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Lauren Hoover & Clare HowardKNH 411November 8, 2016Case Study #30Nutrition Support in Sepsis and Morbid ObesityUnderstanding the Pathophysiology Mr. McKinley’s admission orders indicate he is being treated for probable sepsis and SIRS. Define these conditions.The term sepsis is used when a patient has a documented infection and an identifiable organism. SIRS stands for systemic inflammatory response syndrome and describes the widespread inflammation that can occur in infection, pancreatitis, ischemia, burns, multiple trauma, hemorrhagic shock, or immunologically mediated organ injury; this inflammation is usually present in areas remote from the primary site of infection or injury, affecting otherwise healthy tissue. (Krause 887)Describe the metabolic alterations that occur as a result of sepsis and the systemic inflammatory response. Using the medical record information, identify the specific criteria that are consistent with the diagnosis of sepsis.Another common complication with SIRS is multiple organ dysfunction syndrome (MODS), which begins with lung failure and is followed by the liver, intestines, and kidneys. Patients with these syndromes are clinically hypermetabolic and exhibit high cardiac output, low oxygen consumption, high venous oxygen saturation, and lactic acidemia. These patients also usually have a strong positive fluid balance associated with massive edema and a decrease in plasma protein concentration. (Krause 887) When looking at Mr. McKinley’s medical record, there are multiple aspects that point towards sepsis; these include, but are not limited to, ecchymosis, abrasions, petechiae, and pitting edema. In addition to these, his laboratory results show many abnormalities that are consistent with a sepsis diagnosis. Possible infections are due to rubbing of skinfolds and inadequate post-operative care. Mr. McKinley had a Roux-en-Y gastric bypass 4 months ago and has lost approximately 100 lbs. Describe this procedure. Identify the most probable nutritional concerns associated with this rapid weight loss/surgical procedure.The Roux-en-Y gastric bypass procedure involves the creation of a small pouch, about 20-30 mL, at the top of the stomach, and bypassing the remainder of the stomach, duodenum, and the first part of the jejunum. The jejunum is cut and the distal end is anastomosed to the pouch, while the proximal end of the jejunum draining the stomach and the duodenum is anastomosed to a lower segment of the jejunum, allowing for secretions to enter and mix with the contents leaving the pouch. With the decreased stomach size, there will be a restricted food intake and quickly induced satiety. The bypass of parts of the intestine reduces some food digestion and nutrient absorption as well (Nelms, p269).The concerns most probable with this procedure involve nutrient deficiencies, including the fat-soluble vitamins, Vitamin B12, folate, iron, and calcium. Protein-calorie malnourishment is also a possible complication. Another very common complication is called dumping syndrome. This occurs when an increased osmolar load enters the small intestine too quickly from the stomach. Also, since the duodenum is bypassed, feedback inhibition is lost, so this procedure affects the release of hormones, enzymes, and other secretions. Dumping syndrome results in cramping, diarrhea, hypoglycemia, and other symptoms (Nelms, p368-369).II. Understanding the Nutrition TherapyUsing evidence-based guidelines and the research literature, determine whether Mr. McKinley should receive nutrition support. Address the pros/cons of PN versus EN; early enteral feeding; and full versus trophic feeding. Use this discussion to provide rationale for your decisions.Nutrition support therapy incorporates early EN when feasible, appropriate macro and micronutrient delivery and glycemic control. There are many favorable expected outcomes, including reduced disease severity, shorter stays in the ICU, and decreased infectious morbidity and overall mortality. Other traditional goals of this treatment during sepsis are minimization of starvation, prevention of nutrient deficiency, consumption of adequate calories, and fluid and electrolyte management. (Krause 889) Parenteral nutrition is a means of delivering nutrients to the body through the