Trophic Feeding for Critically Ill Patient on Pressors: A Case Study By Andrea Shelley

Case Presentation Admitted related to need for dialysis access Intubated and on mechanical ventilation Major Problems: End-stage renal disease (ESRD) Symptomatic bradycardia Hyperglycemia

Case Presentation 88 year old Caucasian female Medical History: ESRD Kidney stones Lung cancer Gastroesophageal reflux disease Chronic obstructive pulmonary disease Hypertension Chronic cystitis Hypothyroidism Type 2 diabetes mellitus Depression

Case Presentation Disease Description: ESRD Kidneys are no longer able to clean the blood at an acceptable rate Glomerulus filtration rate (GFR)<15 Fluid and toxins build-up phosphorus & potassium Dialysis or transplantation is needed for survival Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: 811-813

Case Presentation Patient’s Treatment for ESRD: Continues Renal Replacement Therapy (CRRT) Type of dialysis Causes less stress on body Cleans the blood and pulls off extra fluid very slowly Started on day two

Case Presentation Symptomatic bradycardia (slow heart rate): Pulseless electrical activity 7 days post admit Received aggressive resuscitation Heart rate 30-40 Placed on pressors Norepinephrine Dopamine

Case Presentation Hyperglycemia (High blood glucose level) Glucose 332 at first assessment Treatment: Lantus Sliding scale insulin Dextrose, 5%

Anthropometric Measurements at Admit: Nutrition Assessment Anthropometric Measurements at Admit: 162# 4’11” BMI=32.8 Biochemical Data at Admit: Glucose:332 Sodium:137 BUN: 56.4 Potassium:3.8 Cr:5 Phosphorus: 7.8 Ca: 6.5

Nutrition Assessment ARAMARK Nutrition Status Classification Eating chewing problems = 2pts New/Unstable tube feeding = 4pts Stable weight = 0pts BMI >30-34.9 = 2 pts Albumin level of 2.4 = 3 pts Dx chronic renal failure = 3 pts Total points = 14, Level 4-Severely Compromised

Nutrition Assessment Increased Caloric Needs: CRRT Sepsis Mechanical ventilation Low Braden Score (10)

Nutrition Assessment Nutrient Needs: Mifflin St-Jeor (10 x 73.4) + (6.25 x 149.8) - (5 x 88) -161=1069.25kcals Stress Factor: 1.3 x 1069.25= 1390kcals/day OR 30kcals/kg IBW & 1.5g protein/kg IBW 30kcals x 45.45kg IBW = 1363kcals 1.5g protein x 45.45kg IBW = 68g protein Fluids:1ml/kcal =1363ml water

Nutrition Diagnoses PES Statement: NI-5.3: Inadequate protein-energy intake related to hemodynamic instability as evidenced by NPO x 1 day with mechanical ventilation and need for multiple pressor medications.

Nutrition Intervention Enteral Nutrition 2.1 Composition ND-2.1.1 Rate ND-2.1.3 Recommend initiating continuous trophic feeds of Nepro at 10ml/hr with a goal rate of 30ml/hr and auto flush of 25ml water hourly via nasogastric tube while patient continues on high doses of pressors and CRRT. Supplement with 30ml ProMod daily At goal rate: 1396kcals (31kcals/kg IBW), 68g protein (1.5g/kg IBW), and 1123ml water

Nutrition Monitoring and Evaluation Enteral nutrient intake 1.3.1 Formula/Solution FH-1.3.2.1 Medications 3.1 Prescription medications (Rate of Pressor) FH-3.1.1 Glucose/endocrine profile 1.5 Glucose, casual BD-1.5.2

Nutrition Monitoring and Evaluation Monitor Continued: Electrolyte and renal profile 1.2 BUN BD-1.2.1 Creatinine BD-1.2.2 Potassium BD-1.2.7 Phosphorus BD-1.2.11 Acid-based balance 1.1 Partial pressure of carbon dioxide in arterial blood PaCO2 BD-1.1.4

Evidence-Based Nutrition Recommendations Early Enteral Nutrition and Outcomes of Critically Ill Patients Treated With Vasopressors and Mechanical Ventilation By Imran Khalid, Pratik Doshi, and Bruno DiGiovine Nonrandomized controlled trial Compared results received when enteral nutrition was initiated with 48hrs of admit to those received when enteral nutrition was initiated after 48hrs. Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vassopressors and mechanical ventilation. American Journal of Critical Care. 2010:19. 261-268. doi:10.4037/ajcc2010197

Evidence-Based Nutrition Recommendations Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vassopressors and mechanical ventilation. American Journal of Critical Care. 2010:19. 261-268. doi:10.4037/ajcc2010197

Evidence-Based Nutrition Recommendations A Randomized Trial of Trophic versus Full-Energy Enteral Nutrition in Mechanically Ventilated Patients with Acute Respiratory Failure By: Rice, Morgan, Hays, Bernard, Jensen, and Wheeler Results showed that pts on trophic feeds for the first 6 days had similar clinical outcomes to pts receiving full-energy feeds as quickly as possible. Trophic feeds lead to less gastrointestinal intolerance Rice TW et al. A randomized trial of trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. NIH Public Access Critical Care Med. 2011:39(5):967-974. doi:10.1097/CCM.0b013e31820a905a

Rice TW et al. A randomized trial of trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. NIH Public Access Critical Care Med. 2011:39(5):967-974. doi:10.1097/CCM.0b013e31820a905a

Conclusion Tolerated trophic feeds minimal residuals No gastrointestinal intolerance Many co-morbidities End-of-life decision was comfort care

Thank You! Questions?

References Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: p811-813 Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vassopressors and mechanical ventilation. American Journal of Critical Care. 2010:19. 261-268. doi:10.4037/ajcc2010197 Rice TW et al. A randomized trial of trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. NIH Public Access Critical Care Med. 2011:39(5):967-974. doi:10.1097/CCM.0b013e31820a905a Academy of Nutrition and Dietetics. Evidence Analysis Library. Executive summary of recommendations. http://andevidencelibrary.com/topic.cfm?cat=3929. Accessed January 1, 2013