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Case Study : BH
Nutrition services:
concord-logo.jpg
Prior to admit...
Pt was admitted to ED at Alice Peck Day Memorial Hospital by pt’s PCP due to worsening
mouth sores and poor PO.
Due to the concern of sepsis, a full workup was administered prior to being transferred to
Concord.
Recommendations:
- Advanced diet when phos repleted
- Additional B-complex supplement for mouth sores, may be nutritional in nature?
- Monitor vit D levels
Concerns:
- GI consulted following abnormal liver function tests, positive for cirrosis and possible GI
bleed.
- Pt endorses 2-3 drinks/night
- Possible lower lobe pneumonia.
Acute Respiratory Failure
Acute Hypoxemic: Insufficient levels of oxygen in the blood, but levels of carbon dioxide
are close to normal.
- Possibly caused by sepsis, however alcohol and tobacco use are also risk factors.
Sepsis
A potentially life-threatening complication of an infection that occurs when chemicals
released into the bloodstream to fight the infection, triggering inflammatory
responses throughout the body.
Cirrhosis
Late stage scarring of the
liver, caused by liver disease
and conditions such as
chronic alcoholism.
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Methotrexate Toxicity (MTX)
- MTX acts to suppress the body's overactive immune and/or inflammatory systems.
- Pt’s using methotrexate are strongly discouraged from drinking alcoholic beverages
due to the increased risk of liver damage with this combination.
- MTX was first developed as a folate antagonist for cancer treatments. Many side effects
of MTX can be avoided or resolved by taking a folic acid supplement.
- ETOH abuse damages the liver, the major storage organ for folate.
Chronic Malnutrition
- Meets criteria for chronic
severe protein calorie
malnutrition given wt loss
(8% since Dec 2017)
4/23
- Monitor for refeeding, replete lytes
- Consider nutrition support? Chronic maln + poor PO.
- Remains admitted for resp failure
- GI following; deferring EGD and colonoscopy d/t respiratory status
- LABS: Na 133, K 3.0 Mg 1.3
4/24
- Consider Cortrak placement when EGD is done
- Pt remains admitted for management of acute respiratory failure
- Intake remains poor d/t oral lesions
Recommendations:
- Pt would benefit from tube feeds through bleeding risk will have to assessed by GI w/EGD given
cirrosis and Hx of GI bleeding.
Concerns:
- ? if corpak can be placed when pt goes for EGD
- K and mg repletion ongoing
- Remains on thiamin, folic acid, MVI per CIWA
Cortrak
Feeding tube placement that eliminates need for a KUB
4/25 TPN Day 1 - Admitted to ICU
- Start TPN via PICC Clinimix E 5/15 @ 40 mL/hr w/ lipids 2x/wk (provides 825kcal, 48g pro)
- MVI, Minerals and Trace E added
- Adv to goal tomorrow (80 mL/hr)
- Continue to replete lytes PRN.
Harris - Benedict:
Men: 66.4730 (13.7516 weight) (5.0033 height) – (6.7550 age)
Women: 655.0955 (9.5634 weight) (1.8496 height) – (4.6756 age)
● To combat this feedings are often started at a low rate and labs are provided
every day for the first 3 days of feedings.
What is a PICC?
PICC - Peripherally inserted central catheter
PICC-line-front-labelled_tc
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4/28 TPN Day 4
- Change to ClinE 5/20 @ 65mL/hr, continue lipids 2x/wk
- Bolus 2g Mg sulfate
- Adding 150 mg Thiamin to each 1L bag
5/1
- TF increased to 20mL/hr today
- Enteral is started as soon as possible to preserve the GI tract..
- EN can aslo preserve hepatic function and respiratory function.
