Acute management of severe malnutrition. Dr Simon Gabe St Mark s Hospital, London

Transcription

1 Acute management of severe malnutrition Dr Simon Gabe St Mark s Hospital, London

2 Malnutrition definition A state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass), and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease Although this definition is well-accepted, the condition lacks clear and generally accepted diagnostic criteria.

3 Incidence & recognition of malnutrition in hospital Nutrition state General surgery (n=100) General medicine (n=100) Respiratory medicine (n=100) Orthopaedic surgery (n=100) Medicine for elderly (n=100) Undernourished Normal Overweight Weight change Overweight (n=29) Normal (n=28) Undernourished Mild (n=19) Moderate (n=19) Severe (n=17) Mean weight loss (%) McWhirter & Pennington, BMJ 1994

4 Under & overnutrition Underweight Obesity Community 4-5% 28% Care homes 30-35%% 9% Hospitals 30-34% 12.5% * *HSCIC data for 2011/12

5 Malnutrition is a common problem 35% 34% 30% 18% 15% 13% 10% 5% Care home resident On a hospital ward Admission to hospital Admission to mental health unit Hospital outpatients Sheltered housing Visiting the GP Adult population in England

6 Distribution of malnutrition Medium & high risk MUST Estimated costs

7 Cost of malnutrition in England Public expenditure on malnutrition 19.6 billion >15% of total expenditure on health & social care Calculated from the proportion of healthcare activity due to malnutrition and the cost for this activity In some cases costs were uplifted to take into account additional known effects of malnutrition (eg increased LOS) Most of the cost of malnutrition was due to healthcare (78%) rather than social care (22%).

8 Cost of malnutrition per person

9 Causes of malnutrition Saunders et al. Medicine 2015;43(2):

10 Causes of malnutrition in hospital in-patients Medical causes of inadequate and/or poor quality oral intake Environmental causes of inadequate and/or poor quality oral intake Altered requirements Anorexia of disease Nausea and vomiting Gastrointestinal dysfunction Reduced absorption of macro- and/or micronutrients Increased nutrient loses Nil by mouth for investigation or medical reasons Physical disability & inability to feed self Inadequate food quality Inadequate food availability No protected meal times Missed meals when going for investigations Inadequate training and knowledge of medical and nursing staff In critical illness there are altered substrate demands and several sub-groups of patients have a increased energy expenditure

11 Severe malnutrition WHO, 1999: Management of severe malnutrition: a manual for physicians & health workers (ISBN )

12 Refeeding Syndrome Severe fluid & electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding 1 st described in prisoners of war after 2 nd World War Also classic experiments of Keys on conscientious objectors during the war

13 The fasted state Fasting insulin, glucagon, cortisol Gluconegenesis, glycogenolysis protein catabolism Depletion of electrolytes, proteins, fats, minerals, vitamins Adjustments to new metabolic state

14 CHO Insulin Cell Glucose Phosphate Thiamine Glycolysis TCA cycle ATP synthesis K + (Mg 2+ ) Na/K Pump Na +

15 Refeeding syndrome Fasting Refeeding insulin, glucagon, cortisol insulin, glucagon, cortisol Gluconegenesis, glycogenolysis protein catabolism Glucose, PO 4, Mg & K uptake thiamine use Depletion of electrolytes, proteins, fats, minerals, vitamins Adjustments to new metabolic state PO 4, K, Mg, Thiamine deficiency Respiratory / cardiac failure / sudden death

16 Refeeding syndrome May cause serious clinical complications Hallmark biochemical feature: hypophosphataemia Other features: Abnormal sodium & fluid balance Changes in glucose, protein & fat metabolism Thiamine deficiency Hypokalaemia Hypomagnesaemia

17 Main problems of refeeding Problem Result Low phosphate Death Thiamine deficiency Wernicke s encephalopathy Loss of short term memory Re-activation of Na+/K+ pump Oedema LVF

18 NICE 2006 High risk of developing refeeding problems One or more BMI <16 kg/m 2 Weight loss >15% in 3-6/12 Little or no intake >10 days Low K, PO 4 or Mg Two or more BMI <18.5 kg/m 2 Weight loss >10% in 3-6/12 Little or no intake >5 days Alcohol or drug abuse Insulin, chemotherapy, antacids, diuretics

