This Document Contains Cases 25 to 27 Case 25 – Cerebral Palsy I. Understanding the Diagnosis and Pathophysiology 1. What is cerebral palsy (CP)? Identify several risk factors for CP. • Cerebral palsy is the result of nonprogressive brain damage that occurs before the age of 5 that causes motor dysfunctions. Common issues include: seizures, muscle tone complications, impaired cognitive abilities, dysphagia, GERD, constipation, and growth/orthopedic problems. Would just classify as congenital and acquired CP. Risk factors for congenital CP: prematurity, low birth weight, multiparity, severe jaundice, fetal stroke, infections during pregnancy, and birth complications where the oxygen supply to the infant's brain is decreased. Risk factors for acquired CP: Head injury or anoxic insult, brain infection Olivia was born prematurely at 32 weeks GA and was VLBW at 1200g. 2. What functional abilities can be impacted by CP? What is the Gross Motor Function Classification System (GMFCS)? What does the GMFCS score of 3 indicate? • Functional abilities that are impacted include: ○ Swallowing ability and poor oral motor function (dysphagia, drooling, chewing difficulties, dysarthria) ○ Ability to control limbs/hypertonicity/hypotonicity (quadriplegia, hemiplegia, triplegia, etc.) • Ataxia • Rigid motor control • Athetosis • Seizures ○ GI tract mechanical functions (GERD, delayed gastric emptying, constipation) ○ Growth potential/ability and orthopedic problems (poor nutriture and low activity) • GMFCS is a 5 level system of classification that allows healthcare practitioners to classify a child's gross motor functional capacity based upon their age. • A GMFCS score of 3 in Olivia's age group (6-12 yrs old) indicates that she can walk short distances but uses a wheelchair or other mobile wheeled device to travel long distances 3. Describe the classifications of CP according to motor function and severity level. What is a baclofen pump and how is it used to manage CP? • Spastic (pyramidal): hypertonia, (80% of CP cases) ○ Hemiplegia: limbs on the same side of the body are affected (i.e. arm and leg) ○ Diplegia/Paraplegia: legs are affected more than the arms ○ Triplegia: three limbs are affected ○ Quadriplegia: all limbs are affected. The case study patient has spastic quadriplegia. ○ Double hemiplegia: all limbs are affected with one side being more impaired ○ Monoplegia: one limb is affected • Non-spastic (extrapyramidal): fluctuating muscle tone or hypotonia ○ Athetoid: involuntary movements ○ Ataxic: difficulty walking due to decreased coordination/unbalanced gait • Mixed CP: has characteristics consistent with both spastic and non-spastic motor dysfunctions • Classifications range from level 1 (least impaired) to level 5 (most impaired) based upon the GMFCS and differs amongst five distinct age groups (< 2 yrs, 2-4 yrs, 4-6 yrs, 6-12 yrs, and 12-18 yrs). These classifications and their respective levels of impairment are based upon typical motor abilities associated with walking/running, jumping, balance, coordination, and speed and the appropriateness for them in each age group. • Baclofen is a medication used to relieve muscle spasticity associated with CP. A baclofen pump is a device used to administer baclofen intrathecally into the spinal cord and is often more effective in treating muscle spasms than oral baclofen. A pump containing the liquid form of medication is surgically implanted under the skin of the abdomen and is attached to tubing, which is inserted into the spine to deliver the drug. The pump is battery powered and needs to be replaced every 5-7 years.. 4. Poor growth secondary to poor nutrition status is a common problem in pediatric patients with CP. Summarize at least three factors that may contribute to malnutrition and subsequent poor growth in CP. • Mechanical issues with chewing/swallowing (e.g. dysphagia) - tongue or teeth may be arranged in abnormal positions making it difficult to chew/swallow • Limited self-feeding ability - spasticity in the upper body may contribute, increasing the individual's reliance on assistance from a caregiver. They may also use adaptive eating utensils. • Extended time needed to consume meals - can be exhausting and require patience for both the patient and caregiver • Food refusal - this may be due to swallowing/aspiration issues which result in a refusal to eat/limiting of intake to protect oneself • Limited physical activity - needed to promote proper and healthy accumulation of lean body mass (e.g. bone mineral density, skeletal muscle) II. Understanding the Nutrition Therapy 5. What are limitations to using standard height and weight measurement tools in CP patients? What are commonly used methods for assessing height and weight in children with CP? Are there other anthropometric measures that may be useful? • The limitations of standard height and weight measurement tools in CP patients include: ○ Limb contractures ○ Scoliosis ○ Muscle spasms ○ Inability to stand • For children less than 2 yrs of age, recumbent length can be obtained on a length board • Stature is used for individuals from 2 to 20 yrs of age. CP patients may require use of alternative methods to estimate height such