case study selayang

8/7/2019 case study SELAYANG

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CASE STUDY


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` Madam JS` 66/ M/fe mal e` ROA: admit for r ight diab e tic foo t gang re ne in

or thope dic wa r d


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` Curre nt :-GIT blee ding-Perfor at e d duo de nal ulcer ( done He ineke Miku litz

pyrop last y)

-R ight BKA

` Me dical hist ory:-Diab e te s Me llitus

-Hyper te nsi on


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` Be come hypovo le mic` Tr ans ferre d to ICU for f luid re s uscitati on &

manag e me nt of s evere me tab olic acid osis

` In ICU (D a y 1):-stabl e w ithou t inotrope s s uppor t -re s po ns e to call-we a k cou gh with s e cre tion +++


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` ICU (D a y 2):-note d mala e na st oo l

-no abd ominal dist e ntion with minimal gast r ic re sid ual vo lume-PPN: Nu tr if lex (52 ml/H)

` ICU (D a y 4):-s of t abd ome n, no dist e nd e d-minimal gast r ic re sid ual re sid ual-r ight abd ominal f luid note d 1000 ml s erou s f luid

-give n IV human alb umin 20% ( to re duce ascit e s )-tach ypnoe ic with bilat er al ch e st crep s-ac ute pu lmona ry oe de ma n ote d


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` ICU (D a y 6):- give n 30 ml/h with Glucer na- plan to we an off Nu tr if lex- No te d ge ner aliz e d oe de ma

` ICU (D a y 8):- no more mala e na st oo l

` Tr ans fer to s ur gical wa r d (Da y 12):

- still on NG fee ding (bolus 200 ml po lymer ic for mula 3H)- s ugg e st to allow nour ishing f luid or ally


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Drug Indication Side effect

Unas yn Upper and lower rep tr act infe ctions, UTI,prop hylaxisagainst po st op s ep sis

GI dist ur banc e s, s kinr ash e s,bl oo d dis or der

Me tronidaz ole A ntibiotoc-ass ociat e d colitis, an ero bic bact er ial infe ctions

GI dist ur banc e s, na us e a, vomiting,dia rr hoe a

Omepr az ole Duo de nal ulcer D iarr he a,na us e a,vomit, f lat ulanc e ,

Acid re gur gitati on

MgSO 4 Hypo magn e sa e mia Wat ery dia rr he a,

na us e a, vomit,thi r stDop amin e A cute he a r t f ailure N a us e a, vomit,

tach yca r dia, hypo te nsi on


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Drug Indication Side effect

Cef tr iaz one Su scc ep tible infection, GITinfection, UTI,s ep sis

Super infection, dia rr he a, r ash, fever ,leu cope nia

Tr amad ol Moder at e to s evere p ain Swe ating, na us e a, vomiting,d ry mou th, f atig ue

Los e c Duo de nal and gast r ic ulcer (pro ton-pu mp inhibitor)

Diarr he a,na us e a, vomit, f latulanc e ,h e adach e

Fru s e mid e E dd e ma

(ca r diac,h ep atic, re nal ),HTN

De hydr ati on, GI dist ur banc e ,

me tab olic alkalosisPr az osin HTN , he a r t f ailure ,r a yna uds

s ynd romeNa us e a, e de ma,ch e stpain,dia rr he a, vomit,lac k of e ner gy

Me topro lol HTN Br ad yca r dia,h ypo te nsi on, e dema,dia rr he a, GI

pain,na us e a,h e a r tbur nP anta pr az ole GERD ,pep tic ulcer D iarr he a,dizzin e ss, GI tr act

infection,na us e a, pain, hyper glyca e mia


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Day 2 4 6 9

We ight (kg)

52 54.5 51 56.8

He ight (cm )

154 154 154 154


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Day Input Output Balance Urine output(ml/hr)

2 2573 2556 +17 50-60

4 2285.5 2977 -691.5 40-60

6 2226.5 2897 -670.5 65-90

9 2505.8 2322 +183.8 60-110


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P arameter Day 2 Day 4 Day 6 Day 9 Normalrange

Hb(g/L) 12.5 11.1 10.2 12.8 13.0-18.0

Urea (mmol/L) 6.6 8.5 13.1 8.2 2.5-6.4C reatinine( mol/l)

82 105 93 88 80-132

Sodium(mmol/l)

136 140 134 137 136-145

P otassium(mmol/l)