19 Screening for malnutrition MUST tool Most widely used in the UK Detects Malnourished patients Patients at risk of malnutrition Obese with significant wt loss Widely used but variably performed correctly

20 NICE recommendations Management of patients at risk of refeeding Immediately Full dose daily IV vitamin B preparation, or Oral thiamine mg daily & vit B comp 1-2 tab TDS Balanced multivitamin/trace element supplement OD In most patients Extreme undernutrition Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs Cardiac monitor 1g glucose = 4 kcal 1L 5% dextrose = 50g glucose = 200 kcal

21 NICE recommendations Management of patients at risk of refeeding Immediately Full dose daily IV vitamin B preparation, or Oral thiamine mg daily & vit B comp 1-2 tab TDS Balanced multivitamin/trace element supplement OD In most patients Extreme undernutrition 50 kg patient 10 kcal/kg/day glucose = 500 kcal Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs Cardiac monitor 40 kg patient 5 kcal/kg/day glucose = 200 kcal 2.5L dextrose/day 1L dextrose/day

22 NICE recommendations Management of patients at risk of refeeding Immediately Full dose daily IV vitamin B preparation, or Oral thiamine mg daily & vit B comp 1-2 tab TDS Balanced multivitamin/trace element supplement OD In most patients Extreme undernutrition Restore Provide Start at max 10 kcal/kg/day, increase slowly over 4-7 days to meet or exceed full needs Start at 5 kcal/kg/day, increase slowly over 7 days to meet or exceed full needs Cardiac monitor Restore circulatory volume & monitor fluid balance closely Potassium (2 4 mmol/kg/day) Phosphate ( mmol/kg/day) Magnesium (0.2 mmol/kg/day IV, 0.4 mmol/kg/day oral)

23

24 Initial driver for the guidance 12 cases of young people with severe anorexia nervosa who had died on medical units owing to re-feeding syndrome underfeeding syndrome other complications of anorexia nervosa and its treatment

25 Recommendations Adult patients with anorexia nervosa being admitted to a medical ward are often at high risk Risk assessment should include BMI, physical exam, blood tests & ECG Most adults with severe anorexia nervosa should be treated on specialist eating disorders units (SEDUs) Medical admission required for patients needing treatments not available on a psychiatric ward (eg IV infusion)

26 Recommendations Medical ward admission In-patient medical team Should be supported by a senior psychiatrist Expertise in eating disorders Liaison psychiatrist Adult general psychiatrist Should contain a physician & dietician With specialist knowledge in eating disorders Work within a nutrition support team Key tasks Safely re-feed the patient Avoid re-feeding & underfeeding syndromes Manage common behavioural problems eg sabotaging nutrition (with the help of psychiatric staff) Manage family concerns Treat under Section 3 if required (psychiatric support) Arrange transfer to a SEDU as soon as safely possible

27 Nutrition support Oral Parenteral Enteral

28 Misplaced NGs NG placement often by an experienced nurse, but when they fail it is the most inexperienced doctor How often does the NG go into the trachea?

29 Misplaced NGs NG placement often by an experienced nurse, but when they fail it is the most inexperienced doctor How often does the NG go into the trachea? Often quoted as 2-2.5% knowing it is an underestimation 1 35% using Iris NG tube (CCD chip on the end of the NG) 2 1 Sorokin R & Gottlieb JE JPEN 2006;30: Carrera G et al, Clin Nutr 2015;34(S1)S117 S118

30 Undetected misplaced NGs

31 NCEPOD: a mixed bag An enquiry into the care of hospital patients receiving PN adult, 270 neonatal and 70 paediatric notes assessed

32 NCEPOD: quality of care 19% Good practice: A standard that you would accept from yourself, your trainee and your institution

33 Monitoring Inadequate monitoring in 43% patients

34 CVC Complications Complications 26% CVC related 54% thought to be avoidable 2% managed inappropriately

35 Summary Prevalence & cost Obesity common in the community Malnutrition common in hospitals (34%) & care homes (35%) Cost of malnutrition in 2011/12: 19.6 billion Refeeding Hallmark biochemical feature: hypophosphataemia High risk patients & management discussed MARSIPAN Guidance for combined management of high risk anorexic patients NG placement issues very common & do lead to deaths PN administration needs to improve in the UK