Case-28-30 Metabolic Stress And Trauma: Open Abdomen – Medical Nutrition Therapy: A Case-Study Approach : Book Guide

This Document Contains Cases 28 to 30 Case 28– Metabolic Stress and Trauma: Open Abdomen I. Understanding the Disease and Pathophysiology 1. The patient has suffered a gunshot wound to the abdomen. This has resulted in an open abdomen. Define open abdomen. The medical record describes the use of a wound “VAC.” Describe this procedure and its connection to the diagnosis for open abdomen. Open abdomen is a technique for the management of damage with an abdominal injury. A laparotomy is performed in order to open the abdomen to control hemorrhage and contamination in patients with severe physiological compromise. This is left open in order to prevent further complications when there is an increased pressure within the fixed abdominal cavity due to a traumatic event or various surgical conditions (diffuse peritonitis, acute pancreatitis, and mesenteric ischemia). Also, if the abdomen is closed too early, this can lead to a reduced blood flow to abdominal organs. This intra-abdominal hypertension (IAH) can lead to multiple organ dysfunction, or abdominal compartment syndrome (ACS). By relieving this pressure with an open abdomen post-laparotomy, the patient can be managed further in the ICU after transfer from the OR to correct various physiological deficits, through means such as further resuscitation, tissue perfusion, normothermia, correction of acid-base balance, and normalization of coagulation. Because there is a wound purposefully left open to the environment, a complex dressing is required in order to protect this wound from infection or further complications. The most common of these dressings is a negative-pressure wound “VAC” which use suction devices with sponges embedded into a nonadherent plastic material placed in the peritoneal space. This negative pressure helps reduce tissue edema and provides a constant force that draws the fascia to the midline position. Because of this wound “VAC”, the open abdomen procedure is likely to be more successful with proper healing and protection. Thus, it is necessary with this patient’s diagnosis to have a wound vacuum, due to the need for an abbreviated laparotomy and various GI resections. 2. The patient underwent gastric resection and repair, control of liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on this patient’s ability to meet his nutritional needs. Gastric resection and repair could inhibit acid production (thus decreasing iron, calcium and vitamin B12 absorption), intrinsic factor secretion, change gastric motility, and reduce the amount of food he is able to eat at one time initially, but the stomach will adapt over a few months and he will return to normal function. Liver hemorrhage may disrupt liver function—metabolism of fats, proteins, and carbohydrates as well as bile production and synthesis of albumin and clotting factors—which will be noticeable in the lab values and nutritional status of the patient if function is not recovered. Resection of the proximal jejunum usually has very few long-term effects because the ileum compensates for the nutrient absorption of that part of the GI tract. The colon and ileum together absorb the increased fluid load and electrolyte load efficiently and the ileum continues to absorb bile salts so that they do not reach the colon to interfere with salt and water reabsorption. 3. The metabolic stress response to trauma has been described as a progression through three phases: the ebb phase, the flow phase, and finally the recovery or resolution. Define each of these and determine how they may correspond to this patient’s hospital course. Due to this patient’s recent traumatic event, his metabolism was greatly affected. Not only was he experiencing a local stress due to the gunshot wound and various injuries, but he was also experiencing a systemic metabolic response. Critical illness, serious infection, severe injury, burns, or severe psychological stress can initiate this metabolic response. Metabolic stress encompasses three phases: the ebb phase, acute flow phase, and recovery phase or adaptive flow phase. The ebb phase occurs within the first 24-48 hours and is characterized by hemodynamic instability. There is a period of severe shock with depression of enzymatic activity and oxygen consumption, resulting in decreased cardiac output, decreased core temperature, and increased lactic acidosis. It is critical during this time to conduct fluid resuscitation and oxygen delivery. Thus, feeding this patient while he is still hemodynamically unstable is not a top priority for this stage. During the acute flow phase, which occurs from 3 to 10 days after initial stress event, the body is hypermetabolic with increased cardiac rate and oxygen consumption. There is also an increase in glucose production via gluconeogenesis (with resulting hyperglycemia), variable lipolysis, and increased protein breakdown for a gluconeogenic substrate. The body uses more amino acids from this muscle breakdown to create precursors for acute-phase proteins and glutamine for gut metabolism. This causes an increase in protein mobilization, increased urinary nitrogen excretion, and lean body mass wasting. During this acute flow phase, the body is activating its survival mechanisms to maintain organ systems and promote healing. Unfortunately, this also increases the risk for malnutrition and further complications including loss of lean body mass . The goal of this stage is to minimize catabolism. During the last stage of recovery/adaptive flow phase, the acute flow phase subsides and the initiation of recovery and repair processes begins. This results in a decrease in energy and protein needs due to the decrease in inflammation and catabolism, while anabolism begins to occur. This third phase can last up to one year after initial injury. Based on the information we have about this patient, he was admitted with symptoms of shock and was hemorrhaging and then progressed into the flow phase, as indicated by his high metabolic needs of 3657 kcal/day. Also, we can see that the metabolic stress continued for at least 7 days as indicated by his labs. The labs that indicate inflammation—elevated WBC, elevated CRP, and low albumin. The results of his urinalysis also indicate a catabolic state as well as uncontrolled hyperglycemia as he was spilling ketones and glucose into his urine. The presence of edema is due to third spacing of intravascular fluids and due to severe hypoalbuminemia. 4. Acute-phase proteins are often used as a marker of the stress response. What is an acute-phase protein? What is the role of C-reactive protein in the nutritional assessment of critically ill trauma patients? What other acute-phase proteins may be followed to assess the inflammatory stress response? An acute-phase protein is a protein whose plasma concentration increases or decreases at least 25% during an inflammatory condition. They are classified as positive acute phase proteins (ones that increase) or negative acute phase proteins (ones that decrease). Positive acute phase proteins include CRP, hepcidin, ferritin, and complement. Negative acute phase proteins include albumin, transthyretin, retinol binding protein Cytokines and other molecules within the immune system regulate the release of acute-phase proteins. CRP levels are the most commonly measured positive acute phase protein and any elevation indicates an inflammatory process is occurring. However, CRP is nonspecific and could be indicative of almost any inflammatory condition including obesity, type 2 diabetes, cardiovascular disease etc. It is not specific to trauma or metabolic stress.. When IL-6 increases, the production of albumin and prealbumin decreases, so when assessing a patient’s lab values, it is important to look at all three values for an indication of inflammatory response. Other positive acute-phase proteins include fibronectin, ceruloplasmin, and serum amyloid A. II. Understanding the Nutrition Therapy 5. Metabolic stress and trauma significantly affect nutritional requirements. Describe the changes in nutrient metabolism that occur in metabolic stress. Specifically address energy requirements and changes in carbohydrate, protein, and lipid metabolism. There are many changes in the metabolism of carbohydrate, proteins, and lipids during metabolic stress. Carbohydrate metabolism is affected by the increase in proinflammatory hormones, an increase in catabolic hormones (glucagon, catecholamines, and cortisol), and an increase in glucose availability due to the flight or flight response, resulting in increases glycogenolysis and gluconeogenesis. All of these processes result in hyperglycemia .Alternate pathways are activated to meet the increased glucose needs, such as the Cori cycle in the liver (results in an increase in lactate), the glucose-alanine cycle in the liver (increased demand for glutamine), and the glutamine cycle in the kidneys (results in a depletion of muscle glutamine). The alterations in carbohydrate metabolism listed above result in an increase in the catabolism of visceral and skeletal muscle stores.. Protein catabolism and decreased protein synthesis along with a diminished uptake of amino acids by muscles, and an increase in synthesis of acute-phase proteins as a result of hepatic reprioritization and decreased negative acute-phase protein synthesis. Uric acid, urea production, creatinine, and ammonia also increase as the byproduct of increased use of protein as an energy source, leading to protein wasting and an increase in nitrogen losses. Finally, alterations of lipid metabolism result in increased lipolysis for energy due to the increase in epinephrine, norepinephrine, and glucagon; impaired intracellular lipid transport as a result of an abnormal carnitine carrier with the inflammatory response; and an accumulation of lactate and pyruvate with the increased glucose metabolism. Due to the impaired transport and circulation of triglycerides within the liver, hyperlipidemia and fatty liver can result. Because of the risk for severe malnutrition with a prolonged metabolic stress response, it is important to meet the patient’s nutritional needs as soon as possible and as accurately as possible. 6. Are there specific nutrients that should be considered when designing nutrition support for a trauma patient? Explain the rationale and current recommendations regarding glutamine, arginine, and omega-3 fatty acids for this patient population. There are several specific nutrients that should be considered when designing nutrition support for a trauma patient. These include glutamine, arginine, and omega-3 fatty acids, which all have an immune-enhancing effect for the metabolically stressed patient. Glutamine is typically the most abundant amino acid in the body that is utilized by immune competent cells, enterocytes, and hepatocytes, but glutamine becomes depleted in critically ill and surgical patients. Enteral glutamine supplementation may improve gut barrier function and lymphocyte function, however, recent reports indicate that parenteral glutamine should only be used with caution, as there are conflicting reports in the literature with respect to length of hospital stay, infections and survival. . Arginine is the precursor to nitric oxide and becomes an essential amino acid during metabolic stress. During metabolic stress, it can be beneficial by playing a role in wound healing through several potential mechanisms, such as enhanced collagen and hydoxyproline formation. Also, it promotes normalization of T-cell function, which is important in order to blunt the inflammatory response. Arginine is converted in the body to nitric oxide, which increases blood vessel dilation for improved blood flow and stimulates the release of growth hormone, insulin, and other anabolic substances. Excess arginine could be harmful in patients who are hemodynamically unstable. Arginine should be used with caution in critically ill patients, especially those in the ebb phase of the metabolic stress response. Omega-3 fatty acids aid the immune system by competing with omega-6 fatty acids (arachidonic acid) for cyclooxygenase metabolism at the cellular membrane. This allows for fewer inflammatory and immunosuppressive eicosanoids to be produced and thus reduces the inflammatory response. There is currently no standard dosage for omega-3 fatty acids, but typically up to 5 grams/day have been used in critically ill patients with sepsis. Caution should be exercised in those patients with coagulation disorders as an excess amount of omega 3 fatty acids can reduce platelet aggregation. Much more research needs to be conducted in order to make these recommendations more routine in the acute care setting 7. Using current evidence-based guidelines, explain the decision-making process that would be applied in determining the route for nutrition support for the trauma patient. Since feeding a critically ill surgical patient is a high priority for proper recovery and healing, there is a decision-making process that occurs to determine the route for nutrition support. For any patient, PO intake is the preferred choice in order to meet nutritional needs as naturally as possible. However, for critically ill patients such as Mr. Perez, this is not possible because he is mechanically ventilated and recent surgeries to the GI tract. According to the ASPEN guidelines, enteral nutrition would be appropriate for this patient if the GI tract is at least partially functional, there is no intestinal hemorrhage, no ileus or fistulas are present, no intractable vomiting is present, and no short bowel syndrome is present. Unfortunately, for this patient, some of these requirements for EN are not met, such as intestinal hemorrhage and the recent surgeries to the GI tract (removal of proximal jejunum resulting in discontinuity and followed by an anastomotic leak) that interrupts GI function. Due to these contraindications and the inability to meet at least 60% of his nutritional needs by EN, TPN was started for this patient. Additionally, since Mr. Perez is critically ill, nutritional support should be provided within the first 24-48 hours from admission. This patient was S/P a traumatic event and in metabolic stress, meaning it was imperative to begin nutrition support as soon as feasibly possibly, optimally within 24-48 hours after admission into the ICU. Additionally, small amounts of EN (trophic feeds) were started along with PN in order to maintain gut integrity and intestinal mucosa; however, there is a potential for gut ischemia and necrosis if more than trophic EN was administered to meet all of this patient’s nutritional needs. Due to the positive outcomes of open abdomen healing and EN (earlier closure rate, reduced fistula formation, and reduced mortality), it is important to wean this patient from TPN and have EN provide the majority of Mr. Perez’s nutrition III. Nutrition Assessment 8. Calculate and interpret the patient’s BMI. Calculating Mr. Perez’s BMI): Admission weight: 102.7 kg; height: 70” BMI: 102.7 kg/(1.778 m2) = 32.4 kg/m2 (>30 is classified as obese) IBW: 75.5 kg; %IBW: 136% Current weight: 109 kg; BMI: 34.5 kg/m2 (>30 is classified as obese) %IBW: 144% Based on his admission and day #7 weight, Mr. Perez is obese for his height. He is also at 136-144% of his ideal body weight. In order to prevent overfeeding this patient, it is appropriate to estimate his energy and protein needs using his ideal body weight in order to most accurately match his nutritional needs. 9. What factors make assessing his actual weight difficult on a daily basis? Factors that make assessing this patient’s actual weight on a daily basis difficult include possible inaccurate measurements, since this patient may have been weighed on different scales with various trips to and from the OR. Also, this patient has had various devices and equipment taken on and off of him (mechanical ventilation, wound VAC changes, drains), which may affect his weight measurements. This patient is currently experiencing edema as per the medical chart, and along with excess fluid from IV fluids and TPN is resulting in a weight that is falsely high. On the other hand, this patient has also had excessive fluid loss with the various wound VACS and drains after his surgeries. Depending on the time of day, the weight can vary based on his clinical course. Because of this, it is important to use one consistent weight for his clinical course, such as his ideal body weight or usual body weight. 