NUT 116BL Winter 2014

Name WaiSze Tam Section: 1 Case Study #2: Enteral and Parenteral Nutrition Due 2/14/14 60 points

Mr. R, a 35 yo drug user, is hospitalized after a motor vehicle accident (MVA). He is currently suffering from a severe concussion and lapses of consciousness, a broken jaw, multiple broken bones, and possible internal injuries. He had not eaten anything for several days PTA because he was overdosing on drugs. Enteral feeding has been recommended in order to improve his nutritional status and given his decreased level of alertness. The patient will be bedridden until his mental status improves. A nasogastric feeding tube has been inserted and the physician has asked for your recommendation regarding the type of formula and amounts of kcal/protein needed for this patient. Ht: 511 Current wt: 156 # UBW: 167 # Serum albumin: 3.0 mg/dL

1. Write 1 PES statement for this patient. (2 pts) Increased Protein Needs (calcium and vitamin D) (NI-5.1) r/t multiple broken bones AEB MVA. 2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts) Yes. Mr. R has a normal GI digestive function with severe concussion and lapses of consciousness. There are no evident shows that he has any digesting problem with his stomach and nor any aspiration problem yet. Nasogastic feeding route are used for short-term feeding without risk of pulmonary aspiration from gastroesophageal reflux, it reduce the possibility of infectious morbidity. It is the easiest way to achieve and maintain. Nasogastric feeding helps Mr. R to stimulate and maintain his normal gastrointestinal function improving his nutrition status, reduce the time to return to cognitive function, and it is the least expensive in the nutrition therapy. Unless he has obstruction of the intestines, paralytic ileus, protracted vomiting/diarrhea, or acute severe pancreatitis, it is appropriate to use nasogastric feeding route in this moment for Mr. R situation. 3. What daily intake of kcals, protein, and fluids would you recommend for this patient and why? Show calculations for estimated needs, give recommendations as kcal/d, g protein/d, ml fluid/d. (6 pts)
Total Daily Energy would be recommended for 2700 kcal/day according to Mifflin-St. Jeor method and base on patients situation including with the his activity level and injury factor. The Activity factor is1.1 because patient is bedridden and the injury factor is 1.5 due to PTA, head injury, broken jaw, multiple broken bones, and possible internal injuries. Appropriated

amount of nutrients based on his weight is needed for the patient improve his weight loss (6.59% recently) to desired weight to improve his recovery. Underfeeding will delay repletion and wound healing while overfeeding will lead to hyperglycemia, hypertriglyceridemia, and hepatic steatosis. 1

NUT 116BL Winter 2014

Name WaiSze Tam Section: 1

127.62 141.8 g protein/day would be recommended Stress factor would be 1.8-2g/kg/d because patient is suffering PTA, broken jaw, multiple broken bones, the possible internal injures that he might has high nitrogen loss and negative nitrogen balance. His serum albumin level is low that the injury need greater hypermetabolic response and released a lot of hormones so he needs greater amount of protein in this situation. 2127 mL of fluid intake would be recommended. Fluid intake should not be too high and should be given with caution to avoid Edema issue and fluid imbalance. Too much fluid will also affect the density of calories and influence the calories intake in the healing period and further delay the patients recover rate. Calculation: 1. Dosing weight:

! ! !

Weight: 156# x (1kg/2.2#) = 70.9kg Lost recently: (156#/167#) / 167# = 6.59%

(Pocket Resource p. 10)

(PR p.32)

IBW Hamwi for IBW Male: 106# for first 5 + 6 # for every inch over 5+/- 10% Mr. R: 511 5 = 106# + 11 x 6# = 172# IBW = 172# / 2.2# = 78.18 = 78.2kgs

2. Kcal goal: - 70.9 x 25-30 kcal/kg = 1772-2127 calories - Mifflin-St. Jeor: (NTP p.60) REE: 10 x 70.9kg + 6.25 x 180.6cm 5 x 35 yo = 1662.75 - Adjust for activity: Total Daily Energy Requirement: 1662.75 x 1.1(AF-bed ridden) x 1.5 (IF Head injury) = 2743.53 ~ 2700 kcal/day 3. Protein Needs: ! Suffering from severe concussion, broken jaw, multiple broken bones, and possible internal injuries Critically Ill or Excess Losses: 1.8-2 g/kg ! 70.9kg x (1.8 2.0 g/kg) = 127.62 141.8 g protein/d

" #$ %&''"()*'&"+,-./"&'0-.&'1'2*3" ! 415678),"9":;<<" ! =<1567>"?";<$@7>"9"!"!#"15" 4. Based on the needs of this patient, describe three desirable characteristics for the type of formula you would recommend. Give one example of an appropriate enteral formula meeting these characteristics. Use Appendix C2 in NTP text or websites of formula companies, such as Nestlenutrition.com/us or Abbottnutrition.com. (4 pts)
The desirable characteristics of the selected formula should be well tolerated with GI function, whole protein, high carbohydrate, and include calcium and mixture of fat sources. I would recommend using standard formula of Jevity (Abbott).

