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Nutrition in the Patient with Anorexia and Cachexia

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Nutrition in the Patient with Anorexia and Cachexia. Jeanette N. Keith, M.D. Associate Professor of Medicine Departments of Nutrition Sciences and Medicine University of Alabama at Birmingham. Two major types Marasmus Kwashiorkor ( AKA: Protein Calorie Malnutrition ). - PowerPoint PPT Presentation

Text of Nutrition in the Patient with Anorexia and Cachexia

  • Nutrition in the Patient with Anorexia and CachexiaJeanette N. Keith, M.D.Associate Professor of MedicineDepartments of Nutrition Sciences and MedicineUniversity of Alabama at Birmingham

  • Protein-Energy MalnutritionTwo major typesMarasmusKwashiorkor (AKA: Protein Calorie Malnutrition)Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • MarasmusHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • KwashiorkorHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • Minimum Diagnostic CriteriaHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • Physiology of Starvation & StressHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • Metabolic RateLong CL, et al. JPEN 1979;3:452-6Normal range

  • Protein CatabolismLong CL. Contemp Surg 1980;16:29-42Normal range

  • The Course of Protein-Energy MalnutritionMildModerateSevereSeverity of PEMDaysWeeksMonthsYearsKwashiorkorMarasmusSeverely catabolicMildly catabolicHeimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

  • Case Presentation27-year old female with a 35 pound weight loss in the last six months presents to your morning clinic with her mother

    In the last two weeks, she has lost an additional 10 pounds. She reports decreased po intake, mild epigastric discomfort and bloating

    The patients main concern is the loss of appetite, and fatigue

    She is 57 tall and weighs 67 pounds, (BP 90/40, P60, R18, T97.8)

  • Case PresentationThe patients mother calls you at 6 pm stating that her daughter is having palpitations and is on her way to the emergency room.

    The ER staff pages you. Her ECG reveals torsade des pointes and her potassium is 1.9.

    She is admitted to the Cardiology service and you are consulted for feeding recommendations.

  • Case PresentationWhat do you recommend now?Immediate placement of a PICC catheter for TPN initiation.

    Have the inpatient team place a dobhoff and begin tube feedings

    Call GI procedures to arrange for PEG placement and enteral feedings.

    Call Dietary for a 1600 kcal diet and begin a calorie count

    Intravenous fluids while correcting the potassium and awaiting other lab studies.

  • Case PresentationThe patients potassium is now normal but her course has been complicated by recurrent vomiting.

    EGD reveals a decreased gastric motility and a dilated duodenum bulb with normal motility in the second portion of the duodenum.

    What do you recommend next? Advance her diet to clear liquidsBegin TPNPlace a post-pyloric feeding tube and begin enteral nutrition

  • Case PresentationYou place a post pyloric feeding tube for enteral nutrition.What weight do you use for caloric provision? Ideal Body WeightActual WeightAdjusted Body WeightHow many calories per kilogram per day do you recommend?35-40 kcal/kg/d25-30 kcal/kg/d15-20 kcal/kg/d20-30 kcal/kg/d

  • Case PresentationOn the morning after beginning her enteral feeding, the patient complains of palpitations and pain in her hands.

    On exam, her hands are swollen and she has pedal edema. Pulmonary exam reveals rales.

    Her potassium is now 2.9, phophorus is 1.8 and magnesium is 1.4.

    Diagnosis?

  • Refeeding SyndromePatient at risk = cachectic/marasmic patientUnderlying low cardiac output:

    Cardiac atrophy

    Low metabolic rate

    Predominantly fatty acid utilization

    Superimposed demand for increased CO:

    Fluid challenge

    Glucose challenge

    Increased catecholamines & metabolic rate

    Hypophospha-temiaHeart failure:

    Fluid overload

    Cardiac & respiratory decompen-sation

  • Case PresentationThe patient is admitted to inpatient psychiatry for the treatment of anorexia/bulimia nervosa.

    After 4 weeks on tube feedings, she was successfully transitioned to oral diet.

    At discharge, her weight was 99 pounds.

  • Selective Refeeding ApproachesHypometabolic, cachectic/marasmic patientAim = rebuild cautiously to avoid hypophosphatemia & repletion heart failureRefeed gradually with a portion of fuel as fatADEQUATE PHOSPHORUSDays 1-2 BEE x 0.8Days 3-4 BEE x 1.0Days 4-6 BEE x 1.1-1.4Days 7+ BEE x 2 if weight gain is desired

  • Selective Refeeding ApproachesHypermetabolic, stressed patientAim = Replace catabolic lossesRefeed aggressively but not excessivelyCan often achieve calorie & protein goals within 48 hours

    Patient with mixed marasmic/kwashiorkor (starved but also stressed)Metabolism is accelerated by stressTherefore, generally feed as you would a patient with kwashiorkorBut watch carefully for refeeding syndrome

  • Key Points To RememberThe metabolic response to starvation for the hypometabolic patient is to reduce their metabolic rate and use fat as the primary fuel source

    Visceral protein stores are preserved in early in the clinical course of the hypometabolic, starved state

    In underweight patients, use the actual body weight to avoid overfeeding.

    Monitor for re-feeding syndrome with oral, enteral or parenteral nutrition.

  • Take Home PointsThe stressed hypermetabolic patient is more likely to suffer the consequences of underfeeding.

    The starved, unstressed patient is at risk for the complications of overfeeding and rapid re-feeding.

    If protein calorie malnutrition (kwashiorkor-type) predominates, vigorous nutrition therapy is urgent.

    If marasmus predominates, feeding should be more cautious.