Download Case Study #2 Understanding the Disease and

Case Study #2
Understanding the Disease and Pathophysiology
1. Open abdomen is a medical technique, also referred to as laparotomy, in which the fascia of the
abdomen is left open in order to avoid intra­abdominal pressure and hypertension. An open
abdomen is not usually left “open” for longer than 48­72 hours. Some patients suffering from
severe visceral edema cannot be closed and need to wait a few weeks for a skin graft to cover
the abdomen. Intra­abdominal pressure, sepsis and severe abdominal trauma can all lead to
abdominal compartment syndrome (1). Open abdomen is a way to alleviate these etiologies and
prevent further consequences (2).
2. Nutritional implications of these surgeries include:
a. The patient will not be able to use his GI tract until it is connected once again into a
closed system. Therefore, this patient should be placed on parenteral feeding. The
hypermetabolic stress response of severe trauma will greatly increase his protein needs.
The patient will need a central line to receive his nutrients because he will be receiving all
of his nutritional needs intravenously. Since he has lost a portion of his stomach and a
portion of his jejunum, he may still need to be on peripheral parenteral nutrition. This is
because he will be eating smaller meals and his GI tract will not have adapted to a
shorter small intestine, therefore it will be harder for him to absorb all of the nutrients he
needs PO (3).
b. Some potential nutritional complications include the risk of obstruction, abdominal
discomfort and diarrhea which may lead to malabsorption, early satiety, and impaired
digestion and absorption. Anemia may occur due to the loss of acid secretion and rapid
transport of minerals. This may lead to osteoporosis and vitamin and mineral
deficiencies. B12 deficiency may cause megaloblastic anemia due to a decrease in
gastric juices, resulting in reduced intrinsic factor and B12 malabsorption (3).
c. Severe liver trauma can lead to general metabolic distress. The liver is integral to the
breakdown and utilization of all macronutrients, the storage and use of vitamins and
minerals, bile creation, and countless other metabolic processes. Therefore, severe liver
trauma can result in adverse effects on nutritional status.(3)
3. Anasarca is characterized by extreme widespread swelling or massive edema due to effusion of
fluid into intracellular space. It’s a common condition among the critically ill population. The
increase in fluid volume can lead to hypoalbuminemia (dilution effect) which may partially
account for the low albumin levels indicated in the labs (1). The patient may appear to be
malnourished due to low albumin levels when in reality there are many other contributing factors.
This can also affect the interpretation of his nutritional status because weight gain and loss will be
hard to assess due to the bloating the patient is experiencing. (4)
4. Stages of the Metabolic Stress Response to Trauma:
a. The metabolic stress response to trauma has been described as a progression through
three phases: the Ebb Phase, the Acute Flow Phase, and the Adaptive Flow Phase,
often considered a Recovery/Resolution phase. The Ebb Phase occurs immediately
after an injury. Hypovolemia, shock and tissue hypoxia may occur. Decreased cardiac
output, oxygen consumption, insulin production and body temperature are also likely
consequences. This phase takes place within the first 24 hours after trauma, so for this
patient the Ebb Phase occurred after his gunshot wound and his surgeries. This patient is
most likely in the ICU at this point of the metabolic stress response and doctors are
working to prevent the patient from entering multiple organ failure. These stages do not
always occur linearly (3,5). As previously indicated, surgery could cause the patient to
revert back to the Ebb Phase.
b. The Flow Phase may be broken down into two stages: Acute and Adaptive. The Acute
Flow Phase is characterized by increased cardiac output, oxygen consumption, body
temperature, energy expenditure and total body protein catabolism. There is an increase
in the production of catecholamines, glucagon and cortisol as well as an increase in the
production of glucose from gluconeogenesis and lipolysis. This phase takes place 2 days
to one week after the trauma incident. Based on the patients glucose and body
temperature levels, he seemed to be in the Acute Flow Phase from day four to day six
and then again on day ten (3).
c. The Adaptive portion of the Flow Phase is considered a recovery period. Increased
hormone levels begin to diminish, normoglycemia ensues, and anabolic processes take
precedence (3). During the recovery phase, the body normalizes in metabolism and is
well into the healing process if everything is going smoothly. The patient will be anabolic.
