NUT116BLHillaryLawson

Winter2013A01F12:101
CaseStudy#2
Due2/11/2013

CaseA:
1. Assessment:
Subjective:Ms.Jis24yofemalewithaPMHofpartialcolectomyduetoulcerative
colitisandc/oarecentexacerbationwithdiarrheaandbleeding.Patientrecently
hadaninsidiousweightlossandhasanimpendingsurgerytoremovean
unimprovedulcerateddescendingcolonandrectum.Potentialrisksincludeanileus
intheGI.
Objective:
LabValues:
DehydrationLink:
BUN24mg/dL=High
Anthropometrics:
Creatinine1.4mg/dL=High
Age:24
Osmolarity310=High
Sex:Female
Sodium149mEq/L=High
Ht:67
Chloride108mEq/L=High
UBW:166lbsBMI:26.05(overweight)
Inflammation/InfectionLink:
CBW:142lbsBMI:22.8(normal)
Albumin2.2mg/dL(mod.Depletion)=Low
IBW:135lbs
PreAlbumin12mg/dL=Low
%IBW(UBW):123%%IBW(ABW):105%
HsCRP10mg/dL=greaterthan8mg/dLis
WLTotal:24lbsWLin9d:10lbs
seriousinflammation/infection(mayoclinic.com)
%WLtotal:14.5%
Anemia(GIbleed):
%WLsince(2/01):6.6%(PRpg.51)
Hgb10g/dL=low
(insidious/severe)
Hct34%=low
Additional:
HCO319mEq/L=low
CO232mmHg=low
PMHandMxDx:
pH7.4=Normal
PartialColectomy(rectumpreserved)

Calculations:
UlcerativeColitis
ACCP:25x64.54(ABW)=1613.5kcals/d
Methylprednisone(corticosteroid)
MJ:BEE=10(64.54)+6.25(170.18)5(24)161=
AvoidSt.JohnsWortand
1428.025kcals
GrapefruitJuice
IF:1.21.5av.
Suppressesimmunesystem
postop:1.01.5

woundhealing:1.21.6
PlannedSurgery/Risks:
AF:
Colectomyremovingtherestofthe
Bedridden:1.2
colonandrectum
TotalforMJ=rangeof20562570kcals*Middle
Colostomy
(2313)
Ileus=Partialorcompleteblockageof DiffbtwnACCPandMJ:
thebowelPN
=sub700/2=~350
AACP+350=1963(+/50)
Range=19002000kcals/day
Protein:(postopandwoundhealing)
Lowalbumin=(milddepletion(PRpg.22))
1.5x64.54=97gPRO

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2. Alteredgastrointestinal(GI)function(NC1.4)R/Talterationingastrointestinal
tractstructure(partialcolectomyandimpendingfullcolectomy/colostomy)AEB
dehydrationlabvalues(BUN24mg/dL,Creatinine1.4mg/dL,Na149mEq/L,Cl108
mEq/L),abnormalanemiaprofile(Hgb10g/dL,Hct34%),Inflammationand
Infectionprofile(Alb2.2mg/dL,PreAlb12mg/dL,HsCRP10mg/dL),ulcerative
colitisdiagnosis,bowelresection,andabdominalpain.
3. PN(basedoffof1900kcal)toprovide97gProtein,298gDextrose,and50gof20%
lipids(250mlbottle)with65mEqPotassium,65mEqSodium,15mEqCalcium,14
mEqMagnesium,30mEqPhosphorous,withbicarbonateandacetatetobalance.
1900ml/daytorun@79ml/hrx24hrofa3in1formulaadministeredthrougha
Centralcatheterinthesuperiorvenacava.Provide1LPNover24hoursandthen
full1.9Londay2.

ThepatientcannotreceivePNviaPPNbecausetheDextroseconcentrationis
greaterthan10%,at15.68%.Allotherguidelinesfallwithinthecharacteristicsof
PPN(lessthan2000kcal,andshortterm).

