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Rebecca A. Davis ARAMARK Dietetic Internship RICHMOND UNIVERSTY MEDICAL CENTER
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  1. Clinical Case Report:Nutrition support Acute Respiratory Failure On Mechanical Ventilation and End Stage Renal Disease Receiving Hemodialysis Rebecca A. Davis ARAMARK Dietetic Internship RICHMOND UNIVERSTY MEDICAL CENTER

  2. Disease Description What is Respiratory Failure? • Respiratory failure is a rapid decline in respiratory function due to fluid retention in the lungs air sacs. • transport of oxygen to the blood and removal of carbon dioxide becomes impaired. • Failure to conduct proper gas exchange. • It is considered a syndrome rather than a disease state • It can be diagnosed as acute or chronic

  3. Description of Disease Altered gas exchange Altered ventilation

  4. Etiology of Acute Respiratory failure (ARF) • Ailments that damage breathing ability can give rise to ARF. • It can effect nerves, tissue and muscle invovled in breathing as well as impacting the lungs in a direct manner. • When breathing capacity is damaged oxygen cannot move freely into the blood and eliminate CO2

  5. Etiology of Acute Respiratory failure (ARF) • Lung Ailments (COPD, Pneumonia, Pulmonary embolism, Cystic fibrosis, Acute respiratory distress syndrome) • Damage to the chest or ribs and tissue surrounding the lungs can induce ARF. • Damage to Muscles and Nerves regulate breathing (Muscular dystrophy, Spinal cord trauma, ALS, Stroke)

  6. Etiology of Acute Respiratory failure (ARF) • Sudden onset of Lung damage (inhalation of dangerous chemicals and smoke can impair lung functuion) • Substance abuse/ OD • Complications involving the spine specifically scoliosis.

  7. 1

  8. Epidemiology of ARF • ARF is a complex of symptoms rather than a specific disease state. • Overall occurrence of ARF is not well documented. • 2001 and 2009 the number of patients admitted to the hospital for ARF rose from 1,007,549 to 1,917,910 a 56% influx with a p value of 0.0001. • In the United States, over 3 million patients admitted to the ICU for Acute Respiratory Failure require mechanical ventilation

  9. Pathophysiology of ARF • Respiratory failure can result irregularities found in the respiratory system: 1) the central nervous system 2) alveoli 3) peripheral nervous system 4) chest wall 5)respiratory 6) muscles and chest airways. • overall low blood volume, reduced blood movement secondary to the bodies in ability to pump adequate blood to meet the bodies needs.

  10. Clinical Signs and Symptoms • There are no hallmark signs symptoms for Respiratory failure. • signs and indicators are contingent on the volume of carbon dioxide and oxygen found in the blood stream as well as the underlying issue it’s related too.

  11. Clinical Signs and symptoms • REDUCED OXYGEN OUTPUT IN THE LUNGS 1) Shortness of breath 2) feeling that there isn’t enough air to inhale • SEVERE OXYGEN DEPRIVATION 1) Drowsiness 2) abnormal heart rhythms 3) bluish tint to fingernails, lips and flesh.

  12. Co-morbidities • TYPE 2 DIABETES- 1) The most common form of diabetes 2) Defined as insulin resistance 3) progressive ailment and can go unnoticed for many years. 4) Uncontrolled diabetes is linked to raising the chance of developing micro and macrovascularchallenges

  13. Co-morbidities • END STAGE RENAL DISEASE 1) loose ability to create hormones, maintain fluid/ electrolytes homeostasis and to filter out toxins that lead to symptoms of Uremia. 2) ESRD always progresses from Chronic kidney disease. 3) 90% of patients who develop ESRD have other comorbidities such as hypertension, Diabetes and Nephroticsyndrome 4) Patientswho reach the final stage of kidney disease either require renal replacement therapy or transplantation.

