CICM SAQ 2010.2 Q20

Questions

Outline your approach to the assessment of nutritional status in a critically ill patient, including the use of appropriate laboratory tests.

Answers

Answer and interpretation

History and physical examination:

  • Indicators of malnutrition – recent involuntary weight loss, changes in appetite or bowel habit, presence of persistent GI symptoms, muscle wasting, signs of specific micro-nutrient deficiency e.g. glossitis, angular stomatitis, anaemia, bleeding gums, skin/hair/nail condition.

Ancillary blood tests:

  • serum hepatic protein levels are linked to nutritional status and severity of illness.
  • Serum albumin and pre-albumin levels. ( Albumin will be a better indicator of chronic nutritional status and pre-albumin serves more as a marker of changes in current nutritional status).
  • Transferrin and coagulation factors: Useful but may more reflect the poor synthetic function of the liver in this case than nutritional deficiency per se.
  • Fat-soluble vitamin deficiency levels of vitamins A, D and E should be checked. Water-soluble vitamin deficiency, (thiamine), is common in alcoholic liver disease and therefore levels of thiamine and other treatable vitamins e.g. zinc, selenium, Vit B12 and folate should also be checked.
  • Other
    (1) delayed hypersensitivity skin testing
    (2) total lymphocyte count
    (3) anthropometric measurements e.g. mid-arm muscle circumference and skin-fold thickness
    (4) indirect calorimetry to measure energy expenditure – metabolic cart, VO2, VCO2,
    (6) nitrogen balance – but calculations inaccurate in liver and renal failure.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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