Acute Respiratory Failure, Chronic

Malnutrition & Electrolyte

Imbalances

Case Study : BH

Vanika Jethwa - Keene State

Concord Hospital
- Opened 1981
- Acute care hospital
- Services Concord and surrounding 29 towns
- 295 licensed beds and 238 staffed beds
- 5 Centers of excellence

Nutrition services:

- 7 full time RDN’s

- 1 per Diem
- 1 Clinical Director

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Prior to admit...
Pt was admitted to ED at Alice Peck Day Memorial Hospital by pt’s PCP due to worsening
mouth sores and poor PO.
Due to the concern of sepsis, a full workup was administered prior to being transferred to
Concord.

BH was found to have Hypokalemia,

Hypomagnesemia, elevated INR

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BH
- 57 yr old Female, 54.4kg, BMI: 21
- Hx: psoriatic arthritis, COPD
- ETOH - several times per/day
- Marijuana (social) 1-2x/wk
- Lives alone at home, VT
- Supportive friends and family
- Smoker
- MOW 7x/wk
- ‘Allergic to cow's milk’, can tolerate cheese and ice cream.
Diagnosis
1) Acute hypoxic respiratory failure
2) Hypokalemia
3) Hypomagnesemia
4) ETOH
5) Increased INR
6) Anemia
7) Unspecified lesions of oral mucosa
8) Hypophosphatemia
9) Starvation
10) Possible - sepsis?
11) Later - cirrhosis
Home Medications
Pt was on several home medications, however pt was not taking (NT) some medications as
symptoms reduced and reported feeling better.

- Methotrexate - consuming, but not as prescribed (4 tablets BID)

- Humira - Not taking stopped in Dec as it was making her sick (NT)
- Albuterol - NT
- Allopurinol - NT
- Aripiprazole - NT
- Citalopram - NT
- Colchine - NT
- Dexamethazone - NT
- Folic Acid - NT
- Hyrocodone - consuming, but not as prescribed, taking TID
- Lidocane - NT
- Ventolin
- Wellbutrin - NT
Needs Assessment
Total Calories: 1432 kcal
Mifflin St Jeor x AF 1.3
For Men : 10 x weight (kg) + 6.25 x height (cm) – 5 x Age + 5

For Women : 10 x weight (kg) + 6.25 x height (cm) – 5 x Age – 161

Protein: 54-65g Protein
1-1.2 g/kg
Admit - 4/19
- Severe electrolyte disturbances (phos 0.5. mag was 0.5 now at 1.5)
- Hx ETOH abuse
- Receiving 1 meal/day from Meals on Wheels (MOW)
- Depression isolation affecting intake, pt reported ‘I hate to eat alone’
- No PO intake x2.5 wks d/t mouth sores (also affecting esophagus)

Recommendations:
- Advanced diet when phos repleted
- Additional B-complex supplement for mouth sores, may be nutritional in nature?
- Monitor vit D levels

Concerns:
- GI consulted following abnormal liver function tests, positive for cirrosis and possible GI
bleed.
- Pt endorses 2-3 drinks/night
- Possible lower lobe pneumonia.
Acute Respiratory Failure
Acute Hypoxemic: Insufficient levels of oxygen in the blood, but levels of carbon dioxide
are close to normal.
- Possibly caused by sepsis, however alcohol and tobacco use are also risk factors.

Sepsis
A potentially life-threatening complication of an infection that occurs when chemicals
released into the bloodstream to fight the infection, triggering inflammatory
responses throughout the body.
Cirrhosis
Late stage scarring of the
liver, caused by liver disease
and conditions such as
chronic alcoholism.

Cirrhosis occurs in response

to damage to the liver. Each
time the liver is injured, it tries
to repair itself. In the process,
scar tissue forms. As
cirrhosis progresses, more
and more scar tissue forms,
making it difficult for the liver
to function.

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Methotrexate Toxicity (MTX)
- MTX acts to suppress the body's overactive immune and/or inflammatory systems.

- Pt’s using methotrexate are strongly discouraged from drinking alcoholic beverages
due to the increased risk of liver damage with this combination.

- MTX was first developed as a folate antagonist for cancer treatments. Many side effects
of MTX can be avoided or resolved by taking a folic acid supplement.

- ETOH abuse damages the liver, the major storage organ for folate.
 Chronic Malnutrition
- Meets criteria for chronic
severe protein calorie
malnutrition given wt loss
(8% since Dec 2017)

- Muscle and fat wasting

- Minimal PO for weeks to

months
Inpatient Medications
- Advir diskus
- Calcium gluconate
- DuoNeb
- Folic Acid
- Heparin
- Hyrocodone
- Lidocane
- Potassium Phosphate
- NaCl IVF
- MVI
- Thiamine
- Wellbutrin
PES

Malnutrition related to alteration in GI structure/function, depression,

mouth sores, and ETOH abuse as evidenced by, Unintended wt loss
(>5% in 1 month), loss of muscle mass/subcutaneous fat, and
vitamin/mineral deficiency (oral lesions).
4/20
- Receiving K Phos tabs
- Vit D level, pending
- Diet advanced to Na - 2g
- Pt requested diet ed prior to D/C
- Milk intolerance
- Rec add Vit B complex
- Lytes normalizing

4/23
- Monitor for refeeding, replete lytes
- Consider nutrition support? Chronic maln + poor PO.
- Remains admitted for resp failure
- GI following; deferring EGD and colonoscopy d/t respiratory status
- LABS: Na 133, K 3.0 Mg 1.3
4/24
- Consider Cortrak placement when EGD is done
- Pt remains admitted for management of acute respiratory failure
- Intake remains poor d/t oral lesions

Recommendations:
- Pt would benefit from tube feeds through bleeding risk will have to assessed by GI w/EGD given
cirrosis and Hx of GI bleeding.

