This book is a guide for clinicians seeking to use metabolic approaches in the care of hospitalized patients. Since a nutritional component exists for practically any disease process managed, it is important to properly address the macro- and micronutrient issues that can help facilitate a favourable clinical outcome.
Metabolic medicine is a newly recognized speciality that applies proven nutritional approaches to support hospitalized patients within existing standards of care. Optimizing Metabolic Status for the Hospitalized Patient: The Role of Macro- and Micronutrition on Disease Management addresses the gap of nutrition knowledge among physicians who generally care for patients without addressing the nutritional and metabolic perspective.
Features:
- State-of-the-art guidelines for practicing metabolic medicine in the hospital setting
- “Hands on” guide for day-to-day metabolic management of hospitalized patients
- Personal insights from one of the field’s leading practitioners, drawing upon decades of experience
- Historical reviews of key scientific developments
This book is written by Dr Michael M. Rothkopf, Clinical Professor of Medicine at Rutgers/New Jersey Medical School. Dr Rothkopf founded the Metabolic Medicine Center at Morristown Medical Center and is the current Metabolic Medicine Consultant for the Heart Transplant, Lung Transplant, Cardiac Surgery and Wound Care Programs at RWJBH/Newark Beth Israel Medical Center.
This book is directed at the physician level of hospital care. It provides value to a broad range of physicians regardless of their medical specialty or subspecialty. It will also be useful for medical students and resident physicians in training as well as nurse practitioners and physician assistants working in hospital settings.
Author(s): Michael M. Rothkopf, Jennifer C. Johnson
Publisher: CRC Press
Year: 2022
Language: English
Pages: 426
City: Boca Raton
Cover
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
Preface
The Author
The Editor
Acknowledgments
Chapter 1 An Introduction to Metabolic Medicine
Overview of Metabolic Medicine: Definitions, Diseases, Roles and Venues
Definition for the Field of Metabolic Medicine
What Metabolic Medicine Is Not
Scope of Conditions We Treat
Nutrition for Disease Prevention
Adjunctive Nutritional Therapy for Non-Nutritional Conditions
The Primary Diseases of Nutrition
Roles of Physician Nutrition Specialist
Practice Venues of Metabolic Medicine
Factors Driving the Emergence of Metabolic Medicine
Who is This Book Intended For
The Professional “Metabolist”
The Contrasts between Hospital and Outpatient Metabolic Medicine
The Hospital Metabolic Medicine Practice
Case Study 1-3
Patients Who Bridge the Hospital and Clinic/Outpatient Setting
The Outpatient Metabolic Medicine Practice
Summary
References
Chapter 2 A Brief History of Nutritional Medicine and the Emergence of Nutrition as a Medical Subspecialty
Development of the Sub-Specialization in Medicine
Major Milestones in the History of Nutrition in Medicine
Scurvy and the Role of Vitamin C
Beriberi, Wernicke–Korsakoff Syndrome, and the Role of Thiamine
Night Blindness and the Roles of Vitamin A and Beta-Carotene
Rickets and Vitamin D
Pellagra and Niacin
Nutritional Anemias
Microcytic Iron Deficiency Anemia (IDA)
Vitamin B[sub(6)] Deficiency and Anemia
Macrocytic Anemia
The Role of Vitamin B[sub(12)]
Normocytic Anemia and Copper Deficiency
Nitrogen Metabolism
Energy Metabolism
Nutritional Support Services
Bariatric Surgery
Metabolic Syndrome
Major Milestones in Nutritional Science (Chronologically)
Summary
References
Chapter 3 An Abbreviated History of Nutritional Support
Breaking the Nutrition Barrier
Stan Dudrick and the Invention of TPN
Intravenous Fat Emulsions
Nutrition Support Teams (NSTs)
Home TPN
Advances in Enteral Nutrition
Summary
References
Chapter 4 The Practice of Metabolic Medicine
The Role of the Hospital Metabolist
Overview
When It is Needed
What It is
Roles
Types of Patients
Overview
Referral Locations and Sources
Full Nutritional Support (Enteral Nutrition or PN)
Optimizing Oral Intake
Correcting Micronutrient Deficiencies
