ASSESSMENT OF NUTRITIONAL STATUS

Early detection of malnutrition in critically ill patients, whether preexisting or a

result of acute illness, enables prompt and aggressive intervention with
supplemental nutrition. No single measurement or assessment tool can adequately
characterize nutritional status, and the diagnosis of malnutrition remains somewhat
subjective [22]. However, both functional and biochemical parameters should be
examined in order to identify patients who are at increased risk for developing
malnutrition and its complications [23].

Functional assessment — The functional nutritional assessment consists of the

medical history, physical examination, and an appraisal of muscle and organ
function [24].
• Identification of preexisting malnutrition (ie, malnutrition that occurred prior
to the onset of critical illness) should be attempted by careful attention to the
history of present illness, the relevant past medical and surgical history,
medications, social habits, and a focused dietary history. Obtaining this
information from a critically ill patient frequently is impossible, but a patient's
family may be able to provide data on recent dietary habits and/or weight
loss. The degree to which the patient's usual weight deviates from estimated
ideal body weight should be considered (show table 1), and the period of time
over which the weight has changed is important in evaluating the severity of
weight loss (show table 2) [25].
• Historical data should be used to estimate the nutritional consequences of
the current hospitalization. Prehospitalization weights should be documented,
and any weight changes since hospitalization should be noted and evaluated
in the context of concomitant diuresis or fluid supplementation [10]. Critically
ill patients frequently suffer from volume overload, making changes in dry
weight difficult to assess.
• Physical examination may suggest the presence of nutritional and metabolic
deficiencies. Temporal muscle wasting, sunken supraclavicular fossae, and
decreased adipose stores are easily recognized signs of starvation. Careful
inspection of the hair, skin, eyes, mouth, and extremities can reveal
additional stigmata of protein calorie malnutrition or vitamin and mineral
deficiencies (show table 3) [26,27].
• An assessment of muscle mass and function can yield information about a
patient's protein reserves and overall nutritional status. An estimation of
muscle mass and fat stores can be obtained from anthropometric
measurements such as arm circumference (show table 4).
• The function of the cardiovascular, respiratory, and gastrointestinal systems
should be evaluated both for evidence of malnutrition-related dysfunction
and because functional deficits may affect the ability of the patient to
tolerate nutritional supplementation. As examples, the large fluid volumes
associated with parenteral nutrition may not be tolerated in the setting of
impaired cardiovascular function, and a distended abdomen may makes
tolerance of enteral supplementation less likely [24,27].
Metabolic assessment — Information from certain laboratory tests may supplement
the functional assessment, and should be ordered on every patient as part of the
standard nutritional evaluation.
• Serum albumin concentration is the most frequently used laboratory measure
of nutritional status; a value less than 2.2 g/dL generally reflects severe
malnutrition. Despite its popularity as an indicator of nutritional status, the
reliability of albumin as a marker of visceral protein status is compromised
by its long half life of 14 to 20 days, making it less responsive to acute
changes in nutritional status. Furthermore, the serum albumin concentration
rises rapidly in response to exogenously administered albumin, and is altered
in conditions such as dehydration, sepsis, trauma, and liver disease
irrespective of nutritional status [24,27,28].
• Prealbumin (transthyretin) is a more reliable indicator of nutritional status
than albumin because its half life of 24 to 48 hours makes the plasma
concentration more reflective of the current nutritional state [24,27].
However, as is the case with albumin, the concentration of prealbumin is
diminished by renal and liver disease. Transferrin has a half-life of 9 days,
making it intermediate between prealbumin and albumin in its sensitivity for
incipient malnutrition [27].
• Serum chemistry values are important in determining the specifics of
nutritional support, but do not directly reflect nutritional status. Sodium,
potassium, chloride, total carbon dioxide, blood urea nitrogen, glucose,
prothrombin time, partial thromboplastin time, iron, magnesium, calcium,
and phosphate should be measured on admission and rechecked periodically
(show table 5).
• The adequacy of cellular immunity can be estimated through the
measurement of total lymphocyte count (TLC) and by delayed type
hypersensitivity testing with a series of common antigens (eg, Candida,
Trichophyton, tuberculin, diphtheria, and a glycerin control) [29,30]. (See
"Laboratory evaluation of the immune system"). Compromise of cell-
mediated immunity due to malnutrition is suggested by a TLC 1000/mm3 or
a lack of skin test induration greater than 5 mm above glycerin control at 48
hours, unless another cause of lymphocyte dysfunction is present. Delayed
type hypersensitivity testing is least useful during an acute illness because
cell-mediated immunity may be depressed in this setting even in the absence
of malnutrition [31].