Transcript File - Andrea Shelley

Trophic Feeding for Critically Ill
Patient on Pressors: A Case Study
BY ANDREA SHELLEY
Case Presentation
 Admitted related to need for dialysis access
 Intubated and on mechanical ventilation
 Major Problems:
 End-stage
renal disease (ESRD)
 Symptomatic bradycardia
 Hyperglycemia
Case Presentation
88 year old Caucasian female
Medical History:
 ESRD
 Kidney stones
 Lung cancer
 Gastroesophageal
reflux disease
 Chronic obstructive
pulmonary disease
 Hypertension
 Chronic cystitis
 Hypothyroidism
 Type 2 diabetes
 Depression
mellitus
Case Presentation
Disease Description: ESRD
 Kidneys are no longer able to clean the blood at an
acceptable rate
 Glomerulus filtration rate (GFR)<15
 Fluid and toxins build-up
phosphorus & potassium
 Dialysis or transplantation is needed for survival
Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13 th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: 811-813
Case Presentation
Patient’s Treatment for ESRD:
 Continues Renal Replacement Therapy (CRRT)
Type
of dialysis
Causes less stress on body
Cleans the blood and pulls off extra fluid very
slowly
Started on day two
Case Presentation
Symptomatic bradycardia (slow heart rate):
 Pulseless electrical activity 7 days post admit
 Received aggressive resuscitation
 Heart rate 30-40
 Placed on pressors
 Norepinephrine
 Dopamine
Case Presentation
 Hyperglycemia (High blood glucose level)
 Glucose 332 at first assessment
 Treatment:
Lantus
Sliding
scale insulin
Dextrose, 5%
Nutrition Assessment
Anthropometric Measurements at Admit:
 162#
 4’11”
 BMI=32.8
Biochemical Data at Admit:
oGlucose:332
oBUN: 56.4
oCr:5
oCa: 6.5
oSodium:137
oPotassium:3.8
oPhosphorus: 7.8
Nutrition Assessment
ARAMARK Nutrition Status Classification
 Eating
chewing problems = 2pts
 New/Unstable tube feeding = 4pts
 Stable weight = 0pts
 BMI >30-34.9 = 2 pts
 Albumin level of 2.4 = 3 pts
 Dx chronic renal failure = 3 pts
 Total points = 14, Level 4-Severely Compromised
Nutrition Assessment
 Increased Caloric Needs:
 CRRT
 Sepsis
 Mechanical
ventilation
 Low Braden Score (10)
Nutrition Assessment
 Nutrient Needs:
 Mifflin St-Jeor
 (10 x 73.4) + (6.25 x 149.8) - (5 x 88) -161=1069.25kcals
 Stress Factor: 1.3 x 1069.25= 1390kcals/day
OR
 30kcals/kg IBW & 1.5g protein/kg IBW
 30kcals x 45.45kg IBW = 1363kcals
 1.5g protein x 45.45kg IBW = 68g protein
 Fluids:1ml/kcal =1363ml water
Nutrition Diagnoses
PES Statement:
 NI-5.3: Inadequate protein-energy intake related
to hemodynamic instability as evidenced by
NPO x 1 day with mechanical ventilation and
need for multiple pressor medications.
Nutrition Intervention
 Enteral Nutrition 2.1
 Composition
ND-2.1.1
 Rate ND-2.1.3
 Recommend initiating continuous trophic feeds of
Nepro at 10ml/hr with a goal rate of 30ml/hr and auto
flush of 25ml water hourly via nasogastric tube while
patient continues on high doses of pressors and CRRT.
 Supplement
with 30ml ProMod daily
 At goal rate: 1396kcals (31kcals/kg IBW), 68g protein
(1.5g/kg IBW), and 1123ml water
Nutrition Monitoring and Evaluation
Monitor:
Enteral
nutrient intake 1.3.1
Formula/Solution FH-1.3.2.1
Medications 3.1
Prescription medications (Rate of Pressor) FH3.1.1
Glucose/endocrine profile 1.5
Glucose, casual BD-1.5.2
Nutrition Monitoring and Evaluation
Monitor Continued:
Electrolyte
and renal profile 1.2
BUN BD-1.2.1
Creatinine BD-1.2.2
Potassium BD-1.2.7
Phosphorus BD-1.2.11
Acid-based balance 1.1
Partial pressure of carbon dioxide in arterial blood
PaCO2 BD-1.1.4
Evidence-Based Nutrition Recommendations
Early Enteral Nutrition and Outcomes of Critically Ill
Patients Treated With Vasopressors and Mechanical
Ventilation
By Imran Khalid, Pratik Doshi, and Bruno DiGiovine
 Nonrandomized controlled trial
 Compared results received when enteral nutrition
was initiated with 48hrs of admit to those received
when enteral nutrition was initiated after 48hrs.
Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vassopressors and mechanical ventilation. American Journal of Critical Care.
2010:19. 261-268. doi:10.4037/ajcc2010197
Evidence-Based Nutrition Recommendations
Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vassopressors and mechanical ventilation.
American Journal of Critical Care. 2010:19. 261-268. doi:10.4037/ajcc2010197
Evidence-Based Nutrition Recommendations
A Randomized Trial of Trophic versus Full-Energy
Enteral Nutrition in Mechanically Ventilated
Patients with Acute Respiratory Failure
By: Rice, Morgan, Hays, Bernard, Jensen, and Wheeler
 Results showed that pts on trophic feeds for the first
6 days had similar clinical outcomes to pts receiving
full-energy feeds as quickly as possible.
 Trophic feeds lead to less gastrointestinal intolerance
Rice TW et al. A randomized trial of trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. NIH Public Access Critical
Care Med. 2011:39(5):967-974. doi:10.1097/CCM.0b013e31820a905a
Rice TW et al. A randomized trial of trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure.
NIH Public Access Critical Care Med. 2011:39(5):967-974. doi:10.1097/CCM.0b013e31820a905a
Conclusion
 Tolerated trophic feeds minimal residuals
 No gastrointestinal intolerance
 Many co-morbidities
 End-of-life decision was comfort care
Thank You!
Questions?
References
 Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition
Care Process. 13th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: p811-813
 Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of
critically ill patients treated with vassopressors and mechanical ventilation.
American Journal of Critical Care. 2010:19. 261-268.
doi:10.4037/ajcc2010197
 Rice TW et al. A randomized trial of trophic versus full-energy enteral
nutrition in mechanically ventilated patients with acute respiratory failure. NIH
Public Access Critical Care Med. 2011:39(5):967-974.
doi:10.1097/CCM.0b013e31820a905a
 Academy of Nutrition and Dietetics. Evidence Analysis Library. Executive
summary of recommendations.
http://andevidencelibrary.com/topic.cfm?cat=3929. Accessed January 1, 2013