Managing Home TPN/Enteral
Bariatrics
Consulting Considerations
Interaction with Hospital Staff and Administration
RDs
RPhs/PharmDs
Speech Therapy
Respiratory Therapy
Administration
Hospital-Level Metabolic Consultative Services (Overview)
Nutritional Support Consults
Nutritional Evaluation Consults
Follow-Up Consults
Transfer to Subacute Facilities on PN/Enteral
Transfer to Homecare on PN/Enteral
Metabolic Monitoring After Bariatric Surgery
Consultation Components
The Nutritional History
The Nutrition Focused Physical Exam (NFPE)
Labs and Specialized Metabolic Testing
The Initial Metabolic Assessment and Plan
An Example Case for the Initial Metabolic Consultation
History
Past Medical and Surgical History (PMSH)
ROS
Examination
Laboratory Data
Impression
Recommendation
Record Keeping
Subjective
Objective
Assessment and Plan
Billing and Coding
CPT Codes
ICD-10 Codes
Overview of a Typical Day as a Physician Nutrition Specialist
Rounds at the Hospital
Post-Rounds Charting, Billing and Communications
The Metabolic Clinic
Role of Clinic Metabolist
Overview and Roles
Referrals
Clinic-Level Metabolic Consultative Services
Overview of Types of Services Offered
Follow-Up Visits
Specific Types of Services
Medical Obesity Management
Outpatient Follow-Up Metabolic Monitoring of the Bariatric Surgery Patient
Diagnosis and Management of Metabolic Syndrome
Home TPN Management
Specialized Nutrition Programs and Unusual Conditions
Practical Clinic Matters
Summary
References
Chapter 5 Hospital Resources
PN Order Forms and Protocols
Element 1. We Start by Reviewing the PN Order Form
Element 2. Review the Hospital PN Protocol
Element 3. The PN Pharmacist
Element 4. PN Line Insertion
Here’s a Little Tip on How I Handle that Situation
Element 5. Tube Feeding Formulary and Protocols
Element 6. The Nutrition Support Dietitian
Element 7. The Nutrition Committee
Element 8. The Metabolic Laboratory
Element 9. The Metabolic Cart
Element 10. The Homecare Coordinator
Element 11. A Qualified Home PN Provider
The Concept of a “Metabolic Hospital”
Summary
References
Chapter 6 The Initial Metabolic Medicine Hospital Consult
Clinical Forms of Malnutrition
Stages of Deficiency
Screening for Malnutrition: The SGA, MNA, and MUST/MST
The Initial Metabolic Consultation
The Metabolic HPI Plug-In for the Malnourished Patient
General Patient Overview - Nutritional Symptoms
Food Processing Symptoms
Nutrient Incorporation and Utilization Symptoms
Diet and Lifestyle History
The Metabolic Plug-in for the PMFSH in Malnutrition
The Metabolic Plug-in for the Physical Exam in Malnutrition
Metabolic Laboratory Results
The Metabolic Assessment and Plan
The Physician’s Nutritional Assessment
Nutritional Diagnosis
ICD-10 Coding
Estimation of Energy and Protein Requirements
Energy Metabolism (Glucose and Fatty Acids)
Electrolyte Balance, Including the Free Water Deficit (If Present)
Minerals and Trace Elements
Vitamin Status
Fluid Balance
GI Tract Status
The Plan
Nutritional Support
Glucose and Fatty Acid Metabolism
Electrolyte Imbalance
Micronutrient Deficiencies
Fluid Status
Closing Statement
Example Case Report: Initial Metabolic Hospital Consultation
Follow-Up Consultations
Example Template for the Metabolic A/P for a Follow-up Note
Summary
References
Chapter 7 The Nutrition-Focused History and Physical Examination (NFPE) in Malnutrition
Example Case Report: The Nutrition-Focused History and Physical Examination (NFPE)
The Metabolic HPI for the Malnourished Patient
Steps to Follow as You Interview the Patient
Step 1 – General Nutritional Symptoms
Unintentional Weight Loss
Total Caloric Intake
Constitutional Symptoms
Body Image Symptoms
Skin/Nails/Hair Symptoms
Step 2 – Food Process Symptoms
Cerebral Symptoms
Sensory Symptoms
Mouth Symptoms
Throat Symptoms
Stomach Symptoms
Intestinal Symptoms
Step 3 – Nutrient Incorporation, Utilization, and Allergy Symptoms
Step 4 – Diet and Lifestyle History
The Metabolic PMH/PSH in Malnutrition
The Metabolic ROS in Malnutrition
The Metabolic Physical Examination in Malnutrition
Height
Weight
BMI
Assessing Muscle Mass
Fat Depletion
Nutritional Edema
Skin/Nails/Hair