4.2 4.0 3.9 3.7 3.6-5.2

Albumin (g/l) 21 14 15 16 35-50

Dextrostix(mmol/l)

4.0-4.7 12.2-14.2 4.6-12.4 9.5-10.6 3.9-6.1

Insulininfusion

Nil S cal e 2-4 S cal e 2 A ctr a pid 8tds


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Madam JS w as referre d to you for nutr itional ass e ssm e nt in ICU. P le as e comm e nt on her

anth ropo me tr ic me as ure me nts and how wou ld you de ter min e the refere nc e we ight


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Day 2 Day 4 Day 6 Day 9We ight, kg 52 54.5 51.0 56.8

He ight, cm 154

IBW, kg 53.4

Da y 2 D a y 4: I nc re as e d might be due toascit e sDa y 4 D a y 6: I m prove d oe de maDa y 6 D a y 9: I nc re as e d might be due tooe de ma

Refere nc e We ight : as on Da y 2 , 52 k g


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Onc e the nutr itional ass e ssm e nt done , wou ld you consid er e a r ly e nter al fee ding for this pati e nt? Exp lain your re comm e ndati ons


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` Ea r ly e nter al fee ding is re comm e nd e d for this pati e nt

` P ati e nt has no abd ominal dist e nsi on and minimal

gast r ic re sid ual vo lume` S a fe and e a r ly achi eve me nt of the po sitive

nitroge n balanc e in cas e s of gut perfor ati on


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What a re her sh or t & long ter m nutr ition

s uppor t goals? Calc ulat e her nutr itional requ ire me nts (e ner gy, pro te in & e le ct ro lyte s )


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` To improve nutr itional stat us by prov iding nutr ition s uppor t

` To prov ide ad equ at e e ner gy and pro te in to

preve nt we ight loss and maln utr ition` To maintain goo d hydr ation stat us and preve nt

e le ct ro lyte imbalanc e to a void complication


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` MEE = 25 kcal/kg/day (Jolliet P et al.,1998)= 25 x 52 kcal/day= 1300 kcal/day

E nergy requirement (2)E nergy requirement (2)

ASPEN, 2009 = 25-30 kcal/Actual BW/day= (25-30) x 52 kcal/day= 1300 1560 kcal/day

# Energy Requirement Range = 1200 1560 kcal/day


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E lectrolyte Requirement (mmol)

Calci um 7.5 10

Magn e sium 4 10

P hos phoru s 20 50

So dium 80 100

Po tassi um 80 - 100


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` To o btain ad equ at e cal or ie s and pro te in with refere nc e to her act ual dail y requ ire me nts

` To maintain her we ight within he alth y nor mal r ang eof 43.9-59.0k g

` To improve her bioch e mical value s and maintain thevalue w ithin the nor mal r ang e

` To improve her nutr itional stat us and qu ality of life


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` Q uick Method= 30 - 35 kcal/kg/day= 30 35 kcal/day x 53.4

= 1602 1869 kcal/day

- wt at BMI 22.5 kg/m2 = 53.4 kg

E nergy requirementE nergy requirement

# Energy Requirement Range = 1600 1870 kcal/day


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On da y 7 , patie nt s udd e nly deve lope d loo s e st oo ls more than 3 time s per da y and pu t on re ctal tube.

Enter al fee ding was withh e ld by s pe cialist and s ugg e st to sta r t again on pa re nter al n utr ition.

Wou ld you consid er p a re nter al n utr ition at this stag e ? P lan a fee ding re gim e and your monitor ing

st r at e gie s for her.


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` No` Initiati on of PN is not ad visabl e be ca us e p ati e nt

has functi oning gast ro inte stinal tr act .` Initiati on of PN inc re as e s the r isk of infection and

ca us e s gut mucosal at rop hy.` Be ca us e the freque nc y of loo s e st oo l is only 3

time s per da y (moder at e) , s o w ill maintain TFinfusion r at e and re-ex amin e in 6 hour s . (MNT2005)


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` S tep 1: 150 cc Glucer na + 1 sc oop Myote in,run 30 cc /hr for 5 hour s, re st 1 hour (Ener gy: 704 k cal ) (Pro te in: 44 g/da y)

` S tep II : 250 cc Glucer na + 1 sc oop Myote in,

run 5 0 cc /hr for 5 hour s, re st 1 hour (Ener gy: 1104 k cal ) (Pro te in: 60 g/da y)

` S tep III : 350 cc Glucer na + 1 sc oop Myote in,

run 7 0 cc /hr for 5 hour s, re st 1 hour (Ener gy: 1504 k cal (29 k cal /kg IBW)(Pro te in: 76 g/da y (1.4 g/kg IBW)


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` Fee ding toler anc e` S too l freque nc y and consist e nc y` Dex trostix` Albumin leve l` Re nal prof ile` IO cha r t


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Two week s lat er , sh e w as tr ans ferre d ou t from ICU to ge ner al wa r d and re ad y for or al fee ding .De sign fur ther nutr itional manag e me nt plan for

this pati e nt?


