Name: Wan yi Wang Major Case Study: Enteral and Parenteral Nutrition Due 2/13/15 60 points 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 pts) Inadequate oral food/beverage intake (NI-2.1) r/t difficulty swallowing and obtaining adequate nutrition AEB lapses in consciousness, drug abuse, and a broken jaw from a MVA. (source: NTP Appendix C2 p. A-65) 2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts) With the information provided, nasogastric feeding route is not appropriate for this patient. This patient is at high risk for aspiration due to his decreased level of alertness and lapses of consciousness from his severe concussion. However, enteral feeding must be used to because he is unable to take nutrients in by mouth due to his broken jaw and drug doses. So, I would recommend naso-intestinal feeding such as nasodeudenal tube feeding. This kind of enteral feeding is a better solution because this patient still has functional GI tract and enabling him to absorb the nutrients pum from the stomach and goes sright to small intestine where nutrient are able to be absorb without causing regurgitation. However, if Mr.R cannot tolerate the nasoduodenal route, then we would move the tube further down and use nasojejunal route. (source:nut 116BL Lecture on enteral nutrition tube feeding) 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 pts) CBW: 156 lbs. /2.2 lbs. /kg = 70.9kg IBW:5 11 = 106 lbs. + 66 lbs. = 172 lbs. UBW: 167lbs./2.2lbs./kg=75.9kg Height: 71 x 2.54 cm/in = 180.34 cm BMI: 70.9 kg/1.81 m 2 = 21.7 kg/m 2 Wt Loss: 156#/167 # = 6.6% weight loss (a) Estimated Energy Requirements (EER)= REE x activity factor x injury factor (MSJ equation)
REE: (10 x weight (kg)) + (6.25 x height (cm)) (5 x age) + 5 REE: (10 x 70.9kg) + (6.25 x 180.34 cm) (5x 35 yo) + 5 = 1666.1 kcal Activity factor: 1.2 (confined to bed), 1.4 ((IF skeletal trauma) (PR p.3,9) EER= 1666.1 x 1.2 x 1.2 = 2,399 kcal/d EER= 1666.1 x 1.2 x 1.4= 2,799 kcal/d EER= 2,399-2,799 kcal/d (PR p.3,9) I would recommend 2,399 to 2,799 kcal per day for this patient, this range of kcal is need due to patient having multiple bone fracture and head injury. So, more calories are needed to help with healing process and to balance out his current state of protein catabolism. Thus, this can help prevent depletion of energy store and development of muscle wasting. Also increase calories to help patient to maintain his weight. (b) protein requirement: 1.5-2.0 g protein/kg BW I chose this range because this patient is in moderate-severe stress due to multiple broken bones and possible internal injuries. (Enteral Nutrition Lecture) 1.5 g/ protein / kg BW x 70.9 kg= 106.4 g protein/ day 2.0 g protein/ kg BW x 70.9 kg = 141.8 g protein/day (Source: Reviewed this from protein in discussion & PR p.10) So base on this calculation, Mr.R is recommended to consume 106.4 g protein to 141.8 gram of protein per day. As result of motor accident and surgery, Mr.R needs a high protein diet so the muscle and tissue can be repair and also rebuild red blood cells. In addition, patient s body is in the state of muscle protein catabolism, with high protein need it help with restoring his body state to anabolic state and increase production of protein. (c) Fluid Requirement: 1ml/ kcal (source: PR p. 11) 2399 kcal/d x 1 ml fluid/kcal = 2,399 ml fluid/day 2799 kcal/d x 1ml fluid/kcal= 2,799 ml fluid/day Base on my calculation this patient needs 2,399-2,799 ml fluid per day. During the motor vehicle accident he lost a large amount of blood and fluid and maybe during surgery as well. Thus, Mr.R will need a large amount of fluid to compensate for the fluid loss. However, we need to give a right balance of fluid, because excess will cause patient to have edema. 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 pts) 1) The formula needs to have fiber enrichment to ensure that his GI function remains normal, as his nasogastric tube is temporary. 2) The formula would provide slightly beyond the necessary protein levels to ensure healing in his state of critical illness/ trauma. 3) The kcal content of the formula needs to be high enough to prevent any more weight loss, and help his wounds to heal. Based on these three desirable characteristic and the need of immune support in his formula to fight possible infection. I will suggest the use of Jevity 1.2; this formula will meets these requirements. Because he is suffering from trauma from a motor vehicle accident and is in critical condition, he could also take advantage of an immune support specialized formula enhanced with arginine, nucleic acids, omega-3 fatty acids, etc.
