Case Report: Nutrition Support in a Critically Ill Patient at risk for Essential Fatty Acid Deficiency Rebecca Scofield, MS ARAMARK Dietetic Internship Underwood-Memorial Hospital February 7, 2012 Disease State Diverticular Disease Primary cause of patient’s long hospital stay Complications included inflammation, abscesses, sepsis and infection, bleeding, and perforation Usual treatment includes antibiotics, bowel rest ⅓- ¼ of patients require surgery Hartmann’s procedure, splenic flexure takedown, drainage of abscess, colostomy performed Comorbidities Pt became Vent-Dependent Respiratory Failure (VDRF) following surgery Acute Respiratory Distress Syndrome (ARDS), resolved Type 2 Diabetes Mellitus (T2DM) Peanut allergy Risk for Essential Fatty Acid Deficiency (EFAD) EFAD Essential Fatty Acid Deficiency Absence of EPA, DHA, ALA (omega-3 fatty acids) Signs/Symptoms: Dermatitis Fatty liver Hair loss Biochemical indications Death S/S can occur within 2 weeks Evidence-Based Nutrition Recommendations Academy of Nutrition and Dietetics: Evidence Analysis Library Critical Illness Guidelines state: Energy requirements most accurate when using IretonJones 1992 equation and indirect calorimetry not available Enteral Nutrition (EN) recommended over Parenteral Nutrition (PN) in patients with functioning GI tract EN associated with reduced cost, septic morbidity, and infections Delayed PN in pts who are not malnourished Evidence-Based Nutrition Recommendations Casaer et al, 2011 Randomized, controlled, multi-center trial N = 4,640 Intervention: Early vs. late PN in critically ill adults Early initiation on day 3 Late initiation on day 8 Primary Outcomes: ICU length of stay Secondary Outcomes: Infection rates, inflammation, length of VDRF, status at discharge Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17. Evidence-Based Nutrition Recommendations Caesaer et al, continued: Results Late PN Initiation group: Shorter ICU stay Fewer infections Reduction in patients who require > 2 days VDRF $1600 reduction in health care costs No difference in mortality between groups Early initiation of PN appears less beneficial than withholding PN until day 8 Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17. Evidence-Based Nutrition Recommendations De Meijer et al, 2010 Non-comparative study (case series) N = 10 Intervention: PN fish oil as sole lipid therapy for infants in ICU Primary Outcome: Onset of EFAD, defined by triene:tetraene ratio >0.2 Secondary Outcomes: Clinical s/s of EFAD Dermatitis Hair loss Growth impairment deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218. Evidence-Based Nutrition Recommendations De Meijer et al, continued: Results FA composition changed from composition of soybean oil (higher omega-6) to that of fish oil (higher omega-3) No dermatitis, hair loss, growth retardation in any patients Bilirubin levels improved in 90% of patients with cholestasis Fish oil contains sufficient EFAs to prevent clinical and biochemical s/s of EFAD and sustain growth in infants deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218. Evidence-Based Nutrition Recommendations Mateu-de Antonio et al, 2008 Retrospective cohort study N = 42 (final n = 39) Intervention: Soybean- vs. olive oil-based lipid emulsions in PN Primary Outcomes: Infection rate and leukocyte count Secondary Outcomes: Acute phase proteins, length of ICU stay, mortality rate Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54. Evidence-Based Nutrition Recommendations Mateu-de Antonio et al, continued: Results No difference in infection rate or appearance, acute phase proteins, or major outcomes between groups Olive oil group: increase in leukocyte count Soybean oil group: decrease in leukocyte count Soybean oil emulsions Cause increase in omega-6 FA May interfere with immune function, be precursors to inflammatory markers, and inhibit macrophage function Olive oil-based lipid emulsions May serve as a safe alternative to soy-based PN infusions Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54. Case Presentation Patient: SF 58 Year old Caucasian female Dx: Pneumonia, s/p GI surgery, VDRF, ARDS, sepsis, DM GI surgery prevents from enteral access Peanut allergy prevents from receiving lipid emulsion (per pharmacy protocol) Without lipids for 14 days NCP: Assessment Client History Hypothyroidism, diverticulosis, temporal arteritis, HTN, GERD, steroid-induced hyperglycemia, T2DM Allergies: Cipro, Augmentin, Macrobid Ex-smoker NCP: Assessment Food/Nutrition-Related History Unable to obtain from pt due to sedation/VDRF Family friend stated pt tolerated soy-containing foods Good intake at home Cooked for herself Social drinker Medications at home NCP: Assessment NCP: Assessment Nutrition-Focused Physical Findings Overweight Sedated Edema Cushingoid/puffy face +Ostomy NG tube NCP: Assessment Anthropometric