1. Case Report: Medical Nutrition Therapy for Septic Shock
ANGELA GASBARRE
ARAMARK DIETETIC INTERNSHIP
UPPER CHESAPEAKE MEDICAL CENTER
JANUARY 4, 2013

2. Objectives Disease Description of Septic Shock
Evidence-Based Nutrition Recommendations
Case Presentation
NCP: Assessment, Diagnosis, Interventions, Monitoring and Evaluation
Conclusion
Disease Description of Septic Shock
2 Evidence-Based Research Studies and the Nutrition Recommendations by ASPEN
Case Presentation of PW and his course of stay the Upper Chesapeake
Nutrition Care Process, including assessment, diagnosis, interventions, and monitoring and evaluation
Conclusion and Questions

3. Disease Description Sepsis Severe Sepsis
Systemic Infection
SIRS
Severe Sepsis
Decreased urine output
Change in mental status
Septic Shock
Drop in Blood Pressure
Organ Failure
Sepsis and septic shock are conditions that may be life threatening and require special medical attention. Sepsis occurs when an infection, typically bacterial but can be fungal or viral, uncontrollably invades the body. During sepsis, the body exhibits an inflammatory response, or SIRS, in which chemicals are released into the body to inhibit the infection progression causing the symptoms of sepsis.
As the disease progresses into severe sepsis, the patient may exhibit decreased urine output and a change of mental status.
Septic shock occurs when the infection or inflammatory response becomes too overwhelming for the body and the body responds by drastically decreasing blood pressure. The severe drop in blood pressure may lead to a reduction of function or failure of organs, such as the kidneys, liver, lungs, and central nervous system.

4. Evidence-Based Nutrition Recommendations Early vs
Evidence-Based Nutrition Recommendations Early vs. Late Initiation of PN
Participants
Intervention
2312 patients: early-initiation group began PN on day 3 of insufficient enteral feeding.
2328 patients: late-initiation group began PN on day 8 of insufficient enteral feeding.
The EPaNIC study gathered patients admitted to the ICU between April 2007 and November 2010.
Exclusion criteria for this study included patients <18 years of age, those with DNR code status, those patients who were pregnant or lactation, and those receiving oral nutrition.
Patients who are admitted to the ICU with septic shock often require some type of nutrition support. Nutrition support is needed due to illness induced anorexia, increased need for nutrients during high stress or illness, and/or the inability to feed enterally.
Casaer et al. conducted a study called the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) study, which was a prospective randomized, controlled, parallel-group, multicenter trial. The EPaNIC study gathered patients admitted to the ICU between April 2007 and November The final intervention included 2312 patients who received PN early (early-initiation group began PN on day 3 of insufficient enteral feeding) and 2328 patients who received PN late (late-initiation group began PN on day 8 of insufficient enteral feeding). Exclusion criteria for this study included patients <18 years of age, those with DNR code status, those patients who were pregnant or lactating, and those receiving oral nutrition .
Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:

5. Early vs. Late Initiation of PN
Results
p value (respectively)
Length of stay in the late-initiation group was one day shorter than the early-initiation group.
3 vs. 4 days
p=0.02
Late-initiation group had significantly less new infections than the early-initiation group.
22.8% vs. 26.2%
p=0.008
The researchers found that the length of stay in the late-initiation group was one day shorter than the early-initiation group, respectively 3 vs. 4 days, which was significant at p=0.02. A secondary outcome that the researchers found was that the late-initiation group had significantly less new infections than the early-initiation group, respectively 22.8% vs. 26.2%, p=0.008.
The researchers concluded that there was not difference in the mortality rate between the two intervention groups, but they did find a decrease in complications in the late-initiation group vs. early-initiation group, such as length of hospital stay and new infections.
A limitation of this study was that they did not use indirect calorimetry to determine the energy needs of the patients, which is the golden standard and recommended for the development of evidenced-based guidelines.
The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends that EN should be used for the critically ill patient with a working gastrointestinal (GI) tract, unless hemodynamically unstable (8). EN can be initiated once the patient is stable or fully resuscitated (8). ASPEN does not recommend PN until the patient is hospitalized without EN for >7 days (8). These guidelines are supported by Casaer et al. who found that late initiation of PN had better outcomes in ICU patients.
Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:

