Case Study: Nutrition Support VACCHCS Jia Lu Dietetic Intern 8.25.

2013
PEG: Percutaneous Endoscopic Gastrostomy A PEG is used to bypass the upper GI if it cannot be used due to disease or risk of choking. A PEG tube can give a patient adequate nutrition utilizing their GI tract. A PEG tube may be placed in the stomach (gastric), duodenum or jejunum. This method of feeding can used long term and allows for bolus and continuous feedings. There is a risk of irritation and infection at the insertion site. There is a risk of blockage such as clogged, kinked or twisted feeding lines. Blockage can be avoided with adequate flushing in between feedings. Other risks include overfeeding or underfeeding, edema, dehydration, infection at the insertion site and diarrhea or vomiting. The importance of monitoring the insertion site and formula tolerance is priority. NGT: Nasogastric Tube NGT tube is inserted in the nasal cavity and placed into the stomach. It is used for patients with chewing difficulties. It cannot be used if the patient has an obstructed esophagus, esophageal varices, obstructed airways and clotting disorders. The NGT can be placed bedside and provides short time nutrition to the patient. Complications that may arise are sinusitis, infection, tube movement into lungs, kinks, risk of aspiration, diarrhea , vomiting, and reflux of stomach contents into the esophagus. PICC: Peripherally Inserted Central Catheter PICC are lines for designed for administrating medication or nutrition to a patient through a peripheral vein (cephalic, basilica or brachial) then advanced to the heart. Elemental forms of nutrition are given to the patient through PICC lines. Complications that arise from PICC are phlebitis, thrombosis, infection, and sepsis. Nutritional implications will include over and under feeding, edema, hyperglycemia and dehydration. NCJ: Needle Catheter Jejunostomy NCJ is inserted to give temporary access to the small intestine, NCJ with immunonutrition results in overall lower rates of infection and shorted ICU and hospital stay. Nutrition complications include distension, diarrhea, vomiting and pulmonary aspiration due to fast infusion rate and enteral formula. MCT: Medium Chain Triglycerides MCT are used to treat absorption disorders such as diarrhea, steatorrhea, celiac disease, liver disease, digestion complications due to gastronomy or short bowel syndrome. MCT are also used as a source of fat in TPN and help prevent muscle catabolism in critically ill patients. MCT may cause nausea, vomiting, stomach discomfort, intestinal gas, and essential fatty acid deficiencies. Patients with diabetes should avoid using MCT due to the risk of ketoacidosis. EFAD: Essential Fatty Acid Deficiency EFAD can occur in patients with long term TPN without adequate lipid, cystic fibrosis, low birth weight infants and pre-mature infants, severely malnourished patients, patients on long term MCT as a fat source, fat malabsorption, cirrhosis and alcoholism, Crohns disease and short bowel syndrome. PN without lipids with dextrose results in high insulin concentrations leading to a suppression of adipose tissue mobilization and EFAD in 2-4 weeks.

Elemental: Monomeric nutrients (amino acids, glucose polymer) The simplest form of nutrients administrated to patients via PN/TPN and is low in fat, especially LCT. The main source of fat in elemental formulas is MCTs. The nutrition implications are over- and underfeeding, edema, and hyperglycemia. In addition there is a drug shortage throughout the US. Hospitals are having difficulty obtaining elemental formulas due to shortages. Indirect Calorimetry: Indirect calorimetry measures the amount of oxygen (VO2) and carbon dioxide (VCO2), the data collected from the indirect calorimetry are used in a calculation to determine energy requirement for an individuals. It is the most accurate to determine an individuals resting energy expenditure (REE) and resting metabolic rate (RMR). The person must be resting and cannot eat any food prior to trying the indirect calorimetry otherwise the results will not be accurate. Arginine: Arginine is an conditionally essential amino acids when the body is under stress (i.e. trauma, wounds, infection etc). During times of stress supplement promotes wound healing and nitrogen balance. In patients who have renal or hepatic failure will need to avoid arginine supplement. Glutamine: Glutamine is an non essential amino acid that can be produced in the gut lumen. Glutamine combined with arginine plays a role in increasing wound healing because glutamine acts as a fuel for enterocytes, lymphocytes and macrophages. Like arginine, supplementation for patients with renal or hepatic diseases should be avoided. 1. What problems might you encounter when assessing the critically ill patients? There are several issues that may arise from assessing the critically ill. The complications of multiple disease conditions are a challenge because of difficulty determining exactly what to treat. There may be multiple issues that require immediate attention and treatment. A patient with multiple co-morbidities may be on a multi drug regimen, altering lab results. Skewed lab results become a major obstacle to treating a patient, especially in an acute setting because it may mask serious deficiencies or toxicities. 2. Is one method (enteral or parenteral) preferred over the other? If so, explain the reasons. Enteral nutrition is preferred over parenteral nutrition because if the gut is functional it must be used to maintain its integrity otherwise the GI tract will atrophy. In addition, a weakened GI tract increases bacterial permeability resulting in complications and infections. Compared to parenteral, the insertion and formula is less costly. Patients receiving enteral nutrition can still participate in daily activities and feeding themselves, versus patients receiving PN require supervision of a medical team because hyperglycemia and electrolytes must be monitored regularly. The procedure to insert a line for PN puts the patient at risk for sepsis, arterial damager that renders the vein unusable. PN is reserved for in extreme cases when EN is contraindicated, unsuccessful and inadequate in delivering nutrition to a patient.