Lipids:(sub1900kcals)
Protein:

25%lipids=475kcals
97ggoal

20%lipidform=237.5ml
97gx4kcals=388kcalofPRO

250mlbottleof20%lipid=500kcal
388/1900kcal=20.4%

500kcal/1900kcal=26.3%
97gPRO/1900ml=5.1%AAConcentration

50g/1900ml=~3%

LipidOxidrate:

2.5g/kgBW/day=77.448gofFat/day

Dextrose:

Lipids(500)+PRO(388)=888kcals

1900kcals888kcals=1012/3.4=297.65

Rounded=298x3.4=1013.2/1900kcals=53.3%

298g/1900ml=15.68%*greaterthanPNlimitof10%

MAXCHOOxid:7g/kgBW/day=451.78gCHO

4. ParenteralNutritionprovidedthroughacentralcathetercanresultininfectionor
possiblesepsis.Ms.Jisalreadyexperienceinfectionandinflammationinherbowl
andhasaHsCRPvaluethatindicatesseriousinflammationandinfection.Sheis
takingmethylprednisone,acorticosteroidthatsuppressestheimmunesystemand
whichcouldaidinthesepsis/infection.Metabolicdisturbancesthatcouldbe
experiencedbyMs.Jincludehyperorhypoglycemia,andpossiblyfattyliver.In
ordertopreventthemetaboliccomplicationslabvaluesincludingbloodglucose,Hs
CRP,insulin,electrolytes,AlbuminandPreAlbumin,BUN,Creatinine,andweight.
5. TheproperdietaryprogressionwhenMs.Jisreadytotransitiontoanoraldietisto
stopthePNslowly.Therateshouldbereducedbyhalfevery12hoursortoswitch

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toadextroseIV.Averygradualintroductionoforalorenteralnutritioncanbe
pursued.SinceMs.Jwillhaveacolostomybag,thepatientshouldstartwithlowfiber
foodsavoidingseeds,kernels,andtoughskins.Problemfoodsshouldbeavoided
andfoodshouldbethoroughlychewed.Inordertominimizeembarrassmentand
odorMs.Jshouldingestyogurtand/orbuttermilk.

CaseB:
1. ThestateofmetabolicstressinMr.Risastateofhypermetabolicandcatabolic
responsetoacuteinjurywithover25%ofhisbodyburned.Thelevelsofthestress
responseincludetheebb,flow,andrecoveryphases.Theebbphaseoccursinthe
first2to48hoursaftertheinjury,inMr.Rscaseitisrightafterhisburnand
admissiontothehospital.Thephaseishallmarkedbyshockandhypovolemiawith
decreasedoxygenavailabletothetissue.Thehypovolemiaresultsinadecreased
cardiacoutputandurinaryoutput.MrR.experiencedthiswhenhecamein,his
bloodpressurewas90/60,presentingashypovolemic.Thepatientalsohadan
increasedpulseabovethehigherendofnormal,100.Theincreasedheartrate
meanslesstimeforventricularfillingandareducedcardiacoutput.
Thenextphasefollowingtheebbphase,istheflowphasethatoccursacutely
andadaptivelyoverthecourseof0to5days.Theflowphaseoccurswhenthe
patientbeginstostabilizehemodynamicallyandthepatientshowsnormalsignsof
metabolicstresswithouttheshockandthehypovolemia.Mr.Rbegantoovercome
thehypovolemiaasevidencedbythereturnofurinaryoutputandbowelperistalsis
after24hours.Nutritionisintroducedintheacuteflowphasetoattemptto
counteractthenegativenitrogenbalance,hypermetabolism,andcatabolism.
Thenextphase,andthefinalphaseisknownaseithertheadaptiveflowor
recoveryphase.Thisphaseoccurs6to10daysaftertheinitialtrauma.Thisphase
markstheslowreturntoanormalmetabolism.CounterRegulatoryhormones
decrease,decreasingtherateofcatabolism.Therecoveryphasealsomeansthe
movetowardsfullnutritionalrepletion,providingadequatecalories,protein,and
micronutrientstopromoteanabolism.Mr.Risonlyjustreachingtheacuteflow
phaseandwillbeworkingtoreachtheadaptiveflowphase.
2. Mr.Rsestimatedenergyneeds:
a. Curreriformula:
(25kcal/kgx75.45(IBW))+(40x25)=2886.25(2900rounded)kcal
b. PennState2003Equation:
Pennstate=HB(BMR)withPenvitaladditions
RMR=BMR(.85)+Ve(33)+Tmax(175)6433
HB=REEformales=66.5+13.5(IBW)+5.0(H)6.8(A)
=66.5+(13.5x75.5)+(5.0x177.8)(6.8x32)=1779.8(1800)
*HBforcriticallyill=1.31.5=2313.742669.7
RMR=BMR(.85)+Ve(33)+Tmax(175)6433
=2313.74(.85)+7.5(33)+37.5(175)6433=2343.679(2350)
=2313.74(.85)+7.5(33)+37.5(175)6433=2646.245(2650)
PennState2003w/HBw/ocriticallyillfactor
1779.8(.85)+7.5(33)+37.5(175)6433=1889.83(roundedto1900)
range=23502650kcals

