Download Case Study: CABG - Heidi Schultz OHSU Dietetic Intern

Heidi Schultz
Oregon Health & Science University
4/19/2010
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83 year-old Vietnamese female.
Admitted to the hospital on 2/17/10 with
chest pain.
Pt was inpatient for a total of 22 days.
 18 days in CICU.
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This case study will cover her 22 day inpatient
stay.
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Pt seen at another hospital 10/2009.
 Dx with severe 3-vessel coronary artery disease.
Pt seen at this hospital early February for
pneumonia; treated and discharged.
 On 2/17/10 (Day 1), Pt was admitted to the ER at
another hospital.
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 Complaints of chest pain.
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Tx to this hospital for surgery.
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Colonoscopy
CABGx3
Respiratory distress/pneumonia/vented
Nutrition consulted beginning Day 9
TF
Metabolic acidosis
Stabilized
Oral PO
Education provided
Consult with JCAHO
PT IS A VEGETARIAN
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Typical intake:
 Breakfast:
▪ 2 slices of bread or cereal;
coffee with 4 bags of sugar.
 Lunch:
▪ Homemade Vietnamese soup
with veggies.
 Dinner:
▪ Stir-fry vegetables with tofu
and white rice or noodles.
 Snacks/desserts:
▪ Pt likes chocolate and cookies.
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Height: 60” (152 cm)
Weight: 142 lb (64.5 kg)
Weight Change: No significant change
BMI: 27.8 (overweight)
IBW: 100 lbs (45.5kg)
%IBW: 142%
Glucose/Endocrine Profile:
• Glucose, casual: 133 mg/dL high (Ref 60-99)
Electrolyte and Renal Profile:
• Lytes: WDL
• Troponin: negative for MI
Nutritional Anemia Profile:
▪
▪
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HGB: 8.3 g/dL low (Ref 11.7-15.7)
Hematocrit: 24% intitially low; 33% after two units low (Ref 34.9-46.9)
Iron 27 ug/dL low (Ref 40-150)
Ferritin WDL
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Vital Signs:
 Blood Pressure 125/70; WDL
 HR 80 and regular; WDL
 Respiratory rate 18; WDL
Personal History
Pt is an 83 year-old
female.
 Vietnamese.
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 Moved to US from
Vietnam in 1982.
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Non-English speaking.
Social History
 Pt lives at home with her son.
 Pt is a non-smoker and non-drinker.
 Pt does not speak English.
 Pt uses a walker and is not physically active.
 Decreased exercise tolerance.
Code Status: Full Code
Medical History
 Coronary Artery Disease
 Thalassemia
 Pneumonia
 Asthma
 DM2
 Hypercholesterolemia
 HTN
 C-section
Purpose
Drug
Considerations
Antihypertensive
Diovan 160 mg
can also ↓ Hgb, Hct
Platelet Aggregation
Inhibitor for ↓ risk of MI
Plavix 75 mg
Oral Hypoglycemic/
Sulfonylurea
Glipizide LX 10
mg
Anti-hyperlipidemic
Simvastatin 40
mg
Anti-hyperglycemic
Metformin 1000
mg
Anti-diabetic
Actos 45 mg
Asthma
Singulair 10 mg
Osteoperosis
Actonel 150 mg
Anti-asthma (as needed)
Albuterol
can also ↑ TG, LDL
Can ↑ glucose;
angina
Plaque builds up in the
arteries that supply
blood to the heart.
 Reduces blood flow to
the heart (angina).
 Increases chance of
blood clots.
 Can cause heart failure.
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An inherited blood disorder:
 Mediterraneans/Asians/African Americans.
 Abnormal hemoglobin.
Hemoglobinopathy
 Thalassemia:
▪ Underproduction of globin protein (either alpha or beta chain).
 Sickle-cell anemia:
▪ Abnormality of globin protein (mutant of beta globin chain).
Thalassemia Minor:
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Have small red blood cells but few symptoms.
• Typically no specific treatment needed.
Thalassemia Major:
•
Babies may be stillborn or develop severe anemia in their first year
of life.
• Severe Thalassemia can lead to heart failure and early death.
 Regular blood transfusions often required.
• Require chelation therapy to remove excess iron from the body.
• Too much iron can damage the brain, heart, liver and endocrine
system.
• Folate supplements.
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Pt admitted to another hospital
with chest pain.
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Pt tx to this hospital for
CAD surgery.
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MD unsure that surgery is indicated.
 Symptoms may be related to anemia.
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GI evaluation requested.
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Pt underwent
colonoscopy.
5 polyps removed.
Otherwise normal
colonoscopy.
No obvious source of
long-term GI blood
loss.
Scheduled CABG.
During CABG, a healthy
artery or vein from the body
is connected, or grafted, to
the blocked coronary artery.
