Comprehensive Case Study

Dianna Sinni December 6th, 2013 LAWRENCE MEMORIAL HOSPITAL

Carla Wiederholt, RD, LD, CNSC Barbara Hermreck, RD, LD, CNSC Patty Metzler, MS, RD, LD

Table of Contents
Introduction of Patient and Case: ........................................................................................................................................... 3 Etiology and Pathophysiology of Condition: ........................................................................................................................... 4 Medical List of Concerns: ........................................................................................................................................................ 5 Lung Cancer:............................................................................................................................................................................ 5 Acute Renal Failure: ................................................................................................................................................................ 6 Hypoxemic Encephalopathy: .................................................................................................................................................. 6 Nutrition Practice Guidelines for Critically Ill Ventilated Patients: ......................................................................................... 7 Impact of the Nutrition Intervention and Care Plan: .............................................................................................................. 8 Conclusion: ............................................................................................................................................................................ 10 References ............................................................................................................................................................................ 11 Patient Nutrition Care Process Form: Enteral Support ......................................................................................................... 12

Introduction of Patient and Case:

The patient was emergently admitted to Lawrence Memorial Hospital (LMH) on November 9th, 2013; a 49 year old male, self-employed contractor, who presented with acute cardiac arrest. He was found unresponsive by his significant other in their home, likely without oxygen or pulse for 15-25 minutes. The patients past medical history is significant only for a probably diagnosis of lung cancer in 2006, with no follow-up per the patients request. There are no other known medical conditions. The patient is a pack and a half a day smoker for over 35 years and has a history of alcohol abuse. He drinks 6 alcoholic beverages per day. The patient was brought to the Intensive Care Unit (ICU) from the emergency department status post 2 stents and an intra-aortic balloon pump placement related to a 100% occluded left anterior descending aorta. He was placed on intravenous (IV) fluids, mechanical ventilation, Propofol sedation, and multiple vasopressors. The patient was diagnosed with acute coronary artery disease, acute respiratory failure, and a ST-elevated myocardial infarction (STEMI). During his hospitalization, the patient also developed acute renal failure and hypoxemic encephalopathy. Enteral nutrition support was ordered via the oral gastric (OG) route within two days of ICU care. The patient initially began nutrition support with a 24 hour continuous feeding of Jevity 1.2, starting at 15mL/hour with twice daily 30mL water flushes. The tube feeding was gradually increased to a goal rate and formula of Jevity 1.5 at 85mL/hour with six times daily 50mL water flushes. After two days of enteral nutrition support the patient was extubated, tube feeding discontinued, and a clear liquid diet ordered. The clear liquid diet was unsuccessful as the patient was unable to swallow following extubation. He resumed nothing-by-mouth (NPO) for two days until able to successfully tolerate a soft, cardiac diet order with small portion modification.

Etiology and Pathophysiology of Condition:

The patient presented with a chief diagnosis of acute cardiac arrest, relating to subsequent diagnoses of acute coronary artery disease (CAD), acute respiratory failure, and a STEMI. These conditions affect both the circulatory and respiratory systems and resulted in the patients critical condition. According to the American Heart Association, cardiac arrest is commonly misused interchangeably with myocardial infarction; however, these two conditions are actually quite different.1 Cardiac arrest occurs when the heart abruptly stops beating due to an electrical impulse malfunction.1 A myocardial infarction, commonly known as a heart attack, involves a circulation injury of the heart, not an electrical malfunction.1,2 This patient suffered from a STEMI, a heart attack related to the total occlusion of the coronary artery.2,3 Partial or total blockage of a coronary artery is reflected in the etiology of coronary artery disease, a common risk factor for a heart attack.1, 2, 3, 4, 6 The aforementioned cardiovascular conditions, although different in pathophysiology, are oftentimes interrelated or coexisting.4 This information offers clinical insight into the patients condition and diagnoses. According to Mahan, et al, cardiovascular disease (CVD), a grouping of various cardiovascular conditions, is the leading cause of death for both men and women in the US.4 The patients diagnoses of cardiac arrest, STEMI, and acute CAD fall under the classification of cardiovascular disease.4 Most patients diagnosed with cardiovascular disease have one or more of the following risk factors: family history, elevated cholesterol levels, hypertension, diabetes, atrial fibrillation, smoke or drink heavily, are overweight or obese, or are over the age of 55 years old.2,4 Acute respiratory failure is a spontaneous poor exchange of arterial gases resulting in significantly low oxygen and/or excessive carbon dioxide levels in the blood.5 This respiratory condition is often caused by pulmonary injury or correlating respiratory diseases.3 Acute respiratory failure contributes to most ICU hospitalizations and patient need for mechanical ventilation.5 Smoke inhalation, excessive drug or alcohol use, a history of pulmonary conditions, and neuromuscular damage are all potential risk factors for respiratory failure.5 According to Modi and Krahn, respiratory failure can cause cardiac arrest and cardiac arrest can cause multi-organ failure, possibly that of the lungs.7