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c. MifflinSt.JeorEquation:
REEofmales=10(75.5(IBW))+6.25(177.8)5(32)+5
=1711.25(roundedto1700)
AF=Burnscovering2040%=1.5to2.0
1.5=2566.875(roundedto2550)
2.0=3165.8125(roundedto3150)
range=25503150kcals
d. Thesethreedifferentformulasvarywidelyintheirrangesdependingonthe
compensationsmadeorthevariousinterpretationsofapatientsneeds.The
Curreriformulaseemsstraightforward,however,itsinitialcaloriescoincide
withthehigherendoftheASPENrecommendation,butthenthereisa1000
calorieadditionduetotheburnedareas.Theaddedcaloriesfortheburn
causeittobe1000ormoreovertheASPENcalculations.ThePennState
2003formulaalsovariesinmorewaysthanone.ItusestheBMRcalculated
fromtheHarrisBenedictequation,whichisnotrecommendedfortheusein
criticallyillpatients;howeverthePennStateisregardedasusefulyeterror
producing.ThereisalsoambiguityastoifafactorshouldbeusedfortheHBE
BMRtoaccountforinjuriesliketheburnsoractivity.Thefinalformulaused
wastheMifflinSt.Jeor.Thisformulacreatedquitearangeforthecalorie
intakefrom25503150.,similartothehighvalueoftheCurreriformula.
AscomparedtotheASPENformulathatalotsarangeof17502000
caloriesforMr.R,mostofthevaluescalculatedweretoolarge.Oneimportant
knotehowever,isthatwhentheinjuryfactorsorwereignored,allofthe
valuesfellclosetothatoftheASPEN(Currerisub1900,PennStatesub1900,
MifflinSt.Jeorsub1700w/oburncoverage).Withalloftheunfacotred
valuessubtotalingclosetotherangeoftheASPENformula,Iwould
recommendtheASPENrangeof17502000kcalsbasedoffofthepatients
admitweight.Criticallyillpatientsareinaveryunstablestate,overfeeding
themcauseissueswithhyperglycemia,highnutrientoxidation,additionof
proinflammatorynutrients,andcontinuationofthehypermetabolism.
ASPEN=2225kcals/kg
22x75.45=1659.9(1650kcals)
25x75.45=1886.25(1900kcals)
range=16501900kcalsperIBW
22x79.1(CBW)=1740(roundedto1750)
25x79.1=1977(roundedto2000)
range=17502000kcalsperCBW
3. Thepatientscurrententeralformuladoesnotmeethisneeds.Osmolite1cal@
60mls/hronlyprovideshimwithsub1530caloriesper24hours.Oneimportant
notehowever,isthatMr.Risreceiving686.4kcalsfromPropofol,alipidbased
medication(2216.4totalkcal).Additionally,thepatienthassufferedsevereburns
to25%ofhisbodyandisonlyreceivingsub64gramsofproteinfromtheformula.
TheamountofproteinheiscurrentlygettingdoesntevencovertheRDAforhimif
hewereinanormalcondition(.88x79.1(CBW)=69.61g).Aftersustainingsevere
burnsto20to40percentofthebody,inthiscase25%,patientsrequireanamount

