1. Nutrition Therapy for Metabolic Stress and Critical Illness
Lauren Hoover & Clare Howard
KNH 411
November 8, 2016

2. Patient Chris McKinley, Male, 37 y.o.
-Summary: Patient has weighed over 250 pounds. since age 15 with steady weight gain, recently reaching a high of 424 pounds, then lost 24 pounds prior to his bariatric surgery. Four months ago, he received the Roux-en-Y gastric bypass. Total weight loss to date is approx. 100 pounds. However, now he is admitted to the MICU from the ER with probable sepsis.
-Vital Signs (Admitting)--
Temp.: BP: 135/90 Pulse: Resp. Rate: 23
Height: 5’10” Weight: 325 lbs.
Clare

3. Patient History
-Onset of disease: Experienced flu-like symptoms over previous 48 hours, became acutely SOB - brought to ER
-Medical Hx: Type 2 DM, Htn, hyperlipidemia, osteoarthritis
-Medications: Lovastatin 60 mg/day (Also has been off diabetes medications for 2 mo.)
-Tobacco Use: none
-Alcohol Use: Socially, none since surgery
-Family Hx: Father - Type 2 DM, CAD, Htn, COPD; Mother - Type 2 DM, CAD, osteoporosis
Clare

4. Roux-en-Y Gastric Bypass Surgery
-creation of a small pouch, about mL, at the top of the stomach, bypassing the remainder of the stomach, duodenum, and the first part of the jejunum
-decreased stomach size: restricted food intake and quickly induced satiety, reduced some food digestion and nutrient absorption as well
-fat-soluble vitamins, Vitamin B12, folate, iron, and calcium deficiencies
-dumping syndrome

5. Sepsis/SIRS
Etiology - Combination of pro-inflammatory cytokine release, coagulation factor imbalance, altered cell metabolism, hypoperfusion, and hypotension
Diagnosis - increased WBC count, HR, and respirations, and fever or hypothermia. Others include inflammatory variables
Pathophysiology - originating source of infection/trauma, initial inflammatory response resulting in vascular permeability, continues to an anti-inflammatory response with resulting organ dysfunction.
Increased gluconeogenesis = catabolism of muscle mass
Sepsis = uncontrolled immunosuppressive process that prevents an adequate response to an infection or trauma, and includes range of conditions such as Systemic inflammatory response syndrome (SIRS) and multiorgan failure.
Inflammatory variables = elevated C-reactive protein, fibrinogen, complement proteins, etc.

6. Patient’s Laboratory Results
Reference Range
2/23 Value
Potassium (mEq/L)
5.8
Carbon dioxide (mEq/L)
23-29 31
Glucose (mg/dL)
70-99
385
Phosphate (mg/dL)
2.1
Bilirubin, total (mg/dL)
<1.2
1.3
Bilirubin, direct (mg/dL)
<0.3
0.7
Protein, total (g/dL)
6-7.8
Albumin (g/dL)
1.9
Prealbimin (mg/dL)
18-35 11
Clare

7. Patient’s Laboratory Results cont.
Reference Range
2/23 Value
CPK (U/L)
55-170
220
Fibrinogen (mg/dL)
525
Lactate (mEq.L)
4.2
Cholesterol (mg/dL)
<200
320
HDL-C (mg/dL)
>50 32
VLDL (mg/dL)
7-32 45
LDL (mg/dL)
<130
232
LDL/HDL ratio
<3.55
7.5
Triglycerides (mg/dL)
40-160
245
Clare

8. Patient’s Laboratory Results cont.
Reference Range
2/23 Value
HbA1c (%)
<5.7
6.8
PT (sec)
11-13
14.5
INR
1.4
PTT (sec)
24-34 37
WBC (x10^3/mm^3)
23.5
Hemoglobin ( g/dL)
14-17
12.5
Hematocrit (%)
41-51 38
Transferrin (mg/dL)
385
Ferritin (mg.mL)
20-300 14
PT = prothrombin time
PTT = partial thromboplastin time
INR = international normalized ratio

9. Patient’s Laboratory Results cont.
Urinalysis results:
-Protein, glucose ketones, and Bact present,
Clare

10. Treatment for Sepsis Treat the infection first
Support patient with ventilation, antibiotics, hemodynamic, renal, and metabolic support
Insulin therapy, antimicrobial agents, coagulation-modulating drugs
Lauren

11. Physician’s Assessment/Plan
-Diagnosis of severe sepsis, pneumonia
-Maintain current mechanical ventilation, continue vancomycin, Zosyn
-Sedated with Versed and fentanyl
-Initiate enteral feeding per nutrition consult
Lauren

12. Nutrition Therapy - Assessment
Height = 5’10” = 1.78m Current Wt. = 325 lbs. = kg BMI = 46.6 kg/m^2
Usual BW = 425 lbs. %Usual BW = 76.5 %
Ideal BW (using Hamwi method) = 166 lbs. = 75.5 kg
Clare

13. Nutrition Therapy - 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.
Clare

14. Nutrition Therapy - Intervention
Calculation of Energy, Protein and Fluid needs:
Energy kcal/kg IBW Protein g/kg IBW Fluids - 1 mL/kcal
Energy kcals Protein g Fluids mL
Lauren

15. Nutrition Therapy - Intervention
Enteral Nutrition Plan:
-Formula chosen - Isocal HN Plus (1.20 kcal/mL, 54 g protein/L)
-For continuous feeding mL/24 hours = 75 mL/hr. via pump
-For bolus feeding mL/4 feedings = 450 mL/feeding
Initial start rate of 20 mL/hour, increase by 15 mL every 4 hours to achieve 75 mL/hr, change to bolus feeding 6 times/day (300 mL), then to 4 times/day (450 mL).
Lauren

16. Nutrition Therapy - Intervention
Enteral Nutrition:
1800 mL of Isocal HN Plus provides -
-1800 mL fluid
-2160 kcals
-97 g protein
*An additional mL of fluid can be given.
Lauren

17. Nutrition Therapy - 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.
Lauren

18. References
International Dietetic & Nutrition Terminology (IDNT): Reference Manual. Standardized Language for Nutrition
Care Process. Academy of Nutrition and Dietetics, Retrieved from ncpt.webauthor.com
Mahan, L.K., Escott-Stump, S., Raymond, J.L. Krause’s Food Nutrition & Diet Therapy, 13th ed. Philadelphia, PA:
W.B. Saunders Company, 2012
Nelms 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.

19. Questions?