Download File

Nutrition Therapy for Metabolic
Stress and Critical Illness
Lauren Hoover & Clare Howard
KNH 411
November 8, 2016
Patient
Chris McKinley, Male, 37 y.o.
-Summary: Patient has weighed over 250 pounds. since age 15 with steady
weight gain, recently reaching a high of 424 pounds, then lost 24 pounds
prior to his bariatric surgery. Four months ago, he received the Roux-en-Y
gastric bypass. Total weight loss to date is approx. 100 pounds. However, now
he is admitted to the MICU from the ER with probable sepsis.
-Vital Signs (Admitting)-Temp.: 102.5
BP: 135/90
Pulse: 98
Resp. Rate: 23
Height: 5’10”
Weight: 325 lbs.
Patient History
-Onset of disease: Experienced flu-like symptoms over previous 48 hours,
became acutely SOB - brought to ER
-Medical Hx: Type 2 DM, Htn, hyperlipidemia, osteoarthritis
-Medications: Lovastatin 60 mg/day (Also has been off diabetes medications for
2 mo.)
-Tobacco Use: none
-Alcohol Use: Socially, none since surgery
-Family Hx: Father - Type 2 DM, CAD, Htn, COPD; Mother - Type 2 DM, CAD,
osteoporosis
Roux-en-Y Gastric Bypass Surgery
Sepsis/SIRS
• Etiology - Combination of pro-inflammatory cytokine release, coagulation factor
imbalance, altered cell metabolism, hypoperfusion, and hypotension
• Diagnosis - increased WBC count, HR, and respirations, and fever or hypothermia.
Others include inflammatory variables
• Pathophysiology - originating source of infection/trauma, initial inflammatory
response resulting in vascular permeability, continues to an anti-inflammatory
response with resulting organ dysfunction.
– Increased gluconeogenesis = catabolism of muscle mass
Patient’s Laboratory Results
Reference Range
2/23 Value
Potassium (mEq/L)
3.5-5.1
5.8
Carbon dioxide (mEq/L)
23-29
31
Glucose (mg/dL)
70-99
385
Phosphate (mg/dL)
2.2-4.6
2.1
Bilirubin, total (mg/dL)
<1.2
1.3
Bilirubin, direct (mg/dL)
<0.3
0.7
Patient’s Laboratory Results cont.
Reference Range
2/23 Value
CPK (U/L)
55-170
220
Fibrinogen (mg/dL)
160-450
525
Lactate (mEq.L)
0.3-2.3
4.2
Cholesterol (mg/dL)
<200
320
HDL-C (mg/dL)
>50
32
VLDL (mg/dL)
7-32
45
LDL (mg/dL)
<130
232
Patient’s Laboratory Results cont.
Reference Range
2/23 Value
HbA1c (%)
<5.7
6.8
PT (sec)
11-13
14.5
INR
0.9-1.1
1.4
PTT (sec)
24-34
37
WBC (x10^3/mm^3)
3.9-10.7
23.5
Hemoglobin ( g/dL)
14-17
12.5
Hematocrit (%)
41-51
38
Patient’s Laboratory Results cont.
Urinalysis results:
-Protein, glucose ketones, and Bact present,
Treatment for Sepsis
• Treat the infection first
• Support patient with ventilation, antibiotics,
hemodynamic, renal, and metabolic support
• Insulin therapy, antimicrobial agents,
coagulation-modulating drugs
Physician’s Assessment/Plan
-Diagnosis of severe sepsis, pneumonia
-Maintain current mechanical ventilation,
continue vancomycin, Zosyn
-Sedated with Versed and fentanyl
-Initiate enteral feeding per nutrition consult
Nutrition Therapy - Assessment
Height = 5’10” = 1.78m
Current Wt. = 325 lbs. = 147.73 kg
Usual BW = 425 lbs.
%Usual BW = 76.5 %
Ideal BW (using Hamwi method) = 166 lbs. = 75.5 kg
BMI = 46.6 kg/m^2
Nutrition Therapy - Diagnosis
•
Inadequate protein-energy intake related to NPO current diet, as evidenced by lab
results, specifically total protein, albumin, and prealbumin
•
Increased nutrient needs related to inability to consume regular diet as evidenced by
intubation and sedated state.
Nutrition Therapy - Intervention
Calculation of Energy, Protein and Fluid needs:
Energy - 25-30 kcal/kg IBW
Protein - 1.2-1.5 g/kg IBW
Energy - 1890-2270 kcals
Protein - 91-113 g
Fluids - 1 mL/kcal
Fluids - 1890-2270 mL
Nutrition Therapy - Intervention
Enteral Nutrition Plan:
-Formula chosen - Isocal HN Plus (1.20 kcal/mL, 54 g protein/L)
-For continuous feeding - 1800 mL/24 hours = 75 mL/hr. via pump
-For bolus feeding - 1800 mL/4 feedings = 450 mL/feeding
Initial start rate of 20 mL/hour, increase by 15 mL every 4 hours to achieve 75 mL/hr,
change to bolus feeding 6 times/day (300 mL), then to 4 times/day (450 mL).
Nutrition Therapy - Intervention
Enteral Nutrition:
1800 mL of Isocal HN Plus provides -1800 mL fluid
-2160 kcals
-97 g protein
*An additional 100-200 mL of fluid can be given.
Nutrition Therapy Monitoring/Evaluation
-Initially (if unstable): I/O, electrolytes, BUN, creatinine, weight, hydration status, vital
signs, bowel function, blood glucose daily, and TG, liver function tests weekly.
-When Stable: I/O, electrolytes, BUN, creatinine, weight, hydration status, vital signs,
bowel function, blood glucose 1-3 times/week, and TG, liver function tests as needed.
-Monitor any intolerance via symptoms, such as vomiting, nausea, diarrhea, abdominal
pain, etc. Change feeding progression if needed
.
References
International Dietetic & Nutrition Terminology (IDNT): Reference Manual. Standardized Language for Nutrition
Care Process. Academy of Nutrition and Dietetics, 2014. Retrieved from ncpt.webauthor.com
Mahan, L.K., Escott-Stump, S., Raymond, J.L. Krause’s Food Nutrition & Diet Therapy, 13th ed. Philadelphia, PA:
W.B. Saunders Company, 2012
Nelms M. Medical Nutrition Therapy A Case Study Approach 5th ed., Cengage Learning, 2017.
Nelms M. Sucher K, Lacey, K. Nutrition Therapy and Pathophysiology. 3rd ed. Cengage Learning, 2016.
Questions?