Transcript Case Study: Failure to Thrive

Aortic Stenosis
Clinical Case Study
Ema Thake
University of Utah
June 8, 2012
Aortic Stenosis
 As the aortic valve becomes more narrow, the
pressure increases inside the left heart ventricle.
 causes the left heart ventricle to become thicker,
decreasing blood flow
 Can lead to chest pain and shortness of breath.
 Severe forms of aortic stenosis prevent enough
blood from reaching the brain and rest of the body.
This can cause light-headedness and fainting
Aortic Stenosis. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001230/
Aortic Stenosis
 Symptoms
 Breathlessness
 Chest pain
 Fainting, dizziness
 Treatment
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Stop smoking
Treatment for high cholesterol
Surgery to replace or repair the valve
Medications
 Diuretics
 Nitrates
 Beta blockers
Patient GH
 71 year old male
 Admitting diagnosis: for pre-op
consultation for Aortic stenosis with aortic
root dilation and ascending aorta
dilation, with coronary artery disease
 On admit:
 Wt: 113.2 kg; Height: 173 cm
 BMI: 37.82 (obese – grade II)
 Extensive medical history
Medical/Nutritional History
 PAST MEDICAL HISTORY:
 Aortic stenosis with bicuspid aortic
valve.
 Aortic root and ascending aorta
dilation
 Coronary artery disease, status post
CABG in 2001

Type 2 diabetes, non-insulin
dependent.
 COPD

Hypertension
 Hyperlipidemia
 Renal insufficiency
 Lung disease
 The patient complains of irregular
heartbeats or palpitation
 Peripheral vascular disease
 Obstructive sleep apnea, for which
he does not use a CPAP machine
 GERD
 Osteoarthritis in his shoulders
 Chronic low back pain, status post
fusion.
 Pancreatitis
 Non-union of his sternum with
broken sternal wires
Medical/Nutrition History
 PAST SURGICAL HISTORY:
 Coronary artery bypass grafts in 2001
 Angioplasty x 3 with stents to his circumflex
 Cholecystectomy
 Right knee surgery
 Lower back fusions in 1999
Medical/Nutrition History
 FAMILY HISTORY: Significant for coronary artery disease. Father died
from an MI at the age of 52. The patient has 3 brothers, who have had
coronary artery bypass grafts in the past. Another sister had coronary
disease, who is now deceased.

SOCIAL HISTORY: The patient reports approximately 50-pack-year
smoking history. The patient quit 1-1/2 years ago. The patient quit
using alcohol 2 years ago and denies any drug history. The patient is
married, lives with his wife in Green River, Wyoming and is retired.
Anthropometrics
Biochemical
Piper and Kaplan, 2012
Medications
 Furosemide
 Atorvastatin
 Metaprolol
 Metformin
 Omeprazole
 Warfarin
 Sitagliptin
 Potassium Chloride
Clinical
 No apparent skin breakdown
 Edema on legs caused some broken skin
 No pressure ulcers
 Swallowing Evaluations
 POD #12 - First attempt failed by patient
 POD #19 – Passed eval., advanced to dysphagia 3
diet
Nutrition Diagnosis
 Inadequate oral intake related to
intubation and sedation as evidenced
by need for nutrition support.
 Obesity as evidenced by BMI 37.82.
Nutrition Intervention
 DHT placed
5/6 – trophic feeds
5/7 – Promote @ 75 ml/hr
5/10 – Promote @ 90 ml/hr
5/15 – DHT accidentally pulled out
5/16 – Promote @ 25 ml/hr after DHT replacement
5/18 – Promote @ 90 ml/hr – resp. failure, intubated
again
 5/19 – Promote @ 40 ml/hr
 5/20 – Promote @ 75 ml/hr – IDC indicated
underfeeding
 5/25 – DHT accidentally pulled out, diet advanced to
dysphagia 3
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Nutrition Intervention
 Tube feed initiated - Promote
 Adjusted based on needs
 Estimated needs and IDC
 2025-2430 kcal/day (25-30 kcal/kg AdjBW)
 97-122 g protein/day (1.2-1.5 g/kg AdjBW)
 SLP evaluation
 Advanced diet
Monitoring & Evaluation
 IDC to monitor adequacy of the tube feeds
 Calorie counts to assess oral intake when
diet was advanced
 Notes
 Percentage of meals eaten
Reflection/Personal
Assessment
 I had the opportunity to assist in the placement
of a DHT in this patient. I found that experience to
be very valuable.
 It was good to see the patient through each
stage of recovery.
 Would have liked to gain more information about
the education he received for discharge diet.
Questions?
References
 Svagzdiene M, Sirvinskas E, Benetis R, Raliene L, Simatoniene V. Atrial fibrillation and changes in
serum and urinary electrolyte levels after coronary artery bypass grafting surgery. Medicina
(Kaunas). 2009;45(12):960-70.
 Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient.
Surg Clin North Am. 2012 Apr;92(2):189-205, vii. Epub 2012 Feb 9
 Atrial Fibrillation/Flutter. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001236/
 Aortic Stenosis. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001230/