Case Study #2LEAH FAHEYBENEDICTINE UNIVERSITYMASTERS OF NUTRITION

Upon Admission- Day 1

Female 76 yr old 1.6 m (5’6”) 57 kg (126#) BMI: 21 Diet: NPO

At the Emergency Department

Pt was going to get the newspaper and “the door shut on my leg and I couldn’t get out of it so I sat on the floor”

Clinical Impression: Subcutaneous air Leukocytosis Acute on Chronic Renal Microcytic Anemia Tachycardia

Complains of suprapubic pain Took ibuprofen but doesn’t help Positive for erythema of abdominal

wall Feels thirsty with decreased urine

output over the past 2 days

Surgery Consult

Abdomen wall cellulitis concerns for necrotizing fasciitis Procedure: Laparotomy exploratory wide debridement of necrotizing

fasciitis, small bowel resection, diverting colectomy, right subclavian central line placement

**Intubated after surgery as expected Findings: Necrotizing Fasciitis from suspected perforated diverticulum

Necrotizing Fasciitis

Defined as a rapidly progressive inflammatory infection of the fascia with secondary necrosis of the subcutaneous tissues The speed is proportional to the thickness of the subcutaneous layer

Incidence of cases of necrotizing fasciitis is between 500 and 1500 cases per year in the US

First described in 1883, by Joseph Jones, a confederate army surgeon Prognosis is very poor. The sooner the infection is found the better the outcome

Pathophysiology

It is thought to be due to multibacterial symbiosis and synergy Anaerobic bacteria are present in most infections in combination with aerobic

gram-negative organisms Most common aerobic organisms are a hemolytic streptococci and

Staphylococcus aureus Bacteroides Clostridium Peptostreptococcus Enterobacteriaceae Coliforms (eg, Escherichia coli) Proteus Pseudomonas Klebsiella

Symptoms

May begin with warm and red skin, or feel as though you’ve pulled a muscle

Flu-like symptoms Painful red bump, that grows quickly It starts to ooze from infected area or becomes discolored and decays Blisters, bumps, black dots, or skin lesions may appear Fatigue, weakness, fever, nausea, vomiting, dizziness, infrequent

urination

Treatment

Wound debridement Procedure to remove dead tissue and contaminated substances from a

wound Removing the dead tissue and fluid around gives the wound more space to

heal and less chance of becoming contaminated

Day 2 - ICU

Clinical impression: Acute hypoxic respiratory failure – expected Septic Shock Necrotizing fasciitis Acute on chronic kidney disease Protein Malnutrition

Plan: Propofol for sedation Levophed to maintain MAP

Day 3 – ICU – still intubated

Urology consult: placement on bilateral ureteral stents to protect from injury during washout and re-exploration

Consider TPN when off pressors

Day 4 - ICU

Weaned off pressors NPO

Inadequate po intake related to prolonged illness as evidenced by NPO Albumin 1.6

related to malnutrition or malabsorption syndromes, nephropathy

Day 4 – Surgery

Procedure: Second look laparotomy Abdominal washout Small bowel anastomosis: Connected the two ends of the small bowel that

were left from the previous procedure. Rectal sigmoidectomy: Removed a rectosigmoid mass from the colon Ostomy creation: The descending sigmoid colon was mobilized in the above

procedure so an ostomy was created. Appendectomy: Appeared hard and calcified, decision was made to remove

Labs

Day 1 Day 2 Day 3 Day 4Na 135 134 132 133K 3.3 3.7 3.8 2.9Cl 100 106 105 104CO2 18 22 22 23BUN 48 42 34 32Creatinine 2.2 1.4 1.1 1.0Glucose 90 81 105 122

Medications

Scheduled Amount Route How oftenClindamycin (CLEOCIN)

600 mg/50 ml Intravenous Q 8

Fat emulsion 20% 250 ml intravenous Q m & FFurosemide (LASIX)

IV 20 mg Intravenous BID

Heparin Injection 5000 units

Subcutaneous Q12

Lpratropium-Albuterol (DUO-NEB)

0.5-3 mg/mL nebulizer solution 3 mL

Nebulization Q6

Lidocaine (LIDODERM)

5% patch Intravenous Daily

Meropenem (MERREM)

500 mg in NaCl 0.9% 50 ml

intravenous Daily

Potasium Chloride

20 mEq/15 ml Oral Daily

Vancomycin (VANCOCIN)

1000 mg in NaCl 250 mL

Intravenous Q 18

Day 5

Change Zosyn to cefepime Nutrient Needs:

Penn State: 1250 kcal Mifflin x 1.2 x 1.2 = 1500 kcal 1.7-1.9 g/kg protein using 57 kg = 97-108 g protein 25 ml/kg fluid = 1500 ml Goal = wound healing

Weighed 150# in January Lost 25# in 5 months 16% in 5 months

TPN Initiated

IV Access: Right subclavian triple lumen CVC Formula: D10 4.25% aa @ 85.5 ml/hr

Provides 85 g protein, 200 g carbohydrates 1020 kcal Ordering lipids M/F – 20% 250 ml

Extra 2000 kcal/week or 143 kcal/day

Day 6

Nutritional goals are to provide as much nutrition as possible, specifically protein in order to promote wound healing.

When the ostomy is functional, goal to extubate, and start po Probably going to need ensure and prostat in order to encourage

healing

Day 7 – ICU

Still intubated, off sedation

Day 8 - Extubated

Diet: Clear Liquid Current TPN: 2000 ml D20 + 5% AA, 250 ml 20% lipids on Mondays

and Fridays – Provides 2260 kcal and 100 gm protein Per surgery, diet will advance further when bowel function returns Current weight is 161#

Weight in ICU was 176# 15# weight loss in 1 week 8% wt loss in 1 week

Day 8 Continued

Supplement with Ensure Clear TID

Day 11

Diet: Regular PO intake is 0-25% Still ordering Ensure Clear TID Pt is not eating the whole plate. She eats the fruits and jello but

doesn’t want the meat or cooked sides. She says she is Italian and doesn’t like the hospital food. Her son asked about bringing food in for her and was advised to talk to RN to make sure pt doesn’t have a diet change and recording of PO intake is accurate. Son reports that pt eats one cube of jello.

Day 11 - Surgery

Abdominal wall debridement and wound VAC placement Wound VAC (Vacuum-Assisted Closure

Speeds up healing process Removes the fluid from wound through suction Increases blood flow to wound and creates a greater cell

proliferation Reduces bacterial colonization Enhances the formation of granulation tissue

Day 13

Current weight 161# Appetite is fair; eating a little more, including cheerios and some bites

of her muffin for breakfast. Continues to drink ensure clear. Son is bringing in peanut butter and jelly sandwich with some soup. Diagnosis: Inadequate oral food/beverage intake related to alterations

in taste and prolonged illness as evidenced by pt recall of food consumption that is less than adequate (<50%)

Usual weight is 148# Most likely weighs less than documented

Day 15

No updated weight Pt states that she is drinking 6 Ensure clear a day “Today is the first time I really ate” Pt does not want to switch to Ensure Enlive PO intake is 25-50%

Day 18 - Surgery

Abdominal Wall Sharp Debridement; Placement of Xenograft Xenograft is a skin substitute that is used on burn wounds and chronic

wounds They can be natural or synthetic The advantage is that there is fewer complications from infection and

dehydration and accelerates the wound healing.

Day 19

No new weight Pt reports an increase in appetite, chart shows she eats 25-40%,

although she eats outside food because she doesn’t like the food Continues to drink 6 Ensure Clear a day

Day 20

Discharged! WOOOOOOOO