It is evident that both the respiratory and circulatory systems are synergistically involved in the oxygenation and transport of arterial gases in the blood. This cooperative systematic relationship can potentially cause cardiac arrest to occur. The cardiorespiratory diagnoses of the patient reveal this notion as a vital element of this case study.

Medical List of Concerns:

The patients list of confirmed medical conditions is brief. His medical history is significant only for a possible diagnosis of lung cancer in 2006, of which the patient chose not to proceed with any further investigation or treatment. However, upon admission the patients significant other reported to physicians that he had recurring shortness of breath and coughing upon physical exertion. Since the patient presented to the hospital unresponsive and had previously refused medical care (for probable lung cancer), it is unclear as to whether or not the patient had a known medical history. As a result of the patients admitting cardiac arrest and acute respiratory failure, he experienced acute kidney failure and hypoxemic encephalopathy while in hospital care. These conditions were not present upon admission. The following medical conditions affect the overall health of the patient and determine the type of medical nutrition therapy provided:

Lung Cancer:
Although it is unknown as to whether or not the patient had lung cancer, respiratory failure can oftentimes be a fatal complication of it.8,9 According to the National Institutes of Health, lung cancer is the leading cause of cancer death for both men and women.8 It is most prevalent in adults over the age of 45 years old.8 It is often associated with many years of tobacco abuse and can manifest itself through symptoms of fatigue, weakness, shortness of breath, chest pain, and a recurring cough.8 This relates back to the patients stated symptoms of shortness of breath and chronic cough as reported by his significant other. The patients longstanding history of excessive smoking and age over 45 years aligns with lung cancers pathophysiology and etiology. Treatment for lung cancer includes chemotherapy, radiation therapy, or possible lung transplantation.8 Dependent on the treatment route, a nutrition diagnosis and specific medical nutrition therapy is tailored for the lung 5

cancer patient based on assessment factors such as weight changes, lab values, physical findings, and food and nutrition related history.4, 8

Acute Renal Failure:

This condition is characterized by a severe and sudden decrease in the kidneys filtration rate and ability to produce and excrete metabolic waste as urine.4 In the ICU setting this condition can occur as a result of severe trauma, sepsis, or surgery.10 When urine output significantly decreases, a patient is likely to develop electrolyte imbalances.10, 11 Protein synthesis is also metabolically disturbed by acute kidney failure.10, 11, 12 Medical nutrition therapy for this condition involves a delicate balance of increased protein and energy needs with particular attention to a patients metabolic state.10 In a review of research by Vaara, et al, patients with malnutrition at onset of acute renal failure have a greater risk for death and development of chronic kidney diease.13 Vaara, et al, also reveals the necessity of fluid balance and careful monitoring to prevent fluid overload, which can be fatal in acute kidney failure patients.13 Nutrition support, when initiated early on, can improve mortality outcomes from acute renal failure due to protein-energy malnutrition.7, 11, 14 Hemodialysis treatment can also improve a patients risk of mortality.7, 11, 14

Hypoxemic Encephalopathy:
This is a condition characterized by inadequate oxygenation of blood to the brain, resulting in the ischemia of brain cells.11 Symptoms present in mild to severe confusion or brain damage.11 There are many potential reasons for the occurrence of this condition, two patient related causes being cardiac arrest and respiratory failure.15 These conditions have a pathophysiology that either abruptly stops heart/blood circulation (cardiac arrest) or injures proper pulmonary gas exchange (respiratory failure). 1, 5, 7 Treatment for this condition may involve mechanical ventilation and attention to underlying circulatory problems.11,15 In the context of this patient, it is evident that his hypoxemic encephalopathy was likely brought on by the amount of time without a pulse, normal respiration, and blood circulation.

