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Critical Care Case Study. Nate Medunick. Patient JH. 91 YO female Dry weight – 121# (55kg) Height- 66” BMI-19.5

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patient jh
Patient JH
  • 91 YO female
  • Dry weight – 121# (55kg)
  • Height- 66”
  • BMI-19.5

Admission diagnosis: POD#3Hiatal hernia repair, Nissenfundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

estimated nutritional needs
Estimated Nutritional Needs

Based on actual weight in recent PMH (54kg)

Kcals 1350-1620 (25-30kcals/kg)

Protein – 70-81g (1.3-1.5g/kg)

Fluid 1620ml (30ml/kg)

High Nutritional risk

nissen fundoplication
Nissenfundoplication
  • A surgeon wraps the part of the stomach known as the gastric fundus around the lower esophagus (including the LES) in a Nissen fundoplication. This helps to strengthen the barrier and prevent the back flow of acids into the esophagus
diet after nissen fundoplication surgery
Diet After NissenFundoplication Surgery
  • Patients must make dietary and lifestyle adjustments for about six weeks following Nissenfundoplication surgery. Three days following surgery, most patients are on a clear liquid diet, which may include:
  • apple juice
  • beef broth
  • chicken broth
  • cranberry juice
  • decaffeinated tea
  • grape juice
  • Jell-O
  •  After the clear liquid diet, most patients are put on a full liquid diet for an additional three days. This diet consists of anything on the clear liquid diet plus the following:
  • Carnation instant breakfast (not chocolate)
  • creamed soups (strained, no broccoli or tomato)
  • cream of wheat (or cream of rice)
  • ice cream (vanilla or strawberry)
  • milk (no chocolate milk)
  • sherbet
  • yogurt (plain, blended, or custard with fruit or seeds)
  • Seven days after surgery, most patients are able to tolerate a soft food diet. However, to heal properly, patients must keep their stomach from stretching. This will require them to eat small, frequent meals six to eight times per day
hiatal hernia
hiatal hernia
  •  A hiatal hernia is what doctors call it when a part of the stomach moves up into the chest area. Normally, the stomach sits below the diaphragm, the layer of muscle that separates the organs in the chest from the organs in the belly. The esophagus, the tube that carries food from the mouth to the stomach, passes through a hole in the diaphragm. In people with a hiatal hernia, the stomach pushes up through that hole, too.
symptoms of hiatal hernia
symptoms of hiatal hernia
  • Burning in the chest, known as heartburn
  • Burning in the throat or an acid taste in the throat
  • Stomach or chest pain
  • Trouble swallowing
  • A raspy voice or a sore throat
  • Unexplained cough
patient jh1
Patient JH

91 YO female

Dry weight – 121# (55kg)

Height- 66”

BMI-19.5

Admission diagnosis: POD#3Hiatal hernia repair, Nissenfundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

initiating cmh rd k a
Initiating CMH RD- K.A.
  • TPN initiated with Day 1 bag- 50g/AA, 100g/dextrose, and no lipids
  • Recommendations Day 2/goal- 80g/AA, 250g/dextrose, providing 1170 calories
  • 50 g lipids Monday and Thursday ( lipid shortage at the time) with lipids, provides 1670 calories
  • Recommendations based on 25 kcal to

30 kcal per Kg for CCU Patient, not vented.

nutrition care nate di
Nutrition Care – Nate DI

Patient required intubation post op day exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes

  • Day 1 nutrition intervention followed initiating

RD care plan:

  • 50g AA, 100g dextrose, no lipids
  • Day 2 Nutrition plan based on dry wt-121
  • Kcals 1200-1375 (22-25kcal/kg--intubated)
  • Protein- 72-83g (1.3-1.5) wound healing
  • Fluid – Per Intensivist
  • Needs remained constant during care
day 2
Day 2
  • POD #1 S/P exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes
  • POD #5 hiatal hernia repair, Nissenfundoplication
  • patient continued on mechanical ventilation without sedation, but high doses of neosynephrine
  • lab values include: WBC 17.3 trending up (TU), total bilirubin 1.5 - TU, urine output- approximately 10 – 33 cc/hr
nutritional intervention day 2
nutritional intervention– Day 2
  • (intubated) Custom TPN- 1500ml-80gm/AA, 115gm/dextrose + 90 gm dextrose from D5 containing IVF, no lipids. Total: 1017 calories
  • Reviewed with Intensivist and asked if IVF would be adjusted
  • Plan moving forward: increase dextrose in TPN because D5 1/2NS was transitioned to NS
  • lipids would be added Monday and Thursday due to national shortage
  • nutritional monitoring and evaluation:

