Clinical Case Report: Nutrition Management for Left Aspect Medulla Oblongata Infarction

Transcription

1 Clinical Case Report: Nutrition Management for Left Aspect Medulla Oblongata Infarction Alisha Mukadam ARAMARK Dietetic Internship Lafayette General Medical Center December 19,

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3 Disease Description Also known as Wallenberg Syndrome A rare condition in which an infarction (stroke) occurs in the lateral medulla. The lateral medulla is a part of the brain stem. Oxygenated blood does not reach to the medulla when the arteries that lead to it are blocked. A stroke can occur due to this blockage. This condition is also sometimes called lateral medullary infarction. 3

4 Disease Description: Etiology It's not known what initially causes Wallenberg's syndrome. However, some researchers have found a connection between people who have the syndrome and who have peripheral artery disease, heart disease, blood clots, or minor neck trauma. 4

5 Disease Description: Epidemiology Rare Disease Affects less than 200,000 people in the US Overall occurrence of Wallenberg s Syndrome is not very well documented. 5

6 Disease Description: Pathology Since there is no cure for Wallenberg's syndrome, treatment usually involves relieving the symptoms a person is experiencing, which may include the following: A feeding tube to help with swallowing complications Speech therapy to help with talking and swallowing Medication to help alleviate pain, such as the anti-epileptic drug gabapentin (Neurontin) Blood thinner medication, such as heparin or warfarin, to help reduce or dissolve the blockage in the artery 6

7 Disease Description: Clinical Signs and Symptoms Difficulty swallowing (dysphagia) Hoarseness Nausea Vomiting Hiccups Difficulty Walking & Maintaining Balance (ataxia) 7

8 Case Presentation 64 year old African American male was admitted to the hospital from the Emergency Room for shortness of breath, respiratory failure with an O2 saturation of 84%, and dizziness. Diagnoses: 1. Left aspect medulla oblongata infraction 2. Thyroid Mass 3. GI Bleed 4. Severe Dysphagia with tracheal aspiration 5. Sepsis 2/2 Pneumonia 6. Ataxia 8

9 Nutrition Care Process Assessment 9

10 Client History Medical History: Pt has not seen a PCP in over 30 years HTN Food and Nutrition Related History: N/A Social History: Drinks alcohol socially once in a month Smokes 1 ½ - 2 packs of cigarettes a day 10

11 Anthropometric Physical Findings Height: 167 cm, 5 ft 6 in Weight: kg, 207 lbs Body Mass Index: kg/m 2 Obese Class 1- BMI: Usual Body Weight: kg, 210 lbs 11

12 Biochemical Data Abnormal Laboratory Values Upon Admission Patients Value Normal Value BUN 22.0 mg/dl 7-18 mg/dl Creatinine 1.38 mg/dl mg/dl Calcium 8.0 mg/dl mg/dl RBC 4.60 x10/mcl x10/ mcl Hgb 11.8 gm/dl gm/dl Hct 35.0% % Chloride 110 mmol/l mmol/l Sodium 146 mmol/l mmol/l 12

13 Medical Tests and Procedures PICC Line PEG Tube Placement Urine analysis Upper GI Endoscopy Esophagram Barium Swallow Study MRI of the Brain CAT scan of the thorax CT of the soft tissue neck MRA of the head and neck 2-D Echo MRA of the head and neck 13

14 Nutrient Needs Nutrient Estimated Needs Formula Used Calories 2181 kcal/day Mifflin St Jeor 1677 x (stress factor 1.3) Protein 109 grams/day 20% of total calorie requirement Fluid 2363 ml/day 25 ml/kg 14

15 Initial Assessment Continuous nausea and vomiting Spots of blood in vomit Hoarse from vomiting and has a burning throat Labs, BUN (45 mg/dl) and Creatinine (3.37 mg/dl) were elevated. 15

16 Initial Assessment Test Results: CT of the Thorax showed moderate wall thickening of the entire esophagus Electrocardiogram identified severe inflammation of the esophagus. MRI confirmed nonhemorrhagic medulla oblongata infraction. Per Speech Therapy, patient continues to present with dysphagia and remains unsafe for PO intake. Esophagram supported tracheal aspiration per SLP. 16

17 Aramark Nutrition Care Level Initial Assessment (11/3/16) Nutrition Care Indicator Category Priority Points Nutrition/Diet Order or anticipated NPO > 4 days (4 points) Weight Status Primary Diagnosis/Contributing Condition Energy Intake Interpretation of weight loss Total points: BMI (0 points) Sepsis (4 points) <=50% of estimated energy requirements for >/ 5 days (points 4) 1-2% in 1 week (3 points) 15 points High Risk 17

18 Follow up #1 Patient unable to swallow 2/2 to stroke. Modified Barium Swallow: Result: NPO, severe dysphagia with tracheal aspiration. PEG recommended. Patient refusing PEG Personally witnessed living life with a PEG tube. Father-in-law did not enjoy his life because of the adversities he faced Pain and daily flushing and cleaning of tube. Patient did not want PEG tube to hinder his ability to take part in everyday life. Clinimix Started 18

19 Aramark Nutrition Care Level Follow up # 1 (11/7/16) Nutrition Care Indicator Category Priority Points Nutrition/Diet Order or anticipated New Parenteral Nutrition (Clinimix 4.25%/10% + IV IntraLipids) (4 points) Weight Status Primary Diagnosis/Contributing Condition Energy Intake Interpretation of weight loss Total points: BMI (0 points) Sepsis (4 points) <=50% of estimated energy requirements for >/ 5 days (points 4) 1-2% in 1 week (3 points) 14 points High Risk 19