(source: NTP p. 87 & Lecture UCDTF) 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 pts) average of kcal range = 2599 kcal/day / 1.20 kcal/ml =2,165.8 ml formula/ day 2165.8 ml x 55.5g protein /1000ml) = 120.2 g protein 120 gram of protein (Protein range is 106.4 g 141.8 g) So, 120 gram of protein falls within the range of protein need. Thus, this formula Jevity 1.2 is appropriate to use on this patient. b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr infusion? Show calculations. (1 pt) 2165.8 ml/24 hours = 90.2 ml/hour 90ml/hr. 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 pts) Jevity 1.2 is 81% water. 2165.8 ml x 0.81 =1754.3 ml free water. 2599mL 1754.3 ml= 844.7 ml water fluid needed. 844.7mL /6x a day = 140.8 free water free water flush every 4 hrs. 140 ml for ease of feeding. No, since the fluid needs are 2399 ml- 2799 ml/day and the patient is being given 2,165.8 ml of formula that is 81% free water, there is a fluid needs deficit of 844.7 ml per day. So, in order to meet his fluid needs, the patient will need additional free water flushes to make up for the deficit. In order to meet his fluid needs, the patient will need additional free water flushes to make up for the deficit. A recommendation for this could be 140 ml free water flushes every 4 hours on top of continuous feeding. (source: NTP p. 87 & Lecture UCDTF) 6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts) 1. Blood glucose this lab value can help to assess the effect of the enteral nutrition and the formula contains a great amount of CHO. This can lead to an increase in glucose in blood along with that, Mr. R is suffering from multiple injuries. Thus, his body may not be able to handle and produce sufficient amount of insulin to compensate. As result diabetes can occur. So, is necessary to closely monitor his blood glucose to prevent diabetes development. 2. Blood urea nitrogen (BUN). This marker indicates the amount of nitrogen in the blood due to the presence of urea which is a metabolic by-product of protein catabolism. Monitoring this value in Mr. R will further indicate the severity of his hyper-metabolic state and degree of muscle protein wasting. With an improvement in his status and progressing through his recovery, his BUN value should gradually decrease thus indicating an adequate amount of calories and reduction in muscle protein catabolism. 3. Pre-albumin Protein is crucial to wound healing and patient must not deplete the protein store. Pre-albumin is a good marker for the patient s current protein status because it has a half-life of
2-4 days. So it gives a more accurate representation of the patient s current status because it is more sensitive to change in protein energy status. Thus, monitor pre-albumin can help to monitor inflammation, infections and prevent protein energy malnutrition. (source: NUT 116BL enternal nutrition-tube feeding lecture & NTP p. 92 & Nut 116B method of nutrition support lecture Pocket Resource), 7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts) I would monitor the patient s urine urea nitrogen value due to fact that he is in the hyper-metabolic state and lack of adequate nutrition for at least one week. He is likely to be in the state of protein catabolism which means muscle wasting and urinary excretion of nitrogen in the form of urea. This value measure his nitrogen balance and the more catabolism that is occurring, the greater the amount of urea will be seen in his urine likely indicating a negative nitrogen balance. As his body gains the nutrients it needs through nutrition support, it will be able to increase protein synthesis, decrease muscle protein catabolism and ultimately shift the nitrogen balance toward a positive balance and excrete a lesser amount of urea in his urine. (source: NTP p. 53, 54, 92) 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 pts) Inadequate enteral nutrition infusion (NI 2.3) r/t intolerance to feedings AEB diarrhea, pain, and newly diagnosed acute pancreatitis. (source: Lecture UCDTF & Liver Disease II slide & Appendix C2 in NTP p. A-65) 9. Which type of PN support do you recommend central or peripheral? Justify your answer. (2 pts) Central Vein feeding is recommended, as it is usually used when patient is unable to tolerate enteral feeding for more than 5-7days, with moderate to severe metabolic stress and elevated metabolic rate (hyper-metabolism from multiple bone fractures and head injury), it is also used when the patient requires higher caloric needs. With peripheral parenteral nutrition you have to have a decreased osmolality (<900 mosm/l) to prevent thrombophlebitis. Central access allows a higher osmolality formula to be administered because it is a high flow area (large central vein, usually superior vein cava) which can quickly dilutes the solutions. Another reason why the central route is a better choice is because Mr. R will need the IV fluids for a longer period of time. (source: Nut 116 B & BL nutrition support lecture & NTP p. 93-94) 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. (2 pts) 10% fat= 1.1 kcal/ml (11kcal/gram) Kcal need = 2600 kcal x 0.20 fat from kcal = 520 kcal from fat 520 kcal from fat / 1.1kcal/ml lipid emulsion = 472.72 ml of 10% solution 500 ml of 10% lipid emulsion
