Transcript Case Study: HIV/AIDS

Case Study: HIV/AIDS
By Jenny Provo
Facility
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Holy Family Hospital
Founded: 1950
Non-for-Profit Catholic hospital
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383 bed acute care hospital across 2 campuses
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Holy Family Hospital Methuen* 261 beds
Merrimack Valley Hospital in Haverhill 122 beds
Role of the Registered Dietitian
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Monitor, assess and optimize nutrition status based on
the patient’s current medical condition
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Confer with physicians and other healthcare professionals
to coordinate medical and nutritional needs
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Example: tube and intravenous feedings, dietary supplements
HIV/AIDS
(Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome)
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Viral infection caused by the HIV virus
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HIV progresses to AIDS when T-cell count is less than 200
cells/mm3.
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Transmitted through exchange of bodily fluids such as in
sexual contact, blood, contaminated needles from an
infected person.
Pathophysiology of HIV
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HIV invades the genetic code of the CD4+ cells & T-Helper lymphocyte cells, which
are responsible agents that protect against infection (1)
-Causing a progressive depletion of CD4+ cells
Four clinical stages
Acute HIV Infection- transition on HIV to the host where virus is replicating rapidly, gradual build up of
antibodies against the virus called seroconversion.
Clinical Latency- as long as 10 years in duration before evidence of illness occurs. Replication is still
occurring but at a slower rate.
Symptomatic HIV Infection – CD4+ cells fall below 500 cells/mm3. Individuals are more susceptible to
developing s/s such as chronic diarrhea, unexplained wt loss, fevers, bacterial infections.
Progression from HIV to AIDS – CD4+ cells fall below 200 cells/mm3 and immunodeficiency worsens.
Increased risk for opportunistic infections, such as pneumonia,
Diagnosis
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Diagnosed mainly through blood tests
(1) HIV antibody tests, (2) RNA tests, and (3) a combination test that detects both
antibodies and a piece of the virus called the p24 protein
The ELISA Test
(Enzyme Linked Immunosorbent Assay)
is most often used as the first blood test, then the Western Plot test is a secondary
confirmation if ELISA is positive.
Picture: Hema diagnostic systems
Treatment: Antiretroviral Therapy (ART)
No cure for HIV/AIDS
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Highly Active Antiretroviral Therapy (HAART)-”cocktail” of three or more drugs to
reduce the rate of HIV virus replication itself. Used often in the early stages of HIV
diagnosis
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Nucleoside Reverse Transcriptase Inhibitors (NRTI) –interrupt the virus from duplicating
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Protease Inhibitors (PI)- interrupt virus replication at a later step in the virus life cycle.
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Fusion Inhibitors- New class of drug that prevents the virus from replicating by
preventing the virus from fusing with the inside of the cell.
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Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)- block the infection of new
cells by HIV. Often used in combination with other drugs.
General Adverse Effects of HIV/AIDS &
A.R.T
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Weight loss (specifically lean body mass)
Diarrhea or constipation
Nausea/Vomiting
Anorexia
Taste Changes
Hyperglycemia
Hyperlipidemia
Pancreatitis
Dyslipidemia
Food-drug Interaction:
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Example
Didanosine (1. )
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Trade name:Videx,Videx EC, DDL
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Timing Considerations:
Take 30 minutes before or 2 hrs after a meal
Do not mix with acids such as oranges, tomatoes or grapefruit juice
Do not take antacids with magnesium or aluminum within 2 hours
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Common Adverse Effects with Nutrition Implications
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Pancreatitis
Nausea
NRTI’s in general can potentially lead to anemia, loss of appetite, low
vitamin B-12, low copper, low zinc, and low carnitine.
The Patient
Patient
68 year old Hispanic male
5’3
117 lbs
BMI 20.7
Chief Compliant: SOB with cough x 1 week
Admission dx: pneumonia, HIV+, Hep C+
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H&P: States he has lost 30-40# in the past 6 months; denies any
information regarding past medical history as of 7/18/15.
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Social History:
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Lives alone in an apt
IV drug user, currently heroin 8-10x per day (using drugs ~50 years)
Admits to non protected, homosexual activity
Patient
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Family History: unknown
Medical history
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Recently diagnosed with HIV, Hep C+ through Greater
Lawrence Health Center (~2 weeks prior 7/2/2015)
Medical records from GLHC state he neglected to come for
follow-up, hx of noncompliance
No previous medications use
Energy Needs
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Symptomatic HIV Needs
Calories: 1855 kcals (35 kcals/kg)
Protein: 80 g (1.5 g/kg)
Fluids: 1325 (25 mL/kg)
Multivitamin with minerals is recommended
Day 1: ICU
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Sunday 7/19
Pt was on a Regular Diet 7/19 consumed 75-100% of 3
meals.
