BY BRIANA VITTORINI PRECEPTOR: KRISTEN ABATECOLA

Critical Care Case StudyMister J.V.

On AdmissionHistory & Physical Patient is a 33 year old man who was brought

to the ER after he was found unresponsive. He had a cough, fever and vomiting for 1 week PTA. Temperature in the ER was 104 degrees Fahrenheit.

Past Medical History: Unremarkable Social History: He works construction. He does not smoke and only drinks on holidays minimally. Medications at home: None Family History: His mother had diabetes

On Admission History & Physical Physical Examination

He is intubated and sedated, temperature of 106°F, BP 90/45 receiving 100% O2, PEEP of 5

Abdomen soft- no edema Chest X-ray was clear with a right jugular central

line and ET tube in good position Urinalysis showed no ketones A1C- 16.2

On Admission

Impression: Respiratory failure on mechanical ventilation

secondary to change in mental status, most probably secondary to severe dehydration and hyperosmolar state

Hyperglycemia Metabolic acidosis Sepsis with fever Hypertension secondary to his volume status, most

probably caused by acute tubular necrosis (ATN) and sepsis

Renal Failure

On Admission

Initial Plan of Care: Decrease O2 and keep Sat at ~95% Resuscitated with IVF- started on levo Continue Vancomycin, Levaquin, and Zosyn Renal Consult ordered Replete potassium

This patient is a FULL CODE

Metabolic Acidosis

A brief Overview Metabolic acidosis is a clinical disturbance characterized by an increase in plasma acidity.It should be considered a sign of an

underlying disease process and identification of this underlying condition is essential to initiate appropriate therapy.

It occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body.

Acute Tubular Necrosis (ATN)

Acute tubular necrosis (ATN) is usually caused by a lack of oxygen to the kidney tissues (ischemia of the kidneys). It may also occur if the kidney cells are damaged by a poison or harmful substance.The internal structures of the kidney, particularly

the tissues of the kidney tubule, become damaged or destroyed. ATN is one of the most common structural changes that can lead to acute renal failure and is one of the most common causes of kidney failure in hospitalized patients.

Labs on Admission

1/14/13 1/15/13 1/16/13 1/17/13Sodium 141 148 146 149Potassium 2.2 4.0 4.0 3.8Chloride 107 119 121 (H) 128 (H) Bicarbonate 22 16 15 14

Glucose 1485 469 164 130BUN 71 62 46 37Creatine 4.5 5.0 5.1 3.8Phosphorus 1.9 2.7 2.6Magnesium 3.2 2.6 1.8 1.8Amylase 283Lipase 827 136 133Triglycerides

665 373

Nutrition Consult 1/15/13

Clinical Note: Recent Weight Changes? No Height: 5’5” Weight:185# BMI:30.7Estimated Nutritional Needs: based on ABW of 67Kga) Kcals 1474-1675 (22-25 Kcals/Kg) b) Protein 67-80 (in grams) (1.0-1.2 g/Kg) c) Fluid (in ml) 2300 (35 ml/Kg) This is a HIGH risk patient T+3

Nutrition Consult 1/15/13 continued

ICU pt vented- sedated with versed, levo @ 10MCG Severe hyperglycemia (adm glucose 1650) receiving ½ NS with 20K at 250ml/hr. Insulin drip- 0.2U/1ml at 20ml/hr. Acute renal insufficiency BUN-66 Cr-4.6 Phos- 0.5

Nutritional Intervention: If glucose improves within the next 24-48 hours, recommend Glucerna 1.2 @ 55cc/hr. This will provide 1584Kcals, 78g of protein and 1047cc fluid. Nutritional Monitoring/Evaluation: 1. Monitor glucose level, potassium, renal labs, and electrolytes. 2. Initiate TF within 24-48 hours if glucose improves.