veins, enteral nutrition is a means of feeding directly through the GI tract, early enteral feeding is enteral feeding provided within 24 hours of being admitted to the hospital. Enteral nutrition is preferred when the GI tract has not been affected by injury, but parenteral nutrition is useful when the patient is unable to digest nutrients on their own. Full feeding refers to when you supply the patient with all of the nutrition in one dosage, whereas trophic feeding is when the nutrition is broken down into smaller dosages and given over time. We have decided to use enteral nutrition with his NPO diet and will be using the formula Isocal HN Plus. When 1800 mL of this formula are distributed, Mr. McKinley meets his needs for kcals, cc’s, and protein. How will Mr. McKinley’s bariatric surgery affect your recommendations for nutritional support?First of all, method of entry for nutrition support will have to be analyzed due to the altered nature of the patient’s gastrointestinal tract. Part of his small intestine has been bypassed and his stomach volume is significantly decreased. These factors will play a role into the decision regarding which tube to use. In addition to this, Mr. McKinley has reduced nutrient absorption following his bariatric surgery. The Roux-en-Y bypass decreases the availability for nutrients to be absorbed, so his needs for some will be increased. When recommending nutrition support, taking note of increased fat-soluble vitamins, Vitamin B12, folate, iron, calcium, and protein needs will be important (Nelms, p270).Discuss the current literature recommendations for supplementation of omega-3-fatty acids, glutamine, arginine and antioxidants in nutrition support during sepsis.Though glutamine is a nonessential amino acid, the body’s synthesis rate cannot meet the increased needs during the stress of critical illness. Glutamine is the preferred fuel for enterocytes and assists in maintaining intestinal membrane permeability. Additionally, it supports immune cell growth, reduces pro-inflammatory cytokines, and is a precursor to the antioxidant glutathione. While many formulas include glutamine, it can also be supplemented parenterally.Arginine performs numerous roles, including serving in many ways within the immune system. Levels are dependent on glutamine, so levels are often inadequate during metabolic stress. However, there have been negative outcomes with supplementation for patients with sepsis, so it is not recommended in these cases. Omega-3 fatty acids can also aid in reducing proinflammatory cytokines. (Nelms p672-673)While in sepsis, the body’s composition of antioxidants is severely depressed, but the consumption of three specific antioxidants has been shown to aid in maintaining helpful levels of antioxidants throughout sepsis. These are selenium, glutamine, and eicosapentaenoic acid; they have all been shown to help reduce inflammation and enhance micronutrients within the body.Define refeeding syndrome. How will Mr. McKinley’s recent 100 lb weight loss affect your nutrition support recommendations regarding risk of refeeding syndrome?Refeeding syndrome describes several metabolic alterations that may occur during nutritional repletion of patients who are malnourished or in a state of starvation. With starvation lasting more than a few days, liver gluconeogenesis slows, and free fatty acids are used instead to produce energy. The reintroduction of carbohydrates shifts to having glucose as the primary energy source, requiring an increased need of phosphorus, magnesium, potassium, and thiamin. Patients at risk for this have a long history of inadequate oral intake, and those who have had minimal intake as a result of NPO status. It is critical to monitor serum levels, provide supplementation, and begin feedings slowly to prevent refeeding syndrome (Nelms, p103).III. Nutrition AssessmentAssess Mr. McKinley’s height and weight. Calculate BMI and % usual body weight.Height = 5’10” = 70” = 177.8 cm = 1.78 mWeight = 325 pounds/2.2 = 147.73 kgBMI = 147.73kg/(1.78m)^2 = 46.6 kg/m^2Usual body weight = 425 lbs.