10. Calculate energy and protein requirements for Mr. Perez. Use at least two methods (including the Penn State) to estimate his energy needs. Explain your rationale for using each one. For the Penn State calculation, the minute ventilation is 3.5 L/minute and the maximum temperature is 39.2. Because Mr. Perez’s has large open wounds and metabolic stress, this patient will have increased protein and calorie needs. For the most accurate energy and protein estimations for this critically ill patient, it is best to use indirect calorimetry. Other methods that can be used to calculate energy and protein requirements are the nomogram and the Penn State equation for critically ill patients. The nomogram was used because it is convenient to use in the healthcare setting for quickly estimating protein and energy needs. However, because the patient’s obesity dictates use of ideal body weight for the calculation, it can be inaccurate by underestimating nutritional needs in a hypermetabolic state. The Penn State equation was used because it is 79% accurate in measuring nutritional needs for critically ill patients because it accounts for minute ventilation (patient is intubated) and daily body temperature. This is reflective of increased energy and protein needs with hypermetabolism. Even though both of these equations seem to underestimate energy needs, dietitians must understand that an overaggressive caloric prescription can cause other dire consequences like hyperglycemia and hypercapnea. Nomogram: EER: 25-35 kcal/kg IBW = ~1888-2643 kcal/day EPR: 2.0-2.5 grams protein/kg IBW = ~150-189 grams protein/day Penn State: RMR = BMR (0.85) + VE(33) + Tmax(175) – 6433 RMR = 2176(0.85) + (3.5 L/min)(33) + 39.2(175) – 6433 RMR = ~2392 kcal/day Indirect calorimetry (as indicated in chart): REE: 3657 kcal 11. What does indirect calorimetry measure? Indirect calorimetry is the most accurate method of measuring resting energy expenditure/resting metabolic rate (other than direct calorimetry, which is not applicable to many settings including the clinical setting). It is based on the fact that energy expenditure is proportional to the body’s oxygen consumption and carbon dioxide production. Indirect calorimetry is performed by using a metabolic cart at bedside that measures the amount of oxygen consumed and carbon dioxide expelled by the patient (VO2 and VCO2). Using these values, in addition to the patient's basic anthropometric measurements, allow for more accurate energy requirements to be calculated. 12. Compare the estimated energy needs calculated using the predictive equations with each other and with those obtained by indirect calorimetry measurements. While the two equations produced similar caloric needs (~2600 kcal), the metabolic cart showed that he needed closer to 3600 kcal. There could be multiple reasons for this discrepancy. On the one hand, indirect calorimetry has many opportunities for error including system leaks when the seal around the mask is not tight enough, discrepancies in the equation used to calculate VO2 max, and the inability to keep a patient in a steady-state while conducting the test. These along with the fact that the abdominal drains may allow metabolically produced carbon dioxide to leak out all contribute to the possible error in the indirect calorimetry measurement. However, the equations are not completely accurate either, as they account for “trauma,” but are not very specific to his condition. The predictive equations require a healthy mix of science, experience, and art to properly assign the patient to their required needs. That is to say that deciding on the appropriate injury factor or proper range based upon nomograms (e.g. 25-30 kcal/kg vs. 30-35 kcal/kg) provides room for interpretation and professional judgement. 13. Interpret the RQ value. What does it indicate? RQ value = mol CO2 expired/ mol O2 consumed = 0.76 An RQ value of 0.7-0.8 indicates fat as the main energy source, an RQ of 0.8-0.9 indicates a mix of lipids, carbs, and some protein as energy sources, and an RQ of 0.9-1.0 indicates carbohydrates as the main energy source. According to the nutrition consult note, Mr. Perez’s RQ was 0.76. This indicates that while on TPN, fat is his primary energy source. This could be due to the propofol administered at 35 mL/hr (10% lipid solution). Also, this indicates that he is closer to a fasted state (1.0). Although it is optimal to not over feed this patient, this could indicate that he is being underfed and may not be meeting his nutritional requirements. 14. What factors contribute to the elevated energy expenditure in this patient? Factors that may contribute to the elevated energy expenditure in this patient include the trauma/stress from the patient’s GSW, his various corrective surgeries, mechanical ventilation, an anastomotic leak on day 3 of admission, and fluid/electrolyte/protein losses from the patient’s various drains and wound vac. 15. Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and grams of protein are provided with his prescription. Read the nutrition consult follow-up and the I/O record. What was the total volume of PN provided that day? Parenteral nutrition prescription is 140 g/L dextrose, 60 g/L CAA, and 20 g/L lipid at a rate of 135 ml/hr; total volume is 135 mL/hr  24 hours = 3.24 L Protein: 3.24 L  60 g/L = 194 g protein  4 kcal/g = 777 kcal from protein kCal: Dextrose: 3.24 L  140 g/L = 454 g  3.4 kcal/g = 1542 kcal from dextrose Lipids: 3.24 L  20 g/L = 65 g lipid  10 kcal/g = 648 kcal from lipids Total = 2967 kcal and 194 grams of protein The total amount of PN provided on 3/29 was 3312 mL. This was 102% of his goal rate and provided 199 g protein and 3034 kcal. 16. Compare this nutrition support to his measured energy requirements obtained by the metabolic cart on 3/26. Based on the metabolic cart results, what changes would you recommend be made to the TPN regimen, if any? What are the limitations that prevent the health care team from making significant changes to the nutrition support regimen? On day 4, the metabolic cart measured Mr. Perez’s calorie expenditure to be 3657 kilocalories with an RQ value of 0.76. On day 7, Mr. Perez received slightly more than ordered by his nutrition prescription (102%): 199 grams protein and 3034 kcal. Compared to his metabolic cart, he was not meeting his needs by parenteral feeding alone. He received 83% of his energy needs, or 40 kcal/kg IBW and 2.6 grams protein/kg IBW. Based on these comparisons, Mr. Perez is on the higher end or is above his original recommendations for estimated energy and protein needs. If necessary, it is possible to increase his protein intake through TPN. This would not only provide the patient with more energy, but it would also be beneficial for wound healing. It would also be beneficial to increase his energy intake, especially when he is no longer receiving propofol, because his RQ value indicates that the patient is closer to a fasting state. Increased carbohydrate intake can also increase the RQ value. Thus, increasing his CHO intake would match his energy expenditures more closely based on his metabolic cart measurement and cause the RQ value to represent a fed state. Since he is currently receiving propofol as a sedative, he is receiving 25% of his energy needs through the administration of this medication. It is important to not overfeed the patient and to provide Mr. Perez with nutrition support at a level he can tolerate. Thus, there are several limitations that prevent the healthcare team from making significant changes to the nutrition support regimen, such as the patient’s current mechanical ventilation. They will not want to increase carbohydrate content or risk overfeeding, which would interfere with weaning him off of the ventilator. Increasing the dextrose/carbohydrate in the TPN could also exacerbate his hyperglycemia . Also, the team may be hesitant to increase calories from fat because of the risk for continued hypertriglyceridemia and liver dysfunction with liver lacerations. The medical team may not want to increase the risk for pressure changes due to the presence of edema by increasing the PN volume. Next, the medical team may not want to make significant changes to the nutrition support regimen related to the method of delivery because of the patient’s anastomotic leak and previous GI tract discontinuity. In other words, an increase in enteral formula could cause pressure changes within the GI tract, as well as increase the risk for leakage. This could prevent the closure of the abdominal wound, which is the goal of the medical team at this time. 17. The patient was also receiving propofol. What is this, and why should it be included in an assessment of his nutritional intake? How much energy (total kcal, %kcal from fat)did it provide? Propofol is a lipid-soluble, short-acting IV hypnotic/sedative that is administered continuously to provide sedation in mechanically ventilated patients. It has a similar composition to a 10% lipid emulsion that provides 1.1 kcal/mL from fat. The calories provided by this sedative may be ignored by the medical team, but the amount of propofol administered to patients can be substantial and therefore can provide a lot of calories. If these calories are not accounted for with the patient’s nutrition support, it can result in overfeeding. Thus, these calories provided from propofol should be part of the total energy intake in mechanically ventilated ICU patients. Mr. Perez received an additional 924 kilocalories from propofol, which is about 25% of his needs according to his metabolic cart on day 4. Because this medication is providing a large amount of energy, it is important to monitor its delivery and adjust the nutrition support according to clinical course as appropriate. 