Renal Consultation 1/15/13

Renal Consultation Impression:

Acute kidney injury- the patient has acute kidney injury secondary to prerenal azotemia secondary to hyperosmolar non-ketotic coma associated with diabetes and sepsis. He may also have now acute tubular necrosis, as his

creatinine is rising, though he is nonoliguric Small amount of protein in the urine, but not in the

nephrotic range and most likely time will tell if this will clear or not

Hypokalemia. This is rather critical. It is now finally normalizing

Renal Consultation 1/15/13

Renal Consultation Impression:

Hyperosmolar coma- Dr. Yacoub to check phosphorus level

Severe hypophosphatemia- In this setting can cause rhabdomyolysis

Diabetes Renal Consultation

GI Consultation 1/17/13

GI Consult: Reason- ?pancreatitis ?etiology Of note labs: Amylase- 283 Lipase- 133 Triglycerides are normal- 373 (down from 655) Impression:

Judging by his labs he has pancreatitis, but no signs of cause or confirmation by CT scan. ?binge drinking (pancreas divisum is NOT a consideration at this time)

Abdominal ultra sound showed no gallstones, kidneys show atrophia Abdominal/Pelvic CT shows grossly normal pancreas without

evidence of peripancreatic inflammation changes or fluid collection *Consider feeding early to prevent refeeding (he does not appear to

have an ileus)

Neurology Consultation 1/19/13

Neurology Consult Impression:

Nonlocalizing neurologic exam attributable to ongoing, but correcting metabolic derangements

Check EEG to evaluate for possible underlying intermittent seizure disorder

Check Thiamine, B12, and folate

Nutrition Note 1/17/13

Clinical Note: Nutritional Assessment of needs remains the same

ICU pt vented- sedated with versed @6. NPO day #3. Severe hyperglycemia (adm glucose 1650) receiving D5 ½ NS with 20K at 100ml/hr. Insulin drip d/c’d per MD order. Acute renal insufficiency BUN-43 Cr-4.9. Acute pancreatitis noted- amylase 283 Lipase 133. Urine output ~1200-1700

Nutrition Consult 1/17/13 continued

Nutritional Intervention: If patient remains NPO X5 days, recommend Promote with Fiber @65cc/hr X24 hours. This will provide 1560Kcals, 94g protein, and 1246cc fluid (if not on D5 fluids)

Nutritional Monitoring/Evaluation: 1. Monitor initiation of TF, tolerance, and pertinent labs.

Nutrition Note 1/19/13

Clinical Note: Estimated Nutritional Needs Pt remains vented with versed sedation. NPO day

#5. Per Dr. Nass- he is okay with starting tube feedings via OGT. Will start Glucerna 1.2 @10 for a day and then increase per protocol to a goal of 55cc.

Nutritional Intervention: Will start Glucerna 1.2 trickle. Increase per toleration to goal of 55cc/hr per protocolNutritional Monitoring/Evaluation: Pt will tolerate trickle and increase to goal.

JV IS EXTUBATED!!

Infectious Disease Consultation 1/21/13

Infectious Disease ConsultReason: Persistent fevers Impression:

Persistent low-grade fevers Pancytopenia Pancreatitis Acute episode of

hyperglycemia and diabetes Renal insufficiency

Neurology Follow up 1/21/13

Neurology Follow Up Note: Patient is presently extubated and awake. Spanish-speaking but even with the Spanish-speaking translator the patient foes not follow commands and he is unable to communicate. Impression:

The pt’s working diagnosis is metabolic encephalopathy; however, the pt is awake and alert. He does not have lethargy or hypersomnia. Overall, his clinical presentation is somewhat suggestive of brain stem dysfunction. He is unable to communicate or more but his extraocular movements and C-nerve examination seems to be intact.

January Lab Values 1/22/13 1/24/13 1/25/13 1/25/13

Sodium 145 141 143 143Potassium 3.5 4.0 3.8 3.8Chloride 114 110 110 110Bicarbonate 21 23 24 24Glucose 103 128 136 136BUN 24 25 31 31Creatine 2.8 2.5 2.4 2.4Phosphorus 3.9 4.2Magnesium 1.9Amylase Lipase Triglycerides

Nutritional Note 1/22/13

Clinical Note: ICU pt extubated 1/20/13- on D5W with 20KCl @75. Cr still slightly elevated- pt does not follow commands, does not respond to painful stimuli- failed swallow eval. Start TF per MD- NG tube placed. Nutritional Intervention: Will start Glucerna 1.2 @ 30cc/hr with goal of 55cc/hr. This will provide 1584Kcals, and 79g of protein. Nutritional Monitoring/Evaluation: Pt will tolerate TF at goal with minimal residuals.

GI Consultation 1/24/13

GI consult: Reason- PEG placement Impression: Unable to eatSuspected anoxic brain injury Diabetes mellitus

I had a long discussion with the patient’s listed contact person, his sister-in-law, MV. She has discussed the treatment goals with the family, and they have all decided that they wish to have the PEG placement.

JV GETS A PEG!

