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Malnutrition = “An acute, subacute or chronic state of nutrition, in which varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition & diminished function.” (A.S.P.E.N. Board of Directors; http://www.nutritioncare.org/Library.aspx)
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Malnutrition Risk Factors
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- ↓ absorption state: gastric bypass surgery, ulcerative colitis, Crohn's disease, short-bowel syndrome
- Chronic disease: end-stage liver or renal disease, diabetes, chronic wounds/infection, alcohol/substance abuse, cachexia (cancer, HIV/AIDS wasting, cardiac)
- ↑ metabolic needs: trauma, burns, traumatic brain injury (TBI), sepsis
- Involuntary weight Δ >10% usual body weight (UBW)/6mo or >5% UBW/1mo
- ↓ appetite/food intake →↑ risk NPO ∼7–10d (less if additional risk factors)
- ≥20% below ideal body weight (IBW)
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- IBW ♀ = 45kg + 2.3kg/in >5ft; IBW ♂ = 50kg +2.3kg/in >5ft
- Use actual weight unless: ABW 20–30% > IBW, BMI >25–30kg/m2
- NBW = IBW + 0.25 (actual weight – IBW)
- Use adjusted body weight for nutritional calculations if ABW ≥30% IBW
- Interpreting weight → compare dry weight vs IBW
- Factors that alter weight interpretation: edema/ascites, diuretics, fluid shift
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- Oral feeding preferred → enteral (EN) & parenteral (PN) feedings reserved for those unable to take PO
- Enteral Feeding: preferred if GI tract functional
- Indications: functioning GI tract with poor or no PO intake, inadequate PO intake for >7d, malabsorption, hypermetabolic states, complications of pregnancy
- Initiate within 24–48h; advance as tolerated; can feed through stomach (gastric) or small intestine (duodenal/jejunal)
- Enteral formulations:
- Immune modulating: major elective surgery, trauma, burns, head/neck cancer, critically ill patients on ventilation
- Anti-inflammatory: acute lung injury, ARDS
- Soluble fiber-containing formulations → diarrhea
- Monitoring → residual Q4–6h or prior to bolus feeding; chem-7, Mg++, Ca++, PO4 2–3 times/wk; triglycerides, CBC, nitrogen balance & hepatic panel weekly
- Parenteral feeding: only for nonfunctioning or inaccessible GI tract
- Indications: GI tract malabsorption, malnourishment with limited nutrient absorption via the GI tract, severe pancreatitis, critical illness with EN contraindicated, & bowel ischemia
- Administer via central venous catheter (CVC), when possible ( ↑ osmolarity); peripheral vein infusion ...