18. The RD recommended that trickle feeds be initiated. What is this and what is the rationale? The RD recommended the formula Pivot 1.5 for these trickle feeds. What type of formula is this, and what would be the rationale for choosing this formula? Trickle feeds are small amounts of enteral feeding into the gut. Even though parenteral nutrition is successfully meeting this patient’s increased calorie needs and potentially decreasing the risk of aspiration and diarrhea with an altered GI tract, there are some disadvantages to PN. Some complications of PN for the critically ill trauma patient include intestinal villous atrophy with possible bacterial translocation, metabolic disorders (hyperglycemia and hypertriglyceridemia), biliary stasis, multiple organ dysfunction, adult respiratory distress syndrome, acute lung injury, bacteremia, sepsis, pneumonia, urinary tract infection, and catheter-related sepsis. Intestinal permeability is altered in critical illness due to the inflammatory response and metabolic alterations, and it is hypothesized that increased permeability may allow bacterial translocation and predispose the host to systemic sepsis. Because enteral feeding in the critically ill patient can help prevent intestinal atrophy and the above complications, it is the preferred route of nutritional support for the critically ill patient. Unfortunately, these patients may be unable to meet nutritional needs by enteral feeding alone within 7-10 days due to surgeries or intolerance of adequate feed volume. For example, Mr. Perez has had multiple abdominal surgeries with anatomical changes to the GI tract. Trickle feeds in conjunction with PN are important to help prevent further complications and promote healing to the GI tract and earlier closure of the open abdominal wound. For these trickle feeds, the RD recommended Pivot 1.5 enteral formula. Pivot 1.5 is a partially hydrolyzed, elemental formula that is calorically dense and high in protein and designed for metabolically stressed patients. This is an appropriate formula choice for this patient’s individual needs because the elemental macronutrients will allow for ease of digestion and absorption. Also, this formula is very nutritionally dense within a small volume (1.5 kcal/mL and 93.8 g protein/L), so it will help meet this patient’s increased protein and energy needs. Finally, it is an immune-enhancing formula with vitamin A, vitamin C, vitamin E, and zinc to help reduce free radical damage. Also, it provides large amounts of EPA and DHA for their anti-inflammatory properties. There is also 13 g/L of L-arginine for proliferation and function of immune cells, and 7.6 g/L of glutamine for GI tract integrity and energy for immune support. 19. List abnormal biochemical values for 3/29, describe why they might be abnormal, and explain any nutrition-related implications. Abnormal biochemical values on 3/29 and reason for abnormalities: • Sodium (H): Sodium was slightly elevated due to slight dehydration related to extensive fluid loss through his abdominal wounds and drains, despite having a high fluid intake • BUN (H): GI bleeding and dehydration; enhanced gluconeogenesis/protein metabolism • Creatinine (H): Possible renal insufficiency, GI bleeding, and catabolic state • Glucose (H): Possible history of DM, metabolic stress response; currently receiving SSI • Phosphate (L): Low nutritional intake, malabsorption • Osmolality (H): Dehydration, hyperglycemia, hypernatremia • Total protein (L): Metabolic stress/inflammation resulting in decreased production of this acute-phase protein in critical illness, impaired hepatic function • Albumin (L): Fluid overload, metabolic stress/inflammation resulting in decreased production of this negative acute-phase protein in critical illness, impaired hepatic function • Prealbumin (L): Fluid overload, metabolic stress/inflammation resulting in decreased production of this negative acute-phase protein in critical illness, impaired hepatic function • Alkaline phosphorous (H): Damage to the liver (liver laceration) • ALT/AST (H): Damage to liver (liver laceration), recent surgery • CPK (H): Tissue damage to skeletal muscle, possible history of heart disease • Lactate dehydrogenase (H): metabolic stress response, liver damage (liver laceration) • CRP (H): Tissue damage, inflammation, • HDL (L), VLDL (H), LDL (H): Possible history of hyperlipidemia/heart disease related to inadequate diet/lipid metabolism prior to admission, possible history of DM (uncontrolled) • TG (H): Possible history of hyperlipidemia/heart disease related to inadequate diet/lipid metabolism prior to admission; current metabolic stress response related to lipolysis and impaired transport of lipids with liver damage (liver laceration); possible history of DM (uncontrolled); current use of propofol; possible metabolic syndrome related to obesity • A1c (H): Possible history of DM, uncontrolled DM prior to admission • PT/INR/PTT (L): Longer blood clotting time; possible underlying liver disease or recent liver laceration/hemorrhage, low vitamin K intake or change in GI tract microbiota (flora) • WBC (H): Presence of an infection, presence of inflammatory response, stress, tissue damage • RBC (L): Blood loss due to hemorrhaging and recent surgeries, trauma, acute or chronic bleeding of the GI tract, possible history of anemia • Hct (L): Possible history of anemia; acute or chronic bleeding within the GI tract; possible nutritional deficiencies such as folate, vitamin B12, or iron; presence of inflammation Nutrition implications with these lab values include fluid restriction, increased protein/energy needs, and insulin administration. Abnormal urinalysis values and reason for abnormalities: • Cloudy appearance: Possible presence of infection • Specific gravity (H): Dehydration, presence of infection, presence of glucose/ketones, uncontrolled DM, possible renal insufficiency, blood loss (decreased blood flow to kidneys) • Protein (+): Dehydration, possible UTI, possible kidney insufficiency, possible diabetic nephropathy • Glucose (+): Uncontrolled DM, metabolic stress • Ketones (+): Metabolic stress response (increased metabolism), acute or severe illness, possible fever • Bact (+): UTI (infection present) • Mucus (+): UTI (infection present) • Yeast (+): UTI (infection present) 20. Current guidelines recommend using a nitrogen balance study to assess the adequacy of nutrition support. a. According to the Powell (2012) article (see bibliography below), what adjustments should be made to assess for nitrogen losses through fistulas, drains, or wound output? Powell suggests that an adjustment of 15-30 g of nitrogen loss per liter of abdominal fluid output should be made in open abdomen patients. This equates to about 94-188 grams of protein loss per liter of abdominal fluid output and could completely change the interpretation of nitrogen balance. Failing to include this loss would lead to an underestimation of nitrogen loss and an overestimation of the adequacy of protein administration. b. A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42 g. Calculate his nitrogen balance. N2 balance = (dietary protein intake/6.25) – UUN – 4 = (199/6.25) – (42 + 4) = -14 without correction for nitrogen loss from open abdomen 1.7 L of abdominal fluid output  15 g nitrogen = 25.5 g nitrogen loss or 160 g protein loss N2 balance = -39.7 Because of this patient’s negative nitrogen balance, we can assess that he is in a catabolic state on 3/29. This means that he is currently breaking down more protein to use for energy than is being replaced by the nutrition support. Reasons for a negative nitrogen balance are an increased catabolism, low dietary intake of protein, and presence of an infection. Also, as stated above, Mr. Perez has excessive protein losses through drains and wound outputs that may underestimate the severity of nitrogen loss and overestimate the adequacy of his current nutrition support. The goal during this stage of the stress response is to preserve lean body mass by reaching a neutral nitrogen balance, so it is important to increase protein needs and to blunt this hormonal response and excessive losses with anti-inflammatory drugs, antibiotics, and increased nutrition support. IV. Nutrition Diagnosis 21. Identify the nutrition diagnosis you would use in your follow-up note. Complete the PES statement. 