Pamela C Vickers Candler Hospital Dietetic Internship Clinical Rotation Georgia Southern University April 14 2015 Patient Data Name Mr X Sex Male Age 53 years old Height 510 ID: 780434
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Slide1
Intensive Care Unit: Cardiac Arrest – A Case Report
Pamela C. Vickers
Candler Hospital: Dietetic Internship Clinical Rotation
Georgia Southern University
April 14, 2015
Slide2Patient Data
Name: Mr. X
Sex: Male
Age: 53 years old
Height: 5’10”
Weight: 156 lbs.
BMI: 22.5 kg/m
2
, normal
IBW: 166 lbs.
% IBW: 94%
Admit Date: 03/24/2015
Slide3Social, Diet, & Weight History
Social History (per reports):
Happily married with children
Employed
Former smoker: wife unable to report how much he smoked or the duration of his smoking
Drinks 3-4 beers a day Urine tested positive for benzodiazepines and marijuana No significant medical history on file
Diet and Weight History (per reports):
Due to the patient being intubated, the patient’s diet and weight history were unable to be obtained.
Per MD reports, patient was well-nourished upon arrival with a normal body mass index and no signs of malnutrition
Currently nothing-by-mouth
Nutrition provided
enterally
through a percutaneous endoscopic gastrostomy (PEG) tube
Slide4Past Medical History (per reports)
Uncontrolled, systemic hypertension
“High blood pressure in the systemic arteries – the vessels that carry blood from the heart to the body’s tissues (other than the lungs)”
1
Severe degenerative joint disease “form of arthritis that occurs when the protective cartilage on the ends of the bones wear down over time”
2
Iron deficiency anemia
“type of anemia in relation to insufficient iron in the blood stream
.”
3
Slide5History of Present Illness & Presenting Symptoms (per reports)
Witnessed ventricular fibrillation, cardiac arrest on March 24, 2015
Colleagues performed CPR for 45 minutes before EMT arrived and successfully resuscitated Mr. X on the way to the emergency department
Upon arrival to the emergency department, Mr. X was stabilized and placed on a central line. He is currently intubated and under mechanical ventilation.
Slide6Admitting & Current Diagnosis(es) (per reports)
Cardiac arrest in coordination with uncontrolled hypertension
Cardiac arrest: “
unexpected loss of heart function usually resulting from an electrical disturbance in the heart that disrupts the pumping action and stops blood flow to the rest of the body”.
4
Slide7Anoxic Encephalopathy (anoxic brain injury): “results in a patient remaining comatose or demonstrating neurological impairments”
5
Cardiac arrest disrupts blood flow (oxygen) to the brain; “once oxygen is no longer supplied to the brain, the brain will begin to shut down, thus, causing brain damage or eventual death.”
5
Slide8Current & Planned Medical Interventions (per reports)
Ventricular fibrillation: currently on
amiodarone
drip which he will remain on until current arrhythmias are stable
Hypertension: anti-hypertensive medications
Acute Respiratory Failure: ventilation support Per family request, Mr. X remains full code and will receive aggressive care. Mr. X is receiving continuous tube feeding of Jevity 1.2 at 30 mL/
hr
with a goal rate of 65 ml/
hr
through a PEG tube.
Slide9Estimated Energy Needs
Slide10Penn State Compared to Mifflin St. Jeor
Mifflin St. Jeor (
extubation
status)
Estimated Energy Needs:
1,873 – 2,029 kcals/day Estimated Protein Needs: 57-71 grams of protein/day Estimated
Fluid Needs:
1,873
– 2,029
mL/kcal
Penn State is more appropriate for calculating Mr. X’s estimated needs
Ventilation settings
Maximum body temperature in the past 24 hours to determine if a fever is present or not
Slide11Current Diet Order and Feeding Modality
Mr. X is currently receiving nutritional support through a PEG tube with continuous tube feedings.
C
urrently
on
Jevity 1.2 at 30 mL/hr with a goal rate of 65 mL/hr Jevity 1.2 at 30 mL/hr. provides 864 kcals and 42 grams of protein, meeting 50% estimated energy needs and 49% estimated protein needs
.
