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BY ANDREA SHELLEY
Trophic Feeding for Critically Ill Patient on Pressors: A Case Study
Case Presentation
Admitted related to need for dialysis accessIntubated and on mechanical ventilationMajor Problems:
End-stage renal disease (ESRD)Symptomatic bradycardiaHyperglycemia
Case Presentation
ESRDLung cancerChronic obstructive
pulmonary diseaseChronic cystitis Type 2 diabetes
mellitus
Kidney stonesGastroesophageal
reflux diseaseHypertensionHypothyroidismDepression
88 year old Caucasian femaleMedical History:
Case Presentation
Disease Description: ESRDKidneys are no longer able to clean the blood at an
acceptable rateGlomerulus filtration rate (GFR)<15Fluid and toxins build-up
phosphorus & potassiumDialysis or transplantation is needed for survival
Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th 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 admitReceived aggressive resuscitationHeart rate 30-40Placed on pressors
NorepinephrineDopamine
Case Presentation
Hyperglycemia (High blood glucose level)Glucose 332 at first assessmentTreatment:
Lantus Sliding scale insulin Dextrose, 5%
Nutrition Assessment
Anthropometric Measurements at Admit:162#4’11”BMI=32.8
oGlucose:332oBUN: 56.4oCr:5oCa: 6.5
oSodium:137oPotassium:3.8oPhosphorus: 7.8
Biochemical Data at Admit:
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=1069.25kcalsStress Factor: 1.3 x 1069.25= 1390kcals/day
OR 30kcals/kg IBW & 1.5g protein/kg IBW
30kcals x 45.45kg IBW = 1363kcals1.5g protein x 45.45kg IBW = 68g proteinFluids: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) FH-3.1.1
Glucose/endocrine profile 1.5Glucose, casual BD-1.5.2
Nutrition Monitoring and Evaluation
Monitor Continued: Electrolyte and renal profile 1.2
BUN BD-1.2.1Creatinine BD-1.2.2Potassium BD-1.2.7Phosphorus BD-1.2.11
Acid-based balance 1.1Partial 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 VentilationBy Imran Khalid, Pratik Doshi, and Bruno
DiGiovineNonrandomized controlled trialCompared 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 FailureBy: 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