Download Nutritional Management of a Critically Ill HIV

CASE REPORT: NUTRITIONAL
MANAGEMENT OF A CRITICALLY
ILL HIV-1 INFECTED PATIENT
Stephanie Yednak
Disease Description


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HIV causes a progressive decline in cellular
immunity
Leads to Acquired Immunodeficiency Syndrome
(AIDS)
Attacks CD4+ t-helper lymphocyte cells
4 stages of the infection, categorized by


Symptoms
CD4 count
Stages of the Disease

Acute HIV infection
•
2-4 weeks after contraction, flulike symptoms

Asymptomatic Chronic HIV infection
•
8-10 years with no symptoms

Symptomatic HIV infection
•
Symptoms start to appear, CD4 starts to decline <500 mm3

AIDS or advanced HIV
•
A life threatening condition attached to a CD4 count < 200 mm3
How is HIV transmitted?
The HIV retrovirus can be transmitted through:
 Blood and blood transfusions
 Semen, vaginal and other bodily fluids
 Intravenous drug use
 Unprotected sexual contact
 Occupational exposure
 Passage from mother to child from the womb
 Breast milk
A Cure? Medications
Antiretroviral Therapy (ART)
 A combination of medications used to suppress or
kill viral replication and progression of HIV
 Recommended when CD4 counts <350mm3
 Prescribed when CD4 counts <200mm3
 Examples include:
 Combivir,
Epivir, Retrovir, Epzicom and Zerit
Medication Facts

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Drug resistance and tolerance develops over time
At least 95% adherence to medication regimen is
necessary in order to work properly
Not all patients tolerate the drugs
Common side effects
HIV may cost one upwards of $34,000 annually
 Not
all insurances cover all HIV meds
Biochemical Parameters
Albumin
Hemoglobin
and
hematocrit
Cholesterol
Transferrin
Total
protein
Evidenced-Based Nutrition
Blood work of 43 HIV and AIDS patients
 No significant differences observed in:
 BMI
 Total protein
 Albumin
 Transthyretin
 RBP
 However, HIV/AIDS patients have significantly lower
albumin levels compared to reference range

Stambullian M, Feliu S, Slobodianik NH. Nutritional status in patients with HIV infections and AIDS. British Journal of Nutrition. 2007. 98:Suppl.1, S140S143.
Predictors of Survival
Albumin
CRP
Transhyretin
Evidenced-Based Nutrition


Case report following a 44 y/o male
Medication noncompliance secondary to swallowing
difficulty
 Consequences of non-compliance:





Critical illness
Suppressed CD4 count
Elevated viral load
+ for numerous psychological barriers
Percutaneous endoscopic gastronomy (PEG) tube
placement
Major Conclusions


PEG is safe to use in the HIV/AIDS pt
PEG insertion results in:
 improved
quality of life
 improved nutritional status in HIV infected patients

After 15 mo of use:
 undetectable
viral load
 elevated CD4 count
 remission of opportunistic infections (OI)

Leipe J, Hueber AJ, Rech J, Harrer T. Bypassing non-adherence via PEG in a critically ill HIV-1-infected patient. AIDS Care. 2008. 20(7): 863-867.
Health Policy


The nutritional adequacy of HIV + adults was
assessed and compared by:
Whether the household used nutrition care support
(NCS) services including:

Nutritional assessment

Nutrition education/ counseling

Food and nutrient supplementation

Food assistance

Livelihood strengthening
Results of the Screening
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65.3% prevalence of risk of malnutrition
49% of the participants had a high BMI >25.
QOL was similar
Those who received NCS had diminished:
general health
 self care functioning
 QOL

Results

NCS participants also:
 were
more frequently taking ART
 Had more money
 reporting good eating plans
 twice as likely to have oral thrush
 NCS recipients were from households with more than
one provider (p<0.05)

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The non-NCS recipients had been generally sick,
reported fatigue, nausea, appetite loss and
diarrhea
Oketch JA, Paterson M, Maunder EW, Rollins NC. Too little too late: Comparison of nutritional status and quality of life of nutrition care and support
recipient and non-recipients among HIV-positive adults in KwaZulu-Natal, South Africa. Health Policy. 2011. (99) 267-276.
Case Presentation
Nutrition Care Process (NCP)
Case Presentation
A 45-year-old Caucasian female
 Arrived to the ED c/o fever and SOB
 Other symptoms:

 aphasia
 slurred
speech
 persistent drooling
 right sided weakness
 unable to move her jaw
Previous Medical History
HIV
Tonsillar
cancer
Aphasia
PML
Chronic
Pain
TMJ
PEG
placement
Bedridden
Dysphagia
Nutrition Care Process: Assessment

Seropositive for HIV-1 confirmed by:
 ELISA
 Western

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
blot
Living 23 years with the virus
Contraction through infected tattoo
CD4 count 247
Viral Load 563
Patient Data

Pt had PEG placed this year at SOMC
 Due
to impaired swallowing ability
 Non-compliance with ART regimen
 Pt receives all nutrition and hydration through PEG tube


Patient smokes half a pack of cigarettes a day
Pt continues to attempt po consumption of food and
medications
Diet/ Physical Activity

TF regimen
 Jevity
1.2 @ 89 ml/hr for 14 hours nocturnally
 Family encourages po feeds during the day
 Pt has not consumed any food po due to SOB
 No episodes of nausea and vomiting at home

Physical Activity

The patient has recently lost the ability to ambulate
and is bedridden
NCP: Assessment (con’t)