The grafted artery or vein
bypasses (that is, goes
around) the blocked portion
of the coronary artery.
 This creates a new passage,
and oxygen-rich blood is
routed around the blockage
to the heart muscle.
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http://www.youtube.com/wat
ch?v=HYLNDuGsTEw
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Pt underwent a Triple Coronary Artery
Bypass Graft.
 Pt tolerated surgery well.
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Pt experienced
respiratory distress and
was intubated.
Sedated with Propofol.
 Fat emulsion.
 1.1 kcal/cc.
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Rate of Propofol was 4
cc/hour.
 Adds about 11 grams of fat
every 24 hours.
 TGs were checked: 103
mg/dL (Ref <149).
 Respiratory Distress w/Hypoxemia
 Renal Insufficiency
▪ Creatinine 2 mg/dL high (Ref .5 to 1.1)
▪ GFR 34 mL/min/1.73m2 low (Ref 75)
 Metabolic Acidosis
▪ pH ABG 7.30 low (Ref 7.35-7.45)
 Hypotension
▪ BP 98/43 low
 Possible Health Care Associated Pneumonia (HCAP)
▪ Procalcitonin 1.17 ng/mL high (Rev .05 - .50)
Received 2 units PRBCs in past 24 hours
PreTransfusion
PostTransfusion
Reference
Range
RBC
3.08 10^ 12/L WDL
3.8 to 5.20
Hgb
8.6 g/dL
11.1 g/dL
11.7 to 15.7
Hct
25.3%
32.4%
24.9% to
46.9%
Nutrition received a Consult for TF:
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NG Tube
Energy needs - Penn State equation used
 1500 kcal/day
 Protein 1.2 g/kg (78 grams/day)
 Fluid: 1500 ml
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Formula: Jevity 1.2 (house) high fiber
 Goal rate of 55 ml/hr
 Provide 1584 kcal
 1069 ml free water from TF; 300 ml from flushes (total
1369 ml)
 Will get additional free water from IVF
Nutrition Summary:
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Day 9 pt experienced respiratory distress resulting in reintubation; NG placed today to meet nutritional needs.
Pt was ordering and eating adequate amount of kcal
here prior to intubation as per records.
PES:
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Oral intake inadequate related to intubation as
evidenced by NPO.
Plan is short-term enteral feeding with goal of attaining
adequate kcal and protein.
Purpose
Drug
Administration
Wound healing
Vitamin C 1,000 mg
PO BID
Electrolytes
Klor-Con M20
PO BID
Antihypertensive
Captopril 6.25mg
PO q8H
Platelet agg inhibitor
Plavix 75 mg
PO daily
Antihypertensive
Lopressor 25 mg
PO BID
Antibiotic
Bactroban Nasal
Topical BID
Antibiotic
Cipro 400 mg
200 ml IV daily
Antibiotic
Azactam .5 gm
25 ml IV q 6 H
Antisecretory
Protonix 40 mg
10 ml IV daily
Hyperglycemia
Reg Insulin 150 units
1.5 mL IV qBag
Sedation
Propofol 1,000 mg
100 ml IV demand
Sympathomimetic
Dobutamine 500 mg
40 ml IV qBag
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Pt still vented.
Pt still hypotensive (109/55) with chronic
metabolic acidosis.
 Pt taken off Propofol and put on Versed.
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HCAP with fever (101.3 F) persisting.
Acute renal insufficiency improved.
Respiratory – stable vent settings.
Started TF yesterday.
Labs noted – Complete Metabolic Panel:
 BUN 40 mg/dL high
 Creatinine 1.35 mg/dL high
 Protein, Total 5.7 g/dL low
 Pre-albumin 11 low
 Albumin 2.6 g/dL low
 Lytes WDL
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Pt hemodynamically stable and off pressors.
MD changed TF to 2-Cal Concentrated.
Pt needs
2 Cal HN
Prosource
Combined
Calories
1500
1200
60
1320
Rate
Na
25 ml/hr
Na
25 ml/hr
Protein
78 g
50 g
15 g
80 g
427 ml
free; 300
ml flushes.
na
427 ml
free; 300
ml flushes.
Free Water 1500 ml
Nutrition Summary:
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Day 13; pt has been on TF for 4 days while intubated in
CCU; did not reach goal volume (55 ml/hr) on Jevity 1.2;
yesterday MD changed to two-cal for minimal fluid; RD
added 2 packets of Prosource protein per day to
increase protein intake. This enables the current TF
order to meet 88% of est Cal needs; 102% est protein
needs.
Nut problem: Ongoing
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Pt tolerating concentrated formula well and is
at goal rate.
