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NUT 116BL

Winter 2016

Name: __Cindy Chen_______


*******Due 2/12/16*****

Case Study #3: Critical Illness (60 points total)


You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning,
and monitoring throughout his hospitalization.
Initial admission information available from the medical chart:
Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms,
and back in an accident at the chemical plant where he works. After emergency first aid
at the plant, he was transported by ambulance to the university hospital burn center. Mr.
G was in shock when he was admitted.
Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned
skin is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; preinjury wt: 165#
Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem
20 screening panel, ABGs, and UA.
Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck,
upper back, arms, hands, and upper thighs.
Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted.
Urinary output, P, and BP monitored hourly. NPO x 24 hrs. NG tube placed for stomach
decompression. Maalox q 2 hrs through NG tube.
Initial hospital course:
As soon as the shock was under control, Mr. Gs wounds were washed,
debrided, and dressed with silver sufadiazine using fine-mesh gauze. He was
given a tetanus shot and 600,000 units of procaine penicillin were administered q
12 hrs.
After 24 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned;
patient is responsive to pain, but limited alertness; breathing & respiration normal
By 36 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On second day (~ 36 hours), a Nutrition Consult was ordered for feeding
recommendation
Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the
initial consult, on day 2 of admission.

1. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the


following methods. Show your work.
a. Quick shortcut as used by UCDMC burn unit [35-40 kcal/kg BW] (2 pts)
165 lbs = 75 Kg BW
35-40kcal/kg BW x 75kg BW = 2625-3000 kcals

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)


Ht: 510 = 177.8 cm

AF: 1.1

IJ: 1.5-1.85

[(10*75kg) + (6.25*177.8cm) - (5x32yo)] x 1.1 x (1.5-1.85) + 5


= 2812-3467 kcal = 2810-3470 kcals

MNT Pocket Guide

c. Comment on whether these two estimates differ or are similar, and what you
would use as your actual energy recommendation for this patient. Provide
justification for why you selected this energy recommendation. (2 pts)
These two estimates differ: The UCDMC shortcut estimated 2625-3000 kcals
as Mr. Gs estimated energy needs while the Mifflin-St. Jeor equation
calculated 2810-3470 kcals. I would use the estimate from the Mifflin St. Jeor
equation because Mr. G is going through a hypermetabolic state due to his
burns, and I would not want to underfeed him. I would want to meet adequate
energy intake in order for him to limit net catabolism, limit oxidative cell
damage, and promote wound healing.

NUT 116BL Nutrition Care and Critical Illness slides 10, 15. January 25.

2. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your


work. (2 pts)
Burns: 1.5-2.0g/kg/d x 75 kg BW = 110-150 g protein /kg/d

MNT Pocket Guide


3. Discuss the effects of trauma on macronutrient metabolism. (3 points.)
Trauma can cause the patient to be in a hypermetabolic state. This means that in
general, catabolism will be greater than anabolism. During the acute response of the
flow phase (0-5 days post injury), there will be an increase in metabolic rate, proteolysis,
lipolysis, and gluconeogenesis. These processes are mediated by increased levels of
glucagon, cortisol, epinephrine, and norepinephrine, and pro-inflammatory cytokines
TNF-, IL-1, and IL-6 in the body. The net effect will be a negative nitrogen balance,
hyperglycemia, hypertriglyceridemia, and progressive and rapid weight loss, particularly
muscle wasting. During the adaptive response in the flow phase, (>6-10 days post
injury), catabolism diminishes and metabolism returns to normal. Therefore, there is a
decrease in metabolic rate, proteolysis, lipolysis, and gluconeogenesis. This is mediated
by decreasing counter-regulatory hormones and have a net effect of nutritional repletion
for nitrogen and body weight.

NUT 116BL Nutrition Care and Critical Illness slides 9-12, January 25.
4. Based on the patients needs, consider the enteral formula to recommend
a. Describe two desirable features or characteristics of the type of formula
you would select and recommend. (refer to the UCD TF lecture) (2 pt)
1. High calorie formula: to meet the energy needs of the patient
2. High protein formula: to balance the daily losses of nitrogen in urine

NUT 116BL Tube feeding Lecture Slide 26

b. Give one example of an appropriate enteral formula meeting these


characteristics, using the formulary provided on the course Smartsite.(1pt)
(Two Cal HN) Abbott would be an example of an appropriate enteral formula that meets
these characteristics of high calorie (2kcal/ml) and high protein (70g protein/1000ml).

5. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetodine liquid
to be put down the feeding tube? (Use the FMI text for this question) (2 pts)
Famotidine is a histamine H2 receptor antagonist. Its indications are antiulcer,
antiGERD, and antisecretory. It is being used to decrease gastric acid secretions and
increase gastric pH. I think that Famotidine was used instead of Cimetodine liquid
because Cimetodine liquid can precipitate in tube feeding. This can cause clogging of
the tube and affect the delivery of the tube feed to the patient.

FMI p.84, 140, 166-167

6. Describe 3 ways you could determine the adequacy of your recommendations for
energy and protein intake for this burn patient. (In other words, what will you monitor to
decide if your recommendations are adequate, and why?) (3 points)
1. I will monitor the patients weight status to see if he/she is regaining weight since
the injury due to his/her hypermetabolic state from trauma.
2. I will monitor the patients skin status of wound healing to see if the skin is being
repaired from adequate energy and protein intake.
3. I will monitor the patients nitrogen balance to see if daily protein intake is enough
to balance the daily losses of nitrogen in urine.

NUT 116B Tube Feeding Lecture

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.5 @ 60
ml/hr, plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking
100 kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full
TF volume is being delivered each day.
The patient tells you it is difficult for him to eat by mouth due to pain, and that he
doesnt have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current
information available.
a. Energy: (1 pt)
Mifflin-St. Jeor equation: Ht: 510 = 177.8 cm
Current BW: 70 kg

AF: 1.1

IJ: 1.0-1.5

[(10*70kg) + (6.25*177.8cm) - (5x32yo)] x 1.1 x (1.0-1.5) + 5


=1821-2724kcal = 1820-2730 kcal

MNT Pocket Guide

b. Protein: (1 pt)
Burns: 1.5-2.0g/kg/d x 70 kg BW = 105-140 g protein /kg/d

MNT Pocket Guide

c. Fluid: (1 pt)
Method 1 (based on energy intake):
1ml fluid/kcal x 1820-2730 kcal = 1820-2730 ml fluid
Method 2 (based on body weight):
30-35ml/kg x 70kg = 2100-2450 ml fluid

MNT Pocket Guide

8. Calculate the energy, protein, and fluid provided by the current TF regimen.
Show your work
a. Energy: (1 pt)
Jevity 1.5 @ 60 ml/hr
60ml/hr x 24hr = 1440 ml tube feed
1440 ml tube feed x 1.5 kcal/ml = 2160 kcal

UCSF Formulary
NUT 116B Tube Feeding Lecture

b. Protein: (1 pt)
1440 ml tube feed = 1.44 L tube feed
1.44L tube feed x 64g protein/L = 92 g protein
UCSF Formulary
NUT 116B Tube Feeding Lecture
c. Fluid: (1 pt)
1440 ml tube feed x 76% free H20 = 1094 ml free water
UCSF Formulary
NUT 116B Tube Feeding Lecture
9. Calculate Mr. Gs nitrogen balance at day 10. (1 point)
UUN 23 g/24 hr
Nitrogen balance = (92g protein/6.25) (23g/24 hr + 4) = -12.28

MNT Pocket Guide

10. Interpret the results of the nitrogen balance study. Is current TF order adequate to
meet estimated protein needs? (2 points)
The current TF order is inadequate to meet his estimate protein needs because his
estimated protein needs are 105-140g protein/day while the tube feed only provides
92g of protein. Therefore, the daily protein intake is not enough to balance the daily
losses of nitrogen in urine, leading to a net negative nitrogen balance.

11. Write one PES statement that you will use in your note below: (3 pts)
Inadequate enteral nutrition infusion (NI-2.3) r/t poor choice of enteral formula AEB
weight loss, UUN 23 g/24 hr, and net negative nitrogen balance of -12.28.

12. Write an ADIME note for your day 10 follow-up assessment of Mr. G. Hints: Be
sure to evaluate his current anthropometrics (and any trends seen), current kcal/pro
needs, adequacy of the current diet order (including both the TF and PO intake), and
current labs. What do the anthropometric and biochemical data reveal? Is the current
diet order adequate and realistic for the patient? Write two PES statements that reflect
your assessment. In addition to the PES statement in Q 11, write one more PES
statement and include both in your note. In the Plan section, make very specific nutrition
support and monitoring recommendations for this patient at this point in time. (23 points)
A:
32 yo male seen following hospitalization for severe burns. Per medical chart from initial
admission, pt with 15% TBSA burns over lower part of face, neck, upper back, arms,
hands, and upper thighs. NG tube placed for stomach decompression. Nasoduodenal
tube was placed, IV therapy was initiated. Currently has difficulty with PO intake due to
pain and lack of appetite.
MD Rx:
Jevity 1.5 @ 60 ml/hr x 24hr (1440ml formula, 2160kcal, 92g protein, 1094ml free H20),
plus PO intake as tolerated.
Anthropometrics:
Ht: 70in/177.8cm
%IBW: 93% IBW