  14. Co-morbidities • SEPSIS 1) Serious bodily response bacterial infection causing widespread inflammation. also known as systemic inflammatory response syndrome (SIRS). 2) Most common areas for sepsis development is the skin, liver, lungs, bloodstream, Large intestine, bone, Kidneys, and brain. 3) Common indications are lethargy, elevated temperature, juddering, elevated heart beat, dizziness, fever and chills.

  15. Co-morbidities • PRESSURE ULCERS 1) constant pressure that inhibits movement of blood away from the heart to the skin and tissue that lies underneath 2) The key components contribute to pressure ulcers: physical immobility and involuntary urination. 3) it develops in Geriatric patients with psychiatric problems, deeply sedated and those with dementia who cannot independently move. 4) There are four main stages for decubitus based on how deep the wound is and the amount of tissue affected. After stage 4 pressure ulcers considered unstageable

  16. Co-morbidities • HYPERTENTION 1) Elevated blood pressure 2) Pushes blood to come in contact with the arterial wall causing pressure 3) Symptoms may not arise for many years. 4) Uncontrolled blood pressure can contribute to the onset of Strokes and heart attack

  17. Evidence –Based Nutrition Recommendations • Currently equations used to calculate REE are not reliable and make it difficult to truly identify the energy needs of ICU patients causing undernourishment especially among those mechanically ventilated • Patients that are intubated and necessitate mechanical ventilation for extended periods of time are said to have great variation in the amount of energy needed over a 24 hour period also know as REE. Faisy C., Lerolle N., Dachraoui F., Savard JF., AbboudImad., Tadie JM., Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. 2009; British journal of Nutrition. 101: 1079-1087.

  18. Evidence –Based Nutrition Recommendations • In an observational/retrospective study by faisey et al, it was discovered that patients whose’ ICU stay ended in mortality had a much higher daily energy insufficiency compared to those ICU patients who survived with a p- value of 0.004. • Additionally,Twenty-five of these patients had an average daily loss of 1200 calories and had a higher death rate (13 deaths) after a two week period compared to those patients in the ICU with a lower calorie deficit , a significant p- value of 0.01. Faisy C., Lerolle N., Dachraoui F., Savard JF., AbboudImad., Tadie JM., Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. 2009; British journal of Nutrition. 101: 1079-1087.

  19. Evidence- Based Nutrition Recommendation • Challenges with the research: 1) The observed patient population consisted of a small sample size 2) A large percentage of the patients observed had renal failure requiring feed and fluid volume constraints. 3) stops on enteral nutrition support related to serious enteral nutrition GI intolerances and medical procedures took place approximately 23% of time patients were observed and surveyed. Faisy C., Lerolle N., Dachraoui F., Savard JF., AbboudImad., Tadie JM., Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. 2009; British journal of Nutrition. 101: 1079-1087.

  20. Evidence –Based Nutrition Recommendations • Providing adequate nutrition is even more challenging among mechanically vented patients with ARF who also present with ESRD and require renal replacement therapy. • Undernourishment is a occurs often among patients with chronic kidney disease. • Malnutrition is prevalent in 9 to 72% of patients receiving dialysis. Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. MultinutrientOral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

  21. Evidence-Based Nutrition Recommendation • Stratton et al (2005) reviewed 18 studies, 13 non-randomized control trials and 5 studies that were randomized in order to ascertain the advantages of enteral nutrition support among patients getting dialysis treatment. In one particular control trial, studying undernourished hemodialysis patients; a substantial 12% influx of post dialysis weight was discovered after a 3- month mediation of enteral nutrition support. Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

  22. Evidence-Based Nutrition Recommendations • Within the Systematic Review, Meta analysis of 1 Randomized Control Trial and 2 Control Trials uncovered a relationship between higher blood albumin levels and adequate Enteral nutrition feeds. • 95% confidence interval (0.037 to 0.418 g/dL) without significantly effecting serum electrolytes. • Stratton and colleagues also cited an international multicenter study in which albumin levels that were lower than 3.5 g/dL were linked to a 1.38 higher risk of mortality supporting there findings. Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405. CombeC., McCullough KP., Asano Y. et al: Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and practice patterns Study (DOPPS): Nutrition guidelines, indicators and practices. Am J kidney Dis. 2004; 44(suppl 2): S39-S46.

