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Trophic Feeding for Critically Ill Patient on P ressors: A Case Study

Trophic Feeding for Critically Ill Patient on P ressors: 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 .

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Trophic Feeding for Critically Ill Patient on P ressors: A Case Study

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  1. Trophic Feeding for Critically Ill Patient on Pressors: A Case Study By Andrea Shelley

  2. Case Presentation • Admitted related to need for dialysis access • Intubated and on mechanical ventilation • Major Problems: • End-stage renal disease (ESRD) • Symptomatic bradycardia • Hyperglycemia

  3. Case Presentation • ESRD • Lung cancer • Chronic obstructive pulmonary disease • Chronic cystitis • Type 2 diabetes mellitus • Kidney stones • Gastroesophageal reflux disease • Hypertension • Hypothyroidism • Depression 88 year old Caucasian female Medical History:

  4. 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. 13th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: 811-813

  5. 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

  6. 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

  7. Case Presentation • Hyperglycemia (High blood glucose level) • Glucose 332 at first assessment • Treatment: • Lantus • Sliding scale insulin • Dextrose, 5%

  8. Nutrition Assessment Anthropometric Measurements at Admit: • 162# • 4’11” • BMI=32.8 Biochemical Data at Admit: • Glucose:332 • BUN: 56.4 • Cr:5 • Ca: 6.5 • Sodium:137 • Potassium:3.8 • Phosphorus: 7.8

  9. 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

  10. Nutrition Assessment • Increased Caloric Needs: • CRRT • Sepsis • Mechanical ventilation • Low Braden Score (10)

  11. 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

  12. 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.

  13. 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

  14. 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 1.5 • Glucose, casual BD-1.5.2

  15. 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

  16. Evidence-Based Nutrition Recommendations Early Enteral Nutrition and Outcomes of Critically Ill Patients Treated With Vasopressors and Mechanical Ventilation By Imran Khalid, PratikDoshi, 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

  17. 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

  18. 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

  19. 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

  20. Conclusion Tolerated trophic feeds minimal residuals No gastrointestinal intolerance Many co-morbidities End-of-life decision was comfort care

  21. Thank You! Questions?

  22. 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

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