Case Study: Nutrition Support VACCHCS Jia Lu Dietetic Intern 8.25.2013

Case Study #1: A 75-year-old woman is admitted with bilateral weakness and dysphagia. Dx: CVA and aspiration pneumonia. PMHX: DM & HTN. ANTHROPOMETRY: HT: 55 WT: 155# LABS: Albumin 3.5 BUN: 45 H Creat: 1.4 Glucose: 235 H TEMP: 101 degrees F TF Order (via MD): 240 ml Ensure TID, 250 ml H2O p each feeding IBW: 125 lb %IBW: 124% 1. What are the factors that may increase the patients nutritional risk? The factors that increase the patients nutritional risk are the pneumonia, fever, dysphagia and DM. The pneumonia and fever may decrease her appetite in addition to the swallowing difficulties. 2. What are the clinical implications of the abnormal lab values? Are there any other lab values that would be helpful to evaluate this patient? The high BUN suggests the patient is dehydrated, experiencing infection and catabolism. The fever and borderline low albumin and fever denotes the patient is in the state of catabolism. Other lab results that would be helpful to confirm the findings would be prealbumin, CRP, Na, K, and blood osmolality. 3. Calculate the nutritional needs of the patient: BEE: MSJ: 1523 kcal Calories: MSJ X 1.3 = 1979 kcal Protein: 1.2 1.5 g/kg = 85 105 g Fluids: 2000 ml 4. How many calories, protein and water does the present order provide? The present order provides 750 kcals, 27 g of protein, 1860 water. 5. Is the present order appropriate for this patient? If not please explain and provide recommended tube feeding order. Be specific. The tube feeding appropriate because it fails to meet half of the patients calorie, protein and fluid needs. In addition, the formula is not appropriate for her DM or treatment of pneumonia. The inadequate feeding will continue to put her at greater risk mortality because her body is in a catabolic state. The formula I would recommend is Glucerna, it will help stabilize her high blood sugar. High blood sugar slows down the bodys ability to fight off infection. Administration of Glucerna and an antibiotic to help fight off the infection would be the course of action I would recommended. The continuous feed TF would be: Glucerna 1.0 85 ml/hr and 75 ml water q 6 hr 6. Patients starts having high gastric residuals after starting TF, what do you recommend? First I would change the formula to a more calorically dense option like Glucerna 2.0 because the infusion rate will be slowed. The new prescription would be: Glucerna 1.5 @ 55 ml/24 hr plus 170 ml q 4 hr

Once the new rate has been set, I would monitor the gastric residuals every 4 hours in the initial 24 48 hours. The patient should tolerate the feeding better since the infusion rate has been adjusted and glucose solutions are more readily absorbed. Case Study #2: A 35-year-old male PMHX: nausea, vomiting, steatorrhea and a 15# weight loss in a month. He is diagnosed with Crohns disease. GI symptoms are resolving; PT po intake poor ANTHROPOMETRY: HT: 510 WT: 125# LABS: Albumin: 3.0 L BUN: 41 H Creat : 1.4 H Na: 128 L DETERMINE: IBW: 166 lb %IBW: 75.3% UBW: 140 lb K: 2.1 L %UBW: 89.3%

