Malnutrition

VITAMIN A

-Sources of Vitamin A include animal and plant -Involved in several functions Vision Epithelial differentiation Bone development Growth Immune function Reproduction

BULIMIA NERVOSA

-These individuals appear well nourished but alternate between eating and vomiting -A psychological disorder that involves self-image, obsessive-compulsive behavior, and depression -They use laxatives and diuretics -Have esophageal erosions from gastric acid and decreased gastroesophageal sphincter tone, increases risk of pulmonary aspiration

ANOREXIA NERVOSA

A psychiatric/emotional disorder of primarily adolescent and young women -There is a progressive use of body fat for metabolic fuel -All organ systems are affected, with infection being the final step to death -Adults can withstand a 40% decrease below ideal body mass, after this the body will begin to deteriorate -It is prudent to delay surgery until the patient's nutritional status is improved (Must avoid the Refeeding Syndrome) -Have increased morbidity and mortality

Fat soluble vitamins

A, D, K and E

VITAMIN B12

All dietary cobalamin is produced by bacteria and obtained from animal sources It's involved in amino acid metabolism NO2 has been shown to interfere with cobalamin function. It may manifest as an acute deterioration of the nervous system function The neurologic deficit is related to a vitamin B12- dependent production of methionine

Water soluble vitamins

C, B1, B2, B3, B6, B12, and folic acid

Physiologic And Metabolic Effects Of PEM With Anesthetic Implications

Hepatic: Altered metabolic pathway Depressed albumin production Depressed plasma cholinesterase production Altered drug redistribution (fat soluble) Altered sensitivity to narcotics Renal Function in advanced stages: Impaired fluid and electrolyte balance Impaired drug excretion Altered neuromuscular junction activity

VITAMIN C

Humans not able to synthesize Vitamin C Sources include citrus and other fruits and vegetables Vitamin C involved in Synthesis or metabolism of collagen, carnitine, tyrosine, and neurotransmitters Deficiency results in scurvy

Management of refeeding

K: 4 mmol/kg/day Mg: 0.4 mmol/kg/day Folic acid 1 mg/day Zinc 2 mg/kg/day Copper 0.3 mg/kg/day

PROTEIN-ENERGY MALNUTRITION

Primary •Results from inadequate dietary intake •Noted in developing countries Secondary •Caused by decreased absorption or increased nutritional needs •Acute or chronic illness

VITAMIN K

Significant amount is produced by colonic bacteria and its passively absorbed Dietary sources: vegetable oils, green leafy vegetable, and legumes Vitamin K is required for the proper formation of vitamin K dependent clotting factors (II, VII, IX, and X) which are produced in the liver It is important in blood coagulation and clotting Deficiency is rare

VITAMIN E

Sources of this vitamin include plants and animals Vitamin E is an antioxidant Deficiencies are rare Its involved in cell membrane repair and maintenance

UNDERNOURISHED STATES

There is a dietary deficiency in protein and/or caloric intake -Protein-energy malnutrition (PEM): Primary Secondary

Marasmic-Kwashiorkor

combination of chronic energy deficit and chronic or acute protein deficiency

KWASHIORKOR Physical Findings

´Apathetic, listless affect ´Rounded prominence of the cheeks ("moon-face") ´Pursed appearance of the mouth ´Thin, dry, peeling skin with confluent areas of hyperkeratosis and hyperpigmentation ´Dry, dull, hypopigmented hair that falls out or easily plucked ´Hepatomegaly (from fatty infiltrates) ´Distended abdomen with dilated intestinal loops ´Bradycardia, hypotension, and hypothermia ´Despite generalized edema, most children have loose inner inguinal skin folds ´

What happens with Marasmus?

´As a result of the child no longer absorbing the required intake of nutrients, the body will automatically break down and consume its own tissue, fat and muscle. ´This process releases carbohydrates and protein which the body needs to survive.

How is edema graded?

´In malnutrition; ´Mild (1+) Edema involves only the feet ´Moderate (2+) Edema involves the feet and legs and/or the upper limbs ´Severe (3+) Generalized edema or moderate plus facial edema.

KWASHIORKOR cont.

´Kwashiorkor is also referred as the "wet type" of malnutrition because of edema. Edema is an increase in fluids within the body. ´One of the main causes behind kwashiorkor is weaning. The mother's milk usually consists of many vital nutrient such as amino acids which are the building blocks of proteins. ´Unfortunately in poorer countries, protein sources such as meat, are simply too expensive . The result is a diet of starch which is moderate in caloric intake but lacks vital nutrients that the mother's milk provided.

What is the difference between Kwashiorkor & Marasmus

´The main difference between kwashiorkor and marasmus is caloric intake. ´Marasmus is characterized as minimal protein and energy intake, whereas kwashiorkor on the other hand is characterized as having minimal protein but with an average caloric intake. ´In other words, kwashiorkor is a protein deficiency disorder.

VITAMIN D

•Its produced with skin exposure to sunlight Involved in: •Bone growth and development •Vital in the absorption of calcium and phosphorus in the intestines •Hypocalcemia in children can present as rickets •Hypocalcemia in adults presents with brittle bones and joint problems

KWASHIORKOR

•Refers to a child who is weaned from breastfeeding when another child is born •There is a loss of their only source of protein •Occurs in tropical societies where the main source of food comes from carbohydrates with low protein content •These children appear nourished but have severe protein deficiency

MARASMUS

•Refers to a dietary deficiency of both proteins and calories •These children are progressively starved •They are emaciated with generalized muscle wasting •Occurs in areas of famine or in cases of child neglect

ANESTHETIC IMPLICATIONS

•These children must be nutritionally improved before the procedure •Must avoid the Refeeding Syndrome •These children are at extreme risk, surgical procedures must be delayed until the child approaches a "normal" height and weight -Waiting is not always an option but you must stabilize this child as much as possible -Follow the WHO guidelines on resuscitation and stabilization

REFEEDING SYNDROME

•When victims of starvation are provided a high- calorie and high-protein diet •Reductive adaptation- when the body conserves energy and nutrients when severely malnourished •These patients die of gastrointestinal and metabolic derangement