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ofproteinrangingfrom1.5to2.0gramsperkgofBWtopreventcatabolismand
reducemuscleloss.Mr.Rneedsanywherefromsub114to150gproteinperday.
IwouldswitchMr.RtoPivot1.5Cal@55ml/hr.Pivotisaveryhighprotein
formulaforuseinmetabolicallystressedpatientssuchasthosethathave
experiencedburns.Pivotiscaloricallydenseandprovideshydrolyzedproteinsto
promoteabsorption.TheformulaprovidesOmega3Fattyacidstohelpmodulate
inflammationargininetosupportimmunecellsITalsoprovidesVitaminC,Eand
betacaroteneforthereductionoffreeradicaldamageandwoundhealing.Pivot
wouldprovidethepatientwithsub124gofproteinand1980caloriesforthenew
recommendation.TherecommendationhitstheupperlimitoftheASPENestimation
ofneeds,butfallsrightinthemiddleoftheproteinrange,whichisimportantto
reducecatabolismandgetthepatientoutofanegativenitrogenbalance.Itshould
benotedthatthepatientisonpropofol,alipidbasedmedicationthatisalso
providingcalories.
4. Atday10Mr.Risingravenegativenitrogenbalanceof16.8.
Nbalance=proteinintake(g)(UUN+4)
6.25

Nbalance=63.73g(fromENOsmolite1Cal)(g)(23g/24hr+4)
6.25

Osmolite:60ml/hrx24hrs=1440mlx1.06kcal/ml=1526.4kcals
1526.4x.167=254.9088kcalsofPRO
/4kcalsperg=63.73gofPRO
5.
Assesment:
Subjective:Patientisa10daypostinjury32yomalefirefighterinitiallyadmittedfor
severeburnsover25%ofthebody(reassessedat15%).Thepatienthashadinsidious
weightlossof20lbssinceadmitdateandc/olackofappetiteandpaininthemouth;EN
withlittlePOastolerated.Patientpresentswithnosignificantedemaorsignsof
dehydration.
Objective:

Anthropometrics:
CBW:154lbs(70kg)Ht:1.778m
AdmitBW:174lbs(79.1kg)BMI:22.14
IBW:166lbs(75.45kgs)
%IBW:93%
WL:20lbsin10days
%WL:11.5%(insidious/severe)
NbalanceonCurrentFormula:
16.8=SeriousNetCatabolism
Assessment:15%TBSAB(downfrom25%)

LabValues:
Albumin:2.7g/dL=ModerateDepletion
normal=3.55.0g/dL
PreAlbumin:8mg/dL=Low
normal1536mg/dL
UUN:23g/24hr
meansNbalanceisNegative!

MxDx:
OffofPropofol
ImpendingSurgery(skingrafts)

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CurrentENOrder:
Nasoduodenal
Osmolite1Cal@60ml/hrcontinuous
(per24hr)=
sub1530calper1440ml(93%ofminrec)
sub64gPRO(55%ofminrec)
sub49gFat

PO:(Inaccurate)
Patientindicatesthathedoesnot
haveanappetiteandhehasmouth
pain
Intakeof150200kcals
1680to1730kcal=EN+TF