Pt was intubated @ 10:20pm on 7/19
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Malnutrition Screening Tool by nursing was triggered due
to his 30-40# wt loss and eating poorly.
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Consult arrived: Monday morning
7/19 Admitting Labs
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Chemistry
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Hgb 9.2
HCT 27.8
Na 132
Glucose 103
Ca++ 7.1 (no albumin taken)
Mg 1.7
Day 2: ICU
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Mon 7/20
Pt intubated with NG tube in place for use
Consult for RD for nutritional assessment and
recommendation for tube feeding needed
No past weight history available
Active (nutrition related) Medications: Abx, multivitamin, solumedrol, propofol, protonix, NS@
100 mL/hr, precedex
Labs: 7/20 (Monday)
 Na 131
 Glucose 69
 Ca++ 7.4
(Corrected Ca++ 8.68)
 Mg wnl
 AST 43
 Albumin 2.4
 POC Glucose 108/130
 CD4+ = 195 (AIDS)
Day 2: ICU
Mon 7/20
Penn State Equation to find REE when intubated
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One must use their most current Total Mint Vent in liters per minute
Highest vital sign temperature in Celsius over the past 24 hrs.
Age, Height, Actual Weight
Total Vent in L/min: 8.8
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Highest Vital Sign: 98.8 F
Patient REE: 1407.
Propofol is used for sedation
Propofol mL x 24 hrs x 1.1 Kcal/mL.
Pt: 15.9 mL x 24 hrs x 1.1= 420 kcals from Propofol
Subtract: Penn State REE- Propofol kcals
1407-420= 987 kcals is needed through tube feeding
Day 2: ICU
Mon 7/20
1. Estimated Caloric Needs / cal/mL of formula
1000 kcals (REE-Propofol) / 1.0= 1,000 mL
2, mL / 24 hrs= rate of formula given
1,000 mL / 24 hrs=42 mL/hr
3. Calories=1,008 kcals
4. Protein=63 g
Liters given x 63 g protein from formula
5. Free water
831 mL x 1.008= 838 mL
Total fluid needs-tube feeding fluid
1,325 mL-838mL= 487 mL left over
487 mL / 6= 85 mL free water flushes Q4H (6x per day)
+ ProStat (15g protein, 100 kcals)
Tube Feeding Recommendations
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Promote with Fiber
- Start at 15 mL/hr x 6 hrs and increase by 15 mL
Q4H to goal rate of 42 mL/hr x 24 hrs
- Add ProStat packet daily (provides 100 kcal, 15 g
protein)
- If no IV fluids, suggest 85 mL free water flushes Q4H for
overall hydration
-TF @ Goal Rate will provide
1008 kcals (1528 kcal w/ propofol and ProStat), 63 g
protein (78g with ProStat), 838 mL fluid (1348 mL with FWF)
and meets 100% of RDI for vitamins and minerals.
Day 2: ICU
Mon 7/20
1. Tube feeding recommendations ( explained before)
2. Wt pt x2 per week to assess wt gain.
3. Discontinue MVI po; once at goal rate tube feeding will
provide 100% of vitamins and mineral needs. Restart
when pt gets extubated.
4. Monitor BG to goal of 80-150 mg/dL; noted pt on
solumedrol.
Day 2: ICU
Mon 7/20
Nutrition Assignment
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PES statement: Chronic disease related malnutrition
related to newly diagnosed HIV and Hep C as evidence
by pt report of 30-40# wt loss in 6 months (25% bw loss).
*Meets criteria for Severe malnutrition by A.S.P.E.N
standards
Clinical Characteristic: “Malnutrition in the context of
Chronic Illness”-Meets Severe Malnutrition
<75% of estimated energy requirement for > 1 month
> 10 # in 6 months & Severe Visible Muscle Mass Wasting
Day 3: ICU
Tues 7/21/15
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Check-In: Brief note
Pt tolerating at goal rate!
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Propofol increased from 15.9 mL to 22.3 mL
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Now pt is receiving 589 kcals from propofol
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Kept TF the same but recommend d/c Prostat
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Continue Promote with Fiber @ goal rate of 42 mL/hr
with 85 mL flushes Q4H.
Check residuals!