Nutrition Note 1/25/13

Clinical Note Nutritional Needs Assessment remains the same

ICU pt- tolerating TF at 55cc/hr (goal) with minimal residuals- failed second swallow eval- due to neurological prognosis- speech rec PEG placement. Urine output ~2.5-3.2L/day. IVF d/c’d

Nutrition Note 1/25/13 continued

Nutritional Intervention: Continue Glucerna 1.2 at goal rate of 55cc/hr providing 1584Kcals, and 79g of protein.

Nutritional Monitoring/Evaluation: Pt will tolerate TF at goal with minimal residuals. F/U with MD order for PEG placement.

January 25, 2013

LOS: Day #11 JV gets transferred to regular floor!

Nutritional Needs Reassessed a. Kcals 1675-2010 (25-30Kcal/Kg)b. Protein 67-80 (in grams) (1-1.2g/Kg) c. Fluid 2010 ml per pulmonology

February 5, 2013

JV pulls out PEG tube, RN unable to place NG

LOS: Day #21

Highlights of February

Nutritional Highlights: 1:1 for safety Weight is down from 185# on admission to 164#

New ABW used is 65Kg Tolerating Glucerna at goal with minimal residuals

with 300cc fluid flushes 5x/day per MD orderJV pulls out PEG, and passes swallow evaluation. Started on Dysphagia diet regular/thin liquids with

poor PO intake; NG tube d/c’d. Glucerna Shake was added TID Diet advanced to Diabetic 1800Kcal regular solids

and thin liquids with good PO intake. Endocrine- consult only

February Lab Values

2/4/13 2/11/13 2/22/13 2/27/13Sodium 136 142 140 141Potassium 4.5 4.1 4.2 4.4Chloride 101 108 106 106Bicarbonate 24 24 25 27Glucose 150 123 179 123BUN 44 24 28 26Creatine 2.1 1.9 1.9 2.0Phosphorus 4.4 4.3 3.4 1.8(2/26)Magnesium 2.5 2.0 1.9 4.2 (2/26)

March 25, 2013

JV gets transferred to Southeast Rehab

LOS: Day # 69…….

Highlights of March

Nutritional Highlights JV continues on a Diabetic 1800Kcal, regular solids,

thin liquid diet with good PO intake at most meals. Per SLP, pt is only to be fed when he is alert and oriented to

decrease the potential risk of aspiration Patient was transferred to Southeast Rehab A calorie count was ordered from 3/20/13-3/21/13

and good PO was documented for these days Diabetes- now well controlled

Levemir Tradjenta Ac/hs correctional scale

March Lab Values

3/4/13 3/12/13 3/22/13 3/30/13Sodium 142 141 144 142Potassium 4.0 4.5 4.6 4.7Chloride 107 106 111 105Bicarbonate 26 24 27 27Glucose 114 126 73 105BUN 26 58- 29 43Creatine 2.2 2.6 2.3 2.5Phosphorus 4.0 3.6Magnesium 1.8

Highlights of April

Nutritional Highlights JV continues with good PO intake, however his PO

intake can be variable at times The last clinical note was done on 4/14/13

Medically stable, however JV continues with a 1:1 for safety

…LOS: Day #89

April Lab Values

4/4/13 4/10/13 4/19/13Sodium 143 149 142Potassium 4.8 4.8 4.3Chloride 106 113 108-Bicarbonate 26 23 23Glucose 135 159 126BUN 39 47 37Creatine 2.4 2.9 2.3Phosphorus 4.8 (4/12)Magnesium 2.2 (4/12)

April 21st 2013

JV is finally discharged from Charlton Memorial Hospital via a Medflight Helicopter to Mexico.

LOS: Day # 95

Discharge Summary

Discharge Diagnosis1. Metabolic Encephalopathy 2. Diabetes mellitus 3. S/P acute renal failure 4. S/P pancreatitis (resolved) 5. Hypertension (controlled)6. Hx of iron deficiency anemia (on iron) 7. Hx of esophagitis noted on EGD on Jan. 25th

(on Protonix)

Pertinent Discharge Medications

Coreg HeparinIron Sulfate Humalog insulin sliding scale #1 and

Humalog 75/25 twelve units subcutaneous with breakfast and 10 units with supper.

Protonix MiralaxColace

Summary of Interdisciplinary Consults Ordered

Critical Care Endocrinology Nephrology GINeurology Infectious Disease

Psychology Podiatry Dietitian Physical Therapy Occupational

Therapy Speech Pathology

Discharge Summary

¡Gracias!

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