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Rebecca Scofield, MS ARAMARK Dietetic Internship Underwood-Memorial Hospital February 7, 2012

Case Report : Nutrition Support in a Critically Ill Patient at risk for Essential Fatty Acid Deficiency. Rebecca Scofield, MS ARAMARK Dietetic Internship Underwood-Memorial Hospital February 7, 2012. Disease State. Diverticular Disease Primary cause of patient’s long hospital stay

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Rebecca Scofield, MS ARAMARK Dietetic Internship Underwood-Memorial Hospital February 7, 2012

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  1. Case Report:Nutrition Support in aCritically Ill Patient at risk for Essential Fatty Acid Deficiency Rebecca Scofield, MSARAMARK Dietetic InternshipUnderwood-Memorial HospitalFebruary 7, 2012

  2. Disease State • Diverticular Disease • Primary cause of patient’s long hospital stay • Complications included inflammation, abscesses, sepsis and infection, bleeding, and perforation • Usual treatment includes antibiotics, bowel rest • ⅓- ¼ of patients require surgery • Hartmann’s procedure, splenic flexure takedown, drainage of abscess, colostomy performed

  3. Comorbidities • Pt became Vent-Dependent Respiratory Failure (VDRF) following surgery • Acute Respiratory Distress Syndrome (ARDS), resolved • Type 2 Diabetes Mellitus (T2DM) • Peanut allergy • Risk for Essential Fatty Acid Deficiency (EFAD)

  4. EFAD • Essential Fatty Acid Deficiency • Absence of EPA, DHA, ALA (omega-3 fatty acids) • Signs/Symptoms: • Dermatitis • Fatty liver • Hair loss • Biochemical indications • Death • S/S can occur within 2 weeks

  5. Evidence-Based Nutrition Recommendations • Academy of Nutrition and Dietetics: Evidence Analysis Library • Critical Illness Guidelines state: • Energy requirements most accurate when using Ireton-Jones 1992 equation and indirect calorimetry not available • Enteral Nutrition (EN) recommended over Parenteral Nutrition (PN) in patients with functioning GI tract • EN associated with reduced cost, septic morbidity, and infections • Delayed PN in pts who are not malnourished

  6. Evidence-Based Nutrition Recommendations • Casaer et al, 2011 • Randomized, controlled, multi-center trial • N = 4,640 • Intervention: Early vs. late PN in critically ill adults • Early initiation on day 3 • Late initiation on day 8 • Primary Outcomes: ICU length of stay • Secondary Outcomes: Infection rates, inflammation, length of VDRF, status at discharge Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, VandenBerghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.

  7. Evidence-Based Nutrition Recommendations • Caesaer et al, continued: • Results • Late PN Initiation group: • Shorter ICU stay • Fewer infections • Reduction in patients who require > 2 days VDRF • $1600 reduction in health care costs • No difference in mortality between groups • Early initiation of PN appears less beneficial than withholding PN until day 8 Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, VandenBerghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.

  8. Evidence-Based Nutrition Recommendations • De Meijer et al, 2010 • Non-comparative study (case series) • N = 10 • Intervention: PN fish oil as sole lipid therapy for infants in ICU • Primary Outcome: Onset of EFAD, defined by triene:tetraene ratio >0.2 • Secondary Outcomes: Clinical s/s of EFAD • Dermatitis • Hair loss • Growth impairment deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218.

  9. Evidence-Based Nutrition Recommendations • De Meijer et al, continued: • Results • FA composition changed from composition of soybean oil (higher omega-6) to that of fish oil (higher omega-3) • No dermatitis, hair loss, growth retardation in any patients • Bilirubin levels improved in 90% of patients with cholestasis • Fish oil contains sufficient EFAs to prevent clinical and biochemical s/s of EFAD and sustain growth in infants deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218.

  10. Evidence-Based Nutrition Recommendations • Mateu-de Antonio et al, 2008 • Retrospective cohort study • N = 42 (final n = 39) • Intervention: Soybean- vs. olive oil-based lipid emulsions in PN • Primary Outcomes: Infection rate and leukocyte count • Secondary Outcomes: Acute phase proteins, length of ICU stay, mortality rate Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.

