Nutrition Therapy: Transverse Myelitis & Ventilator Dependant Respiratory Failure

Jannick DavisMorrison/Chartwells Dietetic

InternshipFresno, CA

Preceptor: Sheryl DeSantosDecember 3, 2014

Acknowledgements» A special thank you to all my preceptors: Rosel

Salinas, Heather Paulissen, Sheryl De Santos, Karen McNeely, Leslie Luna, MaryBeth BelCastro. I have learned so much from each of you. And to Karissa Bouchie CNM, RD and Karen Smith thank you for making my clinical rotation possible!

Overview1. Introduction2. Background: Nutrition Related Factors-pathophysiology3. Patients History/Data

-Pertinent Patient Events-Nutritional/Social/Growth/Surgical

- Initial Encounter with A.P. -Follow UP encounters

4. Discussion-Role as RD-Effectiveness of treatment

5. Conclusion-Patients current status-Questions??

Introduction» Is a 57 yr old White Male

˃ Admitted to ICU for worsening ascending paralysis & difficulty breathing

» Active Problems˃ Transverse Myelitis * Leukocytosis˃ Impaired glucose intolerance *Hyponatremia˃ Cerebral Palsy (PMH) *MRSA ˃ Hypertension (PMH) *UTI˃ Ventilator dependancy Respiratory * Bradycardia Failure * Cecal Ileus

Pathophysiology-Transverse Myelitis: Nutrition Related Factors

˃ Causes injury to the spinal cord–Has various degrees of severity &

dysfunction to Autonomic Nervous System.1

»Controls Involuntary activity: (Heart, Breathing, Digestive System, Reflexes)»Post infectious: Measles, Rubella,

mycoplasma in spinal fluid

Pathophysiology-Transverse Myelitis cont…» As ascending paralysis worsened patients

autonomic systems began being affected+ Went from breathing on own to

Ventilator dependance+ Heart Healthy diet to strictly Tube Feed + Became glucose intolerant + Unable to speak+ Developed ileus

Pathophysiology-Nutrition Related Factors

Systematic Review showed :Blood Glucose Control:•With Intense Insulin Therapy treatment vs conventional insulin therapy 5,6

•In regards to: (Overall--NO significant benefit)•LOS• some studies showed decrease in mechanical ventilation days 6

•Ventilator Respiratory Dependency Failure•With Enteral Nutrition and permissive underfeeding vs Eucaloric feeding

•Classified as tube feed meeting 60%-70% of estimated nutritional needs

Pathophysiology: VDRF continued…

• Hypocaloric group showed • Decreased LOS & Mechanical Ventilation days• Fewer Antibiotic days• No Significant difference in nitrogen balance or

Serum Protein response4

• With Gastric VS. Small Bowel Feed: • Results showed significant effects• hours to reach target goal rate from admission

with GF was less• Decreased LOS and days on Mechanical

ventilation with Gastric feeds• Avg daily Energy and protein deficit was less with

Gastric feeds• No advantage to early post-pyloric feeding 3,7

Meet the Patient» 57 yo white male» Admitted to ICU for worsening ascending paralysis

+ Height: 180.3 cm (5’10.98”)+ Weight: 125.07 kg (275 lbs 11.2 oz)+ BMI: 38.47 kg/(m^2)+ IBW: 75 kg+ % IBW: 166% + UBW: 286 lbs per A.P.

0

20

40

60

80

100

120

140

160

180

UBW IBW % IBW

●UBW●IBW●%IB

Patient Data: UBW vs IBW

Meet the Patien cont…» Admitted originally on ~7/2014 for Shingles on

trunk area→Readmitted 9/1 for Transverse Myelitis (post

infection)→ Transferred to inpatient Rehab

→ Transferred to ICU for worsening of breathing /unable to move extremities

→Transferred to Stepdown for continued monitoring

Patient Data-Weight Encounters

260

265

270

275

280

285

290

9.1.14 9.3.14 9.7.14 9.13.14 9.15.14 9.21.14 10.21.14 10.23.14 10.27.14 10.29.14 11.20.14

287 286

279

274 276275 276

279 280 280

286LBS

Biochemical Data: LABS(9/21) (10/21) (10/23) (10/27) (10/29) Normal

Range

Na+ 131 ↓ 128 ↓ 129 ↓ 135 135 135-145 mmol/L

K+ 3.9 4.6 4.3 3.9 4.3 3.5-5.3 mmol/L

CO2 33 ↑ 29 ↑ 29 ↑ 38 ↑ 34↑ 22-28 mmol/L

Glucose 114 ↑ 123 ↑ 115↑ 104↑ 107↑ 70-99 mg/dL

BUN 30 ↑ 23 ↑ 33↑ 32↑ 27↑ 6-20 mg/dL

Cr 0.7 0.7 0.6↓ 0.4↓ 0.4↓ 0.7-1.3 mg/dL

Calc Osmol

279 ↓ 271 ↓ 276↓ 287 286 282-300 mosm/kg

Pertinent Patient Events» (9/19) pt was still on Heart Healthy diet

˃ (9/21) Passed swallow evaluation˃ Post infectious polyneuropathy

» (9/23) SLP evaluation/Pt intubated became NPO˃ MRI C Spine showing C2

demyelinating plaque & edema extending from medulla down to C7

» (9/24) Pacemaker placed for bradycardia˃ TF was on Hold

» (10/4) possible Cecal Ileus per CT ˃ (Started on trophic TF rate with

elemental Vivonex)» (10/10) PEG placed

˃ Cecal Ileus resolved

Initial Encounter

Assessment˃ Rt lung collapse 2/2 mucous plug s/p bronchoscopy 10/19.˃ Lasix held 2/2 MAP below 60 ˃ Leukocytosis resolved ˃ GCS 11T-AMS˃ Drop in Na+ noted/ Pt w/Fluid overload˃ TF turned off at time of visit for postural drain˃ Pt on aggressive Bowel Regimen

