Aortic Stenosis Clinical Case Study Ema Thake University of Utah June 8, 2012

Aortic Stenosis  As the aortic valve becomes more narrow, the pressure increases inside the left heart ventricle.  causes the left heart ventricle to become thicker, decreasing blood flow  Can lead to chest pain and shortness of breath.  Severe forms of aortic stenosis prevent enough blood from reaching the brain and rest of the body. This can cause light-headedness and fainting Aortic Stenosis.

Aortic Stenosis  Symptoms  Breathlessness  Chest pain  Fainting, dizziness  Treatment  Stop smoking  Treatment for high cholesterol  Surgery to replace or repair the valve  Medications  Diuretics  Nitrates  Beta blockers

Patient GH  71 year old male  Admitting diagnosis: for pre-op consultation for Aortic stenosis with aortic root dilation and ascending aorta dilation, with coronary artery disease  On admit:  Wt: kg; Height: 173 cm  BMI: (obese – grade II)  Extensive medical history

Medical/Nutritional History  PAST MEDICAL HISTORY:  Aortic stenosis with bicuspid aortic valve.  Aortic root and ascending aorta dilation  Coronary artery disease, status post CABG in 2001  Type 2 diabetes, non-insulin dependent.  COPD  Hypertension  Hyperlipidemia  Renal insufficiency  Lung disease  The patient complains of irregular heartbeats or palpitation  Peripheral vascular disease  Obstructive sleep apnea, for which he does not use a CPAP machine  GERD  Osteoarthritis in his shoulders  Chronic low back pain, status post fusion.  Pancreatitis  Non-union of his sternum with broken sternal wires

Medical/Nutrition History  PAST SURGICAL HISTORY:  Coronary artery bypass grafts in 2001  Angioplasty x 3 with stents to his circumflex  Cholecystectomy  Right knee surgery  Lower back fusions in 1999

Medical/Nutrition History  FAMILY HISTORY: Significant for coronary artery disease. Father died from an MI at the age of 52. The patient has 3 brothers, who have had coronary artery bypass grafts in the past. Another sister had coronary disease, who is now deceased.  SOCIAL HISTORY: The patient reports approximately 50-pack-year smoking history. The patient quit 1-1/2 years ago. The patient quit using alcohol 2 years ago and denies any drug history. The patient is married, lives with his wife in Green River, Wyoming and is retired.

Anthropometrics

Biochemical Piper and Kaplan, 2012

Medications  Furosemide  Atorvastatin  Metaprolol  Metformin  Omeprazole  Warfarin  Sitagliptin  Potassium Chloride

Clinical  No apparent skin breakdown  Edema on legs caused some broken skin  No pressure ulcers  Swallowing Evaluations  POD #12 - First attempt failed by patient  POD #19 – Passed eval., advanced to dysphagia 3 diet

Nutrition Diagnosis  Inadequate oral intake related to intubation and sedation as evidenced by need for nutrition support.  Obesity as evidenced by BMI

Nutrition Intervention  DHT placed  5/6 – trophic feeds  5/7 – 75 ml/hr  5/10 – 90 ml/hr  5/15 – DHT accidentally pulled out  5/16 – 25 ml/hr after DHT replacement  5/18 – 90 ml/hr – resp. failure, intubated again  5/19 – 40 ml/hr  5/20 – 75 ml/hr – IDC indicated underfeeding  5/25 – DHT accidentally pulled out, diet advanced to dysphagia 3

Nutrition Intervention  Tube feed initiated - Promote  Adjusted based on needs  Estimated needs and IDC  kcal/day (25-30 kcal/kg AdjBW)  g protein/day ( g/kg AdjBW)  SLP evaluation  Advanced diet

Monitoring & Evaluation  IDC to monitor adequacy of the tube feeds  Calorie counts to assess oral intake when diet was advanced  Notes  Percentage of meals eaten

Reflection/Personal Assessment  I had the opportunity to assist in the placement of a DHT in this patient. I found that experience to be very valuable.  It was good to see the patient through each stage of recovery.  Would have liked to gain more information about the education he received for discharge diet.

Questions?

References  Svagzdiene M, Sirvinskas E, Benetis R, Raliene L, Simatoniene V. Atrial fibrillation and changes in serum and urinary electrolyte levels after coronary artery bypass grafting surgery. Medicina (Kaunas). 2009;45(12): Svagzdiene MSirvinskas EBenetis RRaliene LSimatoniene VMedicina (Kaunas).  Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am Apr;92(2): , vii. Epub 2012 Feb 9 Piper GLKaplan LJ Surg Clin North Am.  Atrial Fibrillation/Flutter. Atrial Fibrillation/Flutter.  Aortic Stenosis. Aortic Stenosis.