This occurs 1 week to 1 month after the trauma. The patient seemed to begin the
recovery phase at day seventeen to twenty three.
5. An acute phase protein is a secretory protein found in the liver that is employed in the event of a
traumatic injury or infection such as chronic inflammation, tissue damage, acute infection or a
burn. This may result in loss of lean body mass and increased net negative nitrogen balance.
C­reactive Proteins help to identify when the acute hypermetabolic period of the inflammatory
response decreases. They are considered nonspecific markers and show any type of
inflammation and increase in the initial stages of acute stress, generally 4­6 hours following
surgery (3).
Understanding the Nutrition Therapy
6. Some changes that occur in protein metabolism include an overall decrease in protein synthesis
and an increase in proteolysis. However, there is an increase in production of positive acute
phase proteins such as c­reactive proteins. Changes that occur in fat metabolism include
increased lipolysis, hepatic synthesis and ketone production. This can lead to fatty liver and a
high TAG level in the blood. Changes that occur in carbohydrates are increased GNG (which
receives glycerol from lipolysis), increased lactate production, and increased blood glucose
levels (3). Other nutrient changes from metabolic stress include a change in substrate utilization
to about: 55% calories from carbohydrates, 20% of calories from fat (not to exceed 2.5 g/kg),
25% calories from protein (1.5­2.0 g/kg), and fluid intake of 30­40 mL/kg (6).
7. Specific nutrients that should be considered are: Vitamin A, Vitamin C, Zinc, Selenium, Vitamin
E, Arginine, Glutamine, and Omega­3 fatty acids.
a. Glutamine is recommended because it helps cells grow and recover quickly.
Specifically, the enterocytes lining the GI tract prefer glutamine as an energy source.
White blood cells and fibroblasts will also utilize this amino acid. It plays an important
role in wound healing and preservation of lean body mass. The recommendation for
glutamine in a trauma patient is 1000 to 3000 mg daily.
b. Arginine is recommended because of its role in fighting bacteria, providing aid to the
immune system. It is also an important component of infection free wound healing. The
recommendation for arginine in a trauma patient is 17 to 25 g.
c. Omega­3 fatty acid is recommended because of their anti­inflammatory properties.
They help T­cells and natural killer cells to be more effective in the body. The
recommendation for omega­3 fatty acids in a trauma patient is 1400 mg EPA and 1000
mg DHA daily (6).
d. Vitamin E and Selenium offer antioxidant properties that may also be helpful in the
healing process.
8. The first step in the decision­making process of determining a route of nutrition support is
evaluating the condition of the GI tract. If the patient’s gut is in working order, utilizing it is
preferred over IV nutrition. Mr. Perez has endured several GI surgeries and was not able to
absorb nutrients through the gut until Day 11 of his hospital stay. In general, enteral nutrition is a
good choice if the patient is hemodynamically stable and no longer requires large amounts of
fluids to remain that way. Placement of a nasojejunal tube very early after trauma occurs, such
as during the first surgery, is ideal but not always realistic (3). While the patient was receiving all
needs though TPN, the usage of additional TF can promote gut health and GI motility.
However, as the patient is currently unable to fulfill all caloric and nutritional needs through TF,
PN should be continued until the patient can tolerate TF of 50­75% of goal rate.
Nutrition Assessment
9. See Adime Note
10. Excess fluid intake and retention due to anasarca and TPN treatment may distort the patient’s
weight measurements. This swelling is evident in Mr. Perez, who is currently experiencing an
increase in weight from 102 kg to 110 kilograms (7). The patient’s weight will likely fluctuate on
a daily basis due to varied fluid retention.
