Clinical Case Study:Nutrition Support for Multiple Traumas

Brooklyn Harkness

ARAMARK Dietetic Internship

United Regional Healthcare System

December 18, 2013

Disease StateMultiple Traumas

•Secondary to Motor Vehicle Accident

•Complications: large lacerations to scalp,right elbow and right knee

•Treatments: Surgical, Medicinal, & Nutritional

Metabolic Response to Trauma & Stress •Catabolism: destructive metabolism

-Targets lean body mass

-Negative nitrogen balance & muscle wasting

•Characteristic Phases:-Ebb Phase (acute response)-Flow Phase (adaptive response)

Metabolic Response to Trauma & Stress•Ebb Phase - Immediately following injury:

-Hypovolemia

-Shock

-Tissue Hypoxia

-Decreased Metabolic Rate

Multiple Response to Trauma & Stress•Flow Phase: following fluid resuscitation

& renewal of oxygen delivery

-Acute Response

-Adaptive Response

Multiple Response to Trauma & Stress•Flow Phase - Acute Response•Catabolism dominates:

-Increase Glucagon -Increased excretion of nitrogen -Increased metabolic rate -Increased oxygen utilization

Multiple Trauma & Stress•Flow Phase - Adaptive Response•Anabolism Dominates:

-Declined hormone response -Recovery -Possible repair of body protein -Healing

Evidence – Based Nutrition Recommendations•Adam et al, 2013

- Cohort study, Systematic review

-N = 1,179

-Intragastric versus Small Intestinal Feedings

-Findings: Small Bowel Feedings will increasenutrient delivery & decrease pneumonia second to ventilation

-Limited by data interpretation and subjective diagnosis of pneumonia

(5) Deane adam M, Rupinder D, Day andrew G, Ridley emma J, Davies andrew R, Heyland daren K. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care. 2013;17(3):R125.

Evidence – Based Nutrition Recommendations • Alberda et al, 2009

-Cohort Study

-N = 2,884

- Additional Protein

- Findings: More rapid healing & decreased mortality rate

-Limitations: units across 5 different continents and 37 different countries brought variability in standards of care.

-Limitations: BMI was the only indicator of nutritional reserve.

(6) Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728-37.

Evidence – Based Nutrition Recommendations •Berger et al, 2008

- N = 200

-Early Feedings (24-48 hours) after trauma or major surgery

-Early antioxidant supplementation (within 24 hours)

-Findings: significantly dulled the inflammatory response

-Limitations: lack of power

(7) Berger MM, Soguel L, Shenkin A, et al. Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients. Crit Care. 2008;12(4):R101.

Case Presentation•23 Year old Caucasian Male

•Dx: Multiple Trauma secondary to motor vehicle collision

•Initial Emergency Room Care: Sedation, Intubation, & Cervical Collar

•Glasglow Coma Scale: 3

Glasgow Coma Scale• Initial assessments using a neurological scale to determine

the conscious state of a patientKEY: ≥ 13 (minor), 9-12 (moderate), ≤ 8 (Severe)

Eyes Verbal Motor1 Does not open

eyesMakes no sounds Makes no

movements2 Opens eyes in

response to painfulstimuli

Incomprehensiblesounds

Extension to painfulstimuli

3 Opens eyes in response to voice

Utters inappropriate words

Abnormal flexion to painful stimuli

4 Opens eyes in response to voice

Confused, disoriented

Flexion/withdrawal to painful stimuli

5 N/A Oriented, converses normally

Localizes painful stimuli

6 N/A N/A Obeys commands

NCP: Assesment•Client History

-No Prior Medical History

-Substance abuse: positive for methamphetamines and cannabanoids

NCP: Assessment•Food/Nutrition-Related History

- Unable to obtain information from pt due to sedation and intubation

-Mother indicated no diet limitations

NCP: Assessment•Nutrition-Focused Physical Findings: -Intubation -Tracheostomy -Mild abdominal distension -Constipation -Hyperglycemia -Hypoalbuminemia

NCP: Assessment•Anthropometric Measurements

- Height: 6’0” -Admission wt: 198# (90kg) -BMI: 26.8, overweight -IBW: 180#

NCP: AssessmentMeasurement Value Normal RationaleGlucose 170 70-110 mg/ dl Inflammatory