There are only 100 ml, 250ml, and 500 ml bags so we will use a 500 ml bag. So, a 500 ml bag will be used. 500 ml x 1.1 kcal/ml = 550 kcal fat 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 pts) (110g/2000mL) x 100=5.5% amino acid solution 6% AA solution 110g x (4kcal/1g)=440kcal 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 pts) 500 kcal from fat x 1.1 kcal/ml = 550 kcal 110 g protein x 4 kcal/g protein = 440 kcal protein 550 kcal + 440 kcal = 990 kcal from fat and protein Remaining kcals to be provided as CHO: 2600 990 = 1610 kcal to be provided as CHO 1610 kcal CHO/3.4 kcal/g = 474 g dextrose c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts) 474 g dextrose/ 2000mL = 23.7 % Concentration Dextrose d) If the PN solution had to be made from a starting stock solution of D 50 W (500 g dextrose in 1 L of water), what volume of this stock D 50 W would be needed to provide the grams of dextrose that you calculated in question 9b above? Show calculations. (2 pts) 474g dextrose / 500g = 0.948 0.948 x 100 = 94.8% of the solution 1000ml x 0.948 = 948 ml So, 948ml stock D50W solution needed to meet 474 g dextrose requirement 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 pts) 5mg x 70.9 kg BW= 354.5 mg/min 354.5 mg/min x 60 min/ hr = 21,270 mg/ hr 21,270mg/hr x 24 hr/day x 1 g/ 1000 mg= 510.5 gram/ day 474 g/day / 1440min/day = 0.329g/min 0.330 g/min x 1000mg/g = 329.16 mg/min 329.16 mg/min / 70.9kg BW = 4.6mg/kg BW/min Since 4.6 mg/kg/min of dextrose he needs falls under the 5 mg/kg/min the maximum glucose infusion rate. I would not make any change to his PN solution.
12. List three lab values that you would monitor for this patient and the reasons why. (6 pts) 1. Liver Enzymes- there is an association of PN and liver disease, and lack of feeding to the GI tract. Through monitor Mr. R s liver enzymes can help to prevent and early detection of any liver function alteration or malfunction. 2. Electrolytes (Sodium, Magnesium, Calcium, Phosphorous etc.), Electrolyte aid in regulation of body s nerve and muscle function, blood ph, blood pressure and hydration; While sodium and potassium keep the body in homeostasis. However, with PN, abnormal in electrolytes level or severe electrolytes changes are commonly seen, which maybe a result from diarrhea, renal insufficiency, large wounds etc. Thus, corrections to solution content must be made as soon as possible if noticed abnormalities in electrolytes level. As adequate level of electrolyte can help patient maintain hydrated and heals wound properly. 3. Serum lipids, namely triglycerides. The amount of triglycerides present in his blood is reflective of his tolerance of the lipid emulsion and physiological compensation in response to this tolerance. If he is not tolerating the lipid emulsion well, the expectation would be to see high levels of serum triglycerides both from the lipid emulsion as well as his state of catabolism, indicating the release of free fatty acids by extrahepatic tissue for energy usage by cells. (source: Nut 116BL parenteral nutrition lecture & NTP p 101 & table 5.3) 13. 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 pts) 1) I recommend lower the amount of dextrose given per minute or spreading out the dispersal of the required levels of CHO and help his insulin catch up with the tube feeding formula. This is to prevent his blood glucose from going to high. 2) I recommend giving patient an intensive insulin therapy; as there will be development of hyperglycemia when too much sugar is present in the blood. So, is ideal to include his body regulating its own blood glucose levels along with the treatment. The goal of this treatment is to decrease his blood glucose and maintain at normal levels to prevent any abnormal effects on his physiology. (source: NTP textbook P. 101) 14. What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a severely malnourished patient who is started on PN? (4 pts) Refeeding syndrome describe the condition in which several metabolic changes have as a result of starvation of the body. Refeeding syndrome occurs as a patient who has been severely malnourished is first been feed with a highly nutritious diet. With high level of carbohydrate, it will cause electrolytes to move into the cells for metabolism. Refeeding syndrome can result in hypophopatamia, hypomagneisum, hypokalemia and abnormal sodium level, alteration in protein and fat metabolism. Rapid infusion of carbohydrate will stimulate insulin and decrease sodium and water excretion, which can cause retention of fluid in extracellular space (edema). The patient s body is not used to this high amount of calories and nutrient which is the reason there will be dangerous fluctuation of fluids and electrolytes. Refreeding syndrome can also lead to various complications such as hemolysis, weakened respiratory function and cardiac function.
Thus, is crucial to monitor refeeding for severely malnourished patients who have begun PN because the sudden shift from no nutrients to relatively excessive nutrients can cause this potentially fatal shift in fluids and electrolytes. So, to effectively prevent refeeding syndrome in general as well as in PN patients, caution must be taken and start with small amount of nutrient and calories and then gradually increase as the patient start to tolerate. (source: NTP textbook p. 92-93 & Lecture Fluid and Electrolyte Balance & NUT 116B lecture methods of Nutrition Support)