The tube feed at goal rate of 65 mL/
hr
will provide 1,872 kcals and 87 grams of protein, meeting 109% estimated energy needs and 100% estimated protein needs
.
Continuing to advance to goal rate and patient is tolerating at this moment
Slide12Parameter
Normal
Value Range
Patient’s Value (High
or Low)
Reason for Abnormality
Nutrition Implication
Potassium
3.7-5.2
mEq
/L
3.4 (L)
Use of diuretics for treating high blood
pressure
6
When medically feasible, consume a diet high in potassium rich foods to help increase potassium levels in the blood and lower high blood
pressure.
7
Consume potassium supplements either orally or through an IV
drip.
7
Glucose
70-110 mg/dL
128 (H)
Stress response from
injury
6
Monitor blood glucose levels daily to ensure they do not come within hyperglycemic ranges which can result in slower healing and
dehydration.
7
AST
10-34 IU/L
42 (H)
Cardiac arrest and lack of blood flow to the
liver
6
Consume a low-protein diet and avoid alcohol intake to improve AST
levels.
7
Total Protein
5.9-8.4 g/dL
5.1 (L)
Stress response from
injury
6
Total protein should be monitored as an indicator of the healing
process
7
Albumin
3.5-5.2 g/dL
2.3 (L)
Stress response from
injury
6
Though not used as a nutrition indicator, still monitor as an indicator of the healing
process.
7
Slide13Medications
(brand name & generic)
Used
to treat?
Mechanism
of Action
Nutritional
Implications/
Interactions
Ondansetron
HCL
(Zofran)
Used to treat nausea and vomiting caused by cancer drug treatment or after
surgery
8
Inhibition of serotonin 5-HT
3
receptors in turn inhibits the visceral afferent stimulation of the vomiting center, likely at the level of the area
postrema
, as well as through direct inhibition of serotonin activity within the area
postrema
and the chemoreceptor trigger
zone.
9
May cause constipation, diarrhea, or
headache
9
Can take medication with or without
food
9
May contain phenylalanine; those with phenylketonuria should not take this
medication.
9
Clonidine HCL
(
Catapres
)
Treats high blood
pressure
8
Stimulates receptors on nerves in the brain to reduce the transmission of messages from nerves in the brain to nerves in other areas of the body. As a result, clonidine slows heart rate and reduces blood
pressure.
9
May cause constipation, dry mouth, dizziness, or
weakness
9
Can take medication with or without
food.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Hydralazine HCL
(
Apresoline
)
Treats high blood
pressure
8
The precise mechanism of action of hydralazine is not fully understood, the major effects are on the cardiovascular system. Hydralazine apparently lowers blood pressure by exerting a peripheral
vasodilating
effect through a direct relaxation of vascular smooth
muscle
9
May cause nausea, vomiting, loss of appetite, diarrhea, constipation, or
dizziness.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Slide14Medications
(brand name & generic)
Used
to treat?
Mechanism
of Action
Nutritional
Implications/
Interactions
Labetalol HCL
(
Normodyne
)
Treats high blood
pressure.
8
Labetalol blocks receptors of the adrenergic nervous system. When labetalol attaches to and blocks the receptors, arteries expand, resulting in a fall in blood
pressure.
9
May cause dizziness, nausea, vomiting, diarrhea, or
constipation.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Atorvastatin Calcium
(Lipitor)
Treats high
cholesterol.
8
Prevents the production of cholesterol in the liver by blocking HMG-CoA reductase, an enzyme that makes
cholesterol.
9
May cause diarrhea, upset stomach, confusion, dizziness, and
tiredness.
9
Avoid or minimize grapefruit juice because it can increase blood levels of atorvastatin which can increase the risk of liver
damage.
9
Can be taken with or without
food.
9
Metoprolol
Tartrate
(Lopressor)
Treats high blood
pressure.
8
Blocks the action of certain natural chemicals in your body, such as epinephrine, on the heart and blood vessels. This effect lowers the heart rate, blood pressure, and strain on the
heart.
9
May cause dizziness, nausea, vomiting, diarrhea, or
constipation.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Slide15Medications
(brand name & generic)
Used
to treat?