as: ○ Knee height ○ Arm span ○ Tibia length ○ Upper-arm length • Specialized scales using handrails or ones that can be used with a wheelchair may be needed for CP patients. Some other types of available scales include: chair, bucket, and bed scales. • Otherwise, a parent or caregiver may be needed to hold the child while obtaining the weight and then have their weight subtracted from that value. • Other anthropometric measurements of utility: ○ Head circumference for those of 75% of the FVC. ○ Expiratory flow rate is prolonged when there is an increase in secretions or loss of lung elastic recoil. • FVC ○ Forced vital capacity is the maximum volume of air that can be forcibly expelled after inhaling as deeply as possible. ○ Patients with obstructive lung disease will have a normal or slight decrease in FVC due to their inability to exhale efficiently. • Ratio of FEV1/FVC: This is the percentage of vital capacity expired in the first second of maximal expiration. • In COPD, if the FEV1/FVC is less than 0.70, then COPD is indicated. Thereafter, the GOLD classification method can be used. ○ GOLD 1 (Mild): FEV1 ≥ 80% predicted ○ GOLD 2 (Moderate): 50% ≤ FEV1 < 80% predicted ○ GOLD 3 (Severe): 30% ≤ FEV1 250 mL is present after two GRV checks, a promotility agent should be considered. • Probable causes for Mr. Hayato’s high GRV are gastroparesis and/or position. 15. Were any additional signs of EN intolerance documented? Do you agree with the decision to discontinue the feeding? Why or why not? • No. In the Consensus Statement presented by the North American Summit on Aspiration in the Critically Ill Patient, it was recommended that enteral feedings be stopped only if there is definite regurgitation or aspiration of gastric contents, or if a residual volume >500 mL is measured. No measurement of the GRV is given. No aspiration was documented. GRV >500 mL indicates the feeding should be held, and tolerance should be reassessed. GRV <500 mL should be returned to the patient, as this volume does not confirm tolerance or normal gastric emptying. 16. What options are available to improve tolerance of the tube feeding? With high gastric residuals, there are several options: • The enteral feeding can be stopped until the patient can tolerate the feeding. • The feeding can be delivered at a slower rate. • The feeding tube can be placed within the duodenum, which may enhance tolerance. • If the patient exhibits gastroparesis or GRVs ranging from 200-500 mL, and there are no contraindications, promotility agents may be recommended to increase gastric emptying. 17. On 3/27, the enteral feeding was restarted at 25 mL/hr and then increased to 50 mL/hr after 12 hours. What were Mr. Hayato’s energy and protein intakes for 3/27? 1080 kcal and 48.2 g protein from Isosource HN. 18. Examine the values documented for arterial blood gases (ABGs). a. On the day Mr. Hayato was intubated, his ABGs were as follows: pH 7.2, pCO2 65, CO2 35, pO2 56, HCO3- 38. What can you determine from each of these values? • pH and pO2 are low; pCO2, CO2, and HCO3- are high. • Mr. H is suffering from respiratory acidosis and acute respiratory failure. He cannot expire enough CO2 out of his body and thus the kidneys are compensating by retaining HCO3-. b. On 3/28 while Mr. Hayato was on the ventilator, his ABGs were as follows: pH 7.36, pCO2 63, pO2 60, HCO3- 32. What can you determine from each of these values? • Mr. H’s respiratory status appears to have improved with current ventilator support. • All values indicate respiratory acidosis is improving (with pH being within normal limits) and overall oxygenation is considerably improved. c. On 3/30, after the enteral feeding was resumed, his ABGs were as follows: pH 7.22, pCO2 66, pO2 57, HCO3- 37. In addition, indirect calorimetry indicated an RQ of 0.95 and his measured energy intake was 1350 kcal. How does the patient’s measured energy intake compare to your previous calculations? What does the RQ indicate? • The measured energy requirement is below the estimated or calculated energy requirement. • RQ indicates Mr. Hayato is utilizing carbohydrate as the major fuel source, and as it approaches 1.0, may indicate he his being overfed. • Current nutrition support provided excess total calories (estimated about 250 more kilocalories than he needs) and, perhaps, carbohydrate. • If Mr. H was being overfed with the combination of enteral and parenteral support, his increased CO2 production may have stressed his respiratory status. • This is reflected in the change in pH, increased CO2, and decreased oxygenation. 19. The patient was weaned from the ventilator on 4/2 and discharged to home on 4/5. As Mr. Hayato is prepared for discharge, what nutritional goals might you set with him and his wife to improve his overall nutritional status? • Increase caloric intake to 1600 kcal/day with 67-83 g protein. • Identify strategies to increase nutrient density of meals (add butter, drink liquids in between meals to prevent their effect on fullness, etc.). • Determine strategies to increase overall appetite. • Begin general multivitamin. Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157
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