Labs noted – Nutrition Panel:
 Glucose 140 high
 BUN 46 high
 Phosphorus 1.7 low
 Albumin 3.1 low
 Lytes WDL
Nutrition Summary:
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Pt intubated and receiving adequate nutrition and
protein with TF and 2 Prosource per day. Pt tolerating TF
at goal rate. Pt continues with anemia most likely due
to Thalassemia.
Nut Problem:
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Ongoing. NPO x7 days.
Diet order changed to mechanical soft with cyclic TF at night.
 Energy needs calculated with Mifflin:
 REE = 1019 x 1.2 Activity Factor x 1.2 Stress Factor = 1467
 Compared to 25 kcal/kg = 1612 kcal
 Anticipating PO intake to be inconsistent at first, use higher range of:
▪ 1600 kcal for energy needs
▪ Protein 1 g/kg = 65 grams per day
▪ Fluids per MD
 Cyclic TF Order
 Goal 1600 kcal/day (1000 kcal from TF; 600 kcal from oral PO)
 Formula: 2 cal HN concentrated; 40 ml/hour for 12 hours at night
 Provides: 480 ml (960 kcal); 40 g protein; 336 ml water; 4 free water
flushes of 160 ml each (976 ml total water). Pt still on fluid restriction.
Nutrition Summary:
 As per nurse, pt is to continue with TF during evening
only and consume mechanical soft during the day.
Recommend continue with 2-Cal Concentrated at rate
of 40 ml/hr for 12 hours. Will order calorie count as
well.
Nutrition Problem:
 Ongoing; pt extubated on Day 17 of stay; Day 9 of TF.
 Oral intake continues to be inadequate.
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TF discontinued (11 days TF).
 NG removed.
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Pt ambulating.
Diet order changed to general diet w/2000 ml
fluid restriction.
Consult received for nutrition education for
low-fat/low-sodium, heart-healthy diet.
 RD on duty did not perform nut ed due to
confusion about diet order.
Pt transferred to the floor.
Nut Summary:
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Pt discontinued TF 3/8; appetite for oral PO is
improving. Pt is ambulating and hemodynamically
stable. Pt consumed 900 kcal and 108 carb for lunch
yesterday. Will perform low-fat, low-cholesterol nut
ed today.
Nut Problem:
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Improved. Pt consuming adequate PO with >1200
kcal intake yesterday and continued adequate
intake today.
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Provided Heart-Healthy Eating handouts in both
English and Vietnamese.
Took typical dietary intake.
Discussed TLC diet:
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Limit sat and trans fats.
Limit cholesterol.
Increase omega-3s.
Increase fiber.
Continue eating plant based/soy foods.
Referred pt to outpatient RD visit for diabetes
education.
PT IS A VEGETARIAN
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Typical intake:
 Breakfast:
▪ 2 slices of bread or cereal;
coffee with 4 bags of sugar.
 Lunch:
▪ Homemade Vietnamese soup
with veggies.
 Dinner:
▪ Stir-fry vegetables with tofu
and white rice or noodles.
 Snacks/desserts:
▪ Pt likes chocolate and cookies.
Why was TF changed?
How have we
accommodated the
patient’s language
barrier and cultural
preferences?
 How do we decide
which patients to
assess?
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Pt was discharged from the
hospital on 3/11/10.
 Oral diet.
 Nutrition problem improved.
 No Albumin/Pre-Albumin.
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Pt transferred home.
 PT and OT through Home Health.
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In the past month, the pt has been readmitted twice
due to non-nutritional complications/complaints.
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National Heart Lung and Blood Institute:
http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html; Accessed 4/8/10
American Dietetic Association: www.eatright.org; Accessed 4/8/10
National Institute of Health: Medline Plus
http://www.nlm.nih.gov/medlineplus/ency/article/000587.htm; Accessed 4/8/10
Charles JC, Heilman RL. Metabolic Acidosis. Hospital Physician, March 2005: 37-42.
Van Den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill
patients. N Engl J Med. 2001: 345:1359-1367.
Miller J, Kee. Keeping your patient hemodynamically stable. Nursing. May 2007: 37(5) 36-41.
Niedert KC. Position of the ADA: Liberalization of the Diet Perscription Improves Quality of
Life for Older Adults in Long-term Care. Journal of the American Dietetic Association
(Position Paper). 2005: 1955-1965.
Kollef MH, Bedient TJ, Isakow W, Witt CA. The Washington Manual of Critical Care.
Published by Lippincott Williams & Wilkins 2008.
Pronsky ZM. Food Medication Interactions; 15th Edition.
Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference; 9th Edition.
Published by Elsevier Inc. 2009.
Hemila H, Louhiala P. Vitamin C for preventing and treating pneumonia. Cochrane Database
of Systematic Reviews 2007, Issue 1. Art No.CD005532.DOI:10.1002/14651858.
CD005532.pub2.