General Appearance:
 thin
and cachecitic looking
 signs of lipoatrophy in arms, legs and face
 poor dentition, missing teeth
 denies any appetite or significant weight loss
NCP: Assessment (con’t)
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Anthropometric Measurements:
Height: 5’7
Weight 138#, 63 kg
BMI = 21.2
IBW= 135#, 61.3 kg
% IBW = 102%
Parameter
12/11/11
12/13/11
Sodium
134 L
136
Deficient dietary intake,
diarrhea
Potassium
3.8 L
4.1Δ
GI disorders, vomiting,
diarrhea, deficient intake
BUN
23 H
14
MI, GI bleed, alimentary tube
feeding, excessive protein
catabolism, starvation
Glucose
177 H
104
Extensive liver disease,
starvation, medication
induced
Total protein
8.9 H
7.2
Resolved
Albumin
3.4
2.6 L
Albumin levels plummeted
and remained low over the
course of the hospital which
may be attributed to
inflammation and not a
marker of nutritional status.
Alk Phos
138 H
95
Liver tumor, cirrhosis,
ischemia, bililary obstruction
Normal
Hemoglobin
hematocrit
13.1
39
Significance
Normal
Medications
Medication
Dosage
Rationale
Side Effects
Oxycotin
80 mg bid
Used for the management of
moderate to severe pain
Epivir
15 ml bid
HIV infection, antiretroviral
Respiratory depression,
constipation, nausea, dry
mouth, vomiting
Anorexia, diarrhea, nausea,
vomiting, abnormal LFT,
abdominal discomfort
Ziagen
15 ml bid
Management of HIV infection
Compazine
10 mg prn
Antiemetic, management of
nausea and vomiting
Skelaxin
800 mg bid
Muscle relaxant
Nausea, anorexia, dry mouth,
GI upset, vomiting
Dulcolax
Prn
Laxative, treatment of
constipation
Abdominal cramps, nausea,
diarrhea, hypokalemia, muscle
weakness
Bactrim
20 mg daily
Anti-infective, prevention of
PCP in HIV + patients
Nausea, vomiting, diarrhea,
stomatitis
Intelence
200 mg daily
Treats and prevents the
spread of HIV.
Nausea, vomiting, abdominal
pain, diarrhea, increased blood
pressure
Hepatotoxicity, nausea,
vomiting, diarrhea, anorexia,
lactic acidosis
Constipation, dry mouth,
anorexia, ileus
Protein
1.5 g – 2.0 pro/kg
94.5g -126 g pro/
day
Energy
35 -45 kcal
2205-2835
kcal/ day
Fluids
35-40 ml/kg
2205-2520 ml
Nutrient Needs
Needs were based in actual body weight of 63 kg
NCP: Nutrition Diagnosis
PES #1

Swallowing difficulty
(NC-1.1) related to
decreased lingual
strength and PML as
evidenced by
dysphagia, aphasia
and failed swallow
evaluation
PES #2

Inadequate enteral
nutrition infusion (NI-2.3)
related to inadequate
provision of nutrients as
evidenced by loss of
muscle mass secondary
to client history of
human immunodeficiency
virus
NCP: Intervention
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Intervention #1: Implement nutrition education,
specifically the nutrition relationship to
health/disease (E-1.4)
Intervention #2: Collaboration/referral to other
providers (RC-1.3). Requested Speech language
pathologist- aspiration precautions education
Intervention # 3: Change formula solution (ND2.1.1) to TwoCal HN @ 55 ml/hr.
Nutrition Prescription

In order to adequately meet increased needs due
to HIV disease progression:
 increase
protein (95-126 g/day)
 kilocalorie (2205-2835 kcal/day)
 fluid needs (2205-2520 ml/day)

TwoCal HN @ 55 provides:
 2640
kcal
 105 g protein
 2217 ml water

215 ml water flushes q 4 hours.
NCP: Intervention
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Short term goals and expected outcomes:
The patient will be provided with 100% adequate
nutrition and hydration to meet needs
The patient will tolerate feedings with minimal residual
volumes with low occurrence and volume of diarrhea
The patient will maintain weight on the prescribed
regimen
Patient will recognize severity of consuming foods by
mouth at this point in time
NCP: Intervention
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Long term goals:
The patient will replete nutritional stores with
adequate nutrition
Tube feedings will continue to be tolerated with no
significant weight change or skin breakdown
The patient will work with an outpatient speech
language pathologist to condition her muscles and
lessen the degree of dysphagia
NCP: Monitoring and Evaluation

Food/Nutrition- Related History (FH) Food and
Nutrient Administration: enteral and parenteral
nutrition administration (FH-2.1.4)
 With
the provision of recommended change in tube
feeding and formula, patient received and met 100%
of needs
NCP: Monitoring and Evaluation

Biochemical Data, Medical Tests, and Procedures (BD):
Gastrointestinal (BD-1.4)
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Patient had minimal diarrhea
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Constipation relief
Gastric residual volumes were minimal
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Tube feeding continued

NCP: Monitoring and Evaluation

Anthropometric Measurements (AD) Body
composition/growth/weight history (AD-1.1)
 patient’s
weight remained stable throughout her clinical
course

Food/ Nutrition –Related History (FH) Behavior:
Avoidance (5.1)
 per
patient and family the patient did not consume or
attempt any foods by mouth in the course of the
hospital stay
Conclusion
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HIV-1 positive patients require adequate nutrition to
meet needs and to suppress the virus from further
replication
The specific interventions in this case presentation can
be prescribed in other HIV-1 infected patients
HIV/AIDS can be managed with adequate provision of
energy, protein and fluids, combined with life-sustaining
ART therapy
The practice of feeding through a PEG tube has
approved as safe and has shown increased adherence
to nutrition, hydration and medication administration
QUESTIONS??