Organ System-Based Physical Findings in Malnutrition
Categorizing PCM
PCM Quantification Tools
Summary
References
Chapter 8 Metabolic Laboratory Data
The Concept of Clinical Biochemistry
Typical Order Sets
The First Set is Used When We See a Patient with Malnutrition for an Initial Consult
Example Laboratory Order Set for a New Consult in a Malnourished Patient
Example Laboratory Order Set for a New Consult in a Malnourished Critically-ill Patient
Order Set for Renewing PN or Enteral Feedings
Example Laboratory Order Set for a Follow-Up Consult in a Malnourished Patient on Nutritional Support
Optional Addition Labs Based on Clinical Suspicion or Physical Findings
Example Laboratory Order Set for Monitoring a Long-term PN Patient
Laboratory Interpretation
Basic Labs for a New Hospital Consult
Glucose
The Electrolytes (Na, K, Cl, HCO[sub(3)], Ca, PO[sub(4)], Mg)
Blood Urea Nitrogen
Albumin: Structure, Synthesis and Distribution
Liver Function
Micronutrient Levels
Urea Nitrogen, Protein Catabolic Rate, Nitrogen Balance
Creatinine Height Index
Summary
References
Chapter 9 The Metabolic Cart
A Brief History of Indirect Calorimetry
Energy Components and Definitions
Estimating, Calculating and Measuring Energy Expenditure (EE)
Technical Considerations and Validation of Indirect Calorimetry
Interpretation of Metabolic Cart Studies
Example Case Report: REE in a Critically-Ill Patient
Summary
References
Chapter 10 Preparing the Malnourished Patient for Parenteral Nutrition (PN)
Case Presentation
PN Contraindications
Relative PN Contraindications
Allergy
Bacteremia and Fungemia
Liver Disease
Renal Failure
Timing
Risk of PN-Related Complications
Risks Relationship to the Pre-PN Metabolic State
Accumulating Risks of Ongoing PN
Obtaining Baseline Metabolic Data
Getting Appropriate IV Access
Peripheral Access
Central Venous Access
PICC Lines
Specialized PN Catheters
Refeeding Conditions
Wernicke’s Encephalopathy (WE)
Example Case Report: WE/WKS
Beriberi
Avoiding Refeeding Syndrome and WE with PN Initiation
Volume
The “On-Ramp” Approach
Summary
References
Chapter 11 Parenteral Nutrition Components, Admixture and Administration
Nomenclature and Abbreviations
Carbohydrates
Amino Acids
Lipid Emulsions
Multivitamins (MVI) and Trace Elements
Standardized PN Preparations
PN Compounding
Parenteral Nutrition Components
Mixed Amino Acids
Practice Pearl
BCAA-Enriched Amino Acids
Essential Amino Acid Solutions
Dextrose
Lipids
Practice Pearl
tElectrolytes
Sodium
Potassium
Phosphate
Magnesium
Calcium
Calcium Phosphate Microprecipitates
Free Water
Vitamins
Trace Elements
Other Additives
Parenteral Nutrition Administration Factors
Formula Final Osmolarity
Practice Pearl
Practical Considerations: Filters, Bags, Tubing, Hang Time,
Infusion Protocols, Supply Shortages
Filters, Bags, Tubing, Hang Time
Infusion Protocols
Nutrient Supply Shortages
Summary
References
Chapter 12 Writing the Initial Parenteral Nutrition Order
Case Study
Step 1. Preparing the Order Form
Step 2. Macronutrient Selections
Calories
The Simplest Approach: Estimate Caloric Needs
The Next Approach: Calculate Energy Requirements Using a Formula
The Third Approach: Measure
Protein
Volume
Converting Calculated Requirements into Grams of Nutrients
Method 1. Calorie-Based Macronutrient Formulation
Mathematical Formulas for Method 1
Method 1 Applied to the Initial Formula for an Adult Female
Practice Pearl
Method 2. Protein-Based Macronutrient Formulation
Method 1 Applied at Full Dosage for an Adult Male
Method 3. Physiology-Based Macronutrient Formulation
Method 2 Applied to Adult Female Example Case
Mathematical Formulas for Method 3
Method 3 Applied for an Adult Male
Method 4. Glucose Delivery-Based Macronutrient Formulation
Mathematical Formulas for Method 4
Method 4 Applied for an Adult Male
Impact of Artificial Feeding on Metabolism
Step 3. The Electrolyte and Micronutrient Section
Sodium
Free Water
Chloride and Acetate
Potassium
Calcium, Phosphate and Magnesium
Vitamins and Trace Elements
Pharmaceuticals Added to PN
Step 4. Completing the Orders
Summary
References
Chapter 13 The Follow-Up Metabolic Medicine Hospital Consultation
