Major Case Study: Enteral and Parenteral Nutrition

Transcription

1 Major Case Study: Enteral and Parenteral Nutrition Mr. R, a 35 yo drug user, is hospitalized after a motor vehicle accident (MVA). He is currently suffering from a severe concussion and lapses of consciousness, a broken jaw, multiple broken bones, and possible internal injuries. He had not eaten anything for several days PTA because he was overdosing on drugs. Enteral feeding has been recommended in order to improve his nutritional status and given his decreased level of alertness. The patient will be bedridden until his mental status improves. A nasogastric feeding tube has been inserted and the physician has asked for your recommendation regarding the type of formula and amounts of kcal/protein needed for this patient. Ht: 5 11 Current wt: 156 # UBW: 167 # Serum albumin: 3.0 mg/dl 1. Write 1 PES statement for this patient. (2 Inadequate oral intake r/t broken jaw and loss of cognitive function AEB recent hospitalization from MVA. 2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 No, although the nose is the most appropriate entrance route due to the broken jaw, a nasoduodenal or nasojejunal route would be a better short- term enteral feeding choice. Because the patient s body is still responding from a very recent trauma, physiologically he could still be in the Ebb Phase meaning that blood flow to certain areas of his body, like the GI tract, have not returned to a normal functioning level and the patient could be experiencing gastroparesis. As a result of this slow gastric emptying, feeding into the stomach could cause aspiration and because the patient is suffering from a severe concussion and lapses of consciousness, he may not be able to verbally express experiencing these symptoms. Just to be on the safe side, a nasoduodenal or nasojejunal tube should be administered in order to bypass the stomach. 3. What daily intake of kcals, protein, and fluids would you recommend for this patient and why? Show calculations for estimated needs, give recommendations as kcal/d, g protein/d, ml fluid/d. (6 CBW = 156 # = kg, Height = 5 11 = cm, Age = 35 yo REE for Males (Mifflin- St Joer) = (9.99 x Weight) + (6.25 x Height) (4.92 x Age) I used Mifflin St. Jeor instead of Harris Bennedict, because although pt is a young male suffering from head trauma, a situation usually involving the use of the Harris Benedict equation, the pt is a drug user meaning that his nutrition status is probably less then optimum) AF = 1.1 (confined to bed) *NT & P, pg. 688 IF = (closed head injury/ head injury) Estimated Energy Requirement REE = (9.99 x kg) + (6.25 x cm) (5 x 35) + 5 = kcal / day x IF x AF = kcal / day x 1.3 x 1.1 = kcal/day = kcal / day x 1.5 x 1.1 = kcal/day = kcal/day Protein Requirement *NT & P, pg. 688, and Pocket Resource Manual, pg. 9 (used both closed head injury and head injury to give a range)

2 Major Surgery = g protein/kg *NT & P, pg. 688 G Protein / Day = 1.2 g protein x kg BW = g Protein / day G Protein / Day = 1.5 g protein x kg BW = g Protein / day = g Protein / day Fluid Requirement 1 ml / kcal = ml / day 4. Based on the needs of this patient, describe three desirable characteristics for the type of formula you would recommend. Give one example of an appropriate enteral formula meeting these characteristics. Use Appendix C2 in NTP text or the formulary provided on the UCD SmartSite. (4 1) High Protein à to mediate the effects of accelerated protein catabolism, promote wound healing and support immune function. 2) Low- residue à Patient may be experiencing some gastroparesis from recent trauma and therefore a low- fiber formula for the time being is probably safer. 3) Micronutrients à High energy, to account for increased energy needs * Osmolite 1 CAL (Abbott) 5. a) Based on the enteral formula you selected in question 3 above, what daily total volume of formula would meet Mr. R s estimated kcal and protein needs? Show calculations. (3 Goal: kcal/day à (2600 kcal / day) / (1.06 kcal / ml) = 2, ml/day =2,450 ml / day (2,450 ml / day) / 24 hours = ml / hour = 100 ml / hour (100 ml / hour) x 24 hours = 2400 ml / hour (New volume) b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr infusion? Show calculations. (1 pt) (2,450 ml / day) / 24 hours = ml / hour = 100 ml / hour c) Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what else is needed and how it would be added to the current tube feeding. Show calculations. (4 No, the fluid provided by his formula does not meet his fluid needs and fluid flushes will have to be provided ml x 0.84 = 2,016 ml free fluid in formula 2600 ml (estimated fluid intake) - 2,016 ml = 584 ml extra fluid needed 584 ml / 6 = ml = 100 ml Q 4 hours 6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 - Blood Glucose: Blood glucose should be checked regularly to make sure the patient is not experiencing hyperglycemia. During periods of high physiological stress, excess levels of glucose are produced from gluconeogenesis and the Cori Cycle. As a result excess insulin is put out into the circulation. However, the responsiveness of tissues becomes blunted and as a result high levels of glucose are left out in the blood stream. Because our patients is in a hypermetabolic state due to his traumatic injury, glucose is being generated in abundance and utilized as an energy source so there is a good change the patient is experiencing hyperglycemia. - Nutritional Management of Trauma Patients, NUT 116B Notes, Slide 11

