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Nutrition Support Blog: Measuring Malnutrition in the ICU

Posted by SF8N at Feb 02, 2015 10:47 PM |
Nutrition Support Blog: Measuring Malnutrition in the ICU

by Joe Krenitsky, MS, RDN

The world of clinical nutrition is in the midst of a fundamental shift in thinking about malnutrition among hospitalized patients.  This change is LONG overdue because the basic science information that albumin is rapidly redistributed from the vascular space in serious illness or injury has been available since the mid 1950’s, and publications have detailed the limitations of serum proteins as markers of nutrition status since the 1980’s.1,2  Nevertheless, we know that malnutrition was largely defined by hypoalbuminemia until the late 1990’s, and many of us still struggle to educate other medical professionals about the limitations of serum proteins as a marker of malnutrition today. 

I think that the consensus statement from our professional organizations that helps define acute and chronic disease/injury related malnutrition is a tremendous leap forward.3  One of the limitations of this “work in progress” is that the average clinician is not able to objectively quantify loss of muscle mass or changes in functional status in most of our patients.  Unfortunately, complications in the ICU are a bit like the Monty Python description of the Spanish Inquisition (no one ever expects them).4  We all have patients that receive partial, interrupted or variable amounts of nutrition, with fluctuating periods of limited recovery interspaced with unexpected inflammatory, infectious or surgical setbacks.  Currently, there is no readily available, objective way to quantify the nutritional progress (or regress) of our patients in this setting. 

New technology may change that in the future however.  A number of recent studies have investigated ultrasound as a noninvasive method to quantify muscle wasting in critically ill patients.5-8 There is clearly more research that is required, but I think this is an area that holds promise, and one we should keep up with as the new information evolves.  I recommend you sit in your “comfy chair” for a spell and check out the JPEN articles on bedside ultrasound and the review on various methods of lean tissue imaging.

http://pen.sagepub.com/content/38/7/886.long

“However beautiful the strategy,

you should occasionally look at the results.”

- Sir Winston Churchill

 

References:

1.   Fox CL Jr, Lasker SE, Winfield JM, et al.  Albumin, potassium, sodium, and chloride redistribution and erythrocyte loss after surgical trauma and extensive burns.  Ann Surg. 1954; 140(4):524-534.

2.   O'Keefe SJ, Dicker J.  Is plasma albumin concentration useful in the assessment of nutritional status of hospital patients?  Eur J Clin Nutr. 1988;42(1):41-45.

3.   White JV, Guenter P, Jensen G, et al.  Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).JPEN 2012 ;36(3):275-283.

4.   Palin M, Jones T, Gilliam T.  Monty Python's Flying Circus, Series 2 Episode 2, first aired September 22, 1970.

5.   Tillquist M, Kutsogiannis DJ, Wischmeyer PE, et al.  Bedside ultrasound is a practical and reliable measurement tool for assessing quadriceps muscle layer thickness.  JPEN J Parenter Enteral Nutr. 2014 ;38(7):886-890.

6.   Connolly B, MacBean V, Crowley C, et al.  Ultrasound for the Assessment of Peripheral Skeletal Muscle Architecture in Critical Illness: A Systematic Review.  Crit Care Med. 2014 Dec 31. [Epub ahead of print]

7.   Segers J, Hermans G,  Charususin N, et al.  Assessment of quadriceps muscle mass with ultrasound in critically ill patients: intra- and inter-observer agreement and sensitivity.  Intensive Care Medicine. 2015 January 29 (Epub ahead of print).

8.   Prado CM, Heymsfield SB.  Lean tissue imaging: a new era for nutritional assessment and intervention. JPEN J Parenter Enteral Nutr. 2014 Nov;38(8):940-953.

 

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