Case Report - Rebecca L. Scofield MS, RD, LDN
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Transcript Case Report - Rebecca L. Scofield MS, RD, LDN
Case Report:
Nutrition Support in a
Critically Ill Patient at risk for Essential
Fatty Acid Deficiency
Rebecca Scofield, MS
ARAMARK Dietetic Internship
Underwood-Memorial Hospital
February 7, 2012
Disease State
Diverticular Disease
Primary cause of patient’s long hospital stay
Complications included inflammation, abscesses,
sepsis and infection, bleeding, and perforation
Usual treatment includes antibiotics, bowel rest
⅓- ¼ of patients require surgery
Hartmann’s procedure, splenic flexure takedown,
drainage of abscess, colostomy performed
Comorbidities
Pt became Vent-Dependent Respiratory Failure
(VDRF) following surgery
Acute Respiratory Distress Syndrome (ARDS),
resolved
Type 2 Diabetes Mellitus (T2DM)
Peanut allergy
Risk for Essential Fatty Acid Deficiency (EFAD)
EFAD
Essential Fatty Acid Deficiency
Absence of EPA, DHA, ALA (omega-3 fatty acids)
Signs/Symptoms:
Dermatitis
Fatty liver
Hair loss
Biochemical indications
Death
S/S can occur within 2 weeks
Evidence-Based Nutrition
Recommendations
Academy of Nutrition and Dietetics: Evidence Analysis
Library
Critical Illness Guidelines state:
Energy requirements most accurate when using IretonJones 1992 equation and indirect calorimetry not
available
Enteral Nutrition (EN) recommended over Parenteral
Nutrition (PN) in patients with functioning GI tract
EN associated with reduced cost, septic morbidity, and
infections
Delayed PN in pts who are not malnourished
Evidence-Based Nutrition
Recommendations
Casaer et al, 2011
Randomized, controlled, multi-center trial
N = 4,640
Intervention: Early vs. late PN in critically ill adults
Early initiation on day 3
Late initiation on day 8
Primary Outcomes: ICU length of stay
Secondary Outcomes: Infection rates, inflammation,
length of VDRF, status at discharge
Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L,
Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.
Evidence-Based Nutrition
Recommendations
Caesaer et al, continued:
Results
Late PN Initiation group:
Shorter ICU stay
Fewer infections
Reduction in patients who require > 2 days VDRF
$1600 reduction in health care costs
No difference in mortality between groups
Early initiation of PN appears less beneficial than
withholding PN until day 8
Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L,
Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.
Evidence-Based Nutrition
Recommendations
De Meijer et al, 2010
Non-comparative study (case series)
N = 10
Intervention: PN fish oil as sole lipid therapy for
infants in ICU
Primary Outcome: Onset of EFAD, defined by
triene:tetraene ratio >0.2
Secondary Outcomes: Clinical s/s of EFAD
Dermatitis
Hair loss
Growth impairment
deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients.
JPGN 2010;50: 212–218.
Evidence-Based Nutrition
Recommendations
De Meijer et al, continued:
Results
FA composition changed from composition of soybean oil
(higher omega-6) to that of fish oil (higher omega-3)
No dermatitis, hair loss, growth retardation in any patients
Bilirubin levels improved in 90% of patients with
cholestasis
Fish oil contains sufficient EFAs to prevent clinical and
biochemical s/s of EFAD and sustain growth in infants
deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients.
JPGN 2010;50: 212–218.
Evidence-Based Nutrition
Recommendations
Mateu-de Antonio et al, 2008
Retrospective cohort study
N = 42 (final n = 39)
Intervention: Soybean- vs. olive oil-based lipid
emulsions in PN
Primary Outcomes: Infection rate and leukocyte
count
Secondary Outcomes: Acute phase proteins, length
of ICU stay, mortality rate
Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and
leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.
Evidence-Based Nutrition
Recommendations
Mateu-de Antonio et al, continued:
Results
No difference in infection rate or appearance, acute phase
proteins, or major outcomes between groups
Olive oil group: increase in leukocyte count
Soybean oil group: decrease in leukocyte count
Soybean oil emulsions
Cause increase in omega-6 FA
May interfere with immune function, be precursors to
inflammatory markers, and inhibit macrophage function
Olive oil-based lipid emulsions
May serve as a safe alternative to soy-based PN infusions
Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and
leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.