» Meds: Dulcolax, Colace, Senokot, MOM, Phos-Nak, Flagyl, Solu-Cortef, Acyclovir, Vit D3, Vit B12

» TF order: Vivonex running @ 90 mL/hr (Providing (No Residuals)» BMI: 38.47 kg/(m^2) » Skin Intact » GI Abd round/no guarding, LBM (10/18) > BS-Hypoactive > Pitting edema

RUE/LUE

First Encounter continued

Nutrition Dx: Inadequate Energy-Protein Intake Related TO for postural drainage for plasmapharesis AS Evidenced By TF on hold

Estimated Needs: (Calculated w/ Penn State: using 125 kg) 2197 Kcals; 91-113 kg pro (1.2-1.5 g/kg IBW); 2197 mL fluids (1 mL/kcal) or fluids per MD

» Intervention: If ileus resolved, recommend transitioning TF to non-elemental formula Fibersource HN @ 75 mL/hr (to provide 2160 kcals, 97 g pro, 1476 mL free H2O

+ Spoke with NP agreed with above recommendation

» Monitoring/Evaluation:˃ TF transition˃ EN Tolerance˃ Total energy-protein intake

» Goals: Once re-intiated TF will continue to meet 100% of estimated needs by next RD follow up

Nutrition Follow Up 1• Working Dx possibly VSV or HSV

Hyponatremia /low serum osmolality

˃ 2/2 volume depletion vs edematous vs Cerebral salt wasting vs SIADH

» TF Order: ˃ changed to Diabetisource

running @ goal rate of 75 mL/hr (To provide: 2160 kcals, 108 g pro, 1476 mL free water

>Previous Nutrition goal was met

» No significant change to:˃ Nutrition Dx˃ Goals

» Intervention:+ Continue with current TF

order

» Monitoring/Evaluation+ EN tolerance/labs

Nutrition Follow Up 2

» Hyponatremia still being explored- Given NaCl tablets

» No improvement in motor sensory» Plasmapharesis every other day » SLP eval- Working on communicative device» Fluid retained since admission +6,151 L

» Pt retaining large volume of fluids˃ Low Na+ 2/2 fluid overload

Follow Up 2 ContinuedIntervention

Recommended temporarily changing TF to Nutren 2.0 @ rate of 45 mL/hr. (To provide 2160 kcals, 86 g pro, 777 mL free water)

Goal: • If TF changed pt will be at estimated needs within 24-48 hrs• If TF remains the same, will continue to meet 100% of estimated

needs• Previous Goal metMonitor/Evaluation:TF formula change, EN tolerance, Labs

Nutrition Follow Up 3

•Pt started on Nutren 2.0 10/27 (pt tolerating per RN)

•running at goal rate at time of visit•Edema UE +3/ LE +2 •Hyponatremia improving•No Nutrition Diagnosis at this time•No Significant change to:

•Intervention/Goal/Monitor/Evaluation

Discussion» What is the role of the dietitian (and my role) in caring for

this patient and others with similar conditions? • Tolerance of TF • Adequate nutrition with fluctuating ventilation requirements

» What was the patient’s overall response to nutrition care?• Pt tolerated transition of tube feed formulas quite well• No major abdominal issues

» What are some of the barriers to providing appropriate nutrition care in this situation?

• Pt unable to speak• Was sedated on all visits GCS didn’t go above 11

» Did you encounter any unexpected findings in the completion of the case study? Did anything surprise you?

• Patients status- stable no improvement with TM

Conclusion

» Pt was transferred to stepdown a week later» Not quite stable enough to be transferred to a Long

term care facility yet» Unclear if patient will fully recover from TM» Nutritionally he has his PEG for long term EN

References1. Available at: http://myelitis.org/symptoms-conditions/transverse-myelitis/. Accessed November 26, 2014.

2. Labiano-fontcuberta A, Mitchell AJ, Moreno-garcía S, Puertas-martín V, Benito-león J. Impact of anger on the health-related quality of life of multiple sclerosis patients. Mult Scler. 2014; Accessed November 26, 2014 from www.healthline.co/health/multiple-sclerosis/demyelination#Overview1+

3. Arabi YM, Tamim HM, Dhar GS, et al. Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr. 2011;93(3):569-77.

4. Dickerson RN, Boschert KJ, Kudsk KA, Brown RO. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition. 2002; 18: 241-246.

5. Finfer S, Chittock DR, et al, for the The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) Investigators. Intensive versus conventional glucose control in critically ill patients. NEJM. 2009; 360(13): 1,283.

6. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Wijngaerden EV, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical icu. N Engl J Med 2006; 354:449-61.  

7. White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric vs. early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009; 13(6): R187. Epub: 2009 Nov 25. PMID: 19930728.

Any Questions???