The Follow-Up Consult: Approach and Methodology
Step 1. Review Results and Update the Chart
Catching-Up on Metabolic Data Returning to the Chart
Interpreting the REE
Interpreting the UUN
Interpreting the Urinary Creatinine
Interpreting Micronutrient Levels
Step 2. Determining Therapy Tolerance and Monitoring for Complications
Clinical Findings
Routine Follow-Up of Biochemical Parameters
Nutritional Support Complications
Line Complications: Infection and Thrombosis/Occlusion
Volume Complications: Overload, Diuresis and Free Water
Hepatobiliary Complications: Steatosis, Cholestasis, Sludge and Stones
Step 3. Determining the Response to Therapy
Clinical Response
Biochemical Response
Anabolic Resistance
Summary
References
Chapter 14 Parenteral and Enteral Nutrition in Critical Illness
Phases of the Metabolic Response in Critical Illness
Combining Parenteral and Enteral Nutritional Support
Hypocaloric Feeding
Trickle or Trophic Feedings
Maintenance vs Repletion Nutritional Support
Supplemental PN
Nutritional Support for the Critically Ill Obese
Summary
References
Chapter 15 Tube Feedings Formulas and Methods
A Brief History of Enteral Nutrition
Enteral Feeding Formulas
Terminology
Commercially Available Enteral Feeding Products
Elemental and Semi-Elemental Enteral Feeding Formulas
Polymeric Feeding Formulas
Enteral Feeding Devices
Enteral Feeding Techniques
Initiation
Advancement to Goal
Conversion to a Long-Term Feeding Strategy
Monitoring for Enteral Feeding Adverse Effects
Summary
References
Chapter 16 Oral Nutritional Supplements and Appetite Stimulation Therapy
Clinical Evaluation for the Patient with Adult FTT
Socio-Economic Components
Psychological State
Dementia
Medications
Anorexia
Early Satiety
Disturbances of Taste (Dysgeusia)
Disturbances of Olfaction (Hypo/Hyperosmia)
Poor Oral Health, Odynophagia, and Mastication
Dysphagia
Air Hunger
Gastrointestinal Disease
Hypermetabolic and Proinflammatory States
Dietary Restrictions
Nutritional Supplements
Vitamin/Mineral Supplements
Oral Nutritional Supplements (ONS)
Appetite Stimulation Therapy
Progestational Agents
Cannabinoids
Antidepressants
Anabolic Agents
Antihistamines
TNF-Alpha Suppressants
Summary
References
Chapter 17 Transitioning the Nutritional Support Patient to Homecare
A Brief History of Modern Homecare Therapeutics
Case Study Report
Case Study Report
Physician’s Role in the HPN Process – Doctoring in a Hospital without Walls
The Patient’s Perspective on Homecare
HPN Initiation Methods: Hospital Start, Home Start, Cycled, Continuous
Continuous vs Cycled Therapy
Setting Up an HPN Cycle
Starting the HPN Protocol in a Hospitalized Patient
Starting the HPN Protocol in the Outpatient Setting
HEN Options
HPN Management
HPN Follow-Up: Office Visits, Routine Labs, Micronutrient Levels
Summary
References
Chapter 18 The Metabolic Medicine Postoperative Bariatric Surgery Consultation
The Metabolic Hospitalist
Postoperative Days 0–1
Blood Pressure Control in the Postoperative Bariatric Patient
Glucose Control in the Postoperative Bariatric Patient
Electrolytes, Minerals and Vitamins in the Postoperative Bariatric Patient
Other Medical Concerns in the Postoperative Bariatric Patient
Preparing the Bariatric Patient for Discharge
Preparing the Patient for Metabolic Monitoring
Specific Postoperative Concerns
Diabetes Resolution after Bariatric Surgery
Hypertension Resolution after Bariatric Surgery
Hyperlipidemia Resolution after Bariatric Surgery
Atherosclerotic Cardiovascular Disease (ASCVD)
OSA Resolution after Bariatric Surgery, Asthma and COPD Adjustment
Arthritis and Gout
Depression and Other Psychological Conditions
Thyroid Conditions
Female Reproductive Issues
Ethanol
Additional Postoperative Bariatric Medications
Postoperative Metabolic Labs
Weight Loss Failure after Bariatric Surgery
Weight Regain after Weight Loss Surgery
Special Postoperative Bariatric Surgery Conditions that Warrant Metabolic Monitoring
Pregnancy Concerns after Weight Loss Surgery
Hypoglycemia and Nesidioblastosis
Metabolic Encephalopathies Other than Wernicke’s in the Postbariatric Period
Summary
References
Index