  23. Evidence-Based Nutrition Recommendation • Sharma et el, found that standard formulas and those designed for specific disease states were similar in composition. No dissimilarities in protein and caloric intake were identified when comparing patients who received standard formulas against those catering to specific disease states Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

  24. Evidence-Based Nutrition Recommendation • Challenges with the research……. 1) Lack of supportive data to measure the effect of enteral nutrition support on clinical outcomes as well as the use of formulas catering to specific disease states. 2) Large percentage of the results were inconclusive Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

  25. Evidence-Based Nutrition Recommendation • The evidence-based nutrition recommendations for patients with acute respiratory failure with End stage renal disease receiving mechanical ventilation and renal replacement therapy. • However, it is clear that malnutrition contributes to patient mortality and that it is vital for patients to receive adequate calories and protein to increase the chances of survival in the medical ICU. • Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

  26. Case Presentation • An 87 year old black male presented to the ER with altered mental status and decreased arousability. • Hospital course was complicated by cardiac arrest, primarily due to acute respiratory failure. • Patient stabilized, intubated and admitted to the medical ICU.

  27. Case presentation COMORBIDITIES • Septic shock likely due to stage III sacral pressure ulcer • chronic anemia • Dehydration INITIAL TREATMENT • Intravenous vasopressors, Norepinephrine, Vancomycin and Zosyn for septic shock • aggressive IV hydration, (Normal saline 2 liters bolus) • FeSO4 for anemia.

  28. Nutrition Care: Assessment • The American Dietetic Association advocates that Registered Dietitians utilize the Nutrition Care Process as a primary step in the provision of Medical Nutrition Therapy and should be an essential constituent of medical therapeutics and management of specific ailments. The nutrition care process was applied for the current case subject.

  29. Client History The patients’ personal, family, social and immunization history could not be obtained as well as his history and physical due to the fact that the patient is unresponsive and has no family. RUMC Previous Admission: recurrent hypernatremia, AKI, E-coli in the urine, elevated LFT’s calcium and Blood Urea Nitrogen, sepsis, and hyperkalemia. According to the nursing home assessment the patients Past Medical History : Diabetes, GERD, Hyperlipidemia, Hypertension, Schizophrenia, DVT, BPH, Glaucoma, blindness, hypothermia, PEG placement, suprapubic catheter placement, neurogenic bladder, sepsis due to UTI, dysphagia, anemia and Chronic Kidney Disease.

  30. Food/Nutrition-Related History Data could not be obtained from Patient due to intubated and mechanical ventilation. Nursing home assessment note: 1. Diet: Glucerna 1.2 @ 160 ml/hr 2. Daily MVI and 4 Prostat to assist in wound healing. 3. Daily dose of FeSO4 to treat chronic anemia. 4. Medication: NovologAspart – low dose algorithm + Lantus

  31. Nutrition- Focused Physical Findings

  32. Nutrition Focused Physical Findings

  33. Anthropometric Measurements • height is 5’ 11”(AD-1.1.1). • weight upon admission was 163lbs or 74kg • BMI of 22.75 - weight within normal limits. • IBW of 172 lbs. +/- 10% (AD-1.1.2, AD-1.1.5) • Pre and post dialysis weight was also documented.