CBW: 70kg
UBW: 165lbs/75kg

IBW: 166lbs/75kg
%UBW: 93% UBW

Estimated nutrient needs:


Kcals: 1820-2730 kcal (RMR*1.1AF*1.0-1.5 IF)
Protein: 105-140 g protein /kg/d (1.5-2.0g/kg/d)
Fluids: 1820-2730 ml (1ml/kcal)
Labs:
Albumin 2.7 g/dL (L)

Prealbumin 8 mg/dL (L)

UUN 23 g/24 hr

Medications:
Maalox q 2 hrs through NG tube
IV Famotidine (Pepcid)
Nutrition and Weight Hx:
MD diet order was analyzed and reviewed. Energy intake from TF meets the estimated
energy needs, but is on the lower end. Protein intake is below estimated needs. Fluid
intake is also inadequate. MD diet order is inadequate and unrealistic for pts estimated
needs. PO intake is limited due to pain and lack of appetite per pt report. Calculated
nitrogen balance of -12.28 from UUN of 23g/24hr demonstrates net negative nitrogen

balance and inadequate protein intake. Pt with weight loss of 6.7% (5kg) of body weight
in 1 week. This inadequate protein and fluid intake is likely causing weight loss.
D:
Inadequate enteral nutrition infusion (NI-2.3) r/t poor choice of enteral
formula AEB weight loss, UUN 23 g/24 hr, and net negative nitrogen
balance of -12.28.
2. Inadequate protein intake (NI-5.7.1) r/t poor choice of enteral formula AEB
UUN 23 g/24 hr, net negative nitrogen balance of -12.28, and weight loss.
1.

I:
MNT Goal: Increase energy, protein, and fluid intake in TF to meet estimated energy,
protein, and fluid needs. Prevent further weight loss and promote wound healing.
Recommendations:
1. Diet Rx: Use Jevity 1.5 at 75ml/hr x 24hrs (1800ml formula, 2700kcal, 115g
protein, 1368 ml free H20) plus 222ml flushes q 4 hrs, yields 1332ml of free
water boluses. Initiate Jevity 1.5 at 35ml/hr, increase rate 35ml/hr q 4-6hrs, as
tolerated, to goal rate of 75ml/hr.
2. Recommend increase energy and protein intake orally.
3. Recommend gradual PO intake of tolerable foods.
Diet instruction given to pt and family; handout provided on food lists. Compliance is
expected due to the increase awareness of his health status.
M/E:
1. Monitor weight, food intake with food diary, hydration status, UUN lab values,
nitrogen balance, and skin status of wound healing.
2. Follow-up 3-5 days in person.
Cindy Chen
______________________

__February 12, 2016___

____Registered Dietitian__

13. It is now 3 weeks since admission and he is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is interested in trying to eat more foods orally
and his appetite is returning. How could his current continuous TF regimen (the one
recommended in your note above) be modified to provide approximately 1000 kcal/day

and not interfere with his intake at meal times? Make recommendations for an
appropriate transitional TF plan/order and how to monitor. Make a specific
recommendation for both the TF plan and monitoring. (6 points)
I would use a continuous TF overnight to provide 1000kcal/day and not interfere with his
intake at meal times during the day. I would recommend using Jevity 1.5 with a goal
rate of 55ml/hr x 12hr overnight to provide 1000kcal/day through TF. An appropriate
transitional TF order I would recommend would be for Mr. G to orally consume tolerable
foods and beverages high in energy, protein, and fluids to meet his energy
requirements. I would recommend oral supplements if needed or if energy requirements
are not met, and slowly introduce foods as tolerated. I would recommend to discontinue
TF when he is physically ready to consume all intake orally. I will recommend
monitoring this transitional TF plan by monitoring weight, oral food intake, hydration
status, UUN lab values, nitrogen balance, and skin status of wound healing to ensure
Mr. G is meeting his energy requirements.

How many ml of TF to meet 1000kcal/day:


1000kcal/1.5kcal/ml = 667 ml of TF 670 ml of TF
Goal rate:
670ml of TF/12 hr = 55ml/hr