% Usual body weight = 325 pounds/425 pounds * 100 = 76.5% usual body weight(Nelms, p256)After reading the physician’s history and physical, identify any signs or symptoms that are most likely a consequence of Mr. McKinley’s admitting critical illness.There are many signs and symptoms that are likely a consequence of Mr. McKinley’s critical illness, for example elevated heart rate, diminished distal pulses, coarse breathing, ecchymosis on extremities, skin abrasions, petechiae on lower extremities, pitting edema, obesity, and rashes under skinfolds. Other consequences include his abnormal biochemical and lab data. Mr. McKinley is also currently on an NPO diet as a result of critical illness and probable sepsis.Identify any abnormal biochemical indices and discuss the probable underlying etiology.ChemistryReference Range2/23Potassium (mEq/L)3.5-5.15.8Carbon dioxide (CO2, mEq/L)23-2931Glucose (mg/dL)70-99385Phosphate, inorganic (mg/dL)2.2-4.62.1Bilirubin total (mg/dL)Less than or equal to 1.21.3Bilirubin, direct (mg/dL)<0.30.7Albumin (g/dL)3.5-5.51.9Prealbumin (mg/dL)18-3511ALT (U/L)4-3639AST (U/L)0-3541CPK (U/L)55-170220Lactate dehydrogenase (U/L)208-378401C-reactive protein (mg/dL)<1.00110Fibrinogen (mg/dL)160-450525Lactate (mEq/L)0.3-2.34.2Cholesterol (mg/dL)<200320HDL-C (mg/dL)>5032VLDL (mg/dL)7-3245LDL (mg/dL)<130232LDL/HDL ratio<3.557.5Triglycerides40-160245HbA1C (%)<5.76.8PT (sec)11-1314.5INR0.9-1.11.4PITT (sec)24-3437WBC (x10^3/mm^3)3.9-10.723.5Hemoglobin (Hgb, g/dL)14-1712.5Hematocrit (Hct, %)41-5138Transferrin (mg/dL)215-365385Ferritin20-30014The patient’s high potassium level is mostly being caused by the high rate of leukocytosis, the elevated blood glucose, and any catabolism that is occurring (Nelms, p138). The high levels of carbon dioxide are shown from his shortness of breath and being on mechanical ventilation, and his elevated glucose is likely a response to physiological stress caused by the sepsis (Nelms, p102). The low phosphate level corresponds to him being on mechanical ventilation, and the high bilirubin levels indicate organ dysfunction (Nelms, p140, 677 ). His low albumin and prealbumin levels show that this patient was malnourished and not getting adequate protein in his diet. High levels of albumin also indicate an inflammatory response to stress. His high PT, and PPT times show that his blood is taking longer to clot, likely due to the excess stress and sepsis in his body. High levels of lactate dehydrogenase indicate that his body is using up a any available energy and usually means that there is some type of tissue damage. High C-reactive protein shows the excessive inflammation in the patient’s body, and the high fibrinogen is also attributed to the body’s inflammation response (Nelms, p161). The high lactate levels indicate that the body is using up energy and is shown as a response to severe sepsis. When looking at the patient’s lipid profile, unhealthy lipid levels are high and HDL levels are low, which are also likely the body’s response to sepsis. The high WBC count is the body’s response to infection and is an indicator of sepsis, and the low hemoglobin and hematocrit levels, high levels of transferrin, and low levels of ferritin are indicative of blood loss or iron-deficiency anemia, also likely affected from the sepsis.Which laboratory measurements are consistent with sepsis and metabolic stress?Mr. McKinley’s white blood cell count of 23,500 mm^3, his increased heart rate of 98 bpm upon admission, respiratory rate of 30 breaths/minute, and fever of 102.4 degrees F. In addition to this, his elevated C-Reactive protein of 110 mg/dL, his elevated fibrinogen of 525 mg/dL, positive fluid balance, elevated glucose of 385 mg/dL, and hyperbilirubinemia of 1.3 mg/dL (Nelms, p675-677). Assess Mr. McKinley’s current hydration status using the first 24 hours of I/O and the nursing assessment. Mr. McKinley’s 24 hour I/O is in positive fluid balance with a net balance of +1430 mL/kg. This means that his fluid intake is greater than his fluid output; a positive fluid balance is also a sign of sepsis as the patient is retaining fluids. Since sepsis results in proinflammatory cytokine release, imbalance of coagulation factors, altered cellular metabolism, hypoperfusion, and hypotension, fluid is commonly retained within cells (Nelms 675). Looking at the nursing assessment, Mr. McKinley’s urine appears to be clear, yellow, and he also has good skin turgor, and intact mucous membranes. Determine Mr. McKinley’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements.According to Nelms (p671-672), the ASPEN