  11. Evidence-Based Nutrition Recommendations • Mateu-de Antonio et al, continued: • Results • No difference in infection rate or appearance, acute phase proteins, or major outcomes between groups • Olive oil group: increase in leukocyte count • Soybean oil group: decrease in leukocyte count • Soybean oil emulsions • Cause increase in omega-6 FA • May interfere with immune function, be precursors to inflammatory markers, and inhibit macrophage function • Olive oil-based lipid emulsions • May serve as a safe alternative to soy-based PN infusions Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.

  12. Case Presentation • Patient: SF • 58 Year old Caucasian female • Dx: Pneumonia, s/p GI surgery, VDRF, ARDS, sepsis, DM • GI surgery prevents from enteral access • Peanut allergy prevents from receiving lipid emulsion (per pharmacy protocol) • Without lipids for 14 days

  13. NCP: Assessment • Client History • Hypothyroidism, diverticulosis, temporal arteritis, HTN, GERD, steroid-induced hyperglycemia, T2DM • Allergies: Cipro, Augmentin, Macrobid • Ex-smoker

  14. NCP: Assessment • Food/Nutrition-Related History • Unable to obtain from pt due to sedation/VDRF • Family friend stated pt tolerated soy-containing foods • Good intake at home • Cooked for herself • Social drinker • Medications at home

  15. NCP: Assessment

  16. NCP: Assessment • Nutrition-Focused Physical Findings • Overweight • Sedated • Edema • Cushingoid/puffy face • +Ostomy • NG tube

  17. NCP: Assessment • Anthropometric Measurements • Height: 5’8” • Admission wt: 81.6 kg (180 lbs) • BMI: 27.35 • IBW: 140 lbs Pt experienced 40 lb gain during hospital admission due to fluid overload

  18. NCP: Assessment • Biochemical Data, Medical Tests, and Procedures • Intubation/mechanical ventilation • NG tube placement • TLC placement • Tracheostomy • Bronchoscopy • Frequent lab draws • PEG placement

  19. NCP: Assessment

  20. NCP: Assessment • Nutrient Needs • Estimated energy needs (1.1): • Using Ireton-Jones 1992 • 1836 kcal/day • Estimated protein needs (2.2): • 1.3-1.5 g/kg (Using high-end IBW) • 91-105 g/day • Estimated fluid needs (3.1): • 25 ml/kg (Using high-end IBW) • 1750 ml/day

  21. NCP: Assessment Nutrition Status Classification

  22. NCP: Nutrition Diagnoses • #1. Altered GI function (NC-1.4) related to diverticulitis and perforation as evidenced by decreased bowel sounds, little ostomy output, and bowel resection. • #2. Inadequate parenteral nutrition infusion (NI-2.6) related to potential allergy to lipid emulsion as evidenced by lipid emulsion not being administered and no fatty acids delivered to patient. • #3. Predicted food-medication interaction (NC-2.4) related to combined ingestion of levothyroxine and enteral formula via NG tube causing decreased bioavailability of medication as evidenced by 24-hour continuous feeding and p.o. levothyroxine prescribed via NG tube.

  23. NCP: Interventions • Initiate PN (ND-2.2) • ND-2.2.1 Formula/solution: • Parenteral nutrition was started 4 dayss/p surgery • Recommendation: 490 ml 50% dextrose (to start with 30% dextrose first day), 1000 ml 10% amino acids, and 200 ml 20% lipid to provide 1633 kcal, 100 gm protein, and 1690 ml total volume. • To meet approximately 100% of kcal and protein needs and 97% fluid needs. • Lipids not administered for 10 days due to pharmacy protocol and risk for crossover allergic reaction to soy.

  24. NCP: Interventions • Coordination of Nutrition Care (RC-1) • RC-1.3 Collaboration/referral to other providers: • Communication between • Nursing • Physicians • Pharmacy • Nutrition • Required to determine a course of action for testing lipids with the patient before being introduced to PN solution.

