by andrea shelley trophic feeding for critically ill patient on pressors: a case study

BY ANDREA SHELLEY

Trophic Feeding for Critically Ill Patient on Pressors: A Case Study

Case Presentation

Admitted related to need for dialysis access

Intubated and on mechanical ventilation

Major Problems:End-stage renal disease (ESRD)Symptomatic bradycardiaHyperglycemia

Case Presentation

ESRDLung cancerChronic obstructive

pulmonary diseaseChronic cystitis Type 2 diabetes

mellitus

Kidney stonesGastroesophageal

reflux diseaseHypertensionHypothyroidismDepression

88 year old Caucasian female

Medical History:

Case Presentation

Disease Description: ESRDKidneys are no longer able to clean the blood at an

acceptable rateGlomerulus filtration rate (GFR)<15Fluid and toxins build-up

phosphorus & potassiumDialysis or transplantation is needed for survival

Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13 th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: 811-813

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

Case Presentation

Symptomatic bradycardia (slow heart rate):Pulseless electrical activity 7 days post admitReceived aggressive resuscitationHeart rate 30-40Placed on pressors

NorepinephrineDopamine

Case Presentation

Hyperglycemia (High blood glucose level)Glucose 332 at first assessmentTreatment:

Lantus Sliding scale insulin Dextrose, 5%

Nutrition Assessment

Anthropometric Measurements at Admit:162#4’11”BMI=32.8

oGlucose:332oBUN: 56.4oCr:5oCa: 6.5

oSodium:137oPotassium:3.8oPhosphorus: 7.8

Biochemical Data at Admit:


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


Increased Caloric Needs: CRRT Sepsis Mechanical ventilation Low Braden Score (10)


Nutrient Needs:Mifflin St-Jeor

(10 x 73.4) + (6.25 x 149.8) - (5 x 88) -161=1069.25kcalsStress Factor: 1.3 x 1069.25= 1390kcals/day

OR 30kcals/kg IBW & 1.5g protein/kg IBW

30kcals x 45.45kg IBW = 1363kcals1.5g protein x 45.45kg IBW = 68g proteinFluids:1ml/kcal =1363ml water

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.

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

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 1.5Glucose, casual BD-1.5.2

Nutrition Monitoring and Evaluation

Monitor Continued: Electrolyte and renal profile 1.2

BUN BD-1.2.1Creatinine BD-1.2.2Potassium BD-1.2.7Phosphorus BD-1.2.11

Acid-based balance 1.1Partial pressure of carbon dioxide in arterial blood

PaCO2 BD-1.1.4

Evidence-Based Nutrition Recommendations

Early Enteral Nutrition and Outcomes of Critically Ill Patients Treated With

Vasopressors and Mechanical VentilationBy Imran Khalid, Pratik Doshi, and Bruno

DiGiovineNonrandomized controlled trialCompared 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


A Randomized Trial of Trophic versus Full-Energy Enteral Nutrition in Mechanically Ventilated Patients

with Acute Respiratory FailureBy: 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

Conclusion

Tolerated trophic feeds minimal residuals

No gastrointestinal intolerance

Many co-morbidities

End-of-life decision was comfort care

Thank You!

Questions?

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



Academy of Nutrition and Dietetics. Evidence Analysis Library. Executive summary of recommendations. http://andevidencelibrary.com/topic.cfm?cat=3929. Accessed January 1, 2013

by andrea shelley trophic feeding for critically ill patient on pressors: a case study

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