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Jay Porter11.17.14Answer Guide for Medical Nutrition Therapy: A Case Study Approach 4th ed.Case 29 – Metabolic Stress and Trauma: Open AbdomenI.Understanding the Disease and Pathophysiology1.The patient has suffered a gunshot wound to the abdomen. This has resulted in an open abdomen. Define open abdomen. The medical record describes the use of a wound “vac.” Describe this procedure and its connection to the diagnosis for open abdomen.An open abdomen is a procedure where the abdomen is left open after surgery to reduce the build up of pressure within the abdominal cavity. A wound “vac” is the technique of vacuum-assisted closure for the abdomen. A wound “vac” would be a used to close up the open abdomen and reduce the risk of infection from the surgery. 2.The patient underwent gastric resection and repair, control of liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on this patient’s ability to meet his nutritional needs.Discontinuity of the GI tract could lead to malabsorption of many nutrients. If GI function is compromised, alternative strategies for appropriate nutrient supply should be issued, such as parenteral nutrition feeding, to ensure adequate kcal and protein needs. Failing to meet these increased needs of calories and protein could delay wound healing and lead to nutrient deficiencies. 3.The metabolic stress response to trauma has been described as a progression through three phases: the ebb phase, the flow phase, and finally the recovery or resolution. Define each of these and determine how they may correspond to this patient’s hospital course.The three phases of physiological responses to stress are Ebb, Flow, and Recovery. Ebb phase typically occurs 2-48 hours and is associated with hypovolemia, tissue hypoxia, and decreased cardiac and urinary output. Flow phase is dependent on the severity of the stress and characterized by hypermetabolism and catabolism. Flow phase can also disrupt immune and hormonal signaling. Recovery phase is the final step to the response to stress in which the body returns to normal metabolic rate where we see a decrease in the hypermetabolic state and normal hormonal responses. Nutrition support becomes the priority during the recovery phase as we can begin to meet the body’s protein needs. 4.Acute-phase proteins are often used as a marker of the stress response. What is an acute-phase protein? What is the role of C-reactive protein in the nutritional assessment of critically ill trauma patients? What other acute-phase proteins may be followed to assess the inflammatory stress response?Acute phase proteins are released by the liver during the inflammatory response. Acute phase proteins are used to provide a negative feedback for the body during an inflammatory response. C-reactive protein is a member of the acute-phase protein family that is released by the liver in response to cytokine production from macrophages and neutrophils. CPR can be used as a measure for the degree of inflammation during stress or trauma. Other acute phase proteins to follow would be ceruloplasmin and ferritin.II.Understanding the Nutrition Therapy5.Metabolic stress and trauma significantly affect nutritional requirements. Describe the changes in nutrient metabolism that occur in metabolic stress. Specifically address energy requirements and changes in carbohydrate, protein, and lipid metabolism.The energy requirements of metabolically stressed patients are increased dependently on the severity of the trauma. During a state of metabolic stress, substrate metabolism is abnormal compared to normal conditions. Hypermetabolism, protein abnormalities, increased lipolysis, and altered carbohydrate metabolism can be a result of stress related to trauma. Abnormal carbohydrate metabolism related to trauma increases gluconeogenesis and reduces clearance of serum glucose resulting in hyperglycemia. Lipolysis is increased due to a need for an alternative energy source because of the reduced clearance of glucose from blood. Protein abnormalities are a result of increased catabolism of protein and are shown by negative nitrogen balances for the patient. 