  25. NCP: Interventions • Initiate EN (ND-2.1) • ND-2.1.1 Formula/solution: • Goal enteral formula once patient able to begin feedings: • Glucerna1.2 via NG tube at 55 ml/hr continuous over 24 hours. • Provided 1584 kcal and 79 grams protein meeting 98% of kcal needs and 94% of protein needs at that point in time. • Adjusted due to Synthroid: • Glucerna 1.2 at 60 ml/hr continuous over 21 hours with one packet liquidProsourcedaily. • Provided 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs.

  26. NCP: Interventions • ND-2.1.4 Feeding tube flush: • Glucerna1.2 at 60 ml/hr over 21 hours with one packet of liquid Prosource daily met 58% of the patient’s fluid needs, requiring additional water. • Flush the NG tube with 125 ml water every 4 hours • Nursing touse enteral protocol to flush during medication administration.

  27. NCP: Monitoring and Evaluation • Ongoing monitoring of: • Weight • AD-1.1 Body composition/growth/weight • EN/PN regimen intake • FH-1.3.2 Parenteral Nutrition Intake • FH-1.3.1 Enteral Nutrition Intake • FH-3.1 Medication and herbal supplements • Labs • BD-1.2 Electrolyte and renal profile • BD-1.6 Inflammatory Profile • Medications

  28. Conclusion • Complicated cases may not be able to follow evidence-based guidelines at all times • Allergies pose problem to some patients who need enteral or parenteral support • Nutritional management of SF involved EN, PN, multidisciplinary cooperation for optimal outcome • EFAD avoided in this patient after trial dose of soybean lipid emulsion

  29. Conclusion • SF’s nutrition interventions involved initiation of PN, modification of the PN prescription, and finally introduction of EN • EN formula and rate changes made to avoid nutrient-medication interactions • Patient unable to be weaned from ventilator before discharge, but stable

  30. Conclusion • Patient had PEG tube placed for continued EN support • Tolerating tube feeding at goal at discharge: • Glucerna 1.2 @ 60 ml/hr x 21 hours with 1 packet liquid Prosource Daily • Providing total of 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs. • Water flushes: 125 ml q 4 hours and with medications • Trach-to-vent upon discharge • Discharged to long-term acute care facility due to extensive medical needs

  31. References 1. Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. W.B. Saunders; 2007. Pp. 155, 696-97, 741, 769-71, 916-17. 2. Diverticulitis. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION=treatments-and-drugs. Accessed 16 Jan 2012. 3. Acute Respiratory Distress Syndrome. PubMed Health website. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001164/ 4. Peanut Allergy. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/peanut-allergy/DS00710/DSECTION=risk-factors. Accessed 16 Jan 2012. 5. De Meijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218. 6. Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition Practice Guidelines. A.N.D. Evidence Analysis Library website. http://www.adaevidencelibrary.com/topic.cfm?cat=3016. Accessed 20 Jan 2012. 7. Martindale RG, McClave SA, 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 and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med 2009;37:1757-61. 8. Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. ClinNutr 2009; 28:387-400.

  32. References 9. Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, VandenBerghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17. 10. De Meijer VE, Gura KM, Le HD, et al. Fish oil-based lipid emulsions prevent and reverse parenteral nutrition-associated liver disease: the Boston experience. JPEN 2009;33:541–7. 11. Cunnane SC. Problems with essential fatty acids: time for a new paradigm? Prog Lipid Res 2003;42:544–68. 12. Waizberg DL, Torrinhas RS & Jacintho TM. New parenteral lipid emulsions for clinical use. JPEN 2006;30:351–67. 13. Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr2008;99: 846–854. 14. American Dietetic Association. International Dietetics and NutritionTerminology (IDNT) Reference Manual. 3rd ed. Chicago, Il: American Dietetic Association; 2011. 15. Ireton-Jones CS, Turner WW Jr, Leipa GU, Baxter CR. Equations for estimation of energy expenditures in patients with burns with special reference to ventilatory status. J Burn Care Rehabil. 1992;13:330-333. 16. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2010. 17. Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010.

  33. Questions?

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