NUT 116BL Winter 2014

Name WaiSze Tam Section: 1

5. a) Based on the enteral formula you selected in question 3 above, what daily total volume of formula would meet Mr. Rs estimated kcal and protein needs? Show calculations. (3 pts) Total daily volume of Jevity 1 Cal per formula card: Kcal: 2700 (kcal/day) x (1 ml / 1.06 kcal) =2547.2mL ~ 2550 mL Protein: 2.5L x 44g/L = 112.2 g protein b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr infusion? Show calculations. (1 pt) (2550 mL/day) x (1day / 24 hr) = 106.3 ~ 110mL/hr Hourly rate for delivery of this tube feeding as a continuous 24 hr infusion would be 110 mL c) Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what else is needed and how it would be added to the current tube feeding. Show calculations. (4 pts) Initiate at 50mL/hr, increase 50 ml every four hours, as tolerated, to goal rate of 110 mL/hr 50 mL x 4 + 100 mL x 4 + 110 X 16 = 2360 mL + [30 ml x 4 =120mL (free water every six hours)] = 2480 mL We will add ~ 60 ml free water flushes every 4 hours = 360mL So that ~ 2840mL free fluids/day, it will meet Mr. Rs fluid needs. 6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts) 1. Glucose Plasma level - normal value is 65-99 mg/dL. Patient needs to maintain a balance glucose intake and make sure the function of the binding between circulating glucose and hemoglobin in the bloodstream is normal. An evaluated value might be caused by hyperglycemia, hemorrhage, pancreatitis, obesity, and malnutrition. In contrast, hepatitis, cirrhosis might happen when the value is below the normal value. For example, if pancreatitis happens, we should change the treatment immediately in order to reduce the mortality possibility or reduce the inflammation, limit the infection rate to this patient. 2. Serum Albumin level - normal value is 3.5 5.0 g/dL patient might have risk in dehydration, diarrhea, ulcerative colitis, uremia, vomiting if the valve is above the normal value. In the other hand, patient might have risk in overhydration, acute infection, ascite, Cholecystitis, CHF, cirrhosis, Crohns, cystic fibrosis, dementia, diabetes mellitus, liver disease, malabsorption syndrome, malnutrition, nephrotic syndrome, nephrosis, and protein losing nephropathies if the value is below normal. 3. Blood Urea Nitrogen BUN normal value is 8-21 mg/dL. If the test value is above the normal value, excessive fluids, excessive protein intake, GI bleed, intestinal obstruction, GI bleed, nephritis, nephropathy, pancreatitis, protein catabolism, renal insufficiency or failure, might be the cause. If the value is below the normal value, cirrhosis, hepatitis, insufficient protein intake, overhydration, liver damage or failure, malabsorption, malnutrition, and nephrotic syndrome might be the causes. 3

NUT 116BL Winter 2014

Name WaiSze Tam Section: 1

7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts) - Nitrogen balance urine value: a negative nitrogen balance would occur when nitrogen excretion greater then nitrogen intake means catabolism or inadequate nitrogen intake. It helps to monitor the protein status since the patient need more protein for metabolism for his recovery. The patient, Mr. R, is now 5 days s/p his MVA. He did not tolerate the enteral feedings well (diarrhea and pain) and now has been diagnosed with acute pancreatitis. The MD has ordered a nutrition consult for evaluation of parenteral nutrition (PN) support. For the purposes of answering questions 7-12, assume that your current estimated kcal and protein needs for Mr. R are: 2600 kcal/day and 110 g protein/day. 8. Write a PES statement. (2 pts) Altered GI function (NI-1.4) r/t intolerance of enteral nutrition feedings AEB diarrhea. 9. Which type of PN support do you recommend central or peripheral? Justify your answer. (2 pts) Central peripheral feeding should be using in this case because Mr. R has been unable to tolerance enteral for 5 days, and acute pancreatitis might cause a severe metabolic stress. 10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of Mr. Rs total kcal needs. Show calculations. (2 pts) Lipid concentration on 20% goal ! 2600 x 20% = 520 cal / 10 kcal/g = 52 g fat ! 520 calories / 1.1 kcal/mL = 472.7 ~ 473 mL of a 10% soln ! Round up to 500 mL of 10% lipid soln = 50 grams lipid x 10 kcal/g ! 50 grams lipid x 10 kcal/g = 500 kcal ! 500 kcal / 2600 kcal /dal x 100% = 19.23% 11. The MD wants the dextrose and amino acid solution to be a total volume of 2 L/day. (The volume of lipid emulsion is separate from this 2 L.) a) Determine the final amino acid concentration of this solution, which would supply 110 g protein/day. Show calculations. (2 pts) ! Protein: 110g / 2000mL x 100 = 5.5% amino acid soln