6.Are there specific nutrients that should be considered when designing nutrition support for a trauma patient? Explain the rationale and current recommendations regarding glutamine, arginine, and omega-3 fatty acids for this patient population.Carbohydrates, fats, proteins, and electrolytes should all be carefully considered when designing a nutritional support formula for trauma patients. Increased protein needs, increased lipolysis, and risk of refeeding syndrome are cases that need to be addressed for patient’s safety and wound healing. Glutamine, arginine, and omega-3 fatty acids are known for their roles in wound healing and immune response. Glutamine can play an essential role in gluconeogenesis and protein synthesis. They body’s stores of glutamine are significantly decreased during times of metabolic stress. Arginine has a high nitrogen content and can be beneficial in attempting to restore a patient’s nitrogen balance to within normal limits while also thought to be an important player in the immune response during a recovery from trauma. Omega-3 fatty acids are known for their anti-inflammatory properties which is beneficial for recovery and mediating immune response. 7.Using current evidence-based guidelines, explain the decision-making process that would be applied in determining the route for nutrition support for the trauma patient.ASPEN’s guidelines for the provision and assessment of nutrition support therapy for adult critically ill patients states that enteral feedings should be started early within the first 24-48 hours following admission and advanced toward feeding rate goal over the next 48-72 hours. Patients in the ICU that have an absence of bowel sounds and/or evidence of passage of flatus and stool are not required for the initiation of EN feedings. Parenteral nutrition should not be initiated immediately postoperative; 5-7 days should separate the operation and PN initiation. PN should only be initiated if nutrient needs are not being met by EN feedings. III.Nutrition Assessment8.Calculate and interpret the patient’s BMI.BMI: 102.7/(1.782) = 32.4 kg/m2 - Obese Class I9.What factors make assessing his actual weight difficult on a daily basis?Assessing Mr. Perez’s weight on a daily basis is difficult due to his frequent trips to surgery and VAC device. 10.Calculate energy and protein requirements for Mr. Perez. Use at least two methods (including the Penn State) to estimate his energy needs. Explain your rationale for using each one. For the Penn State calculation, the minute ventilation is 3.5 L/minute and the maximum temperature is 39.2.Penn State: (.85 * Harris-Benedict) + Ve(33) + Tmax(175) - 6433= (.85*2166) + (3.5*33) + (39.2*175) - 6433= 2383.6 kcal/d * IF= 2383.6*1.3= 3098.7 kcal25-30 kcal/kg: 25*102.7 = 2567.5 kcal30*102.7 = 3081 kcal11.What does indirect calorimetry measure?Indirect calorimetry measures the respiratory differences of oxygen and carbon dioxide. IC can be used to calculate a resting metabolic rate by measuring the caloric needs during a resting state through the collection of expired air. pare the estimated energy needs calculated using the predictive equations with each other and with those obtained by indirect calorimetry measurements.Metabolic cart measurements for Mr. Perez show a REE of 3657 kcals. This resting energy estimate is ~500 kcals greater than both the Penn State equation estimation and the 30 kcal/kg estimation. 13.Interpret the RQ value. What does it indicate?Mr. Perez’s RQ is 0.76. A RQ near 0.7 indicates the use of fats as the primary substrate for energy needs. 14.What factors contribute to the elevated energy expenditure in this patient?Multiple factors can contribute to the elevated energy expenditure seen in Mr. Perez’s IC. Trauma from the GSW, multiple surgeries, and parenteral nutrition can all contribute to estimated caloric needs. 15.Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and grams of protein are provided with his prescription. Read the nutrition consult follow-up and the I/O record. What was the total volume of PN provided that day?The current nutrition support is: Destrose: 140, CAA: 60, FAT/L: 20 goal Rate: 135 mL/hr. Additionally Propofol @35 mL/hr to provide an additional 924 kcal. These combine to give Mr. Perez a total of 3888 kcal and 194 g protein. pare this nutrition support to his measured energy requirements obtained by the metabolic cart on day 4. Based on the metabolic cart results, what changes would you recommend be made to the TPN regimen, if any? What are the limitations that prevent the health care team from making significant changes to the nutrition support regimen?The resting energy expenditure that was calculated by the metabolic cart shows Mr. Perez’s REE is 3657 kcal/d. The TPN that is being provided supplies Mr. Perez with more than his resting needs. 17.The patient was also receiving propofol. What is this, and why should it be included in an assessment of his nutritional intake? How much energy did it provide?Propofol is a relaxing agent given to patients who are going to receive anesthesia for surgical procedures. Propofol provides significant amount of calories as lipids so it should be included within the nutrition prescription. Mr. Perez’s dose of Propofol supplied 924 kcals. 