1. Inadequate protein intake r/t increased protein catabolism with an open abdominal wound as evidenced by -39 g nitrogen balance. 2. Increased energy expenditure r/t open abdomen and stress response as evidenced by metabolic cart measurement of 3657 kcal/day expenditure 3. Excessive fat intake r/t parenteral nutrition composition and infusion of propofol as evidenced by RQ value of 0.76. V. Nutrition Intervention 22. For the PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 1. • Goal: Maintain nitrogen balance by meeting patient’s protein needs • Intervention: Increase protein intake in conjunction with increased EN tolerance with a high-protein enteral formula 2. • Goal: Decrease parenteral nutrition regimen in conjunction with increased EN delivery to promote normal GI function • Intervention: Consult with physician about the risks with continued TPN and the importance of EN delivery as the main energy and protein source and to promote wound healing of anastomotic leak/abdominal surgeries; EN promotes gut motility; wean PN appropriately with pharmacy and physician recommendations 3. • Goal: RQ value 0.8-0.9 and proper composition of nutrition support for his altered GI tract • Intervention: If continuing propofol, change PN to 2-in-1 solution without lipids • Increase rate of TPN to 150 mL/hr with elimination of lipids to provide 2600 kcal from TPN and 924 kcal from propofol for a total of 3525 kcal. Continue trickle tube feeds of 5 mL/hr to provide an additional 180 kcal and advance rate slowly as tolerated. 4. Goal: Increase enteral nutrition with patient tolerance • Intervention: Modify distribution and type of feeding by continuing both PN and EN to meet nutritional needs; advance EN of Pivot 1.5 via J-tube by 10 mL/hr q 6-8 hours or as tolerated to goal rate of 75 mL/hr with continued propofol use to provide 1800 mL, 2700 kcal, 168 grams protein, and 1431 mL fluid (35 kcal/kg IBW, 2.3 grams protein/kg IBW); adjust rate based on energy and protein needs as metabolic cart measurements change with clinical course; once >60% of energy needs are met enterally, discontinue parenteral nutrition VI. Nutrition Monitoring and Evaluation 23. What are the standard recommendations for monitoring the nutritional status of a patient receiving nutrition support? When a patient is receiving nutrition support, it is important to monitor: physical assessment (signs of fluid and nutrient excess or deficiency), functional status (mobility, sedation), vital signs, actual nutrient intake (oral, enteral, and parenteral) in comparison to nutrition prescription, weight and weight changes, pertinent labs (blood glucose, triglycerides, inflammatory markers, BUN, liver function enzymes, electrolytes), medications administered (propofol, SSI), and changes in gastrointestinal function (bowel sounds, I/O, stool output). Additionally, the RD should ensure that the head of bed is at a 30o-45o angle (for EN) and tube patency is maintained. Monitor wound healing and the progress of his open abdominal wound closure. This can confirm (or not) the adequacy of the patient’s nutrient intake. Nitrogen balance can be helpful to measure the adequacy of nutrient intake as well, even though this can be altered with the abdominal wounds and metabolic stress. 24. Hyperglycemia was noted in the laboratory results. Why is hyperglycemia of concern in the critically ill patient? How was this handled for this patient? What are the current recommendations for glycemic control in critically ill paitents? Hyperglycemia has been shown to correlate with poor outcomes in the ICU patient. It has been shown to lead to increased length of stay and higher risk of in-hospital mortality. Also, in patients with known DM before admission, it has been shown to increase the risk for infection and shock. For our patient, the hyperglycemia was treated using an insulin drip protocol, which is a commonly used therapy in critically ill patients. Tight blood glucose control (80-110 mg/dL) does not confer advantages in these patients. Both Society of Critical Care Medicine (SCCM) and ASPEN recommends a goal of 110 to 150 mg/dL while the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists recommends a goal of 140-180 mg/dL as a reasonable goal for these patients. 25. What would be the standard guidelines and subsequent recommendations to begin weaning TPN and increasing enteral feeds? The standard guidelines and subsequent recommendations for weaning TPN depend on when enteral feedings or PO intake has been advanced to >60% of estimated energy needs. Once this occurs and the patient is tolerating the alternate route of feeding well, the PN formula can be discontinued. Attention to glycemic control post-PN is important to monitor for hypoglycemia. If the patient has a history of hypoglycemia, however, it is reasonable to taper PN over 1-2 hours to avoid this problem. Overall, it is important to meet calorie needs through the transition of PN to EN for this patient in order to avoid complications with glycemic control or underfeeding. Case 29 – Nutrition Support for Burn Injury I. Understanding the Disease and Pathophysiology 1. Describe how burn wounds are classified. Identify and describe Mr. Angelo’s burn injuries. Burn wounds are classified according to the tissue layers involved: • First degree: Epidermis • Second degree (superficial partial thickness): Extends into superficial (papillary) dermis • Second degree (deep partial thickness): Extends into deep (reticular) dermis • Third degree (full thickness): Extends through entire dermis • Fourth degree: Extends through skin, subcutaneous tissue & into underlying muscle & bone Mr. Angelo has an estimated 40% BSA burns. These are a combination of first degree (involving epidermis) and partial thickness second degree burns, which would involve the superficial dermis. It is also noted that he has an inhalation injury as well. 2. Explain the “rule of nines” used in assessment of burn injury. The rule of nines is used to calculate the body surface area burned, where values of 9 or 18 are given to different regions of the body as follows: Head and neck 9%, chest (front) 9%, abdomen (front) 9%, upper/mid/low back and buttocks 18%, each arm (front and back) 9%, each leg 18% (front 9% and back 9%), and perineum 1%. 3. Mr. Angelo’s fluid resuscitation order was: LR @ 610 mL/hr  first 8 hours and decrease to 305 mL/hr  16 hours. What is the primary goal of fluid resuscitation? Briefly explain the Parkland formula. What common intravenous fluid is used in burn patients for fluid resuscitation? What are the components of this solution? The goal of fluid resuscitation is to maintain tissue perfusion, while avoiding under- or over-administration of fluid. The Parkland formula for adults is 2-4 mL of lactated Ringer’s  body weight (kg)  total percent body surface area burn. One half of this volume is to be given over the first 8 hours post injury and the rest over the next 16 hours. The fluid the patient receives en route to a hospital will also be included in the assessment. Lactated Ringer’s (LR or RL) is used for fluid resuscitation. One liter of LR contains: • 130 mEq of sodium ion = 130 mmol/L • 109 mEq of chloride ion = 109 mmol/L • 28 mEq of lactate = 28 mmol/L • 4 mEq of potassium ion = 4 mmol/L • 3 mEq of calcium ion = 1.5 mmol/L 4. What is inhalation injury? How can it affect patient management? Inhalation injury can be caused by thermal injury and/or by inhalation of smoke and other byproducts of incomplete combustion. There are 2 types based on the anatomic location: upper airway (injury to the mouth, oropharynx, and larynx) and lower airway (tracheal, bronchial, and alveolar). A third type of inhalation injury is metabolic in nature and caused by inhalation of toxic agents such as carbon monoxide. Injury in a closed space, presence of facial burns, and carbonaceous material in the airway and in secretions are indications of inhalation injury. Other signs of inhalation injury are hoarseness, cough, singed nasal hair, and wheezing. Inhalation injury can be confirmed by various methods such as endoscopy or transnasal indirect laryngoscopy and bronchoscopy in intubated patients. Patients with significant inhalation injury will require mechanical ventilation. These patients will require nutrition support even if the tissue injury is minimal. 