With respect to nutritional support in the critically ill:
a) Outline how you would assess the nutritional status of a patient with suspected malnutrition.
b) Outline the pathophysiology of severe re-feeding syndrome. (30% marks
This is notoriously unreliable as there are many conditions that can alter the non-specific markers of nutritional status.
A good history should include the circumstances of poor intake (duration, cause, etc.), a background of previous eating behaviours, and GIT symptoms (nausea, vomiting diarrhoea, weight loss)
Serum albumin (longest half-life at 18 – 20d)
Serum transferrin (half-life of 8 – 9d), but also reflects iron status, and low transferrin should be considered an indicator of protein status only in the setting of normal serum iron.
Serum pre albumin (half-life at 2 – 3d) - responds quickly to the onset of malnutrition and rises rapidly with adequate protein intake, but altered in the acute phase response due to acute or chronic inflammation.
Reintroduction of glucose into diet after a considerable period of fasting
Insulin in response to glucose load moves the glucose into cells (with K and Mg) The first step of glycolysis is the phosphorylation of glucose. This holds the glucose in cells. This leads to sudden and precipitous fall in phosphate that is the hallmark of refeeding syndrome Severely reduced phosphate is available for ATP, cAMP
Failure of tissues with high energy requirement - heart, kidney, muscle (rhabdomyolysis), brain, respiratory (diaphragm)
Biochemistry and physiology:
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