Dependant Respiratory Failure Jannick Davis Morrison Chartwells Dietetic Internship Fresno CA Preceptor Sheryl DeSantos December 3 2014 Acknowledgements A special thank you to all my preceptors ID: 780210
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Slide1
Nutrition Therapy: Transverse Myelitis & Ventilator Dependant Respiratory Failure
Jannick
Davis
Morrison/
Chartwells
Dietetic Internship
Fresno
, CA
Preceptor: Sheryl
DeSantos
December 3, 2014
Slide2Acknowledgements
A special thank you to all my preceptors:
Rosel
Salinas, Heather
Paulissen
, Sheryl De Santos, Karen McNeely, Leslie Luna,
MaryBeth
BelCastro
. I have learned so much from each of you. And to
Karissa
Bouchie
CNM, RD and Karen Smith thank you for making my clinical rotation possible!
Slide3Overview
Introduction
Background: Nutrition Related Factors-pathophysiology
Patients History/Data
-Pertinent Patient Events
-Nutritional/Social/Growth/Surgical
- Initial Encounter with A.P.
-Follow UP encounters
4. Discussion
-Role as RD
-Effectiveness of treatment
5. Conclusion-Patients current status
-Questions??
Slide4Introduction
Is a 57
yr
old
White MaleAdmitted to ICU for worsening ascending paralysis & difficulty breathing
Active ProblemsTransverse Myelitis * LeukocytosisImpaired glucose intolerance *HyponatremiaCerebral Palsy (PMH) *MRSA Hypertension (PMH) *UTIVentilator dependancy Respiratory * Bradycardia Failure * Cecal Ileus
Slide5Pathophysiology-Transverse Myelitis: Nutrition Related Factors
Causes injury to the spinal cord
Has various degrees of severity & dysfunction to Autonomic Nervous System.
1
Controls Involuntary activity: (Heart, Breathing,
Digestive System
, Reflexes)
Post infectious: Measles, Rubella,
mycoplasma in spinal fluid
Slide6Pathophysiology-Transverse Myelitis cont…
As ascending paralysis worsened
patients autonomic
systems began being affected
Went from breathing on own to Ventilator
dependance
Heart Healthy diet to strictly Tube Feed
Became glucose intolerant
Unable to speakDeveloped ileus
Slide7Pathophysiology-Nutrition Related Factors
Systematic Review showed
:
Blood Glucose Control:
With
Intense Insulin Therapy treatment
vs
conventional insulin therapy 5,6
In regards to: (Overall--NO significant benefit)LOS some studies showed decrease in mechanical ventilation days 6 Ventilator Respiratory Dependency FailureWith Enteral Nutrition and permissive underfeeding vs Eucaloric feeding
Classified as tube feed meeting 60%-70% of estimated nutritional needs
Slide8Pathophysiology: VDRF continued…
Hypocaloric
group showed
Decreased LOS & Mechanical Ventilation days
Fewer Antibiotic days
No Significant difference in nitrogen balance or Serum Protein response
4
With Gastric VS. Small Bowel Feed
: Results showed significant effectshours to reach target goal rate from admission with GF was lessDecreased LOS and days on Mechanical ventilation with Gastric feedsAvg daily Energy and protein deficit was less with Gastric feedsNo advantage to early post-pyloric feeding 3,7
Slide9Meet the Patient
57
yo
white male
Admitted to ICU
for
worsening ascending paralysis
Height: 180.3 cm (5’10.98”)
Weight: 125.07 kg (275 lbs 11.2 oz)BMI: 38.47 kg/(m^2)IBW: 75 kg% IBW: 166% UBW: 286 lbs per A.P.
Slide10Patient Data: UBW
vs
IBW
Slide11Meet the Patien cont
…
Admitted originally on ~7/2014 for Shingles on trunk area
→
Readmitted 9/1 for Transverse
Myelitis
(post infection)
→ Transferred to inpatient
Rehab → Transferred to ICU for worsening of breathing /unable to move extremities →Transferred to Stepdown for continued monitoring
Slide12Patient Data-Weight Encounters
Slide13Biochemical Data: LABS
(9/21)
(10/21)
(10/23)
(10/27)
(10/29)
Normal Range
Na+
131 ↓128 ↓
129 ↓
135
135
135-145
mmol
/L
K+
3.9
4.6
4.3
3.9
4.3
3.5-5.3
mmol
/L
CO2
33
↑
29
↑
29
↑
38
↑
34
↑
22-28
mmol
/L
Glucose
114
↑
123
↑
115
↑
104
↑
107
↑
70-99 mg/
dL
BUN
30
↑
23
↑
33
↑
32
↑
27
↑
6-20 mg/
dL
Cr
0.7
0.7
0.6
↓
0.4
↓
0.4
↓
0.7-1.3 mg/
dL
Calc
Osmol
279
↓
271
↓
276
↓
287
286
282-300
mosm
/kg
Slide14Pertinent Patient Events
(9/19) pt was still on Heart Healthy diet
(9/21) Passed swallow evaluation
Post infectious
polyneuropathy
(9/23) SLP evaluation/Pt
intubated
became NPO
MRI C Spine showing C2 demyelinating plaque & edema extending from medulla down to C7 (9/24) Pacemaker placed for bradycardiaTF was on Hold(10/4) possible Cecal Ileus
per CT (Started on trophic
TF rate with elemental
Vivonex
)
(10/10) PEG placed
Cecal
Ileus resolved
Slide15Initial Encounter
Assessment
Rt
lung collapse 2/2 mucous plug s/p
bronchoscopy
10/19.