guidelines for estimating energy requirements for patients with a BMI greater than 30 kg/m^2 are 25-30 kcal/kg of ideal body weight per day. Indirect calorimetry is preferred, but when unavailable, ASPEN and other international guidelines recommend this method. They also recommend that protein requirements be at approximately 1.2-1.5 g/kg of ideal body weight. Ideal Body Weight (using Hamwi Method) = 106 lbs. + 10in. (6lbs.) = 166lbs. = 75.5 kgEnergy requirement = 25-30 kcal/kg ideal body weight=25 kcal/kg * 75.5 kg = 1888 kcal=30 kcal/kg * 75.5 kg = 2265 kcalMr. McKinley’s energy requirements are between 1888-2265 kcals per day.Protein requirement = 1.2-1.5 g protein/kg ideal body weight= 1.2 g/kg * 75.5 kg = 91 g protein= 1.5 g/kg * 75.5 kg = 113 g proteinMr. Mckinley’s protein requirements are between 91-113 g protein per day.IV. Nutrition DiagnosisIdentify the pertinent nutrition problems and the corresponding nutrition diagnoses.Inadequate protein-energy intake related to NPO current diet, as evidenced by lab results, specifically total protein, albumin, and prealbumin.Increased nutrient needs related to inability to consume regular diet as evidenced by intubation and sedated state.Are you able to diagnose Mr. McKinley using the proposed ASPEN/AND criteria for malnutrition? If so, describe the information you used to make this diagnosis.According to the ASPEN guidelines, Mr. McKinley has acute disease- or injury-related malnutrition. One clinical characteristic that he falls under is the severe weight loss. This is classified as greater than 7.5% of baseline weight in 3 months. Mr. McKinley lost about 25% of his baseline weight in the span of 4 months. In addition to this, he has moderate fluid accumulation, according to his I/O record and presence of edemas, which is also one of the clinical characteristics included in the guidelines. (Nelms, p 67-68).V. Nutrition InterventionOutline the nutrition support regimen you would recommend for Mr. McKinley. This should include formula choice (and rationale) and rate initiation and advancement.The formula we chose to use is Isocal HN Plus. In this formula there is 54 grams of protein per 1 liter of formula, and it gives 1.20 kcals/mL. Therefore, if we were to give him 1800 mL of this formula per day, he would be receiving 2160 kcals, 97 g of protein, and 1800 mL of fluid. An additional 100-200 mL of fluid could be given, and this would still keep him in his adequate range. So, initially, we would start him on continuous feeding, with a goal of achieving 75 mL per hour via pump. Starting out, he would begin at a rate of 20 mL per hour, increasing 15 mL every four hours until reaching the 75 mL/hour rate. Next, we would progress him to bolus feeding gradually. The patient would start out with six feedings per day, each at 300 mL of formula, and eventually progress to 450 mL for four feedings a day to achieve the ultimate goal rate.VI. Nutrition Monitoring and EvaluationIdentify the steps you would take to monitor Mr. McKinley’s nutritional status in the intensive care unit.Monitoring Mr. McKinley’s nutritional status is important in preventing any complications from occurring. Since the tube feeding will be newly initiated, there will be more intense monitoring. Initially, or if the patient is unstable, the I/O, electrolytes, BUN, creatinine, weight, hydration status, vitals, and bowel function will be checked daily, and then eventually can be checked 1-3 times per week. Monitoring liver function and his triglycerides will also occur weekly in the beginning, and then eventually can be checked as needed.In addition to these parameters, signs of intolerance to his tube feedings should be closely monitored. If any GI distress occurs, such as nausea, diarrhea, or abdominal pain, then the adjusting formula or formula rate might be necessary. As of now, the patient will receive enteral nutrition institutionally, so some education should also be provided once patient is awake and conscious, and this knowledge should be evaluated periodically (Nelms, p100-101).What factors may affect his tolerance to enteral feeding?The rate and type of formula could potentially affect his tolerance to his enteral feedings. The tube itself also has possibilities of causing complications if improperly placed or cleaned. Any medications that the patient is