6. Early vs. Late Initiation of EN in Hemodynamically Instable Patients
PARTICIPANTS
Mechanically ventilated >2 days on vasopressors
707 pts early-initiated (within 48 hrs of ventilation)
467 pts late-initiated (>2 days after ventilation)
Although enteral nutrition (EN) is the preferred route to administer nutrition, it is not always feasible or adequate to feed ICU patients enterally due to their hemodynamically unstable condition. ICU patients often require the use of vasopressors and mechanical ventilation as treatment, especially those in septic shock. Khalid et al. conducted a retrospective analysis study to see the effect of early-initiation of EN vs. late-initiation of EN on hemodynamically unstable patients who were mechanically ventilated for >2 days and on vasopressors. The study included 707 patients with early-initiated EN (within 48 hours of mechanical ventilation) and 467 patients with late-initiated EN (>2 days after mechanical ventilation).
Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19:

7. Early vs. Late Initiation of EN in Hemodynamically Instable Patients
Results
p values
(respectively)
Days in the ICU were higher in the early-initiated group than the late-initiated group.
8.6% vs. 7.7%
p=0.39
Hospital mortality was lower in the early-initiated group than the late-initiated group
33.9% vs. 42.6%
p=0.01
found that, when groups were statistically matched, days in the ICU were higher in the early-initiated group than the late-initiated group, respectively 8.6% vs. 7.7%, p=0.39. Hospital mortality was significantly lower in the early-initiated group than the late-initiated group, respectively 33.9% vs. 42.6%, p=0.01. The researchers concluded that early-initiation of EN has better outcomes for the mechanically ventilated patient on vasopressors and that there were no additional risks to starting EN early in these patients.
A limitation of this study was that it did not take into account the caloric needs of the patients, the advancement of feeding, or the disruptions that may have occurred in the feedings. The researchers based the findings on intent to treat with early EN.
The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends that EN should be used for the critically ill patient with a working gastrointestinal (GI) tract, unless hemodynamically unstable. Khalid et al. did not find additional risks with enterally feeding hemodynamically unstable patients who are receiving medical treatment, such as mechanical ventilation and vasopressors.
Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19:

8. Case Presentation Septic Shock Rheumatoid arthritis
Humira and Methotrexate
Cholangitis
Septic Shock
Vasopressors
Mechanical ventilation
TPN EN
Pureed, nectar thickened liquids
64 year old male
PW is a 64 year old male who was admitted to Upper Chesapeake Medical Center on November 12, 2012 for acute cholangitis and early septic shock. PW was presented to the ER with loose stools, nausea with vomiting, and minimal urine output over the previous 48 hours. PW had been taking Humira to control his severe rheumatoid arthritis. Humira is an immunosuppressive medication, and PW had stopped taking it two-months prior to admission due to recurrent infections. At that time he went on Methotrexate, which is also an immunosuppressive medication used to treat autoimmune diseases. The long term use of these immunosuppressive medications may have caused the cholangitis.
PW was intubated and placed on mechanical ventilation due to his shortness of breath and acidosis. The cholangitis was managed with drainage of the bile ducts and stone removal. PW’s low blood pressure, secondary to severe sepsis caused by cholangitis, caused acute kidney failure. PW became anuric and the acute renal failure was manage by CRRT; eventually he was converted to hemodialysis. Due to PW’s low blood pressure, he was placed on vasopressors in order to constrict his blood vessels to increase his blood pressure. Vasopressors pull blood from the visceral organs (GI tract) to the systemic circulation; because of the inadequate blood flow to the GI tract and intubation, TPN was ordered. TPN and lipids were infused through a triple lumen peripherally inserted central catheter (PICC) line. Once PW became hemodynamically stable and the infection was resolved, enteral nutrition (EN) was initiated and tolerated; this was at 14 days after admission to the hospital. PW was then extubated and evaluated by speech pathology. He was advanced to a pureed diet with nectar thickened liquids.