18.The RD recommended that trickle feeds be initiated. What is this and what is the rationale? The RD recommended the formula Pivot 1.5 for these trickle feeds. What type of formula is this, and what would be the rationale for choosing this formula?Trickle feeding is a very slow rate of enteral nutrition feeding, this would be important as to begin to utilize the GI tract again since Mr. Perez has been on PN feedings for a few days. This slow feeding would be beneficial since Mr. Perez has received many abdominal surgeries with his open abdomen and VAC system. Pivot 1.5 is a formula designed for patients who are under metabolic stress, surgical trauma, and burns. Pivot 1.5 has a very high protein content to help promote protein synthesis and wound healing. Pivot 1.5 is designed to be well tolerated so this would be a beneficial formula to choose for Mr. Perez’s trickle feeding to initially try to regain major function of the GI tract. 19.List abnormal biochemical values for 3/29, describe why they might be abnormal, and explain any nutrition-related implications.Patient’s Value 3/29Normal ValueReason for Abnormal ValueNutrition-Related ImplicationsSodium146136-145Risk for Hypertension if sustained, Electrolyte balanceBUN238-18Loss of fluid from GSWDehydrationCreatinine Serum1.40.6-1.2Glucose16470-110TraumaHyperglycemiaPhosphate2.22.3-4.7Osmolality309.3285-295Fluid lossHydration, Electrolyte balanceProtein5.26-8Truama, SurgeryDelayed wound healing, EdemaAlbumin1.43.5-5Prealbumin3.016-35Alkaline Phosphatase54030-120ALT4354-36AST1900-35CPK18255-170C-Reactive Protein245<1.0TraumaSustained inflammationHDL-C40>45VLDL1107-32LDL140<130Triglycerides27440-160Trauma, DietCardiovascular diseaseHbA1C7.13.9-5.2Insulin resistancePT912.4-14.4INR0.60.9-1.1PTT2124-34WBC15.24.8-11.8RBC3.24.5-6.2Hematocrit3540-54Specific gravity1.0451.003-1.030ProteinPositiveNegativeGlucosePositiveNegativeKetonesPositive NegativeBact50Mucus50Yeast2020.Current guidelines recommend using a nitrogen balance study to assess the adequacy of nutrition support. a.According to the Powell (2012) article (see bibliography below), what adjustments should be made to assess for nitrogen losses through fistulas, drains, or wound output?Achieving a positive nitrogen balance is a primary goal for nutritional support when patients are in need of additional protein as a result of trauma. Patients who retain an open abdomen after surgery are at increased risk for increased protein loss. Drains collected from the open abdomen contain water, electrolytes, and proteins. Since these proteins lost from drains are not incorporated in the calculation for nitrogen balance there is a risk of improper protein feedings. If this additional loss of protein isn’t accounted for wound healing and recovery from trauma could be severely delayed and compromised. b.A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42 g. Calculate his nitrogen balance.Nitrogen Balance = (24 hour Protein Intake/6.25) - (24 hour Urinary Urea Nitrogen + 4)Nitrogen Balance = (194/6.25) - (42 + 4)Nitrogen Balance = -15IV.Nutrition Diagnosis21.Identify the nutrition diagnosis you would use in your follow-up note. Complete the PES statement.Altered GI function RT gun shot wound trauma and surgery AEB gastric resection and repair and altered lab values. 22.For the PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).Parenteral nutrition feedings to meet increased needs for protein and calories. Transition from PN to EN. VI.Nutrition Monitoring and Evaluation23.What are the standard recommendations for monitoring the nutritional status of a patient receiving nutrition support?Monitoring of electrolyte balances (phosphate, potassium, magnesium), blood glucose, and fluid balance. 24.Hyperglycemia was noted in the laboratory results. Why is hyperglycemia of concern in the critically ill patient? How was this handled for this patient?Hyperglycemia is of concern because it is the most common problem with PN feedings and contributes to the metabolic stress Mr. Perez is experiencing. Dextrose feeding should be reduced to prevent hyperglycemia and related issues. Trickle feeding is a good way to improve tolerance through the GI absorption and decrease complications from intolerances to feedings. 25.What would be the standard guidelines and subsequent recommendations to begin weaning TPN and increasing enteral feeds?Gradual reduction of TPN should be supplemented with increased EN feeding support. Monitoring of the patient’s tolerance to EN feeding should be the determining factor for the rate for reduction of TPN. ................
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