Download Heart failure with Resulting Cardiac Cachexia

Heart failure with Resulting
Cardiac Cachexia
BY: Melissa Macias & Rebecca McCredy
Introduction
◼Charles Peterman was brought into the hospital by
ambulance
◼Collapsed at home
◼In acute distress
◼Poor appetite for the past 6 months
◼SOB and nausea
Pre- assessment
◼Dr. Charles Peterman, Retired Physician
◼Male, 85 y.o.
◼Married, lives with spouse
◼No children
◼NKA
◼Parents had HTN, CAD
◼CAD, HTN, HF, mitral valve insufficiency, previous
anterior MI
◼No Tobacco use
Pathophysiology of Heart
Failure
■ Impairment of the ventricles’
■ Begins with injury to the heart or left ventricle
hypertrophy
○ impaired overall heart function
■ renin-angiotension-aldosterone is released
● change in BP
■ Heart becomes enlarged, weakened and cannot
respond to stress
■ Blood flow to kidney is reduced
○ vasoconstriction
Nelms M, Lacey K. Nutrition Therapy & Pathophysiology. 2nd ed. Belmont, CA: Brooks/Cole Cengage Learning; 2011.
R-sided vs L-sided Failure
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L-sided
○ blood is not pumped into the body normally
○ Systolic
○ Diastolic
R-sided
○ usually a result of L-sided failure
○ increased fluid pressure
Nelms M, Lacey K. Nutrition Therapy & Pathophysiology. 2nd ed. Belmont, CA: Brooks/Cole Cengage Learning; 2011.
Signs and Symptoms of Heart
Failure
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SOB
Fatigue
Cough
Lack of appetite
Increased heart rate
Racing heart beat
Ascites
American Heart Association. Warnings signs of heart failure. Accessed on May 6, 2014.
http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-HeartFailure_UCM_002045_Article.jsp
Cardiac Cachexia
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Hypermetabolic State
Form of malnutrition
Pathophysiology is unknown
○ complex imbalance of the body’s systems
Pro-inflammatory state
o cytokines are high
Wasting syndrome
○ decrease in: fat tissue, lean tissue, bone tissue
Signs & Symptoms
○ extreme skeletal muscle wasting
○ fatigue
○ anorexia
Morley J, Thomas D, Wilson M. Cachexia: pathophysiology and clinical relevance. AM J Clin Nutr.
2006;83:735-743.
Cardiac Cachexia
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Unintentional severe weight loss
○ blood backed up in liver & intestine causes
swelling
■ decrease appetite
○ Swelling in intestines
■ decreases nutrient absorption
○ Heart failure
■ work harder to breath & body temp
increased
■ cytokines in bloodstream
● increases metabolic rate of tissues
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Side effects from drugs
■ nausea, vomiting, anorexia
Nutrition Therapy
Congestive Heart Failure
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Restricted Sodium
○ 2000 mg
Restricted Fluid
○ 1500mL
Small, frequent meals
Potassium Supplementations
Thiamin Supplementations
Calcium Supplementations
Limited Alcohol
Nelms M, Lacey K. Nutrition Therapy & Pathophysiology. 2nd ed.
Belmont, CA: Brooks/Cole Cengage Learning; 2011.
Nutrition Care Manual. Accessed on April 27, 2014.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv
1=5803&lv2=8585&ncm_toc_id=8585&ncm_heading=Nutrition%20C
are.
Cardiac Cachexia
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There are no guidelines for
nutrition therapy. Often, the
patient is put on EN to help
prevent weight-loss.
Currently U.S. Institute of
Health is conducting a study on
EN in Congestive HF and
Cardiac Cachexia
Anker S, John M, Pedersen P, Raguso C, Cicoira M, Dardai E, Lacaino A,
Ponikowski P, Schols A, Becker M, Bohm M, Brunkhorst K, Vogelmeier C.
ESPEN guidelines on enteral nutrition: cardiology and pulmonology. Cl Nutr.
2006; 25: 311-318.
U.S. Institution of Health. Enteral Nutrition in Congestive Heart Failure and
Cardiac Cachexia. Accessed on May 6, 2014.
http://clinicaltrials.gov/ct2/show/NCT00654719.
Why would the patient be given
thiamin supplementation when
taking a diuretic?
