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Not
all surgical patients require immediate nutritional support.
However, any catabolic patient described in the table or with
pre-existing weight loss and malnutrition requires early nutritional
intervention.
Assessment
begins with determining the current nutritional and metabolic status of
the patient and then determining the status of the surgical illness or
injury. Both factors
dictate the timing of support as well as the quantity.
As
stated, the presence of a pre-existing protein energy malnutrition in
the now stressed patient necessitates beginning nutritional support. |
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CURRENT STATUS |
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There are a number of risk factors for a pre-existing or evolving (PEM)
protein energy malnutrition. |
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Assessment is based on a history of past and current nutritional intake
as well as a history or evidence of a recent involuntary weight loss.
As described, a weight loss of over 10% of normal weight over 6
months, or a 5% decrease in 30 days, is a good marker for malnutrition. |
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Findings on physical exam of impaired nutrition include wasting,
weakness, delayed wound healing and CNS depression.
However, obvious physical findings will not be present with early
malnutrition. |
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Biochemical markers are often more sensitive.
Albumin levels have been frequently used.
However, it is not a very sensitive marker.
The half-life of albumin is over 30 days so it takes a long time
to see a change.
In addition, albumin synthesis is decreased with onset of the
stress response after burns.
Acute phase protein synthesis increases and albumin decreases
unrelated to nutritional status. |
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Pre-albumin (transthyretin) levels are much more sensitive as the half
life is only a few days.
This protein is not an albumin precursor.
A value 15mg/dl reflects early malnutrition and the need for
nutritional support. |
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