Measurements Height: 5’8” Admission wt: 81.6 kg (180 lbs) BMI: 27.35 IBW: 140 lbs Pt experienced 40 lb gain during hospital admission due to fluid overload NCP: Assessment Biochemical Data, Medical Tests, and Procedures Intubation/mechanical ventilation NG tube placement TLC placement Tracheostomy Bronchoscopy Frequent lab draws PEG placement NCP: Assessment NCP: Assessment Nutrient Needs Estimated energy needs (1.1): Using Ireton-Jones 1992 1836 kcal/day Estimated protein needs (2.2): 1.3-1.5 g/kg (Using high-end IBW) 91-105 g/day Estimated fluid needs (3.1): 25 ml/kg (Using high-end IBW) 1750 ml/day NCP: Assessment Nutrition Status Classification NCP: Nutrition Diagnoses #1. Altered GI function (NC-1.4) related to diverticulitis and perforation as evidenced by decreased bowel sounds, little ostomy output, and bowel resection. #2. Inadequate parenteral nutrition infusion (NI-2.6) related to potential allergy to lipid emulsion as evidenced by lipid emulsion not being administered and no fatty acids delivered to patient. #3. Predicted food-medication interaction (NC-2.4) related to combined ingestion of levothyroxine and enteral formula via NG tube causing decreased bioavailability of medication as evidenced by 24-hour continuous feeding and p.o. levothyroxine prescribed via NG tube. NCP: Interventions Initiate PN (ND-2.2) ND-2.2.1 Formula/solution: Parenteral nutrition was started 4 days s/p surgery Recommendation: 490 ml 50% dextrose (to start with 30% dextrose first day), 1000 ml 10% amino acids, and 200 ml 20% lipid to provide 1633 kcal, 100 gm protein, and 1690 ml total volume. To meet approximately 100% of kcal and protein needs and 97% fluid needs. Lipids not administered for 10 days due to pharmacy protocol and risk for crossover allergic reaction to soy. NCP: Interventions Coordination of Nutrition Care (RC-1) RC-1.3 Collaboration/referral to other providers: Communication between Nursing Physicians Pharmacy Nutrition Required to determine a course of action for testing lipids with the patient before being introduced to PN solution. NCP: Interventions Initiate EN (ND-2.1) ND-2.1.1 Formula/solution: Goal enteral formula once patient able to begin feedings: Glucerna 1.2 via NG tube at 55 ml/hr continuous over 24 hours. Provided 1584 kcal and 79 grams protein meeting 98% of kcal needs and 94% of protein needs at that point in time. Adjusted due to Synthroid: Glucerna 1.2 at 60 ml/hr continuous over 21 hours with one packet liquid Prosource daily. Provided 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs. NCP: Interventions ND-2.1.4 Feeding tube flush: Glucerna 1.2 at 60 ml/hr over 21 hours with one packet of liquid Prosource daily met 58% of the patient’s fluid needs, requiring additional water. Flush the NG tube with 125 ml water every 4 hours Nursing to use enteral protocol to flush during medication administration. NCP: Monitoring and Evaluation Ongoing monitoring of: Weight AD-1.1 Body composition/growth/weight EN/PN regimen intake FH-1.3.2 Parenteral Nutrition Intake FH-1.3.1 Enteral Nutrition Intake FH-3.1 Medication and herbal supplements Labs BD-1.2 Electrolyte and renal profile BD-1.6 Inflammatory Profile Medications Conclusion Complicated cases may not be able to follow evidencebased guidelines at all times Allergies pose problem to some patients who need enteral or parenteral support Nutritional management of SF involved EN, PN, multidisciplinary cooperation for optimal outcome EFAD avoided in this patient after trial dose of soybean lipid emulsion Conclusion SF’s nutrition interventions involved initiation of PN, modification of the PN prescription, and finally introduction of EN EN formula and rate changes made to avoid nutrientmedication interactions Patient unable to be weaned from ventilator before discharge, but stable Conclusion Patient had PEG tube placed for continued EN support Tolerating tube feeding at goal at discharge: Glucerna 1.2 @ 60 ml/hr x 21 hours with 1 packet liquid Prosource Daily Providing total of 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs. Water flushes: 125 ml q 4 hours and with medications Trach-to-vent upon discharge Discharged to long-term acute care facility due to extensive medical needs References 1. Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. W.B. Saunders; 2007. Pp. 155, 696-97, 741, 769-71, 916-17. 2. Diverticulitis. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION=treatments-and-drugs. Accessed 16 Jan 2012. 3. Acute Respiratory Distress Syndrome. PubMed Health website. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001164/ 4. Peanut Allergy. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/peanut-allergy/DS00710/DSECTION=risk-factors. Accessed 16 Jan 2012. 5. De Meijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218. 6. 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