Nutritional Status
Content
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 body’s 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
A
Moderately (or suspected)
of being) malnourished
B
Severely malnourished
C
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 pt’s 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
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 body’s 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
A
Moderately (or suspected)
of being) malnourished
B
Severely malnourished
C
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 pt’s 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