Mechanism
of Action
Nutritional
Implications/
Interactions
Benazepril HCL
(Benazepril HCL)
Treats high blood
pressure.
8
ACE inhibitors such as benazepril lower blood pressure by inhibiting the formation of angiotensin II, thus relaxing the arteries. Relaxing the arteries not only lowers blood pressure, but also improves the pumping efficiency of a failing heart and thereby benefits patients with heart
failure.
9
May cause dizziness, nausea, vomiting, diarrhea, or
constipation.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Chlorthalidone
(
Hygroton
)
Treats high blood
pressure.
8
Reduces the kidneys' ability to hold on to salt and water and increases the kidneys' production of urine (diuresis). It is used to eliminate excess salt and water from the body and to treat high blood
pressure.
9
May cause dizziness, nausea, vomiting, diarrhea, or
constipation.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Docusate Sodium
(Colace)
Treats occasional constipation and is often used when straining to have a bowel movement should be
avoided
8
Reduces surface tension of the oil-water interface of the stool resulting in enhanced incorporation of water and fat allowing for stool
softening
9
May cause diarrhea, nausea, stomach cramps, or throat
irritation
9
Take with a full glass of
water
9
Avoid consuming mineral oil as it leads to mentioned side
effects
9
Slide16Medications
(brand name & generic)
Used
to treat?
Mechanism
of Action
Nutritional
Implications/
Interactions
Polyethylene Glycol
(
Miralax
)
Treats occasional constipation and is used in bowel preparation for
colonoscopies
8
Causes water retention in stool, producing a laxative
effect
9
May cause diarrhea, severe bloating, distention of the stomach, vomiting, nausea, lower abdominal discomfort, or
cramps
9
Add powder to full glass of water, juice, soda, coffee or
tea.
9
Doxazosin
Mesylate
(Cardura)
Treats high blood
pressure
8
Prevents norepinephrine that is released by nerves from binding to alpha-1 receptors on smooth muscle surrounding blood vessels and in the prostate and bladder. By blocking the effect of norepinephrine,
doxazosin
relaxes the smooth
muscle.
9
May cause dizziness, nausea, vomiting, diarrhea, or
constipation.
9
Avoid or minimize alcohol intake because side effects from drinking alcohol may worsen when taking this
medicine.
9
Can be taken with or without
food
9
Slide17Physical Exam (per reports)
Abdomen: soft, rounded, distended
GI: active bowel sounds, but has diarrhea; last bowel movement occurred on April 2, 2015; has a PEG placement for tube feedings
Skin: no edema or wounds
Eyes: can open his eyes but they are deviated to the right when stimulated
Oral: excessive secretions/drooling from one corner of his mouth Respiratory: artificially ventilated and has diminished inspirations and expirations. There is a small amount of white, thick sputum present and he is having difficulty clearing these secretions. Behavior: not oriented to his surroundings and has difficulty waking. He will respond to sternal rubs by opening his eyes but he cannot move any of his extremities.
Vital Signs: uncontrolled hypertension. His most recent blood pressure was 134/97 on April 2, 2015.
Slide18PES Statement
Goal
Intervention
Monitoring
Evaluation
Inadequate energy intake related to current TF regimen as evidenced by TF meeting < 90% of estimated energy needs.
Short-Term:
Advance TF to goal rate of 65 mL/hr.
Long-Term:
Maintain weight within 2% throughout hospitalization.
Advance to goal rate of 65 ml/hr. to provide 1872 kcals and 87 grams of protein, meeting 109% estimated energy needs and 100% estimated protein needs
Increase to goal rate within 24 hours.
Meet 90-110% of estimated needs
Maintain weight within 2% throughout hospitalization
Short-Term:
Tube feed goal rate of 65 mL/hr. is met within 24 hours, thus meeting 90-110% of the patients estimated energy needs.
Long-Term:
Patient maintains weight within 2% throughout hospitalization.
Inadequate oral intake related to mechanical ventilation as evidenced by reliance on tube feedings for nutritional support.
Short-Term:
Advance TF to goal rate of 65 mL/
hr
to meet 90-110% of estimated needs.
