skin integrity

23 CASE STUDY #4 HIGH CALORIE AND PROTEIN NEEDS; PT REQUESTING PEG REMOVAL 69 YO W F presents with TBI:VDRF (Trach/PEG) Noncontributory PMH DOO: Admission to MRH: 7/22 10 days later Anthropometrics: BMI: % wt loss: n/a, masked by edema Skin issues on admit: Stage 1 at PEG site Diet IV fluids on admit: RD assessment: Transfer: NPO, receiving enteral nutrition via PEG tube No Dry oral cavity, loss of LBM, loss of fat mass; Claviclular and scapular wasting.

24 NUTRITIONAL CONCERNS AND INTERVENTIONS Discharge Acute PEG placement High calorie and protein needs sec to TBI Rehab Admitted on NPO diet, PEG in place Seen by SLP Modulars enteral nutrition administration Pt with small appetite Wt loss Intervention Calorie counts Education on recommended needs Structure at meal times and frequent snacks Discharge with PEG in place Ensure adequate nutrition consistent before PEG removal

25 SUMMARY Nutrition interventions and on-going education are important at each stage of recovery Rehab setting can be difficult for managing diet and weight; requires buy-in from patient and family Becoming aware of long-term nutrition-related complications in SCI and TBI may help address issues early on and achieve better outcomes

26 QUESTIONS?

27 REFERENCES J Clin Med Res Aug; 4(4): Published online 2012 Jul 20. doi: /jocmr924w Consensus statement: Academy of nutrition and dietetics and American society for parenteral and enteral nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition) White J.V., Guenter P., Jensen G., Malone A., Schofield M. (2012) Journal of Parenteral and Enteral Nutrition, 36 (3), pp Krakau, K., A. Hansson, T. Karlsson, C.N. de Boussard, C. Tengvar, and J. Borg, Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition, (4): p