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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 .

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Clinical Case Report:






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Slide1

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

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 chronicSlide3

Description of Disease

Altered gas exchange

Altered ventilation

ACUTE

RESPIRATORY FAILURE

TYPE

1 HYPERCAPNIA

TYPE

2

HYPERPOXEMIA

Slide4

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

Slide5

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)Slide6

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. Slide7

1Slide8

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 Slide9

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. 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

1) Drowsiness

2) abnormal heart rhythms

3) bluish tint to fingernails, lips and flesh. Slide12

Co-morbidities T

YPE 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 macrovascular challengesSlide13

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

Nephrotic syndrome

4) Patients who reach the final stage of kidney disease either require renal replacement therapy or transplantation.Slide14

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. Slide15

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 unstageableSlide16

Co-morbidities HYPERTENTION

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

attack Slide17

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., 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.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.

Faisy

C.,

Lerolle

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

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.,

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.Slide20

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. 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

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.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

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.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

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.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

formulas

catering to specific disease

states.

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.,

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.Slide26

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.Slide27

Case presentation

COMORBIDITIES Septic shock likely due to stage III sacral pressure ulcer

chronic anemia

Dehydration

INITIAL TREATMENT

I

ntravenous

vasopressors, Norepinephrine,

Vancomycin

and

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

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. Slide30

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:

Novolog Aspart – low dose algorithm + Lantus Slide31

Nutrition- Focused Physical FindingsSlide32

Nutrition Focused Physical FindingsSlide33

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.Slide34

Biomedical Data, Medical Tests and Procedures

Abnormal Laboratory values upon admission

Normal

Patients value

Sodium

136-145

133

Potassium

3.5-5.1

5.7

CO298-107 14BUN7-18 107

Creat0.6-1.3 4.2Glucose74-106 175Phosphorus2.5-4.9 2.3

Magnesium

1.8-2.4

1.6Slide35

Biomedical Data, Medical Tests and ProceduresPertinent medical tests and procedures

Tunneled hemodialysis catheter place PEG Tube replacementTracheostomyIntubation and mechanical ventilaion

Urine analysisSlide36

Nutrient Needs – Upon admission

Macronutrient requirements were estimated to be at a range of 2000-2200 calories.109-117 g

protein2000 mL /

day

Slide37

Nutrient Needs –B4 dialysis

Calories –

2160Protein 87g

Fluid 783 mL H20Slide38

Nutrition Status ClassificationARAMARK Nutrition status:

Nutrition Care Indicator Category

Highest Points Assigned

Nutrition History

3

Feeding Modality/Nutrition Care Order

4

Unintentional Weight Loss

0

Weight Status

0

*Serum Albumin or Pre-albumin3

Dx/Condition

34

TOTAL POINTS

44 points Slide39

Nutrition Status Classification

Nutrition Status Classification

Points

Severely compromised (Status 4)

> 12

*FOLLOW UP ASSESSENTS TOOK PLACE EVERY 4 DAYS AFTER INITIAL CONSULT

TILL THE DAY OF DISCHARGESlide40

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

diarrheaSlide41

Date

Energy Intake Status

Formula Indication

9/5

NPO

X

S/P intubation

9/6-

9/11

Enteral Nutrition

Replete Plus Fiber

30mL/hr to goal 70 mL/hr

Slow progression of feeds related to abdominal distention

9/12-

9/29

Enteral Nutrition

Nepro

45 mL/hr

Deteriorating kidney function. Possible dialysis.

10/1-

10/13

 

Enteral Nutrition

Nepro

50 mL/ht

Increased to meat caloric needs: 2160 kcal, 97g protein, 870ml H20

10/14-

10/15

Enteral Nutrition

Replete Plus Fiber

50 mL/hr

Electrolytes are within normal limits. Patient is receiving dialysis

10/16 – 10/20

NPO

X

 

Abdominal distention, PEG tube is disconnected. Possibly due to pressure ulcers. Suggested TPN with Prolonged NPO.

10/21-

11/5

Enteral Nutrition

Replete Plus Fiber

50 mL/hr

Peg Tube replaced, safe to restart feeding regimen. It was suggested to increased feed to 90 mL/her

11/6-

12/13

Enteral Nutrition

Replete Plus Fiber

90 mL/hr

Patient received Replete at 90 mL/

hr

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).

#4. Nutrition-Related Medication Management (ND-6), Nutrition related complementary medicine. Recommend Probiotic.Slide43

Nutrition Care Process: Interventions Short-term

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

Conclusion

His hospital course was complicated: 1.Intubation2. Sepsis3. uncontrolled blood

glucose4.multiple deep wound pressure

ulcers

5.

C-DIFF induced

diarrhea

6. Constipation

7. PEG

tub infection8. electrolyte abnormalities9. placement

of a tunneled catheter for dialysis treatment. Slide48

ConclusionMain 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

MVI to 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. 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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