3 - PreAlbumin: Low values can be indicative of the protein catabolism, blood loss, dilution, as well as severity of body s inflammatory response (increased production of negative acute phase proteins and decreased production of positive acute phase proteins). I would monitor to make sure the patient is improving nutritionally. Pre- albumin responds to acute changes and could be a good indicator of malnutrition. - Nutritional Management of Trauma Patients, NUT 116B Notes, Slide 18 - Serum Electrolyte (phosphorus, magnesium, potassium and thiamin) to check for possibility of refeeding syndrome, especially because this patient was NPO for several days previous to admission due to drug overdose. *NT & P, pg Give one urine value that you would monitor and the rationale for monitoring it. (2 Urine Osmolality and gravity could be tested to check on the hydration status as well as renal function of the patient. Checking on hydration status is very important in that you don t want the patient to be underhydrated or overhydrated. This value will indicate whether increase or decreases in flush volume are appropriate. Osmolality would also give you an indication of renal function and whether the organ s reuptake processes were working sufficiently. The patient, Mr. R, is now 5 days s/p his MVA. He did not tolerate the enteral feedings well (diarrhea and pain) and now has been diagnosed with acute pancreatitis. The MD has ordered a nutrition consult for evaluation of parenteral nutrition (PN) support. For the purposes of answering questions 7-12, assume that your current estimated kcal and protein needs for Mr. R are: 2600 kcal/day and 110 g protein/day. 8. Write a PES statement. (2 Impaired nutrient utilization r/t inability to tolerate enteral feeding method AEB diarrhea and pain. 9. Which type of PN support do you recommend central or peripheral? Justify your answer. (2 I would suggest central parental nutrition for several reasons. First, central venous access allows for output into the superior vena cava, an area of high flow volume that can quickly dilute out solutions of high osmolality. Because the patient is receiving all of his nutrition parentally and has high nutritional needs, the solution is likely to have a high osmolality. Peripheral parental nutrition solutions must be limited to < 900 mosm/l to avoid thrombophlebitis of the vein and if the solution was used it would have to be diluted out greatly increasing the volume. Second, central access allows for multiple ports in which fluid, nutrition and medication could all be administered at one time. Peripheral parental nutrition is restricted to one port, limiting the capacity to infuse additional components like medications. (From Parental Nutrition Lecture Slides, NUT 116BL) 10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of Mr. R s total kcal needs. Show calculations. ( kcal x 0.2 = 520 kcal from lipids 520 kcal / 11 kcal / gm = grams lipid = 45 grams lipid 520 kcal / 1.1 kcal / ml = ml = 500 ml of a 10% lipid solution - From Parental Nutrition Lecture Slides, NUT 116BL