Stress

Albumin 2.8 3.5 – 4.8 g/ dl Inflammatory stress 7 trauma response

AST 62 12-40 U / L GI Injury/dysfunction

PT 16.3 11.0 – 13.0 seconds

GI Injury/dysfunction

Methamphetamines Positive Substance abuse

Cannabanoids Positive Substance abuse

NCP: AssessmentNutrient Needs: •Estimated Energy Needs (1.1)

-Ireton Jones Vent Dependent: 2,442kcal/day

•Estimated Protein Needs (2.2)-129-171g daily (1.5-2.0g/kg CBW)

•Estimated Fluid Needs (3.1) -2,442mL/day (RDA – 1mL/1kcal)

NCP: AssessmentNutrition Status ClassificationNutrition Care Indicator Category Points assignedNutrition History 0Feeding Modality/Nutrition Care Order 4Unintentional Weight Loss 0Weight Status 0Serum Albumin 3Dx/Condition 4TOTAL POINTS 11

•Moderately Compromised (Status 3): 8-11 points

• Time Frames for Reassessment/Follow-up: 3-5 days

NCP: Nutrition Diagnoses•1: Inadequate oral intake (NI-2.1) related to

multiple traumas as evidenced by the need for sedation and intubation requiring NPO diet order.

• 2: Altered Nutrition-Related Laboratory Values (NC-2.2) related to trauma as evidenced by Glucose 17-0, Albumin 2.8, and Prothrombin Time 16.3.

• 3: Increased Energy Expenditure (NI-1.1) related to catabolism secondary to trauma as evidenced by elevated Metabolic Resting Rate.

NCP: Interventions• #1. Meals and snacks; Specific (ND-1.3).

Recommend high protein, high calorie dense if medically advised to advance diet.

• #2. Enteral Nutrition (ND – 2.1). Initation of TF.

-Recommend Impact Peptide 1.5 @ goal rate of 70mL/hr to provide 2,520kcal, 158g protein, and 1,294mL free fluid. Water flush 100mL Q 6.

-Initiate TF @ 20mL/hr and increase 10mL Q 6 to reach goal rate of 70mL/hr.

•Short-Term Goals/Expected Outcomes: 1. Tolerance of TF @ goal rate of 70mL/hr within 36-48 hours of initiation. 2. EN to provide >85% assessed nutritional needs.

•Long-Term Goals/Expected Outcomes: 1. Initiation of oral intake within the patient’s length of stay. 2. Patient to consume 100% of nutrient needs via oral intake with no complications.

NCP: Monitoring and Evaluation•#1. Food/Nutrition-Related History (FH).

Energy Intake (1.2.1) Total Energy Intake (FH-1.1.1.1)

•#2. Biochemical Data, Medical Tests, and Procedures (BD). Glucose (1.5) Albumin (BD-1.11.1) and Prothrombin Time (BD-1.4.9)

•#3. Anthropometric Measurements (AD). Weight (AD 1.1.2)

Conclusion•Patient transferred to Rehabilitation

Instituteon EN support

•Discharged tolerating at goal rate of 70mL/hr:

-2,520kcal, 158g protein, 1,294mL free fluids

-water flushes 100mL Q 6 hours

References• 1) (http://www-nrd.nhtsa.dot.gov/Pubs/811856.pdf).

National Highway Traffic Safety Administration (non-article) (2) Manhan LK, Escott-Stump S, Raymond JL. Krause's Food and Nutrition Care Process. 13th ed. St. Louis, MO: EL Sevier Saunders: 2012.(3) Escott-Stump S. Nutrition and Diagnosis – Related Care. 7th ed. Baltimure, ND: Lippimcott Williams & Wilkins: 2012. (4) Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med. 2009;361(14):1339-48.(5) Deane adam M, Rupinder D, Day andrew G, Ridley emma J, Davies andrew R, Heyland daren K. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care. 2013;17(3):R125.(6) Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728-37.(7) Berger MM, Soguel L, Shenkin A, et al. Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients. Crit Care. 2008;12(4):R101.(8) Mcclave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.(9) Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL; 2013.(10) Available at: http://www.mc.vanderbilt.edu/surgery/trauma/Protocols/nutrition-protocol. Accessed December 10, 2013.(11) Pronsky Z, Crowe J. Food Medication Interactions. 16th ed. Birchrunville, PA: Food-Medication Interactions: 2008.

Questions?