EstimatedNeeds:
ASPEN@IBW:(2225kcal/kgBW/day)
Range=1650to1900kcal
*patienthaslostasignificantamountof
weightandmostlikelymusclesmassfrom
catabolicstateandlackofadequate
protein.IBWisappropriateforrepletion.
ProteinNeeds:
1.21.5gPRO/d(basedoffAlbumin)
1.52.0gPRO/d(basedonburns)
Min=115(113.175)gPRO(1.5factor)
Max=150(151)gPRO(2.0factor)
*patienthasaSIGNIFICANTnegativeN
balanceandcatabolicstate.
Fluid:
1mlperkcal
1650to1900ml

Diagnosis:
PES:Inadequate*ProteinEnergyIntake(NI5.3)R/Tphysiologicalconditionincreasing
nutrientneedsduetometabolicstressandcatabolicillnessAEBNegativeNitrogenbalance
(16.8),ModerateProteinDepletionStatus(Albumin2.7g/dL),lowPreAlbuminlab
(8mg/dL),andlowENproteinintake(sub64gPRO,belowevenRDAvalue).

Stateof:Mr.Rsstateofchangeissubjectivebasedonthevoluntarynatureofthe
traumaticinjuryduetoMr.Rsoccupationasafirefighter.Heisprecontemplative,dueto
thefactthatheisrecoveringfromcriticalillnessthatisbeyondhiscontrolandheis
intakingfoodperoral(PO)yethesaysitisdifficultforhimtoeatduetomouthpain.

Intervention:
Itisimportanttomeetwiththispatientonadailybasisuntilhislablevels(Alb,Pre
Alb)havenormalizedandhisnitrogenbalancehasbecomeneutralorpositiveto
makesurehegetsoutofthehypercatabolicstate.
StartMr.RonanappropriateENformulathatprovidesadequateproteinand
caloriesforrepletion.
Changethedietorderto:Pivot1.5Cal@70ml/hrfor18hrs(toaccountfortimes
whentheTFisturnedoff).ThisformulaprovidesMr.Rwith118gofProtein,
1890calsfromTF,andadequateflushesincluded(3flushesat210mlapiecein
ordertogetMr.R1ml/kcal.
PutMr.Ronaproteinregimenthatreduceshishypermetabolicandcatabolicstate,
hisNbalanceisNegative(16.8).
ProvideMr.Rwithavitaminsupplementtoimprovehiswound/burnhealing.

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Goals:
1) MaintainMr.R.onaregimen/dietthatfulfillstheproteinneedofbetween151
150gofProteintoreducethenitrogenbalanceandimprovethepatientscatabolic
stateuntilneutralityorpositivenitrogenbalanceisreached.
2) Level/reduceMr.Rsweightfluctuationsbyprovidingadietof1650to1900kcals
viaTF,whilenotoverfeedingthepatientinordertopreventproinflammatoriesin
thediet,hyperglycemia,andreducethehypermetabolicstate.
3) GraduallyweanMr.RoffofENnutritionbyADATfromthickenedandpureedfoods
andsoonandreducingthemouthpain,andstimulatingtheappetite.Thegoal
wouldbetousePOtoADATandincreaseMr.RsweightbacktoIBWbygettinghim
outofahypercatabolicstateandgaina1lbaweek.
Monitor/Evaluate:
Meetwiththepatientdailytomonitorlabvalues(Alb,PreAlb,HSCRP)relatedto
inflammatory/infectiousstate.
MonitorthepatientsNitrogenbalance,torestoreittoapositiveonepromoting
anabolismandreinstitutionofleanmusclemass.
MonitorthepatientselectrolytestatusfromtheChem20screeningpanel,burn
patientscanhavequiteanimbalanceofelectrolytesandimportanttomakesurethe
levelsstabilize.
Monitor/Evaluatepatientsburnsandtheiroverallimprovementoverthecourse
Mr.Rsrecovery.

PrintedName:Signature:

Date/Time:

Sources:
http://www.mayoclinic.com/healthinformation/
http://www.nlm.nih.gov/medlineplus/ency/article/003356.htm