  34. Biomedical Data, Medical Tests and Procedures

  35. Biomedical Data, Medical Tests and Procedures Pertinent medical tests and procedures • Tunneled hemodialysis catheter place • PEG Tube replacement • Tracheostomy • Intubation and mechanical ventilaion • Urine analysis

  36. Nutrient Needs – Upon admission • Macronutrient requirements were estimated to be at a range of 2000-2200 calories. • 109-117 g protein • 2000 mL / day

  37. Nutrient Needs –B4 dialysis Calories – 2160 Protein 87g Fluid 783 mL H20

  38. Nutrition Status Classification • ARAMARK Nutrition status:

  39. Nutrition Status Classification *FOLLOW UP ASSESSENTS TOOK PLACE EVERY 4 DAYS AFTER INITIAL CONSULT TILL THE DAY OF DISCHARGE

  40. Nutrition Care Process: Nutrition Diagnoses #1. Increased nutrient needs (NI-5.1) related to skin integrity, wound healing as evidence by skin break down. (4 x unstageable decubiti, 2x stage II Deep Tissue Injury and excoriated scrotum). #2. Inadequate intake of enteral nutrition (NI-1.2) related to estimated calorie needs, new admission, s/p intubation as evidence by feeds not at goal. #3. Altered GI function (NC-1.3) related to C-DIFF as evidence by severe diarrhea

  41. Nutrition Care Process: Interventions #1. Enteral Nutrition, (ND-2.1). Recommend substituting current enteral nutrition order for Replete Plus Fiber at 90mL/hr x 24 hours. This will provide 2160 kcal, 127g proteins, and 1703 mL H20. #2. Nutrition-related medication management; (ND-6.1). Recommend modifying insulin dose per MD. #3. Vitamin and mineral supplements; Multivitamin/mineral, magnesium (ND-3.2.1). #4. Nutrition-Related Medication Management (ND-6), Nutrition related complementary medicine. Recommend Probiotic.

  42. Nutrition Care Process: Interventions • Short-term goals • Prevent further skin breakdown • Advance EN to Goal 3. Achieve better control over blood Glucose

  43. Nutrition Care Process: Interventions • Long-term goals • Meet 100% of the patients energy and protein need via enteral nutrition support. • The patient will present will less pressure ulcers and will heal in a timely manner. • The patient will maintain normal blood glucose levels.

  44. Nutrition Care Process: Monitoring and Evaluation #1. Food /Nutrition-Related History (FH). Enteral nutrition intake (1.3.1) Tolerance and rate of enteral nutrition support were monitored during every follow up. #2. Biochemical Data, Medical Tests, and Procedures (BD). Electrolyte and renal profile. The patient’s laboratory values and electrolyte were closely monitored and addressed if abnormal. #3. Biochemical Data, Medical Tests, and Procedures (BD). Gastrointestinal (BD1.4) patient had C-Diff. During the patient’s diarrhea episodes it was recommended to put a hold on the laxatives and to administer a probiotic.

  45. Conclusion The clinical case subject was complex in nature requiring-long term mechanical ventilation and presented with many comorbidities. He was initially diagnosed with acute respiratory failure secondary to cardiac arrest that eventually advance to chronic respiratory failure.

  46. Conclusion His hospital course was complicated: 1.Intubation 2. Sepsis 3. uncontrolled blood glucose 4.multiple deep wound pressure ulcers 5. C-DIFF induced diarrhea 6. Constipation 7. PEG tub infection 8. electrolyte abnormalities 9. placement of a tunneled catheter for dialysis treatment.

  47. Conclusion • Main interventions: • Enteral nutrition support- received different formulas and rates over the course of his hospital stay depending on his clinical state at the time. • The patient was recommended 1.4-1.5 grams per kg or protein. He was also recommended an MVIto aid in wound healing. • Adjustments were made to the patient’s insulin regimen when blood glucose was significantly out of range • The patient was also administered a probiotic to help alleviate C-DIFF induced diarrhea.

  48. Conclusion • During final follow- up assessment Phosphorus was trending up. • Before discharge it was recommended to switch enteral feeding once more back to Nepro@50mLx24. • It was also suggested to continue administering a MVI supplement and to adjust his insulin dose as needed. • patient was stable before discharge and was sent to a nursing home in Brooklyn where he will receive long-term care

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