b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals from CHO and as grams of dextrose. Show calculations. (3 pts) ! ! ! ! ! Dextrose/CHO: 110g protein x 4 kcal/g = 440 kcal; 1mL/kcal = 2000 mL 2000 kcal 440 kcal = 1560 kcal CHO 1560 kcal / 3.4 kcal/g dextrose (CHO = 3.4 kcal/g) = 458.8 ~ 459 g dextrose 4

NUT 116BL Winter 2014

Name WaiSze Tam Section: 1

c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts)
!

Dextrose concentration: 459 g / 2000 mL x 100 = 22.95 ~ 23% dextrose soln

d) If the PN solution had to be made from a starting stock solution of D50W (500 g dextrose in 1 L of water), what volume of this stock D50W would be needed to provide the grams of dextrose that you calculated in question 9b above? Show calculations. (2 pts)
!

459 g dextrose x (1 L/500 g dextrose of D50W) = 918 mL D50W

e) Compare the grams of dextrose to be provided in this solution with the maximum glucose infusion rate for Mr. R of 5 mg/kg BW/min. Would you make any changes to the PN solution based on this information? If so, how would you change it? (2 pts)
! !

1 g = 1000 mg 459 g/dL dextrose x 1000mg/g x (mL/hr) / [70.9 kg x 60 (min/hr) x 100 (ml/dL)] = 1.08 ~ 1.1mg dextrose/kg BW/min which is within the maximum glucose infusion rate for Mr. R. The amount of the maximum glucose infusion rate would be: 5/1.08 x 459 g = 2125g dextrose
IV Rate (mL/hr) * Dextrose Conc (g/dL) * 1000 (mg/g) GIR = Weight (kg) * 60 (min/hr) * 100 (mL/dL)

12. List three lab values that you would monitor for this patient and the reasons why. (6 pts) i. ii. iii. C-Reactive Protein (CRP): this value will be positive when there is inflammation and infection happen. Higher CRP levels associated with increased nutritional risk during stress and illness. Pre-albumin: the normal range of serum pre-albumin is 19 to 43 mg/dL, the level may decrease when there is illness and stress and if there is risk of malnutrition. Phosphorus serum: when the value goes up (normal is 2.4-4.1mg/dL), it might have risk of bone metastasis, diabetic ketoacidosis, hypocalcemia, liver disease, and renal failure. When the value goes below the normal value, it might have risk of hypercalcemia, hyperinsulinism, and malnutrition.

13. Mr. R develops hyperglycemia while on PN support. Describe two actions you would recommend to help lower blood glucose and achieve metabolic control of the patient. (2 pts) i. ii. Reduce dextrose may be to150-250 mg/dL/day (optimization of CHO content) Start intravenous/subcutaneous insulin therapy a. Mix regular insulin with PN may be to 5-7 U/100 gr dextrose since patient no DM b. Supplemental short-acting insulin each 4-6 hours

NUT 116BL Winter 2014

Name WaiSze Tam Section: 1

14. What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a severely malnourished patient who is started on PN? (4 pts) Refeeding syndrome is metabolic alternations that may occur during nutritional repletion of starved patients - Refeeding syndrome is dangerous fluctuations in fluids and electrolytes that lead to metabolic and neuromuscular problems that may occurs in low in potassium, phosphorous, magnesium, high CO2, fatigue, muscle weakness, cardiac dysfunction, High CHO drive glucose and electrolytes shift into cells, rapid CHO infusion that stimulates insulin, and reduces Na and water excretion and lead to fluid overload complications. Monitor for refeeding syndrome can take immediate appropriate adjustment for patient to prevent the potential harmful or even fatal presentation in a severely malnourished patient who is started on PN.