Lasix held 2/2 MAP below 60
Leukocytosis resolved
GCS 11T-AMSDrop in Na+ noted/ Pt w/Fluid overload
TF turned off at time of visit for postural drainPt on aggressive Bowel Regimen
Meds:
Dulcolax
, Colace,
Senokot
, MOM,
Phos-Nak
,
Flagyl
,
Solu-Cortef
, Acyclovir,
Vit
D3,
Vit
B12
TF order
:
Vivonex
running @ 90 mL/
hr
(Providing (No Residuals)
BMI: 38.47 kg/(m^2)
Skin Intact
GI
Abd
round/no guarding, LBM (10/18) > BS-Hypoactive > Pitting edema RUE/LUE
Slide16First Encounter continued
Nutrition
Dx
:
Inadequate Energy-Protein Intake Related TO for postural drainage for
plasmapharesis
AS Evidenced By TF on hold
Estimated Needs: (Calculated w/ Penn State: using 125 kg) 2197
Kcals; 91-113 kg pro (1.2-1.5 g/kg IBW); 2197 mL fluids (1 mL/kcal) or fluids per MD
Intervention: If ileus resolved, recommend transitioning TF to non-elemental formula
Fibersource
HN @ 75
mL
/hr (to provide 2160
kcals
, 97 g pro, 1476
mL
free H2O
Spoke with NP agreed with above recommendation
Monitoring/Evaluation:
TF transition
EN Tolerance
Total energy-protein intake
Goals:
Once re-
intiated
TF will continue to meet 100% of estimated needs by next RD follow up
Slide17Nutrition Follow Up 1
Working
Dx
possibly VSV or HSV
Hyponatremia /low serum osmolality
2/2 volume depletion vs edematous vs Cerebral salt wasting vs SIADH
TF Order:
changed to Diabetisource running @ goal rate of 75 mL/hr (To provide: 2160 kcals, 108 g pro, 1476 mL free water
>Previous Nutrition goal was met No significant change to:Nutrition DxGoals
Intervention:Continue with current TF orderMonitoring/Evaluation
EN tolerance/labs
Slide18Nutrition Follow Up 2
Hyponatremia still being explored- Given NaCl tablets
No improvement in motor sensory
Plasmapharesis every other day
SLP eval- Working on communicative device
Fluid retained since admission +6,151 L
Pt retaining large volume of fluids
Low Na+ 2/2 fluid overload
Slide19Follow Up 2 Continued
Intervention
Recommended temporarily changing TF to Nutren 2.0 @ rate of 45 mL/hr. (To provide 2160 kcals, 86 g pro, 777 mL free water)
Goal:
If TF changed pt will be at estimated needs within 24-48 hrs
If TF remains the same, will continue to meet 100% of estimated needs
Previous Goal metMonitor/Evaluation:TF formula change, EN tolerance, Labs
Slide20Nutrition Follow Up 3
Pt started on
Nutren
2.0 10/27 (pt tolerating per RN)
running at goal rate at time of visit
Edema UE +3/ LE +2
Hyponatremia
improving
No Nutrition Diagnosis at this timeNo Significant change to:Intervention/Goal/Monitor/Evaluation
Slide21Discussion
What is the role of the dietitian (and my role) in caring for this patient and others with similar conditions?
Tolerance of TF
Adequate nutrition with fluctuating ventilation requirements
What was the patient’s overall response to nutrition care?
Pt tolerated transition of tube feed formulas quite well
No major abdominal issues
What are some of the barriers to providing appropriate nutrition care in this situation?
Pt unable to speakWas sedated on all visits GCS didn’t go above 11 Did you encounter any unexpected findings in the completion of the case study? Did anything surprise you?Patients status- stable no improvement with TM
Slide22Conclusion
Pt was transferred to stepdown a week later
Not quite stable enough to be transferred to a Long term care facility yet
Unclear if patient will fully recover from TM
Nutritionally he has his PEG for long term EN
Slide23References
1.
Available at: http://myelitis.org/symptoms-conditions/transverse-myelitis/. Accessed November 26, 2014.
Labiano
-
fontcuberta
A, Mitchell AJ, Moreno-
garcía S, Puertas-martín V, Benito-león J. Impact of anger on the health-related quality of life of multiple sclerosis patients. Mult Scler. 2014; Accessed November 26, 2014 from www.healthline.co/health/multiple-sclerosis/demyelination#Overview1+Arabi YM, Tamim HM, Dhar
GS, et al. Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr
. 2011;93(3):569-77.
Dickerson RN,
Boschert
KJ,
Kudsk
KA, Brown RO.
Hypocaloric
enteral
tube feeding in critically ill obese patients.
Nutrition.
2002; 18: 241-246.
Finfer
S,
Chittock
DR, et al, for the
The
Normoglycemia
in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) Investigators. Intensive versus conventional glucose control in critically ill patients.
NEJM.
2009; 360(13): 1,283.
Van den
Berghe
G, Wilmer A,
Hermans
G,
Meersseman
W, Wouters PJ, Milants I, Wijngaerden EV, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical icu. N Engl J Med 2006; 354:449-61. White H, Sosnowski K, Tran K, Reeves A, Jones M. A randomised controlled comparison of early post-pyloric vs. early gastric feeding to meet nutritional targets in ventilated intensive care patients. Crit Care. 2009; 13(6): R187. Epub: 2009 Nov 25. PMID: 19930728.
Slide24Any Questions???