Dr. B. Ravinder Reddy is a Consultant Gastrointestinal & General Surgeon, CARE Hospitals, Hyderabad. This video explains the effects of malnutrition in critical illness, the types of nutritional assessment. Dr. Reddy also outlines ways to conduct a bed side assessment of an ICU patient and the problems in assessing nutritional status of a patient. The talk details the components of standard nutritional and subjective goal assessment that relies on the practitioner to take an informed decision while evaluating and assessing a patient – outline of which includes considering the history of the patient, functional capacity and the visible physical traits such as muscle wasting to arrive at a cumulative score.
It is mandatory to assess the nutritional status of all the patients within 24 hours of admission. The effects of malnutrition in ICU includes decrease in immune competence & wound healing, respiratory function, hepatic function, renal function while there is an increase in skeletal & cardiac muscle wasting and GI mucosal atrophy. The various types of nutritional assessments are SGA — Subjective Global Assessment, MUST— Malnutrition Universal Screening Tool, NRS— Nutrition Risk Screening, NRI — Nutrition Risk Index, MNA— Mini Nutritional Assessment, PNI — Prognostic Nutrition Index, DMS— Dialysis malnutrition Score, MIS—Malnutrition Inflammatory Score and PINI— Prognostic Inflammatory & Nutritional Index. Any one of the methods can be used with reasonable ‘accuracy’. There is no ‘gold-standard’ tool for nutritional assessment especially in the critically ill patient.
In critical illness, metabolic responses and energy requirements are different in every critically ill patient. Metabolic alterations are dynamic in the same patient and energy requirements vary with the level of illness. Problem in assessing nutritional status in critically ill patients is that history may not be available or it may be inadequate or it may not be reliable. Physical examination cannot be performed or the patient is sedated or ventilated or is on medications. There might be laboratory parameters which depend on volume status (ECV) which may falsely increase or decrease or are time consuming. Specificity and sensitivity are also the issues that laboratories face.
There are four basic questions that are faced while nutritional risk screening. Is the BMI less than 20.5? Has the patient lost weight in last 3 months? Has dietary intake reduced in last week? Is the patient severely ill (in intensive therapy)? If the answer is yes to any of the questions then proceed to further assessment. The parameters of Subjective Global Assessment are history of weight changes, history of dietary changes, persistent gastrointestinal symptoms, functional capacity effects of disease on nutritional requirements and physical appearance. On the basis of these parameters, patients can be categorized into well-nourished, moderate or suspected malnutrition and severe malnutrition. SGA correlates with percentage of weight loss, TSF, MAMC, BMI, ICU stay, and APACHE Il and SAPS scores. It has been said that SGA is simple, feasible, and may predict patient mortality and length of stay in the ICU.