1. What are the clinical implications of the lab data? The labs indicate that the patient is experiencing dehydration and protein catabolism. The combination of the high BUN and creatinine implies dehydration. The low Na and K is related to loss to water through vomiting and diarrhea. The patient is at serious risk for malnutrition. 2. Calculate the nutritional needs of the patient BEE: MSJ: 1529 Calories: MSJ X 1.3 = 2000 kcal Protein: 1.2 1.5 g/kg = 70 85 g Fluids: 2000 ml 3. What information would be helpful to assess if the patient is tolerating the TF? Labs would need to be closely monitored to assess the patients tolerance. Changes in lab results will be tracked and treatment will be adjusted accordingly. In addition it would be advised to have the gastric residuals checked every 4 hours within the initial 24-48 hours. The residuals must be monitored closely because the patients history of GI distress, ensuring the formula is being adequately absorbed is priority. 4. What TF formula would you recommend for this patient? Explain why. Outline in details the initial rate the formula should be started & the final goal/plans for this patient. I would recommend Vital 1.0 because the formula is designed for patients with malabsorption, maldigestion and overall impaired GI function or intolerance. The formula features MCT, elemental protein, and 4.2 g of NutraFlora (a prebiotic that stimulates beneficial bacterial growth). The initial rate is 85 ml/24 hr + 80 ml water q 4hr. If the infusion rate is too high for the patient, I can reduce the rate and switch to a higher dense formula such as Vital 1.2, 1.5 or HN. The goal for this patient is to resolve the diarrhea, vomiting and steatorrhea. Once resolved, the patient can get adequate nutrition and hydration to stop the catabolism. Once stabilized the goal is to increase the patients PO intake while supplementing his needs with TF. 5. After several days on tube feeding, patient develops severe diarrhea, what do you recommend? I would consult with the doctor to determine if the diarrhea is a result from a bacterial infection such as C. diff. If the diarrhea is related to a bacterial infection, he will need antibiotics to treat the infection. I will continue with the same tube feeding formula and add

Case Study: Nutrition Support VACCHCS Jia Lu Dietetic Intern 8.25.2013

a fiber supplement such as Benefiber to help the GI tract make more formed stools. If all else fails, and EN cannot provide the patient with adequate nutrition he will need PN until his diarrhea resolves. Case Study #3: A 75-year-old male ESRD with HD. MD ordered diet of 40 GM pro, 1 gm Na with 1L fluid restriction. Po intake is poor with increased risk of aspiration due to altered mental status. ANTHROPOMETRY: HT: 58 WT: 165# UBW: 155# DETERMINE: IBW: 154 %IBW: 107% %UBW: 106% LABS: Albumin 2.7 L Na 121 L K 5.0 H BUN 65 H Creat 6.6 H Prealbumin 12 mg/dl L P 1. Explain the potential cause for the lab abnormalities? The cause for the lab abnormalities is edema as evidenced by hyponatremia. Excess water will alter the lab results; once the edema has been resolved another lab should be drawn to better assess the patient. 2. Calculate the nutritional needs of the patient. BEE: MSJ: 1400 Calories: MSJ x 1.3 = 1800 kcals Protein: 1.2 g/kg = 85 g Fluids: 1000 ml 4. Complete a nutritional assessment Patient is experiencing edema, and will require fluid restriction of 1000 mL/day. The patient is allowed to have 2 g of sodium; patient may also need to be placed on diuretic therapy to eliminate excess water. When the excess water has been removed from the body, labs should be redrawn for more accurate assessment. The amount of protein the MD order is not enough to meet the patients needs, because he is on dialysis he is allowed 1.0 1.2 g of protein per kg of body weight. During the HD process protein can be lost, inadequate protein intake will result in protein energy malnourishment. The recommended formula is Nepro at 40 ml/24 hr + 70 mL water q 6 hr. Nepro fulfill the patients nutritional needs. The patient should be monitor and evaluated for tolerance, fluid balance and assessing nutrition status post diuretic therapy.