Case Presentation
Patient: SF
58 Year old Caucasian female
Dx: Pneumonia, s/p GI surgery, VDRF, ARDS, sepsis,
DM
GI surgery prevents from enteral access
Peanut allergy prevents from receiving lipid emulsion
(per pharmacy protocol)
Without lipids for 14 days
NCP: Assessment
Client History
Hypothyroidism, diverticulosis, temporal arteritis,
HTN, GERD, steroid-induced hyperglycemia, T2DM
Allergies: Cipro, Augmentin, Macrobid
Ex-smoker
NCP: Assessment
Food/Nutrition-Related History
Unable to obtain from pt due to sedation/VDRF
Family friend stated pt tolerated soy-containing foods
Good intake at home
Cooked for herself
Social drinker
Medications at home
NCP: Assessment
NCP: Assessment
Nutrition-Focused Physical Findings
Overweight
Sedated
Edema
Cushingoid/puffy face
+Ostomy
NG tube
NCP: Assessment
Anthropometric Measurements
Height: 5’8”
Admission wt: 81.6 kg (180 lbs)
BMI: 27.35
IBW: 140 lbs
Pt experienced 40 lb gain during hospital
admission due to fluid overload
NCP: Assessment
Biochemical Data, Medical Tests, and Procedures
Intubation/mechanical ventilation
NG tube placement
TLC placement
Tracheostomy
Bronchoscopy
Frequent lab draws
PEG placement
NCP: Assessment
NCP: Assessment
Nutrient Needs
Estimated energy needs (1.1):
Using Ireton-Jones 1992
1836 kcal/day
Estimated protein needs (2.2):
1.3-1.5 g/kg (Using high-end IBW)
91-105 g/day
Estimated fluid needs (3.1):
25 ml/kg (Using high-end IBW)
1750 ml/day
NCP: Assessment
Nutrition Status Classification
NCP: Nutrition Diagnoses
#1. Altered GI function (NC-1.4) related to diverticulitis and
perforation as evidenced by decreased bowel sounds, little
ostomy output, and bowel resection.
#2. Inadequate parenteral nutrition infusion (NI-2.6) related
to potential allergy to lipid emulsion as evidenced by lipid
emulsion not being administered and no fatty acids
delivered to patient.
#3. Predicted food-medication interaction (NC-2.4) related to
combined ingestion of levothyroxine and enteral formula via
NG tube causing decreased bioavailability of medication as
evidenced by 24-hour continuous feeding and p.o.
levothyroxine prescribed via NG tube.
NCP: Interventions
Initiate PN (ND-2.2)
ND-2.2.1 Formula/solution:
Parenteral nutrition was started 4 days s/p surgery
Recommendation: 490 ml 50% dextrose (to start with
30% dextrose first day), 1000 ml 10% amino acids, and
200 ml 20% lipid to provide 1633 kcal, 100 gm protein,
and 1690 ml total volume.
To meet approximately 100% of kcal and protein needs
and 97% fluid needs.
Lipids not administered for 10 days due to pharmacy
protocol and risk for crossover allergic reaction to soy.
NCP: Interventions
Coordination of Nutrition Care (RC-1)
RC-1.3 Collaboration/referral to other providers:
Communication between
Nursing
Physicians
Pharmacy
Nutrition
Required to determine a course of action for testing lipids
with the patient before being introduced to PN solution.
NCP: Interventions
Initiate EN (ND-2.1)
ND-2.1.1 Formula/solution:
Goal enteral formula once patient able to begin feedings:
Glucerna 1.2 via NG tube at 55 ml/hr continuous over 24 hours.
Provided 1584 kcal and 79 grams protein meeting 98% of kcal
needs and 94% of protein needs at that point in time.
Adjusted due to Synthroid:
Glucerna 1.2 at 60 ml/hr continuous over 21 hours with one
packet liquid Prosource daily.
Provided 1572 kcals, 91 grams of protein, and 1014 ml of free
water, meeting 98% of kcal needs and 100% protein needs.