Date
Time
Tues 7/21
4:00 pm
10 mL residuals 30 mL/hr
Tues 7/21
8:20 pm
10 mL residuals 42 mL/hr
Wed 7/22
12:10 am
120 mL
residuals
0 mL
Wed 7/22
4:00 am
120 mL
residuals
0 mL
Day 4: ICU
Wed 7/22/15
Staff stopped the TF due to high residuals!
Higher residuals but still within normal limits
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Brief Nutrition Note
Recommend Reglan to help gastric emptying
Re-start at 30 mL/hr to goal of 42 mL/hr
Hold for residuals >250 mL
Day 5:ICU
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Thur 7/23
Pt extubated Wed 7/22 @ 10:45pm
Nutrition Follow Up
Recommendations:
1. Per MD, recommend advance to Regular Diet
-Monitor for s/s of dysphagia, consider SLP Eval
2. Wt pt 2x per week and record in EMR
3. Maintain BG to 80-150 mg/dL, while of solumedrol
4. Continue MVI
5. Monitor elevated K+, reassess need for renal restriction
Interventions
1. When diet advances, will arrange for Ensure Complete BID to promote wt gain.
Day 5: ICU
Thurs 7/23
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Diet advanced to Regular/ Soft Diet
Consumed 2 meals: 25-50% of lunch and dinner.
Sister came to visit
Pt threatening to leave AMA (against medical advice)
Refusing IV access in the am
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Labs:
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Hgb 10.2
Na 135
HCT 30.5
Cl 19
POC 117/134/131
Glucose 82
Ca 5.9
Day 6/7: St. Mary’s
7/24-Sat 7/25
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Fri
Pt transferred to St. Marys
Advanced to Regular Diet
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Ensure Complete BID to promote wt gain
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Consumed 75% of breakfast, 50% of lunch on Friday
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Discharge planning to short-term rehab
Saturday 7/25 4pm
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Pt left via cab home to appt with plan to follow via outpatient
services @ HFH
Medical Nutrition Therapy
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Goal of MNT for HIV/AIDS patients is to:
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Combat symptoms of the Antiretroviral Therapy
Adequate & balanced nutrient intake to maintain a healthy
immune system
Prevent malnutrition
Maintain a healthy weight
Food Safety
Current Research
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Batterham, et al found that HIV patients burned an
average of 10% for calories while at rest, compare to nonHIV patients. (4)
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In those taking antiretroviral therapy, losing as little as 35% of body weight significantly increases the risk of death;
losing 10% increases four-to-six fold. (5)
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Food is an essential part of HIV/AIDS treatment! Taking
antiretroviral drugs on a empty stomach is like ingesting razor
blades. Sometimes enough so that patients don’t take their
therapy.
Note: HIV and Hepatitis C Virus Coinfection
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About 25% of HIV infected persons in the US are also
infected with the Hepatitis C virus (6)
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The metabolism and excretion of antiretroviral
medications may be impaired, affecting the efficacy of HIV
treatment.
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Three out of four antiretroviral medications are
associated with hepatoxicity.
Patient Summary of Care
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HIV/AIDS is the root cause for admission (opportunistic
infection of pneumonia)
Diagnosis is very new. No ART was given
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Pt will need f/u appt with MD to start ART therapy
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With patients IV heroin use, nutrition and adherence
becomes even more of a battle to overcome
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References
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1. Escott-Stump, Sylvia. Nutrition and Diagnosis Related Care. Sixth Edition. Section 15: AIDS
and Immunology, Infections, Burns and Trauma. Pag 762-768.
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2. Mahan, K, Escott-Stump, S, Raymond, J. Krause’s Food and the Nutrition Care Process.
Edition 13. Elsevier. Medical Nutrition Therapy for HIV and AIDS. Chapter 13. Pg 864-883.
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3. UCSF Medical Center. AIDS Treatment. www. Ucsfhealth.org/conditions/aids/treatment. Page
1-3.
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4. Batterham, MJ. Investigating heterogeneity in studies of resting energy expenditure in
persons with HIV/AIDS: meta-analysis. Amer Jour of Clin Nutr.March 2005: 81 (3).
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5. Tang, AM et al. Weight loss survival in HIV-positive patients in the era of highly active
antiretroviral therapy. JAIDS Oct 2002; 31 (2).
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6. Centers for Disease Control. HIV and Viral Hepatitis.
http://www.cdc.gov/hepatitis/populations/pdfs/hivandhep-factsheet.pdf. March 2014.