The Generalist: Nutrition Support in Hospitalized Patients
Jake Anderson, DO, and Vanessa Cardy, MD
Hospitalized patients are at high risk of being undernourished, but specialized nutrition support via enteral or parenteral feeding can be confusing. Vanessa and Jake break it down in this month’s generalist segment.
- Hospitalized patients are at high risk of being undernourished.
- Acute illness is a catabolic state.
- Nutritional intake can be impaired due effects of illness:
- Shortness of breath
- Nausea and vomiting
- Altered mental status
- What does the research say about nutritional support?
- There is a lack of rigorous trials, with most data being of low quality and heterogeneous.
- Data are mixed as to the benefits of nutritional support.
- Early nutritional support for the highest risk patients probably helps decrease risk for infections and might decrease the risk of readmissions.
- The effect on mortality is less clear.
- Patients should be screened for malnutrition risk soon after admission:
- Nutritional Risk Score 2002
- NUTRIC Score
- Labs such as albumin, prealbumin, and transferrin are less accurate and not recommended.
- Screening should be repeated during admission, particularly if there is a change in clinical status.
- When to start supplementation?
- High nutritional risk patients should immediately start supplementary enteral nutrition.
- Patients at low nutritional risk who are expected to resume adequate intake within 5-7 days do not need immediate supplementation but require reassessment.
- Discontinue supplementation when patients are able to meet their needs with independent oral intake.
- Nutritional goals
- Caloric goal can be determined via weight-based calculation.
- Protein goal should be determined separately and is typically higher for patients with more critical illness.
- Route of supplementation
- Enteral feeds are preferred due to lower cost and fewer complications.
- Deliver via orogastric or nasogastric tube:
- Duration of therapy (can be weeks)
- Confirm placement with X-ray
- Consider post-pyloric placement in those at high risk of aspiration or who don’t tolerate gastric feeds
- For anticipated use >1 month, consider percutaneous tube placement, eg, percutaneous endoscopic gastrostomy (PEG) tube.
- Potential complications:
- Aspiration and vomiting
- Consider adjusting the feeding rate or switching from bolus feeds to continuous.
- Consider post-pyloric tube placement.
- Additional fiber may help
- Metabolic issues like refeeding syndrome
- Parenteral nutritional should be reserved for
- Those with a contraindication to enteral feeds:
- total intestinal obstruction
- intractable vomiting or diarrhea
- uncontrolled diffuse peritonitis
- paralytic ileus
- gastrointestinal ischemia
- bowel perforation
- Those with inadequate intake (ie, <60% of caloric goal) via enteral feeds.
PEARL: Remember that hospitalized patients are at risk of malnutrition, and the enteral route is preferred over the parenteral for nutritional supplementation.
ACG Clinical Guideline: Nutrition therapy in the adult hospitalized patient
McClave SA, DiBaise JK, Mullin GE, et al. Am J Gastroenterol. 2016;111(3):315-334. doi: 10.1038/ajg.2016.28
Nutritional management of medical inpatients
Reber E, Gomes F, Bally L, et al. J Clin Med 2019;8(8):1130. https://doi.org/10.3390/jcm8081130
Nutrition Risk in the Critically Ill (NUTRIC) Score - MDCalc
Nutrition Risk Screening 2002 (NRS-2002) - MDCalc
PCMA Archive 2017 November PEG Insertion In Patients With Dementia Does Not Improve Nutritional Status And Has Worse Outcomes AS Compared With PEG Insertion For Other Indications