9. NCP: Assessment 64 year old male Hx of rheumatoid arthritis
Humira and Methotraxate
Well nourished, intubated
BMI 29.2
5’ 11”
95.2 kg
Monitored for electrolyte and nutrient changes, and organ function
g protein/day
- Fluids per MD
kcal/day
ARAMARK NSC
Diarrhea Vomiting Intubation Sepsis
Does not meet criteria of DRG
PW is a 64 year old, white male. Past medical history includes rheumatoid arthritis, hypertension, coronary artery disease (CAD) with stent placement, myocardial infarction, and chronic pneumothorax. PW is a former tobacco smoker with mild COPD; family medical history includes COPD, CAD, CHF, and diabetes. PW is retired, single, without children, and owns cats.
Patient appeared to be a well-nourished, overweight male, who was intubated. He was sedated, so affect was limited. Upon admission, PW was 5’11”, 95.2 kg, with a BMI of 29.2 (overweight), and 122% of his IBW.
Various labs were collected during PW’s stay at the hospital, such as Na, K, BUN, Creatinine, GFR, Glucose, Ca, P, and Mg. These labs were taken in order to monitor TPN tolerance and increasing or decreasing nutritional needs.
Upon admission to the ICU, PW’s kilocalorie (kcal) needs were determined using Ireton Jones equation. This equation was used because it is recommended for non-obese critically ill patients who are on mechanical ventilation; PW’s admission weight was used when calculating kcal needs. PW’s calorie needs were 2042 kcal/day.
Protein needs were calculated using g/kg/day of protein and IBW. His protein needs were established at g/kg/day, or g of protein per day.
Fluid needs were left up to the MD due to the extent of renal failure and sepsis. To determine fluid needs, 1 ml/kcal, or 2042 ml fluid/day could be used.
ARAMARK’s Nutrition Assessment was used to determine the nutritional status of PW.
PW had diarrhea and vomiting for two days prior to admission, and was intubated upon admission causing swallowing problems (3 points), but was not reported to have any significant weight loss (0 points). Upon admission, PW had a BMI of 29.2 putting him in the overweight category (0 points), and albumin was not measured (0 points). PW was admitted to the hospital with severe sepsis, pneumonia, and ascending cholangitits (4 points), and PW’s anticipated feeding modality was TPN (4 points). This puts PW at moderately compromised and to be seen every 3-5 days. Because PW was in the ICU, so he was rounded on everyday by the MD, dietitian, and nursing staff in the ICU.
PW does not meet any of the criteria in the Diagnosis-Related Group (DRG) because PW was overweight and not malnourished.

10. NCP: Nutrition Diagnosis
Inadequate oral intake (NI-2.1) related to intubation and initiation of vasopressors as evidence by a need for parenteral nutrition support.
Swallowing difficulty (NC-1.1) related to prolonged intubation as evidence by speech language pathology report and recommendation of a pureed diet, nectar consistency liquids.
1. Inadequate oral intake (NI-2.1) related to intubation and initiation of vasopressors as evidence by a need for parenteral nutrition support (9).
2. Swallowing difficulty (NC-1.1) related to prolonged intubation as evidence by speech language pathology report and recommendation of a pureed diet, nectar consistency liquids (9).

11. Drainage of gallbladder
NCP: Interventions
Medical
Drainage of gallbladder
Intubation
Vasopressors
CRRT
Hemodialysis
Nutritional
PN: 2 L of Clinimix 5/15 with 250 ml of 20% lipid at ml/hour over Q24H (ND-2.2.1)
EN: Vivonex at 85 ml/hour Q24H with 200 ml water flushes Q4H (ND-2.1.1, ND-2.1.4)
The gallbladder was the source of PW’s septic infection. Though the cholangitis was the origin of the sepsis, PW was not stable through his most recent hospital stay to get his gallbladder removed.
PW was started on vasopressors and mechanical ventilation upon admission. While intubated, PW could not be fed by mouth. Vasopressors are used to increase blood pressure by constricting blood vessels; vasopressors also pull blood away from the GI tract. PW was hemodynamically unstable, so parenteral nutrition had to be initiated.
CRRT was initiated due to renal failure. As PW became more hemodynamically stable, his kidney function increased and was able to be advanced to hemodialysis, which he remained on until December 3rd.
PW was placed on 2 L of Clinimix 5/15 with 250 ml of 20% lipid at ml/hour over 24 hours; this regimen provided 1920 kcal/day, 300 g dextrose/day (1020 kcal), 100 g protein/day (400 kcal), and 50 g lipid/day (500 kcal). This specific facility did no have a compounder, thus an individualized PN formula could not be mixed. PW’s needs were met to the best of the facilities abilities.
As PW became more stable, TF were initiated via nasogastric tube (NGT). PW received Vivonex at 85 ml/hour over 24 hours. This regimen provided 2040 kcal/day, 102 g protein/day, 1734 ml of water, and 136% of the RDI. As TF was tolerated, PN was discontinued. Vivonex was chosen because it is an elemental formula with a low fat content as to not irritate PW’s cholangitis.