20 Follow up #2 Hiccups for 2 days Agreed to PEG- Big thank you to his wife! TPN Consult Received PICC Line inserted 20

21 Aramark Nutrition Care Level Follow up # 2 (11/10/16) Nutrition Care Indicator Category Priority Points Nutrition/Diet Order or anticipated New Parenteral Nutrition (TPN) (4 points) Weight Status Primary Diagnosis/Contributing Condition BMI (0 points) Sepsis (4 points) Energy Intake (0 points ) Interpretation of weight loss Total points: 1-2% in 1 week (3 points) 11 points High Risk 21

22 Follow up #3 PEG tube endoscopically: unsuccessful thick endometrial lining TPN was started 2nd Attempt: PEG placement surgically placed: Successful. Enteral Feeding Started; TPN Discontinued 22

23 Aramark Nutrition Care Level Follow up # 3 (11/14/16) Nutrition Care Indicator Category Priority Points Nutrition/Diet Order or anticipated New Enteral Nutrition (Jevity ml/hr.) (4 points) Weight Status Primary Diagnosis/Contributing Condition Energy Intake Interpretation of weight loss Total points: BMI (0 points) Sepsis (4 points) Meeting greater than 75% of needs (0 points ) 1-2% in 1 week (3 points) 11 points High Risk 23

24 Degree of Malnutrition: Non-Severe (moderate) Malnutrition Malnutrition Identification 1. Pt has been NPO for 5 days % weight loss in 5 days 3. Fat wasting in tricep region and orbital region 4. Muscle wasting in temporal region 24

25 Nutrition Care Process Nutrition Diagnoses 25

26 Initial Nutrition Diagnoses: PES Statements 1) Acute disease or injury related malnutrition related to stroke resulting in dysphagia as evidence by mild muscle and fat wasting, 1% weight loss in the past 5 days, and meeting </=50% of estimated energy for >/= 5 days. 2) Altered nutrition-related laboratory values related to GI bleed as evidence by medical dx and decreased hgb/hct. 26

27 Nutrition Care Process Intervention 27

28 1. Advance to GI Soft- low residue diet when medically appropriate per MD and SLP rec s 2. Recommend Clinimix 4.25%/10% + IV IntraLipids 83 ml/hr. This will provide the pt with 1515 calories (69% of needs), 85 grams of protein (78% of needs), and 1992 ml of fluids (84% of needs). 3. If patient agrees to NG/PEG tube feeding use the following recommendations: Osmolite ml/hr increasing slowly to goal rate of 75 ml/hr. This will provide the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 ml of fluid (62% of needs). 28

29 Medical Intervention Consultations: GI Neurology Speech Therapy Physical Therapy Surgery Rehydration 29

30 Goals Short Term Goals: Meet at least 75% of nutritional needs through Parenteral Nutrition (Clinimix) Maintain Weight throughout Hospitalization If patient continues to refuse Enteral Nutrition, advance to TPN and meet a 100% of nutritional needs. Long Term Goals: Meeting a 100% of needs through PEG placement and Enteral Nutrition 30

31 Nutrition Care Process Monitoring and Evaluation 31

32 Monitoring & Evaluation Tolerance and rate of PPN/EN support were monitored during every follow up. Laboratory values and electrolyte were closely monitored and addressed if abnormal. 32

33 Conclusion Pt was discharged to home health with a PEG tube on enteral nutrition of 75 ml/hr. This provided the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 ml of fluid (62% of needs). 33

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35 Question 1 What syndrome does this patient have? FREE RESPONSE 35

36 Question 2 Wallenberg affects. a. more than 200,000 people in the world b. less than 200,00 people in the world c. None of the above 36

37 Question 3 and needs to be monitored to check TPN tolerance a. Triglycerides b. Sodium c. Phosphorus d. Glucose 37

38 Question 4 What could have been done differently with this patient s nutrition intervention? 38

39 Question 5 Did you learn anything new or interesting from this case study? 39

40 References 1. Oshima F. Dysphagia with lateral medullary infarction (Wallenberg s syndrome). Rinsho Shinkeigaku. 2011;51(11): doi: /clinicalneurol Kwon M, Lee JH, Kim JS. Dysphagia in unilateral medullary infarction: Lateral vs medial lesions. Neurology. 2005;65(5): doi: /01.wnl d8. 3. Cassata C. Cathy Cassata. Accessed January 19, Kinman Medically T. Wallenberg syndrome. Accessed January 19, Wallenberg syndrome. National Institutes of Health. Published March 12, Accessed January 14, PEARCE J. Wallenberg s syndrome. Journal of Neurology, Neurosurgery, and Psychiatry. 2000;68(5):570. doi: /jnnp Mahan L, Escott-Stump S, Raymond J. Krause s Food and the Nutrition Care Process. St. Louis, MO: Elsevier Saunders; Madsen H, Frankel EH. The hitchhiker s guide to parenteral nutrition management for adult patients. Practical Gastroenterology. 2006;30(7): Definition of Terms List. Academy of Nutrition and Dietetics Web site. Updated August Accessed January 13, Hui K, McCauley S. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. Journal of the Academy of Nutrition and Dietetics. 2013;11 3(6):S17-S28. 40