First Assessment
A 44-year-old man was admitted to a hospital with an incarcerated ventral hernia and probable bowel compromise. He underwent a small bowel resection and hernia repair and required re-exploration 2 days later because of wound evisceration. His abdominal wound was left open. His postoperative course was complicated by acute respiratory distress syndrome and sepsis related to aspiration pneumonia. He was mechanically ventilated and sedated. On hospital day six, he underwent a third surgical procedure in which his recurrent hernia was repaired, his abdomen incision was closed, and a wound vacuum system was placed. He was (NPO) since admission with a nasogastric tube in place draining more than 1 L of green fluid.
Screening and Assessment Data
Height 5 72” (183 cm) Weight 5 364 lb (165 kg) Body mass index 5 49 kg/m2 Ideal body weight 5 178 lb (81 kg) Weight change in the 1 months before admission: no Decreased intake in the previous month: no Physical examination: bilateral severe pitting edema of ankles and upper extremities. Abdominal examination: distended with absent bowel sounds Radiologic examination: moderately dilated small bowel loops consistent with adynamic ileus Currently receiving 0.45% normal saline @ 120 mL/hr Intake/Output 5 3305/3725 mL
Laboratory Values
Sodium: 138 mmol/dL Potassium: 3 mmol/dL Chloride: 105 mmol/dL Carbon dioxide: 27 mmol/dL Blood urea nitrogen: 13 mg/dL Creatinine: 1.28 mg/dL
Glucose: 185 mg/dL’
Ionized calcium: 1.12 mm/L Magnesium: 1.6 mg/dL Phosphorus: 2.1 mg/dL Albumin: 1.9 gm/dL
1. Write pertinent nutrition diagnosis statements (problem, cause, and signs and symptoms [PES] format) in order of priority for this patient. Malnutrition in the context of acute illness as evidenced by energy intake ,50% of requirements ( 5 days) and severe fluid accumulation. Altered nutrition-related laboratory values related to the metabolic response to stress and a lack of electrolyte intake in diet and intravenous fluids as evidenced by low serum sodium, potassium, and phosphorus.
2. Should he be started on parenteral nutrition (PN)? Explain. By the information presented in the case, he should be started on PN because he is malnourished, has been NPO for 6 days, and does not appear to be ready to begin enteral feeding (secondary to ileus). It will be important to discuss enteral feeding via jejunal access with the physicians once ileus has resolved.
3. Calculate his nutritional needs. His caloric requirement should be estimated using the hypocaloric, high-protein approach because he is morbidly obese (Grade III) and renal function is normal. Ideal body weight should be used. Hypocaloric regimen for this patient is 14 kcal/kg actual body weight: 2310 kcal/day. Protein requirement may be set at 2 to 2.5 g/kg ideal body weight or 162 to 203 g/day
First Change of Status with Reassessment On hospital day 10 the patient’s body temperature spikes to 39° C, and he is found to have multiple infected abdominal abscesses. He goes to the operating room for abscess drainage. During this time his blood pressures (BP) and urine output drop considerably requiring initiation of fluid resuscitation and vasopressive agents for BP stabilization. His kidney function is noted to worsen. There is no plan for renal replacement therapy at the present. Current status is noted: Tmax 39.3º C VE 5 15.6 L/min (minute ventilation) PN continues Intravenous fluids: 0.45% normal saline solution 150 mL/hr 1 additional fluid boluses Sodium: 131 mmol/dL Potassium: 5.1 mmol/dL Chloride: 96 mmol/dL Carbon dioxide: 15 mmol/dL Blood glucose: 225 mg/dl Ionized calcium: 1.01 mm/L Magnesium: 2.8 mg/dL Phosphorus: 4.8 mg/dL Albumin: 1.2 gm/dL Arterial blood gas: 7.31/24/115/11
4. Upon monitoring, what is his metabolic state? He has become hypermetabolic, hypercatabolic and with worsening kidney function Hyperglycemia has worsened. Electrolyte excess (potassium, phosphorus, magnesium).
5. What is his acid-base status? He has a metabolic acidosis resulting from an impaired renal excretion of acid, and reabsorption and regeneration of bicarbonate.
6. Write updated PES statements: Increased nutrient needs (energy and protein) related to a systemic inflammatory response as evidenced by fever and elevated minute ventilation. Altered nutrition-related laboratory values (hyperglycemia) related to stress metabolism and glucose intake as evidenced by blood glucose of 225 mg/dL. Altered nutrition-related laboratory values related to acute kidney injury as evidenced by elevated potassium, phosphorus, and magnesium.
7. Is the patient’s blood glucose control adequate? If not, why and what should be done? His blood glucose is not adequately controlled. There is evidence that when glucose levels are controlled between 180 to 215 mg/dL, survival is better. The dextrose load in his PN should be reduced or a standardized insulin protocol should be instituted, or both. In addition, energy intake should be assessed to confirm absence of overfeeding because this could result in hyperglycemia.
8. Why is his serum albumin level falling? Decreased acute-phase proteins are a response to the inflammatory process his body has mounted to try to reestablish homeostasis.
9. Recalculate his nutritional needs. Energy assessment methodology will change due to the patient’s acute kidney injury and the need to provide normal protein requirements. Calorie requirement via Penn State Equation 2003b 5 3035 kcal/day Penn State Equation 2003b: Mifflin-St. Jeor equation 3 (0.96) 1 Ve (31) 1 Tmax (167) – 6212 Mifflin-St Jeor equation using actual weight, Ve is minute ventilation in L/min, Tmax is maximum body temperature in the past 24 hours in degrees centigrade. Protein requirement has decreased (1.2 to 1.3 g/kg ideal body weight or 97 to 105 g/day).
Second Change of Status with Reassessment
On hospital day 13, an abdominal film showed improvement in the patient’s ileus picture. The patient has not yet stooled, but his abdomen is soft and he has hypoactive bowel sounds. His acute kidney injury continues, although hemodialysis has been initiated and electrolyte levels have normalized. On rounds, the dietitian asks whether the patient is stable enough to start tube feeding through the nasojejunal tube. The surgical and critical care teams believe that the patient’s gastrointestinal status has improved sufficiently to initiate an enteral feeding.
10. What feeding formula should be used? Is an immune-enhancing tube feeding formula indicated? Commercial immune-enhancing formulas that combine several nutrients thought to enhance immune function are not indicated for routine use, and may be contraindicated in the severely critically ill, such as this patient. A polymeric nonfiber formula can be chosen. If a 1 kcal/mL formula is utilized, the infusion volume will be 3 L/day, if 1.5 kcal formula is used, the infusion volume will be approximately 2 L/day; and if a 2 kcal/mL formula is chosen, the volume will be approximately 1.5 L/day. A polymeric enteral feeding was initiated via nasojejunal access and gradually advanced to goal rate during the next 3 to 4 days. Tolerance was demonstrated via no change in abdominal distention, pain, or nausea and vomiting. As the feeding advanced, the PN was gradually weaned, then discontinued when goal enteral feeding was achieved.