Nutrition Practice Guidelines for Critically Ill Ventilated Patients:

According to the American Society of Parenteral and Enteral Nutrition (ASPEN) 2009 Guidelines, anthropometric measurements and laboratory biomarkers are not reliable indicators of the nutritional status of a critically ill patient.10 The severity of inflammation in this population taxes the entire body system, causing a hypermetabolic state, which alters both physical and biochemical markers that would normally be suitable for assessment in the non critically ill patient.10 However, the research clearly supports early initiation of nutrition support, within 24-48 hours of hospitalization, to dramatically improve a critically ill patients outcome by regulating the hypermetabolic state.10 There is no need for present bowel sounds, stool, or flatus before initiating enteral feedings in the critically ill patient, nor is it contraindicated if these signs are absent.4,10 When hemodynamic stability is achieved, enteral nutrition support is preferred over parental nutrition support due to the use of the gastrointestinal (GI) tract.4,10,14 When the GI tract is unused for prolonged periods of time it can result in a negative bacterial overgrowth and possible tissue or organ ischemia related to decreased bloodflow.4 Therefore, the enteral nutrition support route decreases the possibility of sepsis and maintains gut integrity more so than intravenous nutrition support.4,10,14 The following list is a review of pertinent ASPEN 2009 guidelines in regards to the critically ill and ventilated patient receiving enteral nutrition support: Enterally feed into the stomach/gastric; if not tolerated use the small bowel/jejunum.10 Enteral feedings should provide >50-65% of nutrition needs within the first week of hospitalization.10 Protein requirements for the critically ill patients are substantially higher; a patient may benefit from modular protein if an enteral formula does not provide adequate protein itself.10 Serum protein values (albumin, prealbumin, transferrin, c-reactive protein) are not valid indicators of protein adequacy/malnutrition.10 BMI and ideal body weight is preferred over adjusted body weight when estimating the critically ill obese patients energy needs.10 7

The head of the bed should be elevated to 30-45 degrees to prevent aspiration.10 Continuous feedings are preferred over bolus feedings.10 Investigate medications, stool cultures, and electrolyte imbalances for cause of diarrhea.10 Anti-inflammatory formulas, including borage oil or omega-3 fatty acids, may aid in acute lung injuries.10 Soluble fiber formulas may help the hemodynamically stable ICU patient with diarrhea.10

Impact of the Nutrition Intervention and Care Plan:

After assessing the patient, consulting with the medical team and reviewing the ASPEN guidelines, the following nutrition diagnosis and intervention was initially created. Figure 1 details the nutrition diagnosis and recommended intervention for the patient within the first few days of ICU care. Figure 1: Nutrition Diagnosis and Recommended Nutrition Intervention

Due to the patients critical need for mechanical ventilation, medical sedation, and multiple vasopressor therapy, enteral nutrition was initiated rather than parenteral nutrition. According to Escott-Stump, enteral nutrition is best used to meet the nutritional needs for critically ill patients with a functioning gastrointestinal tract.14 Also, since the patient was receiving Propofol, an intravenous sedation medication in a lipid solution, this was taken into account in his total caloric intake. In order to prevent refeeding syndrome from occurring, since the patient has been without adequate nutrition support for approximately two to three days, the recommended initial tube feeding titration provides minimal nutrition support for the first 24 hours.10,14,16 Refeeding syndrome, caused by a glucose (carbohydrate) overload, results in severe

electrolyte imbalances which can result in negative respiratory and cardiovascular symptoms.14,16 These life-threatening indications reveal the bodys inability to handle aggressive nutrition therapy, especially in the setting of critical illness.10,14,16 In order to prevent this syndrome from occurring, nutrition support is best tolerated by nutrition prescriptions offering a moderate carbohydrate quantity.10 Figure 2 shows the progression of the patients nutrition prescription with goal rate and formula after 24 hours of toleration of the initial recommendations detailed in Figure 1. Figure 2: Enteral Nutrition at Goal Rate/Formula

Jevity 1.5, a polymeric enteral formula, is ideal for this patient because it offered condensed calories and concentrated fluid. This benefited his diagnosis of acute kidney failure. According to Vaara, et al, a positive fluid balance puts critically ill acute kidney failure patients at a higher risk for mortality.12 Fluid overload in the critically ill with multi organ failure should be monitored carefully for necessary restriction.10, 12 Since the patients intravenous medications offered a significant amount of fluid, clinical judgment advised the use of a calorically concentrated formula. When the patient was successfully removed from mechanical ventilation and vasopressors, his nutrition support tube feeding was also discontinued per physician orders. His diet was advanced to clear liquids, however he was unable to tolerate swallowing liquids immediately following extubation. This was likely due to the patients reported esophageal soreness from intubation. Results of a large cohort study of extubated patients with acute respiratory failure concluded that post-extubation dysphagia pain is frequent in duration and may last for a median of three days within this population. 17 In regards to this cases patient, a Speech Therapist was consulted for a bedside swallow of which the

