David Hu

CNMC Case Study

Nutrition Support of an Infant with Acute Respiratory Failure

Subjective:
1. Patient LE is a previously healthy 10 month old male admitted on 1/25/16 for acute
respiratory failure, failed outpatient management of pneumonia, acute kidney injury,
and shock. Patient came in dehydrated but currently looks well-nourished and
proportional.
2. Per MDs note, LEs parents reported no issues with feeding until the past week,
when PO intake started decreasing. LE usually takes Similac Advance 19kcal/oz at
home. LEs mother reports feeding him Enfalyte mixed with Similac in a syringe
when his appetite started decreasing.
PES:
1. PES Statement: Inadequate oral intake r/t intubation AEB need for PN support.
a. Optimal nutrition is required for the patient, being a growing 10 month old
child. TPN was initiated due to his inability to maintain PO intake while
intubated. In addition, EN support was considered unsafe as the patient
was not hemodynamically stable and on multiple pressors.
b. Patient developed persistent cough and recurrent fevers starting on 1/8. LE
was determined to have pneumonia and sent home on amoxicillin on 1/12.
His parents brought him back to the CNMC ED on 1/20, when he was sent
home again on Augmentin. His symptoms worsened, and he was brought
into the PICU on 1/25 with hypoxemia and tachypnea. He was placed on
high flow nasal cannula but quickly escalated overnight and required highfrequency intubation.
2. Diet Order: NPO, on TPN 960mL total volume (519kcal) with 21g 10%AA
(2g/kg), 95g D70 (GIR=6.2mcg/kg/min), 12.6g IL20% (1.2g/kg)
3. Age: 10 months old, ex-full term baby
4. Weight: 10.5kg
a. 88th percentile weight for age
5. Length: 75cm
a. 71st percentile length for age
6. Head Circumference: 47cm
a. 88th percentile head circumference
7. Weight/Length: 88th percentile weight for length
a. Justification: Patient is 10 months old
8. Body Mass Index/percentile: N/A, patient is an infant
9. Growth History
a. Growth Charts for Patients 0-2 years old

b. Evaluate patients growth: No previous growth history available

10. Estimated Requirements
Calorie Requirements in the PICU
Intubated
Enteral
525 (50kcal/kg)
Parenteral
473 (45kcal/kg)
a.
b.
c.
d.

Extubated
788 (75kcal/kg)
709 (68.5kcal/kg)

Current needs: Between 473-525kcal/day

1.2 grams protein/kg
1025 mL/day to meet maintenance fluid needs
Estimated energy needs based on Schofield equation for infants.
Intubation enteral needs based on BMR as calculated, extubation enteral
needs based on BMRx1.5 injury factor. Needs while on TPN adjusted with
10% kcal decrease. Protein needs based on DRI for infants. Fluid needs
based on Holliday-Segar formula. All formulas per facility standards.
11. Nutrition related Medications Reviewed
a. KCl 10 mEq BID, PRN, max 40 mEq over 2 hours
b. Dopamine, initially 12mcg/kg/min, weaned off on 1/27
c. Epinephrine, up to 0.07mcg/kg/min on 1/27, currently 0.02mcg/kg/min
d. Lasix, 4mg/kg/day on 1/28 to 2mg/kg/day on 1/29
12. Pertinent Labs Reviewed (Admission vs. Current)

Assessment:
1. Moderate
a. Patient currently on oscillator and unable to take PO nutrition or EN
support due to high pressor support. TPN initiated on 1/26.
2. Pertinent Lab values
a. Sodium
i. 140 on admission, up to 149 on 1/26, trending back down.
Elevated sodium possibly due to Lasix
b. Potassium
i. 5.8 on admission, sharp drop to 2.8 on 1/28, likely due to Lasix
drip. Receiving KCl BID and PRN
c. Creatinine
i. Elevated on admission, returned to WNL with improvement of
AKI
d. BUN
i. Elevated on admission, returned to WNL with improvement of
AKI
3. IV fluids
a. Only fluids needed for IV meds. NS @ 2mL/hr to keep line patent
4. Growth
a. N/A, no recent weight changes noted
5. Diet prior to admission
a. N/A, unable to obtain diet history
b. Patient plotting well on growth curve
6. Diet order

a. TPN currently provides: 960mL total volume with 21g 10%AA (2g/kg),
95g D70 (GIR=6.2mcg/kg/min), 12.6g IL20% (1.2g/kg). Currently
meeting 100% of patient estimated energy and protein needs.
b. TPN volume (960mL) with medication drips currently meeting 100% of
patient estimated fluid needs.
c. Appropriateness of supplements: N/A, no supplementation
d. Contribution of supplements to overall intake: N/A
e. Appropriateness of administration: N/A
7. Accuracy of data available: All data accurate and collected while in PICU except
previous diet history
Plan/Goals and Justification:
The overall plan for LE is to be able to tolerate PO intake and resume his home feeding regimen.
Nutritionally relevant goals include initiating enteral nutrition support while weaning TPN in
order to meet the patients estimated needs and stimulate gut function.
Conventional recommendations by ASPEN state that early enteral nutrition (EEN) in
hemodynamically unstable patients is contraindicated and may lead to non-occlusive bowel
necrosis or mesenteric ischemia, among other complications. However, current research is
beginning to highlight some of the flaws in previous studies used for these recommendations.
Many dietitians are now advocating for the initiation of EEN in ICU patients on multiple
pressors, citing decreased morbidity and mortality. However, much of the research is still
inconclusive and larger scale clinical trials are needed. In managing LE, a more conservative
approach was taken with the initiation of TPN due to the lack of clear evidence for EEN as well
as his currently well-nourished state.
The goal for the patient while on TPN is to meet his nutritional needs without overfeeding, as
excessive intake is associated with increased ventilator dependency. Thus, the patients needs on
TPN are slightly lower than what he would be receiving on enteral feeds.

References:
Shuofei Yang, Xingjiang Wu, Wenkui Yu and Jieshou Li. Early Enteral Nutrition in Critically Ill
Patients With Hemodynamic Instability: An Evidence-Based Review and Practical Advice. Nutr
Clin Pract 2014 29: 90.
Apurva K. Panchal, Jennifer Manzi, Susan Connolly, Melissa Christensen, Martin Wakeham,
Praveen S. Goday, and Theresa A. Mikhailov. Safety of Enteral Feedings in Critically Ill
Children Receiving Vasoactive Agents. J Parenter Enteral Nutr 2012 40:12.
Nilesh M. Mehta, Lori J. Bechard, Melanie Dolan, Kately Ariagno, Hongyu Jiang, and
Christopher Duggan. Energy imbalance and the risk of overfeeding in critically ill children.
Pediatr Crit Care Med 2011 12:4.