5. Burns are often described as one of the most metabolically stressful injuries. Discuss the effects of a burn on metabolism and how this will affect nutritional requirements. Burns, as a type of severe injury or trauma, initiate the stress metabolic response. There is progression through three phases: the ebb phase, acute flow phase, and recovery phase or adaptive flow phase. The ebb phase occurs within the first 24-48 hours and it characterized by hemodynamic instability. This is a period of severe shock with depression of enzymatic activity and oxygen consumption, resulting in decreased cardiac output, decreased core temperature, and increased lactic acidosis. It is critical during this time to conduct fluid resuscitation and oxygen delivery. Thus, feeding this patient while he/she is still hemodynamically unstable is not a top priority for this stage. During the acute flow phase, which occurs from 3 to 10 days after the initial stress event, the body is hypermetabolic with increased cardiac and oxygen consumption. Other changes include increased glucose production via gluconeogenesis, variable lipolysis, and increased protein breakdown to supply a gluconeogenic substrate. The body also uses amino acids from this muscle breakdown to create precursors for acute-phase proteins and glutamine for gut metabolism. This causes an increase in protein mobilization, increased urinary nitrogen excretion, and lean body mass wasting (weight loss). During this second phase, the body is activating its survival mechanisms to maintain organ systems and promote healing. Unfortunately, this also increases the risk for malnutrition and further complications to the initial event if not treated properly. The goal of this stage is to maintain nitrogen balance to prevent catabolism and the patient will require high levels of protein and energy with nutrition support. During the last stage, the recovery/adaptive flow phase, the acute flow phase subsides and the initiation of recovery and the repair processes begin. This results in a decrease in energy and protein needs due to the decrease in inflammation and catabolism as anabolism begins to occur. This third phase can last up to two years after initial injury in extreme cases. 6. List all medications that Mr. Angelo is receiving. Identify the action of each medication and any drug-nutrient interactions that you should monitor. • Ascorbic acid – support of wound healing • Chlorhexidine – oral hygiene protocol • Famotidine tablet – stress ulcer prophylaxis • Heparin injection – provided for DVT prophylaxis; interactions: maintain fixed vitamin K intake • Insulin regular injection – treatment of hyperglycemia and underlying history of diabetes mellitus; interactions: be aware of potential for hypoglycemia • Multivitamin tablet – support nutritional needs and wound healing • Zinc sulfate – support nutritional needs and wound healing • Methadone – pain management • Oxandrolone – anabolic steroid used to reduce catabolism • Senna tablet – used as bowel/ stool softener; interactions: can cause electrolyte disturbances • Docusate oral liquid – used as bowel/ stool softener; interactions: can irritate throat, cause nausea, or abdominal cramping • Silver sulfadiazine – used for topical treatment of burn wound • Midazolam HCl (Versed) 100 mg in sodium chloride 0.9% 100 mL IV infusion, initiate infusion at 1 mg/hr – sedative; interactions: avoid grapefruit • Hydromorphone (Dilaudid) – pain management • Fentanyl (Sublimaze) – pain management • Propofol (Diprivan) – sedative. Since propofol is in a 10% IV fat emulsion, need to monitor triglyceride level and lipid clearance and account for energy provided by this medication within nutrition intervention. • Thiamin – prescribed due to history of regular alcohol ingestion for prevention of Wernicke’s encephalopathy • Folate – prescribed due to history of regular alcohol ingestion for prevention and treatment of potential deficiency II. Understanding the Nutrition Therapy 7. Using evidence-based guidelines, describe the potential benefits of early enteral nutrition in burn patients. Animal and human studies have demonstrated various beneficial effects from early enteral nutrition. There is no conclusive evidence that all these benefits will also be seen in burn patients, but the reported benefits include: • Supports functional and structural integrity of gut • Modulates the hypermetabolic response to injury • Reduces bacterial translocation, infection, organ failure, and length of stay • Improves protein retention, thereby facilitating earlier positive nitrogen balance and wound healing • Stress ulcer prophylaxis 8. What are the common criteria used to assess readiness for the initiation of enteral nutrition in burn patients? • Body surface area burned >20% (in adults) • Inhalation injury requiring mechanical ventilation • Elderly • Pre-existing malnutrition • Comorbidities • Prolonged, inadequate oral intake is expected 9. What are the specialized nutrient recommendations for the enteral nutrition formula administered to burn and trauma patients per ASPEN/SCCM guidelines? What additional micronutrients will need supplementation in burn therapy? What dosages are recommended? Immune-modulating solution supplemented with arginine, glutamine, nucleic acids, omega-3 fatty acids, zinc, and antioxidants (e.g. vitamin A,C, and E). • Glutamine: Glutamine is typically the most abundant amino acid in the body that is utilized by immune competent cells, enterocytes, and hepatocytes, but glutamine becomes depleted in critically ill and surgical patients. Thus, it is important to supplement this (typically nonessential) amino acid because it has also been shown to reduce gut permeability and the inflammatory response the gut produces during a trauma. Providing this exogenous source of glutamine can avoid catabolism and muscle glutamine depletion. It is currently recommended to supplement glutamine early and in doses of 0.3-0.5 g/kg/day divided between 2-3 doses. • Arginine (controversial in septic patients): Arginine is the precursor to nitric oxide and becomes an essential amino acid during metabolic stress. During metabolic stress, it can be beneficial by playing a role in wound healing through several potential mechanisms, such as enhanced collagen and hydoxyproline formation. Also, it promotes a return to normal T-cell function and helper T-cell levels, which are important in order to blunt the inflammatory response. Arginine is converted in the body to nitric oxide, which causes blood vessels to open wider for improved blood flow and stimulates the release of growth hormone, insulin, and other anabolic substances. Dosages up to 30 grams/day have been noted in the literature. Regimens for supplementation differ The Ross Tilley Burn Center (Nutrients. 2012; 4: 1554-65) recommends: Vitamin C: 500 mg twice daily )(≥20% TBSA full thickness and intubated or ≥ 30% TBSA): Vitamin E: 400 IU twice daily Selenium (≥20% TBSA full thickness and intubated or ≥ 30% TBSA): 1000 μg/day parenterally for 14 days, then 200 μg twice per day via feeding tube or PO Zinc 30 mg elementally /day intravenously x 5 days and then 50 mg elemental zinc daily by mouth or feeding tube ASPEN guidelines: 40.4mol copper/day x 30 days post burn 2.9 mol selenium/day x 30 days post burn 406 mol zinc/day x 30 days post burn III. Nutrition Assessment 10. Using Mr. Angelo’s height and admit weight, calculate IBW, % IBW, BMI, and BSA. Ht 6’0”, weight 71.2 kg, IBW 81 kg, %IBW 88%, BMI 21.3, BSA 1.9 m2 11. Energy requirements can be estimated using a variety of equations. The Xie and Zawacki equations are frequently used. Estimate Mr. Angelo’s energy needs using these equations. How many kcal/kg does he require based on these equations? • Zawacki et al: RMR (kcal/day) = 1440/BSA (m2) 1440  1.9 (m2) = 2736 kcal/day 2736 kcal / 71.2 kg = 38.4 kcal/kg • Xie et al: 1000  body surface area (m2) + 25  burned surface area (% TBSA) (1000  1.9 [m2]) + (25  40) = 2900 kcal/day 2900 kcal / 71.2 kg = 40.7 kcal/kg 12. Determine Mr. Angelo’s protein requirements. Provide the rationale for your estimate. ASPEN guidelines recommend 2 g protein/kg. Mr. Angelo’s protein needs range from 140-145 grams (71.2 kg  2 g). 