1. Presented by Heather Collins

2.  VM had been hospitalized twice over the course of 2 weeks with complications from Staph Aureus infection of her Hickman Catheter  She was visibly malnourished, with subcutaneous tissue loss, confirmed by anthropometrics: 89% of IBW  VM was NPO for at least 7 days by the time TPN was re-established  Patient complains of vomiting with oral intake or Enteral Nutrition  Diagnosed with Failure to Thrive

3.  Patient blames current problems on “Chronic Post-Lyme Disease Syndrome”  Patient has long Hx of vomiting and constipation with oral intake or Enteral Nutrition  Previous admissions include *5/19/14: N/V, hypokalemia, tremors, tachycardia *8/5/14: Hyperventilating *12/29/12: RUQ abdominal pain, N/V, cholelithiasis

4. Infectious Diseases Society of America criteria: Within 6 months of Lyme Disease diagnosis and persistence of 6 months: *Fatigue *Musculoskeletal Pain *Cognitive Difficulties

5.  VM meets several criteria based on the Academy’s warning signs of eating disorders: *Disproportionate time spent thinking about food or body weight *Marked weight changes *Low pulse, dizziness, Low blood pressure *Abdominal pain, constipation, reflux, vomiting, delayed gastric emptying *anxiety, obsessiveness over concern with weight and shape

6. VM met criteria for severe malnutrition in the context of acute illness: Less than 50% of estimated energy requirements for >5 days with moderate subcutaneous fat loss and likely muscle wasting observed in the thighs and calves

7. TestReference RangePatient ResultDate HGB12.0-16.0 g/dL8.1 (L)12/7/14 Blood Urea Nitrogen 6-24 mg/dL<2 (L)12/9/14 BUN/Cr Ratio7-25 Unable to calculate d/t low BUN 12/9/14 Potassium3.6-5.0 mmol/L2.8 (L)12/9/14 Total Protein6.4-8.2 g/dL6.1 (L)12/9/14 Albumin3.4-5.0 g/dL3.2 (L)12/9/14 Albumin/Globulin Ration 1.2-2.21.1 (L)12/9/14 Magnesium1.8-2.4 mg/dL1.6 (L)12/9/14

8. MedicationUse/Purpose Food/Drug Interactions & Side Effects FentanylOpioid: pain management Anorexia, dyspepsia, N/V, abdominal pain, constipation, diarrhea Magnesium hydroxideLaxative, AntacidNausea, Cramping, Diarrhea VancomycinAntibioticNausea Thyroid Tablet Thyroid Hormone –treat hypothyroidism Take Fe, Ca or Mg suppl separately from drug by 4 hours; decreased abs reported with soy products, walnuts, high fiber foods; caution with grapefruit and related citrus—appetite changes may occur VenoferTreatment of iron deficiencyN/D/V

9.  Patient NPO  Home TPN Infusion: Cyclic 2000 mL x 12 hrs; D70=>320 mL, A10=>600 mL, L20=>200 mL to provide 1402 calories per day, 60 g PRO, 2000 mL fluid  Treatment of infection with antibiotics; replacement of infected catheter  Intravenous Venofer to treat Anemia

10. Inadequate oral intake related to physiological and questionable psychological causes affecting ability to take adequate oral intake as evidenced by patient reports of nausea, vomiting, bloating, and abdomen pain with oral intake and Enteral Nutrition, and Parenteral Nutrition recently initiated to meet nutrition needs.

11.  Base on the patient’s ABW of 52.3 kg Recommendation: **1308-1569 kcal/day based on 25-30 kcal/kg for maintenance **63-73 g/day based on 1.2-1.4 g/kg for acute illness, infection, and repletion **1308-1569 mL fluid/day based on 1 mL/kcal

12. Prefer to feed patient through Jejunal tube with the following prescription: *Peptamen Bariatric @ 20 mL/hr continuously via J-tube with the patient’s Parenteral infusion making up the majority of her calorie and protein intake *By family and MD request, alternately re-start TPN as follows: 65 mL/hr via new tunneled central venous catheter =>320 mL D70, 750 mL A10; 200mL L20 to provide 1462 kcal, 75 g PRO, 1560mL total fluids **A continuous infusion with slow titration to goal rate was recommended to prevent refeeding syndrome in patient with no nutrition for >7 days

13. Ljostad, U & Mygland, A. (2013). Chronic Lyme; diagnostic and therapeutic challenges. Acta Neurologica Scandinavia 2013: 127 (Suppl. 196). 38-47 Jacob, M. & Waterhous, T. (2011). Nutrition intervention in the treatment of eating disorders. Retrieved from: http://www.eatrightpro.org/~/media/eatrightpro%20fil es/practice/position%20and%20practice%20papers/pra ctice%20papers/practice%20papers/practice_paper_nut rition_intervention.ashx Master malnutrition definitions, coding rules. Briefings on Coding Compliance Strategies [serial online]. November 2014; 17 (11) 1-5. CINAHL Complete, Ipswich, MA. Retrieved February 1, 2015.