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HOW DO I ASSESS THE

NUTRITIONAL STATUS OF MY
ICU PATIENTS
S. Sunatrio
Department of Anesthesiology, Faculty of Medicine,
University of Indonesia/Cipto Mangunkusumo Hospital,
Jakarta - Indonesia

Nutritional status (NS)


a multi dimensional phenomenon that requires
several methods of assessment, including
nutrition-related health indicators, nutritional
intake and energy expenditure

Illness and injury are physiologic stressors that


alter the bodys metabolic and energy demands
30-55% of hospitalized pts: malnutrition
Nutrition screening and assessment is integral
part of the evaluation of the critically ill pts

Nutritional assessment (NA)


used to identify pts who would benefit from
nutritional support and suggests a design for
that thx
a key to improving the care of surgical pts
no single nutritional marker is of consistent
value use of combinations of indicators from
several categories to measure NS

Mourao F et al. Nutritional risk and status assessment in


surgical patients. A challenge amidst plenty. Nutr Hosp
2004;19:83-88

This study supported the use of unintentional


weight loss >10% and SGA as being appropriate
measures to identify undernourished pts at risk

Nutritional assessment (NA)


relies on a complete history and PE, lab
measurements and diagnostic testing
a single lab result may be helpful for nutritional
screening
there is no single parameter that is both
sensitive and specific for dx of malnutrition

Nutritional assessment (NA)


NA must be ongoing and be derived from a
variety of sources in order to identify nutritional
trends over time
Early identification and nutritional intervention
can morbidity and mortality risks
Underlying acute and/or chronic diseases
processes often need to be identified and
corrected before the body can reverse abnormal
nutrient metabolism

A comprehensive NA incorporated
with clinical status the basis for a
NS plan and evaluation strategies

Nutritional assessment (NA)


Begins with a thorough history (not always
practical)
DM, COPD, renal failure, weight gains, weight losses
Alcohol intoxication, coma, pharmacologic
management of the ventilator, frequent anesthesia
Underlying mechanism

Nutritional assessment (NA)


Collect and evaluate clinical conditions, diet, body

composition and biochemical data, among others


Classify patients by nutritional state: well-nourished
or malnourished

Screening and NA: Common Objectives


-

Complications
Treatment failures
Physiological problems
Health care costs

Nutritional assessment (NA)


Body composition
Biochemical data
Clinical Assessment
Subjective Global
Assessment (SGA)

Subjective Global Assessment of Nutritional Status


A. History
1. Weight change
Overall loss in past 6 months: ________ kg

Percent loss ________

increase

Change in past 2 weeks:

no change

decrease

2. Dietary intake change relative to normal


No change ________
Change: duration

________ weeks

___ ____ months

Type: sub-optimal solid diet ________ full liquid diet ________ hypocaloric liquid diet _______ starvation ______
3. Gastrointestinal symptoms (persisting more than 2 weeks)
None

Nausea ________

Vomiting

Diarrhea ________

Anorexia _______

4. Functional capacity
No dysfunction ___________
Dysfunction: duration

_______ weeks _______ months

Type: working sub-optimally ________

ambulatory _________

bedridden _________

5. Disease and its relationship to nutritional requirements


Primary diagnosis: ____________________________
Metabolic demand / Stress: none ________ low ________ moderate ________

B. Physical Examination
(for each specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)
Loss of subcutaneous fat (triceps, chest) ______________
Muscle wasting (quadriceps, deltoids) _________________
Ankle edema ________ Sacral edema ________

Ascites ________

C. Subjective Global Assessment Rating


Well nourished

Moderately (or suspected)


of being) malnourished

Severely malnourished

high ________

Nutritional assessment (NA):


Body composition parameter

Weight and height


BMI = weight / height2
Triceps or subscapular thickness of skin fold
Mid-arm muscle circumference and mid-arm muscle
area

Body mass index calculator

Body weight (BW)


BW change in ICU pt is not a good measure of
outcome because it usually reflect fluid shifts
BW is most useful as serial measurement of the
hospitalized pt to assess fluid status and
response to thx
A more optimal nutritional indicator is BMI

Nutritional assessment (NA):


Biochemical parameters

Serum albumin
Total lymphocyte count
Serum transferrin
Serum pre-albumin
Total iron-binding capacity
Serum cholesterol

At Risk Level
< 3.5 g/dL
< 1500 cell/mm3
<140 mg/dL
< 17 mg/dL
< 250 mcg/dL
< 150 mg/dL

Heymsfield SB, et al. In: Modern Nutrition in Health and Disease. Philadelphia, PA: Lea &
Febiger;1994:812-841.