13. The MD’s progress note indicates that the patient is experiencing acute kidney injury. What is this? If the patient’s renal function continues to deteriorate and he needs continuous renal replacement therapy, what changes will you make to your current nutritional regimen and why? Acute kidney injury is defined as an abrupt cessation or decline of kidney function. The injury can be classified as stage I, II, or III based on the serum creatinine level and urine output. Patients who are on CRRT have increased protein needs up to 2-2.5 g/kg and electrolyte restriction is not indicated. Therefore, we will continue with the current regimen, monitor for recovery of renal function, and also change in treatment. Will monitor for vitamin A and C intakes and reduce doses if renal recovery is slow. If indirect calorimetry is available, doing so may provide a more accurate estimation of calorie needs with the additional stress of renal injury. Monitoring the patient's nitrogen balance will also allow the dietitian to determine if his high protein needs are being met. 14. This patient is receiving the medication propofol. Using the information that you listed in question #6, what changes will you make to your nutritional regimen and how will you assess tolerance to this medication? Patient is on 25 mL/h of propofol, which will provide 660 kcal/day. Discuss with medical team and if plan is to continue with propofol will need daily monitoring of calorie intake and titration of tube feeding goal rate accordingly. With the 60 mL/hr rate of infusion of Impact with Glutamine and the 25 mL/hr of propofol, the patient is receiving 2532 kcal/day (vs. needs of 2700-2900 kcal/day). Given this, consider increasing the goal rate to 66 mL/hr with propofol or 87 mL/hr without the propofol. Since propofol is in a 10% IV fat emulsion, need to monitor triglyceride levels and liver enzymes as a possible marker for ability to metabolize triglycerides. IV. Nutrition Diagnosis 15. Identify at least 2 of the most pertinent nutrition problems and the corresponding nutrition diagnoses. Increased energy expenditure: Patient with extensive tissue and inhalation injury resulting in increased metabolic and catabolic state. Patient cannot meet the nutritional demands due to mechanical ventilation and need for consistent intake that is very high in calories and high biological value protein. Inadequate enteral nutrition infusion: Even with initiation of continuous enteral nutrition patients will have multiple interruptions due to dressing changes, rehab therapy, surgery, and tests/procedures. Due to the hypercatabolic state and high rate of gluconeogenesis, patients will break down lean body mass to fuel the glucose production. An average adult loses about 60-70 g of protein with simple fasting, which is about 240-280 g of lean body mass. With high-metabolic demand states like the burn injury, patients may lose up to 600-1000 g of muscle mass a day. 16. Write your PES statement for each nutrition problem. Increased energy expenditure related to metabolic stress of burn and inhalation injury as evidenced by predicted energy requirement of 2700-2900 kcal/day. Inadequate enteral infusion related to interruptions for medical treatment as evidenced by patient receiving <40% of prescribed enteral formula. Inadequate protein intake related to increased needs from burns/inhalation injury as evidenced by predicted protein requirement of 140-145 g/day and estimated intake of 112 g/day (if goal rate reached and constant infusion). V. Nutrition Intervention 17. The patient is receiving enteral feeding using Impact with Glutamine @ 60 mL/hr. Determine the energy and protein provided by this prescription. Provide guidelines to meet the patient’s calculated needs using the Xie equation. The current prescription of Impact with Glutamine @ 60 mL/hr will provide 112 g protein and 1872 kcal/day. With the 660 kcal of propofol added to this, 2532 kcal/day will be administered. This means that the patient will be energy deficient per the Xie equation and protein deficient per the 2.0 g/kg nomogram (140-145 g/day). Estimated calorie need based on Xie equation is 2900 kcal/day. If patient remains on propofol drip the calorie goal will be 2900 kcal – 660 kcal = 2240 kcal Impact with Glutamine provides 1300 kcal and 78 g protein/L 2240/1.3 = 1723 mL/d /24 hours = 72 mL/h or round up to 75 mL/h 75 mL/h  24 hours = 1800 mL 1800 mL  1.3 (kcal/mL of Impact with Glutamine) = 2340 kcal/d 1800 mL  0.078 g (protein/mL of Impact with Glutamine) = 140 g protein = ~2 g protein/kg of admit weight Recommend continuing to advance TF from current goal of 60 mL/h to 75 mL/h. Once propofol is discontinued advance TF to 95 mL/h in 6 hours to provide the following: 95 mL/h  24 hours = 2280 mL  1.3 (kcal/mL) = 2964 kcal/d which is ~ 42 kcal/kg admit weight of 71.2 kg 95 mL/h  24 hours = 2280 mL  0.078 (g protein/mL) = 178 g protein which is ~2.5 g protein/kg/d of admit weight of 71.2 kg 18. By using the information on the intake/output record, determine the energy and protein provided during this time period. Compare the energy and protein provided by the enteral feeding to your estimation of Mr. Angelo’s needs. Mr. Angelo received 565 mL of Impact Glutamine providing 734.5 kcal and 44.07 g protein. This provides approximately 25% of prescribed energy and 31% of prescribed protein requirements. 19. One of the residents on the medical team asks you if he should stop the enteral feeding because the patient’s blood pressure has been unstable. What recommendations can you make to the patient’s critical care team regarding feeding and hemodynamic status? Patients may develop multisystem organ dysfunction due to multiple reasons such as bacterial translocation, inadequate fluid resuscitation, poor perfusion, inhalation injury, medications, and medical procedures. Nutritional regimens should be catered to meet the challenges of the condition and treatments. It will be important to discuss with the team the risk of gut ischemia if the patient’s hemodynamic status further declines, especially if vasopressors are used, since this patient’s TF is administered by nasojejunal enteral access. Factors to be considered for those patients who are hemodynamically unstable include: • Hemodynamic status: MAP <60 • Enteral access: Jejunal placement • Medications: Addition of vasopressors, number of agents being used, and trend in titration of dose • I/O: Urine output, nasogastric tube output (amount and content) • Labs: Increased WBC • Abdominal exam: Distention, firmness Currently, the patient is hypotensive but mean arterial pressure remains acceptable at 71 mmHg per MD progress note dated 9/9. Patient is not on any vasopressors. Will continue with EN at this time but will monitor very closely for changes in hemodynamic status, medications, I/O, abdominal exam, and biochemical indices. VI. Nutrition Monitoring and Evaluation 20. List factors that you would monitor to assess the tolerance to and adequacy of nutrition support. • Since feeding access is in jejunum, checking of gastric residual volumes is not indicated. Monitor for abdominal distention, pain, emesis, bowel movements. • Weekly indirect calorimetry will be beneficial to assess under or over feeding. • Monitor weekly CRP and prealbumin levels. • Monitor weekly LFTs due to oxandrolone treatment. • Monitor labs for electrolyte imbalance, renal function (e.g. BUN, creatinine), and glycemic control; 1-3 times daily. • Daily I/O charts: tube feeding intake, bowel movements • Wound healing assessment with burn team • Nitrogen balance: UUN (weekly) 21. What is the best method to assess calorie needs in critically ill patients? What are the factors that need to be considered before the test is ordered? The gold standard is to get weekly indirect calorimetry studies to assess nutritional needs and adequacy of feeding. • Patient must have rested in a supine position for a minimum of 30 min. • Measurement should be done in a quiet, thermo-neutral condition (for example, should not be done if room temperature is increased for any reason). • Routine nursing care, therapies, and family visitation should be completed 30 minutes before the study (these are not allowed during the study). • If patient needs pain or agitation control, he/she should be treated 30 minutes before the study and this information should be documented. • If patient is on mechanical ventilation, FiO2 should be <0.6. • Must have stable, non-fluctuating FiO2 (variation should be <0.01). • Ventilatory settings are not changed for 90 minutes before the study is initiated. • Air leaks from the system should be avoided (ETT/trach cuff leak, chest tube leak, or bronchopleural fistulas). • Patients who are not on mechanical ventilation should be able to tolerate room air (all sources of supplemental oxygen, i.e., nasal canulas, masks, or trach collars should be turned off during the study). • Enteral and parenteral nutrition should have been infused at goal rate for the past 12 hours without any change in regimen and infusion should continue through the study. • If patient is on bolus or cyclic nutrition or on a diet, study should be done approximately an hour after feeding/eating. • Patient should not have received general anesthesia for the past 6-8 hours. • For patients on scheduled hemodialysis, study should be done on non-dialysis days. If patient is on PRN dialysis regimen, the study may be done 4 hours after the completion of the treatment. • Study should be delayed for an hour after burn dressings or other painful procedures. 