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 .
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Clinical Case Report:
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Clinical Case Report:Nutrition support Acute Respiratory Failure On Mechanical Ventilation and End Stage Renal Disease Receiving Hemodialysis
Rebecca A. DavisARAMARK Dietetic InternshipRICHMOND UNIVERSTY MEDICAL CENTER Slide2
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 chronicSlide3
Description of Disease
Altered gas exchange
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
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.
Sudden onset of Lung damage (inhalation of dangerous chemicals and smoke can impair lung functuion)
Substance abuse/ OD Complications involving the spine specifically scoliosis. Slide7
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
Pathophysiology of ARF
Respiratory failure can result irregularities found in the respiratory system: 1) the central nervous
system 2) alveoli
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. Slide10
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. Slide11
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
2) abnormal heart rhythms
3) bluish tint to fingernails, lips and flesh. Slide12
YPE 2 DIABETES- 1) The most common form of diabetes 2) Defined as insulin resistance
3) progressive ailment and can go
for many years
Uncontrolled diabetes is linked to raising the chance of developing micro and macrovascular challengesSlide13
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.
90% of patients who develop ESRD have other
such as hypertension, Diabetes and
4) Patients who reach the final stage of kidney disease either require renal replacement therapy or transplantation.Slide14
intestine, bone, Kidneys, and brain. 3) Common indications are lethargy, elevated temperature, juddering, elevated heart beat, dizziness, fever and chills. Slide15
PRESSURE ULCERS 1) constant pressure that inhibits movement of blood away from the heart to
the skin and tissue that lies underneath
The key components contribute to
ulcers: physical immobility and
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 unstageableSlide16
1) Elevated blood pressure2) 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
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
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.Slide18
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.
N., Dachraoui F., Savard JF., Abboud Imad
., 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.Slide19
Evidence- Based Nutrition Recommendation
Challenges with the research: 1) The observed patient population consisted
of a small sample size
percentage of the patients
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.,
JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. 2009;
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
% of patients receiving
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.Slide21
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
Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.Slide22
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
higher risk of mortality supporting there findings.
Stratton RJ., Bircher G.,
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.Combe C., 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.Slide23
Evidence-Based Nutrition RecommendationSharma 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
Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.Slide24
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
catering to specific disease
2) Large percentage of the results were inconclusiveStratton 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.Slide25
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.,
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.Slide26
An 87 year old black male presented to the ER with altered mental status and decreased
course was complicated by cardiac arrest,
primarily due to acute respiratory failure.
Patient stabilized, intubated and admitted to the medical ICU.Slide27
COMORBIDITIES Septic shock likely due to stage III sacral pressure ulcer
Zosyn for septic shock aggressive IV hydration, (Normal saline 2 liters bolus) FeSO4 for anemia. Slide28
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. Slide29
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
and Blood Urea Nitrogen, sepsis, and hyperkalemia.
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. Slide30
Data could not be obtained from Patient due to intubated and mechanical ventilation. Nursing home assessment note:
Electrolytes are within normal limits. Patient is receiving dialysis
10/16 – 10/20
Abdominal distention, PEG tube is disconnected. Possibly due to pressure ulcers. Suggested TPN with Prolonged NPO.
Replete Plus Fiber
Peg Tube replaced, safe to restart feeding regimen. It was suggested to increased feed to 90 mL/her
Replete Plus Fiber
Patient received Replete at 90 mL/
till the day of discharge Slide42
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).
goalsPrevent further skin breakdownAdvance EN to Goal3. Achieve better control over blood Glucose Slide44
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. Slide45
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. Slide46
ConclusionThe 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. Slide47
His hospital course was complicated: 1.Intubation2. Sepsis3. uncontrolled blood
glucose4.multiple deep wound pressure
tub infection8. electrolyte abnormalities9. placement
of a tunneled catheter for dialysis treatment. Slide48
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
MVI to aid in wound healing.
Adjustments were made
to the patient’s insulin regimen when blood
significantly out of range
The patient was also administered a probiotic to help alleviate C-DIFF induced diarrhea. Slide49
ConclusionDuring 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 Slide50
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Clinical Case Report: - Description
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 ID: 325169 Download Presentation
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