Serum albumin in critically ill pt


most common measure of prot NS
Critical illness synthesis of alb, shifts in
distribution of alb from the vasc space into
interstitial space, and releases hormones that
metab destruction of alb
indicator of severity of illness
a less sensitive indicator of NS as compared
with clinical judgement based on pts medical
history and PE

Hypoalbuminemia
Often associated with poor outcomes
The National Veterans Affairs Surgical Risk
Study (1999): preop serum alb as predictor of
operative mortality and morbidity
Reinhardt cs (1980) :
25% pts with Alb < 34 gram/L died
2% pts with normal Alb died

Hypoalbuminemia
In acutely ill surgical pts: difficult to attribute
this risk solely to under-nutrition
Alb conc are influenced by fluid redistributions
during critical illness and the acute phase
response
Hence, short-term fluctuations in alb conc
cannot be a solely ascribed to nutritional
deprivation

Prealbumin in critically ill pt


a more immediate indicator of
physiological stress and nutrition, but less
frequently monitored
the earliest lab indicator for NS
a marker of nutritional evaluation

Prealbumin in critically ill pt


a sensitive and cost-effective method of
assessing the severity of illness due to
malnutrition
an accurate predictor of pt recovery
correlate with pt outcomes

Nutritional assessment (NA)

Nutritional assessment (NA)

Nutritional parameters:
Change per type of malnutrition
Chronic
Acute
Malnutrition Malnutrition
Weight
Mid-arm Circumference
Albumin
Lymphocyte Count
Immune Function

Mixed

Subjective Global Assessment (SGA)


1. Weight changes
2 Changes in dietary intake
3. Gastrointestinal symptoms
4. Functional capacity
5. Link between disease and nutritional requirements
6. Physical exam focused on nutritional aspects

Detsky AS, et al. JPEN 1987;11:8-15.

SGA:
1. Weight changes
Over the last six months
During the past two weeks

SGA:
2. Dietary intake
No change
Changes
Duration
Type:
Inadequate conventional diet
Total liquid diet
Clear liquid diet (hypocaloric)
Fasting

SGA:
3. Gastrointestinal symptoms

Nausea
Vomiting
Diarrhea
Anorexia

SGA:
4. Functional capacity
Dysfunction
Duration
Type:
ambulatory
bedridden

Body physiologic function


Direct measurements can be used as markers of
the degree and significance of malnutrition
In critically ill pts who are not able to follow
commands, bedside muscle function can still be
tested

SGA:
5. Illness and Nutritional Requirements
9.3%
Mental Illness
Including Alcohol Abuse Problems

21%
No Risk

11%
Endocrine, Nutritional,
Metabolic, and Immune Diseases
14%
Respiratory Illness
14%
Diseases of the Digestive
System

29.7%
Cancer

Weddle DO, et al. J Amer Diet Assoc 1991;91:140-145.

SGA:
6. Physical Exam

Loss of subcutaneous fat


Muscle wasting
Ankle edema
Sacral edema
Ascites
Mouth, teeth, gum problems

Chewing / swallowing

problems
Angular stomatitis
Fractures or bone pain
Glossitis
Skin alterations

Physical examination (PE)


Body habitus, obesity, muscle mass, pretemporal wasting and edema
Anthropometrics measures (triceps, skin fold
thickness, mid-arm muscle circumference):
objective evaluations of energy pools
Measurement of body prot and fat stores using
anthropometric methods are inaccurate

Subjective Global Assessment:


Diagnosis
Well-nourished
Moderately malnourished or suspected

malnutrition
Severely malnourished

Immunocompetence in malnutrition
Immunity is suppressed by malnutrition (cell
mediated immunity is more affected than
humoral)
TLC and DHST are most frequently used, but not
useful in critically ill pt since sepsis, trauma,
and DIC also depress immune function