4 11. The MD wants the dextrose and amino acid solution to be a total volume of 2 L/day. (The volume of lipid emulsion is separate from this 2 L.) a) Determine the final amino acid concentration of this solution, which would supply 110 g protein/day. Show calculations. (2 (110 g Protein/day) / 2000 ml solution = 5.5% AA Solution 110 g Protein/day x 4 kcal/g = 440 kcal from protein b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals from CHO and as grams of dextrose. Show calculations. (3 110 g Protein/day x 4 kcal/g = 440 kcal from protein 500 ml of a 10% lipid solution = 500 ml x 1.1 kcal/ml = 550 kcal 2600 kcal = kcal from lipid + kcal from protein+ kcal from CHO 2600 kcal = 550 kcal kcal + kcal from CHO = 1610 kcal from CHO (dextrose) Grams of Dextrose = 1610 kcal / 3.4 kcal/gram = = 474 g dextrose c) Determine the final dextrose concentration of the solution. Show calculations. (2 474 g dextrose / 2000 ml = 23.7% dextrose solution d) If the PN solution had to be made from a starting stock solution of D 50W (500 g dextrose in 1 L of water), what volume of this stock D 50W would be needed to provide the grams of dextrose that you calculated in question 9b above? Show calculations. (2 (500 gm dextrose / 1000 ml stock D 50W) = (474 gm dextrose / X ml stock D 50W) = L stock D 50W or 948 ml stock D 50W e) Compare the grams of dextrose to be provided in this solution with the maximum glucose infusion rate for Mr. R of 5 mg/kg BW/min. Would you make any changes to the PN solution based on this information? Explain your rationale. If so, how would you change it? (2 474 g Dextrose/day / 70.8 kg = 6.70 g Dextrose/kg BW/day 6.70 g Dextrose = 6700 mg Dextrose 24 Hr/Day x 60 min/hour = 1440 min/day =6700mg Dextrose/day / (1440 min/day) = 4.7 mg Dextrose/ kg BW/ min No, I would not make any changes to the PN solution because the calculated grams of dextrose fall under the maximum glucose infusion rate. However I would monitor the patient to make sure he reacts well to this infusion rate 12. List three lab values that you would monitor for this patient and the reasons why. (6 - Micronutrients and anemia: Nutrients, especially iron and folate should be carefully. Iron deficiency related anemia is common in patients with parental nutrition and as a precaution his hemoglobin and hematocrit should be monitored regularly. - Parental Nutrition Lecture, NUT 116BL, Slide 44 - Electrolytes: It is important to monitor electrolytes upon admission of parental feeding due to the risk of refeeding syndrome. Because the patient was malnourished upon admission he is at increased risk and thus should be monitored carefully. Also, because electrolyte requirements of the patient are established based on body weight, existing electrolyte deficiencies, ongoing electrolyte losses and changes in organ function, there is a lot of room for estimation error as well

5 as individual variability that may cause increased or decreased requirements depending on the variability of the patients status. It is crucial to watch patient electrolytes to observe any of these fluctuations and be able to account for them. - MT & Pg Glucose and Lipids: Excessive carbohydrate as dextrose in patients on parental nutrition can have adverse effects such as hyperglycemia leading to development of diabetes and development of steatosis. Excessive lipid as emulsions of safflower or soybean oil in parental nutrition can lead to hyperlipidemia as well as impaired immune response. - MT & Pg Mr. R develops hyperglycemia while on PN support. Describe two actions you would recommend to help lower blood glucose and achieve metabolic control of the patient. (2 I would first looking at the ratio of dextrose to lipid to protein. It is possible that the ratio of dextrose in the solution is to high and if we were to reduce the % of dextrose and increase the ratio of either lipid or protein we could still provide adequate energy while reducing the peripheral resistance of insulin. If this method wasn t working or the patient s parental solution could not be adjusted due to other factors, I would consider adding exogenous insulin to the solution to bring down blood glucose. - Parental Nutrition Lecture, NUT 116BL, Slide What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a severely malnourished patient who is started on PN? (4 When the body experiences a state of starvation lasting longer than a few days, it begins to switch over to ketone use for its primary source of energy and malnutrition of other vitamins, minerals and electrolytes begins to occur. When large loads of carbohydrate are suddenly introduced back into the system, glucose metabolism requires large quantities of phosphorous and other electrolytes to shift intracellularly. Levels of these electrolytes in the serum are already low and as a result of their increased utilization for intracellular anabolism, serum levels drop to even lower levels. If severe enough, this sudden shift can result in hemolysis, impaired cardiac function, impaired respiratory function, and even death. This situation can easily occur in severely malnourished patients who are started on PN and suddenly administered rapid volumes of dextrose. - - MT & Pg