taking may also affect his tolerance and could cause GI distress symptoms that could be mistaken for enteral intolerance. Since Mr. McKinley is currently sedated, he is also at risk for aspiration. To avoid this, his head will need to be elevated higher than his stomach during feedings. Since Mr. McKinley’s enteral feedings were calculated based on his “dosing weight”, which ended up being his ideal body weight instead of his actual weight, underfeeding could potentially be a complication (Nelms, p101-102).Write a note for your initial inpatient nutrition assessment with nutrition support recommendations.Assessment:Anthropometrics: Mr. McKinley is a 37 year old male who has recently undergone Roux-en-Y gastric bypass. He has lost 100 lbs and currently weighs 325 lbs and is 5’ 10”. His temperature at the time of admission was 102.5, his pulse was 98, his respiration rate was 23, and his blood pressure was 135/90. Client and family history: Type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis. Medications: lovastatin 60 mg/day (previously on lantus and metformin- currently off diabetes medication for 2 months). Family history of type 2 DM, CAD, Htn, osteoporosisBiochemical: Abnormal Laboratory valuesReference Range2/23 ValuePotassium (mEq/L)3.5-5.15.8Carbon dioxide (mEq/L)23-2931Glucose (mg/dL)70-99385Phosphate (mg/dL)2.2-4.62.1Bilirubin, total (mg/dL)<1.21.3Bilirubin, direct (mg/dL)<0.30.7Protein, total (g/dL)6-7.85.8Albumin (g/dL)3.5-5.51.9Prealbimin (mg/dL)18-3511Reference Range2/23 ValuePotassium (mEq/L)3.5-5.15.8Carbon dioxide (mEq/L)23-2931Glucose (mg/dL)70-99385Phosphate (mg/dL)2.2-4.62.1Bilirubin, total (mg/dL)<1.21.3Bilirubin, direct (mg/dL)<0.30.7Protein, total (g/dL)6-7.85.8Albumin (g/dL)3.5-5.51.9Prealbumin (mg/dL)18-3511Reference Range2/23 ValueHbA1c (%)<5.76.8PT (sec)11-1314.5INR0.9-1.11.4PTT (sec)24-3437WBC (x10^3/mm^3)3.9-10.723.5Hemoglobin ( g/dL)14-1712.5Hematocrit (%)41-5138Transferrin (mg/dL)215-365385Ferritin (mg.mL)20-30014Clinical: 37-y.o. Male transferred from ED with severe sepsis, pneumoniaDiet: Mr. McKinley’s diet is currently NPO and will progress from this diet to enteral nutrition as he is being treated for sepsis. Needs have been calculated to be 1890-2270 kcals/day, 91-113 g protein/day, and 1890-2270 mL fluid/day.Diagnosis:Inadequate protein-energy intake related to NPO current diet, as evidenced by lab results, specifically total protein, albumin, and prealbumin.Increased nutrient needs related to inability to consume regular diet as evidenced by intubation and sedated state.Intervention: Our dietary intervention includes the energy consumption of 25-30 kcal/kg IBW, which ends up being 1890-2270 kcal/day, the protein consumption of 1.2-1.5 g/kg IBW, which ends up with 91-113 g/day. Enteral nutrition prescription - Isocal HN Plus (1.2 kcal/1 mL, 54 g protein/L, 1800 mL of formula per day, providing a total of 2160 kcals, 97 g protein, and 1800 mL of fluid. Enteral nutrition rate - Initially 75 mL per hour goal for continuous feeding (start at 20 mL/hour and increase by 15 mL every 4 hours until goal achieved). Progress to bolus feedings, start at 300 mL six times a day, eventually achieving 450 mL four times a day.An additional 100-200 mL of fluid can be administered.Monitoring/Evaluation:-Initially (if unstable): I/O, electrolytes, BUN, creatinine, weight, hydration status, vital signs, bowel function, blood glucose daily, and TG, liver function tests weekly. When Stable: I/O, electrolytes, BUN, creatinine, weight, hydration status, vital signs, bowel function, blood glucose 1-3 times/week, and TG, liver function tests as needed. Monitor any intolerance via symptoms, such as vomiting, nausea, diarrhea, abdominal pain, etc. Change feeding progression if needed.ReferencesInternational Dietetics & Nutrition Terminology (IDNT): Reference Manual. Standardized Language for Nutrition Care Process. Academy of Nutrition and Dietetics, 2014. Retrieved from ncpt.Mahan, L.K., Escott-Stump, S., Raymond, J.L. Krause’s Food Nutrition & Diet Therapy, 13th ed. Philadelphia, PA: W.B. Saunders Company, 2012Nelms M. Medical Nutrition Therapy A Case Study Approach 5th ed., Cengage Learning, 2017.Nelms M. Sucher K, Lacey, K. Nutrition Therapy and Pathophysiology. 3rd ed. Cengage Learning, 2016. ................
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