NCP: Interventions
ND-2.1.4 Feeding tube flush:
Glucerna 1.2 at 60 ml/hr over 21 hours with one packet of
liquid Prosource daily met 58% of the patient’s fluid
needs, requiring additional water.
Flush the NG tube with 125 ml water every 4 hours
Nursing to use enteral protocol to flush during medication
administration.
NCP: Monitoring and
Evaluation
Ongoing monitoring of:
Weight
AD-1.1 Body composition/growth/weight
EN/PN regimen intake
FH-1.3.2 Parenteral Nutrition Intake
FH-1.3.1 Enteral Nutrition Intake
FH-3.1 Medication and herbal supplements
Labs
BD-1.2 Electrolyte and renal profile
BD-1.6 Inflammatory Profile
Medications
Conclusion
Complicated cases may not be able to follow evidencebased guidelines at all times
Allergies pose problem to some patients who need
enteral or parenteral support
Nutritional management of SF involved EN, PN,
multidisciplinary cooperation for optimal outcome
EFAD avoided in this patient after trial dose of soybean
lipid emulsion
Conclusion
SF’s nutrition interventions involved initiation of PN,
modification of the PN prescription, and finally
introduction of EN
EN formula and rate changes made to avoid nutrientmedication interactions
Patient unable to be weaned from ventilator before
discharge, but stable
Conclusion
Patient had PEG tube placed for continued EN support
Tolerating tube feeding at goal at discharge:
Glucerna 1.2 @ 60 ml/hr x 21 hours with 1 packet liquid
Prosource Daily
Providing total of 1572 kcals, 91 grams of protein, and 1014 ml
of free water, meeting 98% of kcal needs and 100% protein
needs.
Water flushes: 125 ml q 4 hours and with medications
Trach-to-vent upon discharge
Discharged to long-term acute care facility due to extensive
medical needs
References
1. Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. W.B. Saunders;
2007. Pp. 155, 696-97, 741, 769-71, 916-17.
2. Diverticulitis. The Mayo Clinic: Health Information.
http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION=treatments-and-drugs.
Accessed 16 Jan 2012.
3. Acute Respiratory Distress Syndrome. PubMed Health website.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001164/
4. Peanut Allergy. The Mayo Clinic: Health Information.
http://www.mayoclinic.com/health/peanut-allergy/DS00710/DSECTION=risk-factors.
Accessed 16 Jan 2012.
5. De Meijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy
Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN
2010;50: 212–218.
6. Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition
Practice Guidelines. A.N.D. Evidence Analysis Library website.
http://www.adaevidencelibrary.com/topic.cfm?cat=3016. Accessed 20 Jan 2012.
7. Martindale RG, McClave SA, Vanek VW, et al. Guidelines for the provision and
assessment of nutrition support therapy in the adult critically ill patient: Society of Critical
Care Medicine and American Society for Parenteral and Enteral Nutrition: executive
summary. Crit Care Med 2009;37:1757-61.
8. Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition:
intensive care. Clin Nutr 2009; 28:387-400.
References
9. Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut
S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van
Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral
Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.
10. De Meijer VE, Gura KM, Le HD, et al. Fish oil-based lipid emulsions prevent and reverse
parenteral nutrition-associated liver disease: the Boston experience. JPEN 2009;33:541–7.
11. Cunnane SC. Problems with essential fatty acids: time for a new paradigm? Prog Lipid
Res 2003;42:544–68.
12. Waizberg DL, Torrinhas RS & Jacintho TM. New parenteral lipid emulsions for clinical
use. JPEN 2006;30:351–67.
13. Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative
effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte
count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008;99: 846–854.
14. American Dietetic Association. International Dietetics and NutritionTerminology (IDNT)
Reference Manual. 3rd ed. Chicago, Il: American Dietetic Association; 2011.
15. Ireton-Jones CS, Turner WW Jr, Leipa GU, Baxter CR. Equations for estimation of energy
expenditures in patients with burns with special reference to ventilatory status. J Burn Care
Rehabil. 1992;13:330-333.
16. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status
classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2010.
17. Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication
Interactions; 2010.
Questions?