patient did fail with moderate dysphagia. After two days of speech therapy and esophageal rest with a NPO diet order, the patient was able to resume a soft diet. A cardiac diet restriction was added by the patients attending hospitalist. The restrictions of this diet order include low sodium, low fat, and low cholesterol meals, which is supported by the American Heart Association Dietary Guidelines for cardiovascular disease.18 A diet low in sodium encourages maintenance of optimal blood pressure, while low fat and cholesterol benefit a patients total cholesterol and lipoprotein values.18 Ultimately, each of these help to prevent cardiovascular incidents.18 Figure 3 details the small portion modification to the aforementioned diet order. Prior to admission and post extubation the patient experienced dyspnea, a common symptom of cardiorespiratory conditions.11,15 Frequent small meals is recommended because it allows for a shorter period of mastication and steadier respiration rates.11,14 With this specific diet modification, the patient achieved optimal dietary intake greater than or equal to 75% at all meals prior to discharge.

Conclusion:
The patient was followed for a total of two weeks with a progressive recovery. Upon admission he was intubated and sedated with no nutrition support until hemodynamically stable. Early initiation of enteral nutrition support via the oral-gastric route began at the end of day two in ICU care. The tube feeding was increased to goal rate and formula within 24-36 hours. The patient was on nutrition support for a total of approximately 48-72 hours before extubation. Following extubation, the patient was unable to successfully swallow a clear liquid diet without moderate aspiration. Upon failure of a bedside swallow examination, the Speech Therapist was able to provide techniques and precautions for the patients swallow improvement. After two days without adequate nutrition but with speech therapy, the patient successfully swallowed and tolerated a soft diet order. This diet order included a cardiac diet restriction of low fat, cholesterol and sodium. The patient was also given small portions. The patients intake was above 75% for most meals for two days prior to home discharge. 10

References
1. Heart Attack or Sudden Cardiac Arrest: How Are They Different? American Heart Association.http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Heart-Attack-orSudden-Cardiac-Arrest-How-Are-They-Different_UCM_440804_Article.jsp#. Updated May 14, 2013. Accessed November 23, 2013. 2. Mayo Foundation for Medical Education and Research. Heart Attack. Mayo Clinic. http://www.mayoclinic.com/health/heart-attack/DS00094/DSECTION=causes. Accessed November 23, 2013. 3. National Heart, Lung, and Blood Institute. Coronary Artery Disease. National Institutes of Health. http://www.nhlbi.nih.gov/health/health-topics/topics/cad/signs.html. Accessed November 23, 2013. 4. Mahan KL, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th Ed. St. Louis, MO: Elsevier Saunders; 2012. 5. National Heart, Lung, and Blood Institute. Respiratory Failure. National Institutes of Health. http://www.nhlbi.nih.gov/health//dci/Diseases/rf/rf_whatis.html. Accessed November 23, 2013. 6. Rimmerman C. Coronary Artery Disease. Cleveland Clinic Center for Continuing Education.http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/coronaryartery-disease/. Accessed November 23, 2013. 7. Modi S, Krahn AD. Contemporary Reviews in Cardiovascular Medicine: Sudden Cardiac Arrest without Overt Heart Disease. JAHA. 2011. doi: 10.1161/circulationha.110.981381. 8. Chen YB, Zieve D. Lung Cancer. National Institutes of Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004529/. Reviewed August 24, 2011. Accessed November 23, 2013. 9. Lin YC, Tsai YH, Huang CC, et al. Outcome of lung cancer patients with acute respiratory failure requiring mechanical ventilation. Respiratory Medicine. 2004; 98(1): 43-51. doi:10.1016/j.rmed.2003.07.009. 10. Mueller CM, Kovacevich DS, McClave SA, Miller SJ, Schwartz DB. The A.S.P.E.N Adult Nutrition Support Core Curriculum. 2nd Ed. Silver Springs, MD: American Society for Parenteral and Enteral Nutrition; 2012. 11. Nelms M, Sucher K, Long S. Nutrition Therapy and Pathophysiology. Belmont: Wadsworth, Cengage Learning 2007. 12. Gervasio JM, Garmon WP, Holowatyj M. Nutrition Support in Acute Kidney Injury. Nutr Clin Prac. 2011; 26(4): 374-381. doi: 10.1177/0884533611414029. 13. Vaara ST, Korhonen AM, Kaukonen UM, et al. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Critical Care. 2012; 16(5): R197-206. doi:10.1186/cc11682. 14. Escott-Stump S. Nutrition and Diagnosis-Related Care. Philadelphia, PA: Lippincott Williams & Wilkins 2012. 15. Baudouin SV, Evans TW. Nutrition Support in Critical Care. Clin Chest Med. 2003; 24: 633-644. doi: 10.1016/S0272-5231(03)00101-1. 16. Mehanna HM, Moledina J, Travis T. Refeeding Syndrome: What it is, and how to prevent and treat it. BMJ. 2008 June 28; 336(7659): 14951498. doi: 10.1136/bmj.a301.