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P ati e nt abl e and willing to e at or ally(allow or ally + tube fee ding )

Be gin full liqu id

Be gin Additi onal Supp le me nts

If or al inta ke is


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8 sc oop s Nu tre n Diab e tic + 300 cc wat er 3 hour ly, 6 time s /da y

(1728 k cal, 67.2 g/da y Pro te in)

MNT for Nu tr ition Suppor t in Cr itically Ill Adults, 2005

Disc ontin ue E nter al Tube Fee ding- If or al inta ke is be twee n 2/3 and of nutr itional requ ire me nts

Or al Fee ding


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Q uick MethodE = 30 - 35 kcal/kg/dayE = 30 35 kcal/day x 53.4E = 1602 1869 kcal/day

- wt at BMI 22.5 kg/m2 = 53.4 kg

` Pro te in Requ ire me nt Po st -op= (1.0-1.2) x 53.4 g/da y= 53.4 64.1 g/da y


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S am ple of me nu E=1600 k cal, Pro t=53.4-64.1 gSof t, high Pro te in, diab e tic die t

Breakfast ( 7-8 am)

9 T bs p cere als +

2/3 glass of s oy milk or LF M +

cup yo gur t (p lain )

Morning Tea (1 0 am)

2 p cs s of t bun (plain ) +

1 ts p s of t ma r ger in +P lain wat er (1 glass )

Lunch (12 1 pm)

2 cup chic ke n porr idg e ( s of t) +

Ve ge tabl e s s oup ( s pinach +

po tat oe s )

+2 ts p ble nd e d oil

+1 p ie ce of mash e d pa pa ya

Afternoon Tea (4 -5 pm)

6 T bs p o ats +

glass of Low F at Milk

Dinner ( 7-8 pm)

2 cup f ish porr idg e +Ve ge tabl e s s oup ( ca rro ts, sa wi) +

1 ts p ble nd e d oil + of w hole mang o

Supper (1 0 pm)

2 p cs s of t bun + glass of LF M

Menu Planning (after stop enteral feeding)


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Currently nutrition support practices in your hospitalare not satisfactory and you are planning to design anevidence-based nutrition support protocol for

patients in ICU. Draft the suggested enteral feeding protocol based on MNT guidelines.


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` Definition: Delivery of enteral products through an enteral access deviceinto a functioning gastrointestinal (GI) tract.

` Target group: Physicians, nurses, dietitian, pharmacists, respiratory and physical therapists

` References:AS PEN. 2009. Enteral Nutrition Practice Recommendations. Journal of

Enteral and Parenteral Nutrition .AS PEN. 2009. Guidelines for the Provision and A ssessment of NutritionS upport Therapy in the A dult Critically Ill Patient: : S ociety of CriticalCare Medicine ( S CCM) and A merican S ociety for Parenteral and Enteral

Nutrition ( A .S .P.E.N.). Journal of Enteral and Parenteral Nutrition.Ministry of Health. 2005. Medical Nutrition Therapy for Critically IllA ddult.


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` Enteral nutrition should be provided within the first 24 48hours following admission for those who are hemodynamicallystable and fully resuscitated.

` Enteral nutrition is the preferred choice whenever GI isfunctioning and with sufficient length and absorptive capacity.

` Presence of bowel sounds or evidence of passage of flatus andstool is not required for the initiation of enteral feeding.

` Patients at high risk for refeeding syndrome and other metabolic

complications should have mineral and electrolytes replaced prior to initiating feeding.

(AS PEN 2009, MNT 2005)


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` Trickle or trophic feeds (10 30 ml/hour) should be given when full enteralfeeding is not possible.

` 5 0 % - 60 % of goal calories should be achieved within the first week of hospitalization.

` Ad equacy of protein provision should be assessed and additional modular proteincan be supplemented in order to achieve requirement.

` F or bolus feeding, enteral feeding can be started at the rate of 5 0 ml 3 hourly andadvance the feed rate by 20 40 ml 3 hourly if patients tolerate (refer part D:Monitoring).