tolerance of TPN with goal of 80gm/AA, 200gm/dextrose, transition to jejunal tube feeding when appropriate per surgery recommendations

day 2 of care
Day 2 of Care

PES

  • P-Inadequate energy intake(improvement shown-unresolved)
  • E- S/P exploratory laparotomy (2/18)
  • S-TPN prescribed

GI assessment

  • abdomen-distended and soft
  • Bowel Sounds-hypoactive
  • Emesis color- tan

Skin

  • 2+ General edema
  • wounds-six total wounds including surgical wounds, Jackson Pratt, and G tube

fluid balance-2411.1ml

pharmacy-calcium chloride repletion

day 3 of care
Day 3 of care
  • POD#2 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity1 cal@ 10ml/hr (254kcal, 11gm/protein) prescribed by Thoracic surgeon (jevity1calwas MD preferred)
  • labs included: phosphorus 3.0 trending down (TD), potassium 4.1 stable, calcium 7.6 stable, magnesium 2.0 (TD), CO2/PCO2 38 (TD)
  • TPN order and discussed with Intensivist- 1500ml, amino acids-80gm (320kcal), dextrose-140gm (476kcal), lipids-40gm (400kcal)- no MVI, no trace elements, with trophic feeding, total calories/protein:1450 total kcals, 91 gm protein
  • Custom electrolytes K acetate 40mEq (potassium stable), Na phosphate 25 mEq ( repletion), Na acetate 22,Ca gluconate 9(stable), Mg sulfate 7(repletion)
learning experience
Learning experience
  • the original electrolyte plan - K acetate 40mEq , Na phosphate 25 mEq , Na acetate 22, Ca gluconate 9, Mg sulfate 7
  • Plan changed following a discussion with the Intensivist - concern was- Although; CO2 was TD, pH-7.38 Slightly more Acetate would possibly increase pH over 7.38
  • Acetate is added to correct Acidosis; Intensivist felt that the Patient was not trending toward acidosis at the time
day 4 patient declining
Day 4 – Patient declining
  • POD#3 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity 1cal @ 10ml/hr (254kcal, 11gm/protein)
  • patient continued on mechanical ventilation with propofol sedation and Neo-Synephrine weaned to lower dose
  • IVF-NS @ 50ml/hr continued
  • Labs include: Ca 8.0, Cl 112, Mg 2.0, Phos 1.8, and Potassium 3.7
  • nutritional intervention-TPN – 1500ml:
  • 80gm/amino acids (320kcal),
  • 165 gm /Dextrose (561kcal)
  • 6 ml/hr propofol (158 calories )
  • trophic TF (254 calories, 11 gm protein)
  • D5 carriers with multiple antibiotics (127 kcal)
  • Total ~1420 calories, 91 gm protein
  • TPN electrolytes 40mEq K acetate, 15 mEq K phosphate, 25 mEq Na phosphate, 9 mEq Ca gluconate, 7 mEq Mg sulfate. TPN discussed with Intensivist
  • Promote with fiber was recommended in note—no renal problems at the time; thoracic surgeon paged by RD. MD still preferred Jevity 1 cal
conclusion
Conclusion
  • JH was in poor condition toward the end of my nutritional care rotation:
  • Patient was requiring multiple antibiotics, including zyvox
  • LFTs/renal labs were elevating, multisytem organ failure ensued
  • I found out that JH soon expired due to poor condition and advanced age
  • I would not have changed anything with my nutritional plan of care
what i learned
What I learned
  • What I learned:
    • TPN and electrolyte needs
    • pH and acid/base balance
    • Intensivistsare approachable and a great information source
    • RD’s recommendations can show direct results in lab work
sources
Sources
  • http://www.healthline.com/health/gerd/nissen-fundoplication#2
  • http://www.uptodate.com/contents/hiatal-hernia-the-basics?source=search_result&search=Hiatal+hernia&selectedTitle=2%7E75