17. Macht M, Wimbish T, Clark BJ, et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Critical Care. 2011; 15(5):R231. doi:10.1186/cc10472. 18. Eckel RH, Jackicie JM, Ard JD, et al. 2013 AHA/ACA Guidelines on Lifestyle Management to Reduce Cardiovascular Risk. JAHA. 2013. doi: 10.1161/01.cir.0000437740.48606.d1.
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Patient Nutrition Care Process Form: Enteral Support

NUTRITION ASSESSMENT
Food and Nutrition Related History: ETOH abuse 6x alcoholic drinks/day Tobacco abuse pack and a half/day, 35 year hx *Unable to obtain nutrition/food history or usual intake d/t pts severe critical condition. Anthropometric Measurements Age: 49 Gender: M Ht: 185cm Wt: 100kg IBW: Wt Hx: n/a % Wt change: n/a Biomedical Data, Medical Tests & Procedures Labs/Date Alb Glu HbA1C BUN Creat Na+ K+ Hgb Hct 11/10 n/a 12 0.5 139 13.7 2.6 130 3.5 38.3
(11/13) (11/13)

BMI: 29.22

MCV 94.1

Other WBC: 13 Ca+: 7.4 Mg:1.6 AST:185 ALT: 121 INR:1.02 PTT: 30.5

Medical Diagnosis/PMH/Relevant Conditions: Symptoms prior to admission: SOB, recurrent cough Dx: cardiac arrest, acute CAD, acute respiratory failure, STEMI PMH: probable dx of lung cancer w/ no treatment or investigation per pt preference. Pertinent Medications: No known meds upon admission. On mechanical ventilation. Diprovan 40mL/hr x 24 provides 1056 kcal/24hr IV fluids, dopamine, epinephrine, dobutamine, sliding scale insulin, K+ prn Skin status: Intact Pressure Ulcer/Non-healing wound; Comments: Estimated Nutritional Needs Based on Comparative Standards: Calories: 3000-3500 kcal Protein: 120-150g Diet Order NPO Feeding Ability Independent Limited Assistance Extensive/Total Assistance Oral Problems Chewing Problem Swallowing Problem Mouth Pain

Fluid: 3L Intake Good (> 75%) Fair (approx. 50%) Poor (<50%) Minimal (<25%)

No Nutritional Diagnosis at this time NUTRITION DIAGNOSIS

N/A

None of the Above Proceed to Nutrition Diagnosis Below

E (Etiology) oral intake inability as evidenced by:

NPO

P (problem) inadequate oral intake related to:

S (Signs & Symptoms): ventilation, NPO diet order, critical illness related to dx

INTERVENTION
Nutrition Prescription: Recommend Jevity 1.2 @ 15mL/hour x 24hour w/ 50mL with 30mL BID water flush through the oral-gastric route. (This will provide 432 kcals, 19.8g protein, and a total of 549mL free water from formula and flushes. Total fluids with IV meds 2700mL. With IV Propofol, the patient will be receiving a total of 1488kcals.) After 24 hours and with Propofol decreased, recommend nutrition support be advanced towards progression of goal nutrient needs. Recommend continuous Jevity 1.5 @ 20mL/hr, increasing 10-30mL q8 hours until goal rate of 85mL/hour. Water flush 50mL water q6 hours. (At goal rate, tube feeding will provide 3107 kcals, 128g protein, and 1550mL free water. With water flushes a total of 2025mL fluid) For both feedings, recommend pts head be placed at 30-45 degree angle to prevent aspiration. Food or Nutrient Delivery: Enteral Nutrition (ND-2) via OG tube Nutrition education: N/A Nutrition Counseling: N/A Coordination of Care (refer to): MD, Nurse (RC-1) Goal(s): 1- To initiate nutrition support slowly in order to prevent aspiration and re-feeding syndrome. 2- To provide adequate nutrition support to maintain weight.

MONITORING & EVALUATION

Indicators: I/O, medications, labs (electrolytes/glucose), weight, GI tolerance Criteria: >100mL gastric residuals, steady weight, electrolytes & CBGs within normal limits, and vasopressor/Propofol reduction or d/c.

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