Long-Term:
Wean dependence on tube feedings once medically feasible.
Maintain weight within 2% throughout hospitalization.
Advance to goal rate of 65 ml/hr. to provide 1872 kcals and 87 grams of protein, meeting 109% estimated energy needs and 100% estimated protein needs
Increase to goal rate within 24 hours.
Meet 90-110% of estimated needs
Maintain weight within 2% throughout hospitalization
Short-Term:
Tube feed goal rate of 65 mL/hr. is met within 24 hours, thus meeting 90-110% of the patients estimated energy needs.
Long-Term:
Once medically feasible, initiate PO diet with clear liquids and advance diet as tolerated.
Patient maintains weight within 2% throughout hospitalization.
Slide19Prognosis (per reports)
Mr. X is stable but unresponsive due to anoxic encephalopathy.
Neurology:
grim prognosis due to brain damage caused by oxygen
deprivation
Scheduled to receive a trach-collar and be weaned from mechanical ventilationMifflin St. Jeor will be used to determine his estimated
needs, once
extubated
,
which should be around 1,873 – 2,029 kcals/day and 57-71 grams of protein/day
.
T
ube feedings will remain unchanged because Jevity 1.2 at 65 mL/hr will provide 1,872 kcals and 87 grams of protein, meeting 100% estimated energy needs and 102% estimated protein needsIf Mr. X regains motor skills and the ability to feed himself, his needs will remain within Mifflin ranges and dietary intake will be closely monitored to determine if he can successfully meet his nutritional needs through a PO diet.
Slide20Literature Review
Slide21Lee HK, Lee H, No JM, Jeon YT, Hwang JW, Lim JY, Park, HP. Factors influencing outcome in patients with cardiac arrest in the ICU.
International Journal of Anesthesiology and Intensive Care, Pain and Emergency Medicine.
2013; 57: 784-792.
Where: Seoul National University Hospital, Seoul, Korea
Objective: Identify pre- and intra- arrest factors associated with survival 3 months after CPR in ICU patients and to identify post-arrest factors associated with long-term survival in those who survived 24 hrs
after CPR
Who: 131 ICU patients from Seoul National University Hospital who underwent CPR
When: January 2009 – June 2010
Methodology: Data was collected retrospectively by one anesthesiologist and categorized into pre- and intra- arrest variables. Pre-arrest variables included age, sex, location, probable cause of CPA, reason for ICU admission, APACHE II score, and Glasgow Coma Scale score. Intra-arrest variables included electrocardiogram rhythm at time of CPR, duration of CPR, response time, time to epinephrine injection, total dose of administered epinephrine, and body temperature prior to CPR. Neurological outcomes were measured in patients who survived 3 months after CPR was performed.
Results: Early enteral nutrition within 48 hours and maintenance of
normoxia
after return of spontaneous circulation was predictive of 3-month survival in patients who survived 24 hours after CPR. 22 out of 57 patients were started on early enteral nutrition; their survival rate at 1 and 3 months was 81.8%. Applications: Early initiation of enteral feeding in critically-ill patients, such as those suffering from cardiac arrest, enhances the probability of survival and better quality of life.
Slide22Parikh M, Webb ST. Cations: potassium, calcium, and magnesium. Continuing Education in Anesthesia, Critical Care & Pain.
2012; 12: 195-198.
Where:
Cambridge, United Kingdom
Objective:
Inform the reader of the role potassium, calcium, and magnesium play in the body and how too much or too little of these minerals can affect the human body. Who: Educational article for the general public
When:
August, 2012
Summary: Potassium functions include heart and skeletal contraction, thus, hypokalemia and hyperkalemia can cause cardiac arrhythmias and changes in electrocardiographic abnormalities. Calcium is responsible for exocrine, endocrine, and
neurocrine
function;
hypercalacaemia
can cause cardiac arrest, anorexia, nausea, vomiting, and constipation. Magnesium is involved in energy metabolism; hypomagnesium is directly correlated with hypertension, angina, and cardiac arrhythmias. Applications: Maintaining appropriate mineral levels in critically-ill individuals can help ensure proper care throughout the patient’s hospital stay.
Slide23Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia? Resuscitations. 2014; 85: 1469-1472.