Calculation of Nutrient Requirements
11. Energy needs:
i. IBW: 166#
ii. %IBW:135%
iii. ABW: (225#­ 166#) x .25+166#= 181# → 82.3 kg
a. Mifflin­St. Jeor: BEE X 1.6­1.8 for severe stress
10(82.3kg) + 6.25( 177.8cm)­ 5(29 yrs)+ 5= 2870­3229 kcal
We picked Mifflin­St.Jeor because it is more accurate than the HBE equation.
We used the activity factor of 1.6­1.8 because he is under severe stress.
b. IJEE­ used because he is ventilator dependent
1784 ­ 11(29 yrs) + 5(102.3 kg) + 244+ 239= 2460 kcal
Ireton­Jones was selected as it accounts for the fact that our patient is on the
ventilator. This would lower his calorie needs as he is not spontaneously
breathing, and explain the lower value.
c. Protein needs: used 1.6­1.8 because he needs more protein because he had surgery.
Protein is needed for wound healing and nitrogen balance.
1. 1.6­1.8 g/ kg x ABW (82.3kg)= 132­148 g
12. Indirect calorimetry measures the type and rate of substrate utilization. An individual’s energy
requirements are estimated by gas exchange measurements, specifically oxygen consumption
and carbon dioxide production. It is noninvasive and may be combined with other techniques to
evaluate energy expenditure (8).
13. Indirect calorimetry should be used to determine energy requirements in critically ill patients.
Indirect calorimetry can be performed as the patient’s health status changes, which allows for a
more accurate assessment of energy requirements. Chest tubes, acidosis and use of
supplemental oxygen may produce inaccurate results for indirect calorimetry (3). We do not
have a diet history for the patient so we cannot judge how many calories the patient usually
consumes. Equations can be helpful to get a general idea of our patients needs but because of
the severe trauma our patient has sustained, the indirect calorimeter would give us a more
accurate estimate so we can make sure the Mr. Perez gets the nutrients he needs. Using a
metabolic cart measurement may be the best way to ensure the patient is getting the proper
amounts of nutrients to support a healthy recovery from his injuries.
14. The results yielded from the indirect calorimeter were much higher than the values given by the
two equations in #11. Compared to the indirect calorimetry values of day 4 (3657 kcal) and
day 10 (3765 kcal), all of these estimates were too low by about 1,000 kcal. Patient's ABW
was used during calculations, which was lower than his actual body weight and may be the
source of the error. The equations give only estimates of patient needs, not exact measurements
like the indirect calorimeter. This could also account for the calorie difference. When measuring
indirect calorimetry, N balance should also be measured. For every 1g of nitrogen excreted,
about 6L of oxygen is consumed and about 4.8L of CO2 are produced (9). In a trauma patient
experiencing proteolysis, there is likely an increase in urinary N. While we do not have a UUN
lab value for out patient, his BUN level is high. This may account for the difference in calories.
15. RQ values: Day 4: 0.76 and Day 10: 0.70.
a. These values mean that the patient is not getting enough calories and may be
experiencing prolonged malnutrition, therefore he is using his body stores for energy. His
body is metabolizing lipids and proteins which is not ideal when he is recovering from
such a severe surgery. This is because he needs to use protein in order to aid in wound
healing (3).
16. Elevated energy expenditure in this patient is caused by the severe trauma the patient has
undergone in the past several days, including a gunshot wound and an open abdomen. Not only
has he sustained massive tissue damage, his body is also hypermetabolic due to the stress
response. The endocrine system produces the stress hormones glucagon, catecholamines, and
glucocorticoids which helps raise the metabolic rate (3).
Intake Domain
17. Carbohydrates received daily: 300g x 3.4 kcal = 1020 kcal; Amino Acids received daily: 170
g x 4 kcal = 680 kcal; Lipids received from propofol daily: 1.1 kcal/mL x 35 ml/hr x 22 hrs =
847kcal; Total calories received daily: 680 kcal + 1020 kcal + 847 kcal= 2547 kcal Mr. Perez
was receiving 75 mL/hr every day for 22 hours which give him a total of 1650mL.