22. Write an ADIME note that provides your nutrition assessment and enteral feeding recommendations and/or evaluation of the current enteral feeding orders. 9/10 0730 A: 65 YOM admitted with 40% BSAB with PMH of DM, HTN, GERD and PSH of s/p cholecystectomy. S/P intubation and escharotomy 9/09. Ht 6’0”, Weight 71.2 kg, IBW 81 kg, %IBW 88, BMI 21.3, BSA 1.9 m2 EER: 2700-2900 kcal (Zawacki and Xie equations) EPR: 140-180 g protein (2-2.5 g protein/kg) Meds reviewed; includes vitamin C, Pepcid, insulin, MVI, zinc sulfate, oxandrolone, senna, docusate, methadone, Versed, Dilaudid, propofol, thiamin and folate. Labs: K+ 5.9, Cl 113, CO2 20, Cr 1.26, Glu 211. Mg 1.5, Ca 6.9, Alb 2.1, Prealb 12, AST 44, CRP 12 Current Nutrition: NPO + TF using Impact with Glutamine @ 60 mL/h. D: Increased energy expenditure related to metabolic stress of burn and inhalation injury as evidenced by predicted energy requirement of 2700-2900 kcal/day. Inadequate enteral infusion related to interruptions for medical treatment as evidenced by patient receiving 30, which is consistent with Mr. McKinley. Possible benefits of underfeeding include lower omega-6 fatty acid intake to reduce substrate for proinflammatory mediator synthesis, limited carbohydrate intake resulting in reduced hyperglycemia, and decreased hypermetabolism resulting in reduced CO2 production. IV. Nutrition Diagnosis 14. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses. Nutrition Problem Nutrition Diagnosis 1. Increased energy and protein requirements associated with sepsis Increased protein needs 2. Poor oral intake of nutrients over the past four months r/t recent bypass surgery Inadequate oral intake 3. Depletion of lean body mass d/t sepsis and inability to take in enough protein on a regular diet Malnutrition 4. Recent Roux-en-Y bypass surgery, restrictive and malabsorptive digestion Altered GI function 5. Reduced absorptive surface secondary to bariatric surgery Predicted suboptimal vitamin/mineral intake 15. Are you able to diagnose Mr. McKinley using the proposed ASPEN/AND criteria for malnutrition? If so, describe the information you used to make this diagnosis. This patient’s weight loss due to bariatric surgery and edema associated with his acute illness make this malnutrition diagnosis difficult. Guidelines indicate that you need 2 of the 6 criteria –and this case does not provide any physical assessment data. Assessing for muscle or subcutaneous fat wasting would provide additional criteria but are also difficult in this morbidly obese patient. Certainly his diagnosis of sepsis and the critical nature of illness and inflammatory response places him at significant risk. Furthermore, his recent bariatric surgery presents potential nutrient deficiencies that could further compromise the pre-injury state. It would be useful to know from previous physician visits and assessments how supplementation has been going and if his feeding has been successful post-treatment. V. Nutrition Intervention 16. Outline the nutrition support regimen you would recommend for Mr. McKinley. This should include formula choice (and rationale) and rate initiation and advancement. 20 mL/hour of Peptamen Bariatric and increase as tolerated by 10-20 mL every 8-12 hours until goal rate of 80 mL/hour (based on 22 hours per day for an ICU patient) is reached. This will provide 1760 mL total volume, 1760 total kcalories, 164 g protein, and 1478 mL free water. Provide approximately 5 flushes of 60 mL free sterile water throughout the day (every ~4 hours). This formula is chosen for Mr. McKinley because it has a high protein-to-calorie ratio and can help meet the protein requirement for the critically ill obese population. It is also a hydrolyzed formula, which may assist in optimal absorption. It has a lipid profile to support modulation of proinflammatory mediators in the critically ill, along with carbohydrate levels to support the nutrition management of blood glucose levels for those with diabetes or under metabolic stress. A continuous feed would be best for Mr. McKinley because a continuous feed with a slower advancement will be better tolerated with his bowel reconstruction and allow for a more stabilized blood glucose. VI. Nutrition Monitoring and Evaluation 17. Identify the steps you would take to monitor Mr. McKinley’s nutritional status in the intensive care unit. • Sufficiency of nutrient intake/intake-output: daily • Electrolytes, BUN, creatinine: daily, then when stable 3 times per week • Liver function tests: weekly • Triglycerides: weekly • Weight, hydration, vital signs, bowel function: daily • Serum glucose: 3 times daily until stable • Nitrogen balance: weekly 18. What factors may affect his tolerance to enteral feeding? A number of factors could affect his tolerance, including a worsening disease state (which could affect GI motility). Hyperglycemia and electrolyte imbalances can also impact his response to the enteral therapy. Fluid needs (or fluctuations in fluid status) could also potentially impact tolerance. 19. Write a note for your initial inpatient nutrition assessment with nutrition support recommendations. DATE/TIME A: 37 yo M Admitted with SOB now on mechanical ventilation with probable sepsis PMH: T2DM, HTN, Hyperlipidemia, Osteoarthritis PSH: s/p Roux-en-Y bariatric surgery 4 months previously, total knee replacement Meds: lovastatin 60 mg/day (d/c Lantus and metformin 2 months ago) Skin: warm, dry to touch; ecchymosis, abrasions, petechiae on lower extremities, 2+ pitting edema Abdomen: obese appearance with rashes under skinfolds; soft, active bowel sounds I/O: +1430 mL Labs: K 5.8, CO2 31, Glu 385, Phos 2.1, Pro 5.8, Alb 1.9, Prealb 11, Ammonia 35, WBC 23.5, CRP 110, Ferritin 14, Transferrin 385, Lactate 4.2, Fibrinogen 525, Hgb 12.5, Hct 38, TG 245 Urine: Pro +, Glu +, Ket +, Bact +, WBC + Diet: NPO Diet Hx: unable to speak to patient due to mechanical ventilation. Hx of childhood obesity. Patient’s highest historical weight was 425 lbs – recent weight loss of 76# after bariatric surgery. Ht: 5’10” Wt: 325# UBW: 425# %UBW: 76% IBW: 166# %IBW: 196% BMI: 46.7 kg/m2 EER: 1660-1886 kcal/d (based on 22-25 kcal/kg IBW); EPR: 151-189 (based on 2.0-2.5 g/kg/IBW) D: Predicted suboptimal energy intake related to induced sedation as evidenced by an order for nothing by mouth and mechanical ventilation status. I: Goal to meet 100% nutritional needs via enteral feeding. When medically able, recommend a post-pyloric feeding tube to prepare for enteral feeding. Within 24-48 hours after hemodynamically stable, initiate Peptamen Bariatric @ 20 mL/hour. Increase as tolerated by 10-20 mL every 8-12 hours until goal rate of 80 mL/hour (based on 22 hours per day -ICU protocol). This will provide daily 1760 mL total volume, 1760 total kcalories, 164 g protein, and 1478 mL free water. Provide approximately 5 flushes of 60 mL free sterile water throughout the day (ever ~4 hours). Make HOB elevated between 30-45 degrees. Communicate with team the nutrition support recommendations per above. M/E: RD to follow patient in ICU. Monitor weight changes, I/O, abdominal sounds, and GI tolerance. Monitor BG and suggest insulin therapy if consistently above 180 mg/dL. Monitor lab trends and risks for refeeding syndrome. Reassess enteral feeding needs once weaned off of ventilator. Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157