A: increase
inflammatory process
and improve
micronutrients
B: decrease
inflammatory process
and improve
micronutrients
Dr. Peterman’s Medications
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Lanoxin 0.125 mg
Lasix 80 mg
Aldactone 25 mg
Lisinopril 30 mg
Lopressor 25 mg
Metamucil 1 tbsp
Calcium Carbonate 500 mg
MVI
Dr. Peterman’s Lab Values
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Sodium 132 mEq/L
BUN 31 mg/dL
Creatinine Serum 1.6 mg/dL
Protein 5.8 g/dL
Albumin 2.8 g/dL
Prealbumin 15 mg/dL
WBC 12 x103/mm3
White J, Guenter P, Jensen G, Malone A, Schofield A. Consensus statement of the academy
of nutrition and Dietetics/American Society for parenteral and enteral nutrition: characteristics
recommended for the identification and documentation of adult malnutrition (undernutrition). J
Acad Nutr Diet. 2012;112:730-738.
Signs of Malnutrition
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Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation that
may sometimes mask weight loss
■ Diminished functional status as measured by hand
grip strength
White J, Guenter P, Jensen G, Malone A, Schofield A. Consensus statement of the academy of
nutrition and Dietetics/American Society for parenteral and enteral nutrition: characteristics
recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad
Nutr Diet. 2012;112:730-738.
Red Flags
■ Temporal wasting
■ Jugular venous distension
■ 4 + pedal edema
■ weak hand grip
■ BP: 90/70
■ Skin: grey, moist
■ Abdominal appearance: distended
■ Skin color: grey
■ Skin temperature: moist
■ Skin turgor: TENT
■ Intake < 5% of meals
■ Liver tender to A&P
Nutrition Assessment
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CHF which has caused:
Fluid Retention
○ -4+ pedal edema
○ ascites
IBW is used to determine EER and EPR
○ Hard to determine actual weight because of the
fluid retention
Poor intake <5%, sips drinks
Related Problems
Intake Domain
Clinical Domain
Inadequate energy intake
Swallowing Difficulty
Inadequate protein intake
Altered GI Function
Inadequate fluid intake
Increased energy expenditure
Inadequate oral intake
Malnutrition
Behavioral
Domain
Estimate Requirements
Energy Requirements:
IBW = 106 lbs. for first 5 feet + 6 lbs for every inch over
5 feet
= 106 + 6(10)
= 166 lbs or 75.5 kg
25 kcal/kg
= 25(75.5)
= 1,887 kcal/day OR
= 1,800- 1,900 kcal/day
Protein Requirements:
= 1.2(75.5)
= 90.6
= About 90 g of protein/day
PES Statements
1. Malnutrition related to cardiac cachexia as
evidence by a documented PO intake of
less than 5% of meals served.
1. Inadequate energy intake related to cardiac
cachexia, secondary to Congestive heart
failure as evidence by ascites, temporal
wasting, and jugular venous distension.
Nutrition Intervention
1. Prevent refeeding syndrome because the
patient is suffering from malnutrition.
1. Patient’s enteral nutrition is at a rate of 31
mL per hour X 22 hours of 1.5 calories per
mL formula and slowly advance to 55 mL
per hour as tolerated.
Which Enteral Formula Would You
Use?
A. Isosouce 1.5
C. Renalcal 2.0
a.
1500 kcals
a.
2000 kcals
b.
Protein Source: sodium and
calcium caseinates (milk)
b.
Protein Source: whey protein
concentrate, amino acid blend
c.
67.6 g protein
c.
34.4 g protein
B. Peptamen 1.5
a.
1500 kcals
b.
68 g protein
c.
Protein Source: enzymatically
hydrolyzed whey protein
Peptamen 1.5
kcal/mL: 1.5
Caloric Distribution
Protein: 18%
Carbohydrate: 49%
Fat: 33%
Semi-Elemental
Monitoring and Evaluation
1. Monitor patients PO intake and review
labs.
1. Monitor tube feeding initiation, his
tolerance, and the progression.
Feeding DifficultyEnteral Nutrition
● Dr Peterman was not able to tolerate the enteral
feeding due to diarrhea.
● What recommendations could be made to
improve tolerance to the tube feeding?
● Intolerance continued, what would be your next
step?
Palliative Care
■ Dr. Peterman stated he wanted no
extraordinary measures taken to prolong
his life.
■ What is the dietitians role during palliative
care?
Conclusion
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Dr. Peterman will not be placed on a restricted diet.
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Due to no extraordinary measures
○ we want the remaining days of his life to be
enjoyable
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We will continue to check on Dr. Peterman