18. The calculations in #17 are much lower than the values given by the metabolic cart on hospital
day 4. These lower values are due to the fact that the patient is on a ventilator which is also
demonstrated by the values given by the Ireton Jones Energy Equation in #11. The patient’s
hospital course indicates that his dextrose was increased to 350 g per day and his protein was
increased to 180 g per day. We would recommend increasing his carbohydrate intake to 500 g
per day to raise his RQ value and increase his caloric intake while ensuring the carbohydrate
infusion rate remains at 3.4, well under the limit for critically ill patients (5mg/kg/min) (5).
19. The patient was receiving propofol at an infusion rate of 35 mL/hour. Propofol is a type of
anesthetic given to patients. It is administered as part of a lipid emulsion and provides about 1.1
kcal per mL. In the case the patient is receiving about 847 kcal from lipids per day from
propofol. (1.1 kcal/mL X 35 ml/hr X 22 hrs) (7,10). This meets the patient’s daily needs,
indicating that there is no need for additional lipids in his parenteral nutrition formula.
20. Enteral feeding was started to attempt to bring the patient back to a normal method of intake via
the gut. Total parenteral feeding through central vascular access carries higher risks of infection,
pneumothorax, and arterial puncture. If the patient’s GI tract is able to properly absorb the
nutrients his body needs, enteral feeding is ideal to avoid these potential setbacks (3).
21. Impact is a metabolic stress formula that contains immunomodulatory ingredients (11). It also
contains arginine as a free amino acid. It is considered an elemental formula, meaning that
nutrients are broken down into smaller components. For example, protein is available in the
form of free amino acids. This helps to reduce the workload of digestion. This is fitting for this
patient as the GI tract is still highly compromised (6,12,13). The patient started on 10 mL/hr
and then was advanced to 15 mL/hr. Impact contains 1.5 kcal/mL, 37% carbohydrate, 38% fat
and 25% of protein. If the patient is receiving enteral nutrition for 20 hr/d enteral nutrition
represents 300­450 kcal a day depending on the 10 or 15 mL/hr speed. Based on the indirect
calorimetry measurement for this patient enteral nutrition is accounting for 8.2% ­ 12.2% of his
daily caloric needs.
22. Inadequate fluid intake (NI­3.1), Increased protein needs (NI­5.1), Inadequate protein­energy
intake (NI 5.3), increased nutrient needs (NI 5.1).
Clinical Domain
23. ***citation for all (3).
Parameter
Normal
Value
Patients
Value
Reason for
Abnormality
Nutrition Implication
Albumin
3.5­5 g/dL
1.4 (day 4)
and 1.9 (day
10) g/dL
­Anasarca leads to
­While low serum
widespread inflammation albumin levels may be
and volumic dilution of an indicator of
blood proteins
malnutrition,
­Albumin is a negative widespread edema
acute phase protein
such as in this patient
meaning its production is may distort the value
limited in a time of
and discredit that
metabolic stress. Due to indication
our patients condition, ­Indicators of
there will be decreased morbidity and mortality
production of this
help identify patients
protein negatively
who are at increased
affecting his lab values. risk of trauma/ illness
Prealbumin
16­35 mg/dL
3 (day 4) and
5 (day 10)
mg/dL
­Sensitive
protein­energy balance
indicator
­Responds to nutrition
intervention
­ Also a negative acute
phase protein
­Stress reaction will
decrease prealbumin
levels
­May indicate a
protein­energy
imbalance, although
not always reliable
Glucose
70­110 mg/dL 164­140
mg/dL
­Glucose is elevated in a
metabolic state as
gluconeogenesis is a
prominent metabolic
pathway. Lipolysis
provides glycerol as a
substrate. There is also
less insulin present due
to metabolic stress
­High blood glucose