` F or intermittent feeding, enteral feeding can be started at the rate of 10 ml 40ml/hour and advance the feed rate by 10 20 ml if patients tolerate (refer part D:Monitoring).

` Conservative initiation and advancement rates are recommended for patients whoare:

Critically illHave not been kept NBM for some timeReceiving high-osmolality or calorie-densed formula.

(AS PEN 2009, MNT 2005)


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` A septic techniques should be practiced during handling, preparation and delivery of enteral formula.

Practice good hand washing technique and use of disposable gloves

when handling enteral formula and enteral tube is recommended.S trict adherence to the recommended hang time of enteral formula (4 6hours for powder formula and 6 8 hours for decanted formula)Opened decanted formula should be covered and kept in refrigerator and

be discarded after 24 hours.A dministration sets for enteral feeding should be changed at least every24 hours. Washing with tap water is not recommended to preventintroducing of micro-organisms into the administration sets.

(A dapted from AS PEN AL ERT Campaign 2009)


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` Make sure correct enteral formula an d fee d ing rate is administered tothe patient as ordered.

` Patients hea d of be d shoul d be elevate d at least 30 d egrees whenclinically possible during feeding in order to mitigate risk of reflux and

aspiration.

` F lushing feeding tube with 30 ml of clear fluid before and after the feedingis recommended.

` M ed ications should not be added into enteral feeding together. Instead itshould be administered as directed by pharmacists.

(A dapted from AS PEN AL ERT Campaign 2009)


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1 . G astric Resi d ual Volume ( G RV)If > 250 ml, please continue the same rate of the feedingagain. Consecutively of GRV > 250 ml twice might requireuse of pro-kinetic agents.If > 500 ml please check patients tolerance to the feeding.If high GRV consistently being aspirated, please consider:x Reduce the rate of feedingx Reduce the calorie density of the formulax

Intermittent/continuous feeding (if patient is on bolus feeding)x Post pyloric feeding

(MNT 2005)


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2. D iarrheaIt is not an indication to stop feedingChecking etiology of diarrhea is important (such as medications(lactulose, oral magnesium salts, wide-range antibiotics) or

having faecal impaction.Consistent diarrhea without any possible etiology found mightsuggest use of formula with soluble fiber or small peptides.If 1 -2times/day, continue feeding as protocolIf 3-4 times/day, maintain feeding rateIf more than 4 times/day, decrease T F infusion rate by 50%,review medications, send stool for fecal leucocytes and toxins. If

persist more than 48hour, change to elemental feeding(MNT 2005)


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3. Vomiting>1 time/ 1 2 hour Check feeding tube

Decrease feeding rate by 50% and notify dietitian(MNT 2005)


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4) Dur ing ac ute p has e , prefer abl y re ce ive fee ding contin uou sly. C an s witch tointer mitte nt fee ding lat er

(i) Continuous Feeding - S ta r t 20 40 ml/hr contin uou sly & as pir at e every 4 hr - If aspirate < 2 00 ml

Re tur n all as pir at e r at e 20 ml/hr every 3 cycle s til mee t ta r ge t cal or ic nee ds

Af ter , ma y fur ther dilute d with wat er to mee t f luid requ ire me nt- If aspirate > 2 00 ml

Re tur n 200 ml as pir at e & r at e by 50% of initial r at eEx clude bowe l obst ruction administ r ati on prok ine tic ag e nts

(a ) Fur ther as pir at e < 200 ml` -Fo llow if as pir at e < 200 ml (a ) (b) Fur ther as pir at e cont > 200 ml` -Co nsid er small bowe l fee ding & e le me ntal for mulas


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( i) Intermittent Bolus Feeding - S ta r t 50 ml every 3 hr & as pir at e before every fee d- If aspirate < 2 00 ml

Re tur n as pir at eby 50 ml a f ter every 4 fee ds

by 100 ml/fee d every 24 hr till cal or ic nee ds m ee t Af ter , ma y fur ther dilute d with wat er to m ee t f luid requ ire m e nt

- If aspirate > 2 00 mlRe tur n 200 ml as pir at e & by 50 ml/fee dExclude bowe l obst ruction administ r ati on prok ine tic ag e nts

(a ) Fur ther as pir at e < 200 ml` -Fo llow if as pir at e < 200 ml(b) Fur ther as pir at e cont > 200 ml

` -Co nsid er u s e of contin uou s fee ding

(MNT 2005)

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