Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support
| d. | Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition |
|---|
Consensus Malnutrition Characteristics (JPEN J Parenter Enteral Nutr 2012;36:275-83)
Diagnosed by the presence of two or more of the following:
| (a) | Insufficient energy intake |
|---|---|
| (b) | Weight loss |
| (c) | Loss of muscle mass |
| (d) | Loss of subcutaneous fat |
| (e) | Localized or generalized fluid accumulation (may sometimes mask weight loss) |
| (f) | Diminished functional status as measured by hand grip strength |
| (1) | In the context of these criteria, hand grip strength intended to be used to document |
decline in physical function as appropriate to patient circumstances
ii.
Nonsevere (moderate) or severe malnutrition determined by duration and severity of above
symptoms, which is further categorized as:
| (a) | Acute illness or injury-related malnutrition |
|---|---|
| (b) | Chronic disease-related malnutrition |
| (c) | Social or environmental-related malnutrition |
iii.
Visceral protein concentrations (e.g., albumin, prealbumin, transferrin) are not reliable
indicators and not included in this definition. They should not be used to assess nutrition status
in critically ill patients (JPEN J Parenteral Enteral Nutr 2016;40:159-211; Nutr Clin Pract
2021;36:22-8).
iv.
BMI is not included in this classification because patients become malnourished regardless of
body habitus.
Empiric weight adjustment for amputations (Table 24)
Body Part Amputation
Approximate Contribution to Body Weight (%)
Foot
1.5
Calf, foot
5.9
Leg (from hip)
Hand
0.7
Hand and forearm
2.3
Arm
Assessing caloric requirements: Indirect calorimetry – Measured energy expenditure by oxygen consump-
tion and CO2 production – The “gold standard”
Respiratory quotient (Vco2/Vo2); 1 for carbohydrate oxidation; 0.7 for fat oxidation; 0.8 for protein
oxidation; greater than 1 usually implies overfeeding (net fat synthesis), less than 0.7 suggests ketosis
or an error in measurement (too much fraction of inspired oxygen [Fio2] variability at higher Fio2
concentrations). Widespread use in clinical practice is limited by availability and cost of indirect
calorimeters. Furthermore, accuracy of measurements is affected by many common factors in the ICU
(presence of chest tubes, use of supplemental oxygen, FiO2 settings, PEEP settings, CRRT, anesthesia,
movement).