Major Case Study NUTRITION SUPPORT

(1)

Major Case Study

(2)

Patient

Introduction

• HH is a 68 YOM admitted for

acute respiratory failure following

subdural hematoma

• Pt underwent emergency

craniectomy to alleviate pressure

from intra-cranial swelling

• Transferred to MSICU for

treatment & recovery

• Study began 3/23/17 and

concluded 5/5/17 at D/C

(3)

Patient Background and Social History

• Retired body shop owner

• Currently owns 2100-acre farm and manages 33 rental properties with spouse

• Has been married to current spouse for 33 years

• Has 7 adult children and 20 grandchildren

• Physically active daily with farm responsibilities

• Religion: Baptist, non-attending

• Insurance: Humana & Medicare

(4)

Medical History

Pre-existing conditions:

◦ CHF ◦ Pancreatitis ◦ HTN ◦ Seasonal allergies

Surgeries:

◦ Stent placement ◦ Back surgery ◦ Knee replacement

(5)

Admitting Diagnosis and Disease Explanation

Subdural Hematoma (SDH)

• Blood collects between dura and arachnoid

• Often a result of a traumatic head injury

• May also present spontaneously in elderly

• Acute or Chronic

(6)

(7)

SDH Risk Factors

Blood thinning medications Long-term alcohol use

Repeated head injury Advanced age

(8)

Common Symptoms and Complications

SYMPTOMS • Memory loss • Dizziness • Headache* • Anxiety • Difficulty concentrating • Blurred vision* COMPLICATIONS • Seizures

• Short or long term weakness/numbness

• Difficulty with speech

• Difficulty with chewing/swallowing

• Change in personality*

• Coma*

• Death

(9)

Present Medical Status & Treatment

Emergent craniectomy procedure to relieve swelling

◦ Craniectomy (vs craniotomy)

Transfer to Medical Surgical ICU Vasopressors to control BP

◦ Pt presented hypotensive, low diastolic (120/59)

◦ Likely due to craniectomy related blood loss (2L) Sedation

◦ Proprofol

Medications to relieve swelling

◦ Diuretics & Corticosteriods

Anti-seizure medications

◦ Keppra

IV fluids

◦ KCl, D5, NaCl

Antibiotic

Early Enteral Nutrition (EEN) started within 24 hours of transfer to MSICU

◦ Via OG tube

◦ Vital HP

◦ Switched to Vital AF 1.2 @ 70mL/hr with 25mL Q4H flush once stable

(10)

Lab values

Na+ 141mEq/L WNL K+ 3.9mEq/L WNL Cl- 103mmol/L WNL CO₂ 24mmol/L WNL BG 133mg/dL HIGH PTT 24s HIGH WBC 15.3k/µL HIGH Hbg 17.1g/dL WNL Hct 50.6% WNL Platelet 192 x1000/µL WNL Troponin I <0.04ng/mL WNL CPK 60U/L WNL Lactate 1.7mmol/dL WNL

(11)

Medications

PRIOR TO ADMISSION

Cozaar Protonix Plavix Simvastatin Ambien Testosterone

Fish Oil Supplements

Cinnamon Aspirin Cetirizine Co-Q-10 Multivitamin for 50+

IN-PATIENT

Pantaprazole Apresoline Coreg Nystatin Catapres Potassium Chloride Novolog (PRN) Trandate (PRN) Morphine (PRN) Zofran (PRN) Norepinephrine Vasopressin Epinephrine Proprofol

(12)

Complications In-Patient

Constipation

◦ Total duration: 12 days

◦ Was placed on bowel regimen after 3 days

◦ Dulcolax, Docu, Miralax, HealthyLax, Lactobacillus, Sorbitol

◦ TF was decreased to 50mL after 10 days

◦ Enema and then “brown bomb” was used after 10 days Hypernatremia ◦ Increased TF flush gradually to 50mL/hr ◦ IV D5 kept PRN ◦ Eventually contraindicated by neuro Edema / Swelling ◦ Neurology instructed d/c of IV fluids and TF flush

◦ Flush with meds only

◦ Desired elevated Na+

◦ Would allow for cells to “dry out/shrink”

◦ Reduce cranial swelling

Comatose

◦ Diagnosed by MD 2 wks after admission

◦ Responds to painful stimuli

◦ RN reports rare case of squeezing hand on command

(13)

48hrs after admission, patient

was recommended for PEG and

(14)