Where:
Intensive Therapy Unit, Royal United Hospital,
Combe
Park, United Kingdom
Objective: To determine whether patients undergoing therapeutic hypothermia following cardiac arrest could tolerate early enteral nutrition. Who: 55 patients treated with therapeutic hypothermia following resuscitation from cardiac arrest
When:
April 2006 – December 2010
Methodology:
A single-
centre
longitudinal cohort analysis was performed. The therapeutic hypothermia treatment was separated into three different phases: 24 hours at target temperature (32-34ºC), 24 hours rewarming to 36.5ºC, and 24 hours maintained at core temperature below 37.5ºC. Demographic information was collected from the local database; data on enteral feedings and body temperature were collected from nursing observation charts. Data extraction occurred when the patient reached the target temperature of 32-34ºC.
Results: During period 1,patients tolerated 72% of administered feed. During period 2, patients tolerated 95% of administered feed. During period 3, patients tolerated 100% of administered feed. Feedings are tolerated better as patients are rewarmed. Applications: Understanding the proper feeding methods for patients undergoing specific treatments can enhances the probability of survival and better quality of life.
Slide24References
1. Cove Point Foundation.
Systemic Hypertension.
May 2011. Available at
http://www.pted.org/?id=syshypertension1
, Accessed April 5, 2015. 2. Mayo Clinic. Diseases and Conditions: Osteoarthritis. January 2015. Available at http://www.mayoclinic.org/diseases-conditions/osteoarthritis/basics/definition/con-20014749, Accessed April 5, 2015. 3
.
Mayo Clinic.
Diseases and Conditions: Iron Deficiency Anemia.
January 2015. Available at
http://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/basics/definition/con-20019327
, Accessed April 5, 2015.4. Mayo Clinic. Diseases and Conditions: Sudden Cardiac Arrest. January 2015. Available at http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/definition/con-20042982, Accessed April 5, 2015.5. Fausto J. Center to Advance Palliative Care. Prognosis of Anoxic-Ischemic Encephalopathy. January 2015. Available at
https://www.capc.org/fast-facts/234-prognosis-anoxic-ischemic-encephalopathy/, Accessed April 6, 2015.
6
.
U.S. National Library of Medicine. Medicine Plus
.
February 2015. Available at
http://www.nlm.nih.gov/medlineplus/
, Accessed February 25 2015.
7
.
American Association for Clinical Chemistry. Lab Tests Online
.
Inside the Lab.
January 2015. Available at
http://labtestsonline.org/
, Accessed February 25, 2015.
8
.
Canadian Institutes of Health Research.
DrugBank
.
Drugs
. January 2015. Available at
http://www.drugbank.ca/drugs
, Accessed February 24, 2015.
9
.
HealthLine
Networks.
HealthLine
.
Drug Interaction Checker.
January 2015. Available at
http://www.healthline.com/druginteractions
, Accessed February 26, 2015.
Slide25References Cont.
10. Lee
HK, Lee H, No JM, Jeon YT, Hwang JW, Lim JY, Park, HP. Factors influencing outcome in patients with cardiac arrest in the ICU.
International Journal of Anesthesiology and Intensive Care, Pain and Emergency Medicine.
2013; 57: 784-792.
11. Parikh M, Webb ST. Cations: potassium, calcium, and magnesium. Continuing Education in Anesthesia, Critical Care & Pain.
2012; 12: 195-198
.
12.
Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia?
Resuscitations
. 2014; 85: 1469-1472.
13. Adam. HWCRC. Health Illustrations. January 2015. Available at http://www.hwcrc.org/Health/illustrations%20of%20human%20anatomy/picture1.htm, Accessed April 6, 2015. 14. McKenzie County Healthcare Systems. Cardiac Arrest or Heart Attack? January 2015. Available at https://plus.google.com/+Mckenziehealth/posts, Accessed April 6, 2015.15. Reyst H. Rainbow Rehabilitation Centers. Neuroplasticity after Acquired Brain Injury.
February 2015. Available at http://www.rainbowrehab.com/neuroplasticity-aquired-brain-injury/, Accessed April 6, 2015.