5/2
- TPN dc’d today
- Thiamine, folate, MVI changed to EN
- TF adv to goal rate 45mL/hr
5/3
- High serum K and Na
- TF changed to nepro (high cal formula)
5/4
- Improvement in stooling 5/16
- CAPS still high and lytes becoming - Diet adv to house (successful extubation
closer to normal levels on 5/14)
- Pt on goal tube feeding - Providing Beneprotein shake
supplements
5/9
- Increase Nepro to 40ml/hr 5/17
- Lytes finally WNL! - Pt with hallucinations and AMS
- Status changed to CMO
5/11
- Family meeting today - ongoing plan
of care 5/18
- TF changed to osmolite 1.0 @ - Pt discharged to hospice house on
40mL/hr comfort measures
- KUB shows possible ileus
- K and Mag dropped this morning
Hepatic Encephalopathy (HE)
● Hepatic encephalopathy is a syndrome observed in patients with cirrhosis and is
defined as a spectrum of neuropsychiatric abnormalities.
● However studies have show thant protien restriction does not effect the outcome of HE
especially since protein is important for patients with PCM (Protein calorie malnutrition)
2.5-4.5 mg/dL
Lab Values - Phosphorus
1.7-2.2 mg/dL
Lab Values - Magnesium
Lab Values - Potassium 3.5-5.0mEq/L
Lab Values - Sodium 135-145 mEq/L
Impact of Patient care
- Pt had aggressive support throughout stay
- Due to difficulty weaning off the vent and poor mental acuity, pt ultimately left
CMO, and was dc’d to hospice house.
- Nutrition support was constantly changing: ? Could TPN have been started sooner?
- Decision to advance to low Na diet (was this necessary given poor PO)
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Questions?
References:
Eghtesad, S., Poustchi, H., & Malekzadeh, R. (2013). Malnutrition in Liver Cirrhosis:The Influence of Protein and Sodium. Middle East Journal of
Digestive Diseases, 5(2), 65–75.
Parish, M., Valiyi, F., Hamishehkar, H., Sanaie, S., Asghari Jafarabadi, M., Golzari, S. E., & Mahmoodpoor, A. (2014). The Effect of Omega-3 Fatty
Acids on ARDS: A Randomized Double-Blind Study. Advanced Pharmaceutical Bulletin, 4(Suppl 2), 555–561. http://doi.org/10.5681/apb.2014.082
http://www.rtmagazine.com/2007/02/nutritional-management-of-ventilated-patients/
https://journals.lww.com/ccmjournal/Abstract/1999/08000/Effect_of_enteral_feeding_with_eicosapentaenoic.1.aspx
Nutrition Care Manual - Concord Hospital
Roch, A., Guervilly, C., & Papazian, L. (2011). Fluid management in acute lung injury and ards. Annals of Intensive Care, 1, 16.
http://doi.org/10.1186/2110-5820-1-16
Friesecke S, Lotze C, Kohler J, Heinrich A, Felix SB, Abel P. Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a
randomised controlled trial. Intensive Care Med. 2008;34(8):1411–20
García de Acilu, M., Leal, S., Caralt, B., Roca, O., Sabater, J., & Masclans, J. R. (2015). The Role of Omega-3 Polyunsaturated Fatty Acids in the
Treatment of Patients with Acute Respiratory Distress Syndrome: A Clinical Review. BioMed Research International, 2015, 653750.
http://doi.org/10.1155/2015/653750
Gupta, A., Govil, D., Bhatnagar, S., Gupta, S., Goyal, J., Patel, S., & Baweja, H. (2011). Efficacy and safety of parenteral omega 3 fatty acids in
ventilated patients with acute lung injury. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical
Care Medicine, 15(2), 108–113. http://doi.org/10.4103/0972-5229.83019
Roch, A., Guervilly, C., & Papazian, L. (2011). Fluid management in acute lung injury and ards. Annals of Intensive Care, 1, 16.
http://doi.org/10.1186/2110-5820-1-16
Escott-Stump, Sylvia. (1992) Nutrition and diagnosis-related care /Philadelphia : Lea & Febig
Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L.Krause, Marie V. (Eds.) (2012) Krause's food & the nutrition care process /St. Louis,
Mo. : Elsevier/Saunders,