Concerns:
- ? if corpak can be placed when pt goes for EGD
- K and mg repletion ongoing
- Remains on thiamin, folic acid, MVI per CIWA
Cortrak
Feeding tube placement that eliminates need for a KUB
4/25 TPN Day 1 - Admitted to ICU
- Start TPN via PICC Clinimix E 5/15 @ 40 mL/hr w/ lipids 2x/wk (provides 825kcal, 48g pro)
- MVI, Minerals and Trace E added
- Adv to goal tomorrow (80 mL/hr)
- Continue to replete lytes PRN.

4/26 & 4/27 TPN Day 2/3

- Increase to goal rate 80 mL/hr (provides 1506 kcal, 96g pro
- Add 5 units Insulin to each 1L bag (10 units total)
- Continues on 100mg thiamin and 1mg folic acid
- TPN labs 4/30
Needs Re-Assessed
Total Calories: 1300 kcal
Penn St:
(0.85x value from Harris-Benedict equation (using actual body wt)) + (175 xTmax) + (33 x V ^E) – 6,433
Tmax = Tidal Volume (L)
V^E = Minute Volume (L/min)

Harris - Benedict:
Men: 66.4730 (13.7516 weight) (5.0033 height) – (6.7550 age)
Women: 655.0955 (9.5634 weight) (1.8496 height) – (4.6756 age)

Protein: 67-84g Protein

1.2-1.5 g/kg
Refeeding Syndrome
● Refeeding syndrome can occur in patients who have adapted to starvation,
and then receive increased calories. (Usually PN/EN)

● The increased calories results in a sudden increase in insulin production,

causing a decrease in serum potassium, magnesium, and phosphorus as
these ions are drawn from the blood, into the cells

● Refeeding syndrome is also associated with increased respiratory rates, as

well as fluid and sodium retention.

● To combat this feedings are often started at a low rate and labs are provided
every day for the first 3 days of feedings.
What is a PICC?
PICC - Peripherally inserted central catheter

- A thin, soft, flexible tube — an intravenous (IV) line.

Potential Treatments, such as IV medications or TPN

solution can be given through a PICC.
- The line goes to a large vein by the heart for
concentrated solutions to be quickly diluted.

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4/28 TPN Day 4
- Change to ClinE 5/20 @ 65mL/hr, continue lipids 2x/wk
- Bolus 2g Mg sulfate
- Adding 150 mg Thiamin to each 1L bag

4/29 TPN Day 5

- Switch to custom lipid free TPN to further conserve fluid
- 42mL/hr via PICC (567mL AA 15%, 307ml Dex 70%, providing 1020 kcals, PRO 85g)
- Decrease insulin to 5U/bag
- Add folate to TPN d/c PO
- Pt started on propofol
- Trickle feeds started via OGT
4/30
- Continue custom TPN (day 6)
- provides 1260cal and 82.5g pro/day

5/1
- TF increased to 20mL/hr today
- Enteral is started as soon as possible to preserve the GI tract..
- EN can aslo preserve hepatic function and respiratory function.

5/2
- TPN dc’d today
- Thiamine, folate, MVI changed to EN
- TF adv to goal rate 45mL/hr

5/3
- High serum K and Na
- TF changed to nepro (high cal formula)
5/4
- Improvement in stooling 5/16
- CAPS still high and lytes becoming - Diet adv to house (successful extubation
closer to normal levels on 5/14)
- Pt on goal tube feeding - Providing Beneprotein shake
supplements

5/9
- Increase Nepro to 40ml/hr 5/17
- Lytes finally WNL! - Pt with hallucinations and AMS
- Status changed to CMO
5/11
- Family meeting today - ongoing plan
of care 5/18
- TF changed to osmolite 1.0 @ - Pt discharged to hospice house on
40mL/hr comfort measures
- KUB shows possible ileus
- K and Mag dropped this morning
Hepatic Encephalopathy (HE)
● Hepatic encephalopathy is a syndrome observed in patients with cirrhosis and is
defined as a spectrum of neuropsychiatric abnormalities.

● Episodes can be triggered by infections, GI bleeding, constipation, electrolyte problems,

or certain medications.

● Protein restriction can aggravate malnutrition leading to an increased muscle

breakdown, and release of amino acids with a consequent increase of ammonia levels,
worsening the prognosis of HE

● However studies have show thant protien restriction does not effect the outcome of HE
especially since protein is important for patients with PCM (Protein calorie malnutrition)
 2.5-4.5 mg/dL
Lab Values - Phosphorus
 1.7-2.2 mg/dL
Lab Values - Magnesium
Lab Values - Potassium 3.5-5.0mEq/L
Lab Values - Sodium 135-145 mEq/L
Impact of Patient care
- Pt had aggressive support throughout stay
- Due to difficulty weaning off the vent and poor mental acuity, pt ultimately left
CMO, and was dc’d to hospice house.

- Cause and effect?

- Nutrition support was constantly changing: ? Could TPN have been started sooner?

- Electrolyte repletion was oral, not via IV.

- Decision to advance to low Na diet (was this necessary given poor PO)

- Type of TPN used (low fat, high protein)

Learning Points:

- Ensuring the pt understands appropriate use of all medication prior

discharge.
- Significance of delivering and receiving ‘the full picture.’
- Importance of the multidisciplinary team.
- Anything can happen, look beyond face value.

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Questions?
References:
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Nutrition Care Manual - Concord Hospital
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