Current ICU Needs and Nutrition

Anthropometrics: ◦ 68 YOM ◦ Ht: 72in (183cm) ◦ Wt: 216# (98kg) ◦ BMI: 29 ◦ IBW: 178# (80.9kg) ◦ 121%IBW ◦ REE: 1935kcals ◦ Penn ’03: 2445kcals

Calculated needs – critical care ◦ 1960-2450kcals ◦ (20-25kcals/kg CBW) ◦ 117-196g protein ◦ (1.2-2g protein/kg CBW) ◦ Minimum 1500mL fluid

Current diet – Vital AF 1.2

◦ @ 70mL/hr with 25mL Q4H flush

◦ 2016kcals

◦ 126g protein

◦ 1361mL free water

(15)

Rationale for Current Diet

Pt is comatose, requiring nocturnal ventilation with trach, with TF supplying 100% of calculated needs via PEG

Vital AF 1.2 @ 70mL with 25mL flush Q4H

◦ Provides:

◦ 2016kcals

◦ 126g protein

◦ 1511mL H2O (with flushes)

◦ 100% RDA vitamins and minerals

Both Vital HP and AF contain hydrolyzed proteins, EPA/DHA, and are low residue for better tolerance Contains medium chain triglycerides (MCT) which are typically better tolerated and absorbed

Higher protein concentration helps meet increased critical care needs without fluid overload or overfeeding

(16)

MNT: Nutrition History

Most meals prepared and consumed at home

Wife is primary food shopper and preparer of meals Does not follow a prescribed diet

◦ Consume typical southern style cuisine

◦ Spouse offers more heart healthy options

◦ Shift towards heart healthy cooking methods

Breakfast & lunch intake is light; Dinner is largest meal

Water is primary beverage consumed, followed by Gatorade, then lemonade

◦ Average 2L fluids per day consumed based on diet recall

(17)

Usual Diet Recall

Breakfast ◦ Biscoff cookies (2-4) ◦ Coffee ◦ 2% milk Or ◦ Eggs (1-2)

◦ white toast (2 slices)

◦ Coffee ◦ 2% milk Lunch ◦ Tuna or deli sandwich (smoked ham or turkey)

◦ On white bread, with tomato, mayonnaise, and cheese

◦ Hot peppers

◦ Potato chips (fun pack size)

◦ Water, 2% milk, Gatorade, or lemonade

Dinner

◦ Cubed steak (2x6oz pcs fried or grilled)

◦ Cornbread (2.5x2.5x1” square)

◦ Beans (lima, pinto, black eyed, baked)

◦ Cooked collard greens (1 cup)

Or

◦ Salmon filet (6oz grilled or baked) ◦ Salad ◦ Corn (1 cup) ◦ Asparagus Estimated Daily Nutrition ◦ 2131kcals ◦ 78g protein (15%) ◦ 108g fat (46%) ◦ 185g CHO (39%)

(18)

Discharge

Currently pending transfer to LTAC or similar facility

◦ First request denied due to insurance; family considering

home care

◦ While in-patient, intensivist has recommended transfer to

another floor based on stable status If patient were to become alert/oriented

◦ Would require speech evaluation by SLP

◦ If safe to consume PO diet – transition feeding

(19)

Prognosis

Stable

Traditionally, survival rate of subarachnoid hemorrhage is 50%

◦ Influenced by age, severity of trauma, timeliness of craniectomy/craniotomy, Glasgow Coma Scale (GCS)

Grey matter was reported to spread after 5 days in-patient During recovery pt may experience…

◦ Changes in personality

◦ Difficulty regulation speech/language

◦ Coordinating motion

◦ One-sided weakness

◦ Regulation of emotions

◦ Impacted memory

(20)

Conclusion

HH, a 68 YOM, admitted for acute respiratory failure following subdural hematoma, is ongoing in critical care

A craniectomy was preformed immediately following admission to the ER to drain blood and relieve pressure, sparing any further damage to brain matter

Pt was transferred to the MSICU for recovery and continues to be in-patient

◦ Pending transfer to another floor, LTAC (or similar facility), or home care

Patient was placed on protocol for seizure and bowel regimen to treat constipation

Pt is currently in comatose state, requiring the use of a ventilator at nights in addition to trach dependency

Has been receiving Vital AF 1.2 @ goal rate of 70mL/hr – meeting 100% needs

Survival rate of subarachnoid hemorrhage patients is roughly 50% with poorer prognosis in the elderly and those requiring decompressive craniectomy