12. NCP: Monitoring and Evaluation
Food/Nutrient-related history (FH)
Enteral nutrition order (FH )
Modified diet (FH )
Anthropometric Measurements (AD)
Weight (AD-1.1.1)
Weight change (AD-1.1.4)
Biochemical Data, Medical Tests, and Procedures (BD)
BUN (BD-1.2.1), Creatinine (BD-1.2.2)
Sodium (BD-1.2.5), Potassium (BD-1.2.7)
Magnesium (BD-1.2.8), Calcium, ionized (BD ), Phosphorus (BD )
Glucose, casual (BD-1.5.2)
Nutrition-focused Physical Findings (PD)
Digestive system (PD-1.1.5)
PW was monitored for TF tolerance on Vivonex once initiated. This was done to assure that his GI tract was able to tolerate enteral feeds. PW was advanced to an oral diet of pureed consistency once he was able to pass a swallowing evaluation. Due to PW’s prolonged intubation, his ability to swallow without aspirating into the lungs was weakened, thus a pureed diet with nectar thickened liquids was recommended. The goal was for him to consume >50% at each meal to meet his energy and protein needs. Once this occurred his TF could be discontinued.
PW was weighed daily. Although his weight fluctuated between 87.6 kg and kg, other things, such as fluid status, were considered and evaluated for these drastic changes in weight. PW was admitted to the hospital at 95.2 kg, and he was transferred to another facility at kg. He was appropriately nourished through his stay at this facility.
BUN, Cr, Na, K, Mg, Ca, P, Glucose.
Speech pathology was consulted twice throughout PW’s stay in the hospital to see whether or not he would be at risk for aspiration if an oral diet was initiated. He failed the first speech evaluation, and remained NPO until re-evaluated. After passing the second evaluation, PW was advanced to a pureed diet, and was monitored for tolerance of this advancement by nursing staff.

13. Conclusion
Septic Shock is a life threatening condition.
Vasopressors, intubation, and sedation as medical treatment indicates need for nutritional support.
TPN was initiated to maintain nutritional status of patient.
As patients became hemodynamically stable, EN became route of nutrition therapy.
Upon extubation and regain of strength, patient began oral intake.
Length of hospital stay: November 12-December 18.
PW is a 64 year old male, presented to the hospital with septic shock due severe cholangitis. He was put on mechanical ventilation and vasopressors, requiring TPN support. The calorie, protein, and fluid needs were based on PW’s admission weight, IBW, and height. The TPN formula was 2 L of Clinimix 5/15 with 250 ml of 20% lipid at ml/hour over 24 hours; this regimen provided 1920 kcal/day, 300 g dextrose/day (1020 kcal), 100 g protein/day (400 kcal), and 50 g lipid/day (500 kcal). Once hemodynamically stable, EN of Vivonex at 85 ml/hour over 24 hours with 200 ml water flushes every 4 hours. This regimen provided 2040 kcal/day, 102 g protein/day, 2934 ml of water, and 136% of the RDI. PW was monitored for electrolyte balance, glucose control, and renal function during his stay at the hospital. Nutritional support was adjusted according to these indications.
TPN was initiated within two days of PW being admitted to the hospital. The MD made this decision in anticipation of PW’s medical course of action, although literature has found that late initiation of TPN may result in a shorter hospital stay and decrease risk of further infection (6). Initiation of EN while the patient is on vasopressors is an uncommon practice, and PW was not put on EN until he was hemodynamically stable. This is the recommendation by ASPEN guidelines (8), but further research on the benefits and risk of enterally feeding during hemodynamic instability in septic shock needs to be done.

14. References
Sepsis. A.D.A.M Medical Encyclopedia. PubMed Health. Updated August 23, Accessed December 28, 2012.
Siner, JM. Sepsis: Definitions, Etiology, Epidemiology, and Pathogensis. Chest. 2009; 4. Accessed December 23, 2012.
Septic Shock. Medline Plus. Updated January 14, Accessed December 28, 2012.
Pinsky MR, Mink S, Sharma S, et al. Septic Shock: Epidemiology. Medscape Reference. Updated August 13, Accessed December 28, 2012.
Shock. A.D.A.M Medical Encyclopedia. Pubmed Health. Updated January 10, Accessed December 23, 2012.
Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:
Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19:
McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patients. J Parenter Enteral Nutr. 2009;33:
American Dietetic Association. International Dietetics and NutritionTerminology (IDNT) Reference Manual. 3rd ed. Chicago, Il: American Dietetic Association; 2011.
Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition Practice Guidelines. A.N.D. Evidence Analysis Library website. Accessed 2 Jan 2013.
Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010.   
ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2010.

15. QUESTIONS?