can lead to poor
wound healing. Insulin
may need to be
adjusted in order to
control these levels
BUN
8­18 mg/dL
­BUN could be elevated
because he is on a high
protein diet to support
wound healing. The
patient is also
experiencing excessive
protein catabolism as a
result of metabolic stress
(3)
­GI bleeding may also
­Increased protein
intake is necessary to
combat excessive
protein catabolism (3)
23­25 mg/dL
cause high BUN levels
ALT
4­36 U/L
435 U/L
­Medication may
increase levels
­Increases with
inflammation and severe
muscular, bone,
intestinal, or liver
damage (3)
­Ensure proper energy
and protein intake to
support healthy and
timely healing
processes
AST
0­35 U/L
190 U/L
­Medications such as
antibiotics or stains may
increase levels of AST
­AST is used to help
monitor liver function in
patients with TPN (3)
­Ensure proper energy
and protein intake to
support healthy and
timely healing
processes
Alk Phos
30­120 U/L
540 U/L
­Infection and
cholestasis can increase
serum alkaline
phosphatase levels (3)
­Increased protein
intake may be
necessary to support
liver recovery (3)
C­reactive
protein
<1.0 mg/dL
245 U/L
­C­reactive protein is a
positive acute phase
protein and therefore is
produced more in
metabolic stress.
­An increase in CRP is
associated with trauma
and infection
­A high c­reactive
protein level means
that all negative acute
phase proteins are not
accurate markers of
nutrition
24. Case Study Guidelines from Scholar says it is not necessary to answer this
25. Altered GI function (NC­1.4), Impaired nutrient utilization (NC­2.1).
Nutrition Diagnosis
26. Increased protein needs related to hypermetabolic stress and wound healing and as evidenced
by abdominal gunshot wound, open abdomen, and GI surgeries (NI­5.1).
Altered GI function related to modified ability to digest and absorb nutrients as evidenced by
resection of proximal jejunum and stomach (NC­1.4).
Nutrition Intervention
27. a. Formula/solution (ND­2.2.1) Change PN rx to provide 75% of protein and energy
requirements. Pt to receive 1.0L of a 10% amino acid solution providing 100g PRO
and 400kcal, 500g dextrose to provide 1700kcal and 80g IV lipids per day to provide
720kcals.
i. Goal: PN tolerance Formula/solution (ND­2.1.1)
b. Initiate EN providing remaining 25% of protein and energy requirements. Pt to receive
Impact 1.5 at goal rate of 20ml/hr to provide 41g PRO and 660kcal. Begin TF at 50%
goal rate and increase incrementally as tolerated
i. Goal: TF tolerance Total Nutrition support to provide: 3480kcal and 141g
PRO Goals: Wt Maintenance TF an PN tolerance Continued abdominal and GI
healing allowing for increase in EN
Nutrition Monitoring and Evaluation
28. The standard recommendations for monitoring the nutritional status of a patient receiving
nutritional support are to check the patient’s in’s and out’s, check patient’s daily weight and lab
values for hydration status, check patients urine for sugar, acetone, and protein levels, check
liver function, and check acid/base balance. Look at the patient to check visual clues of nutrition
status. If these things are not within normal limits, re­evaluate nutritional support (5).
29. Mr. Perez’s blood glucose level on day 4 is 107­185 dL/mg. Hyperglycemia is important to be
aware of in critically ill patients because of the hypermetabolic response their bodies are going
through. The patients are experiencing an increase in glucose production and uptake and an
increase in epinephrine which hinders insulin release in the body. With continual breakdown of
energy stores in the body and low insulin levels, glucose can easily build up in the body which
can lead to ketoacidosis. Mr. Perez was put on an insulin drip to bring down his blood glucose
levels and reverse the hyperglycemia. (3)
[ADIME Note required]
References
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