1. Critical Care Case Study
Nate Medunick

2. Patient JH 91 YO female Dry weight – 121# (55kg) Height- 66” BMI-19.5
Admission diagnosis: POD#3Hiatal hernia repair, Nissen fundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

3. Estimated Nutritional Needs
Based on actual weight in recent PMH (54kg)
Kcals (25-30kcals/kg)
Protein – 70-81g ( g/kg)
Fluid 1620ml (30ml/kg)
High Nutritional risk

4. Nissen fundoplication
A surgeon wraps the part of the stomach known as the gastric fundus around the lower esophagus (including the LES) in a Nissen fundoplication. This helps to strengthen the barrier and prevent the back flow of acids into the esophagus

5. Diet After Nissen Fundoplication Surgery
Patients must make dietary and lifestyle adjustments for about six weeks following Nissen fundoplication surgery. Three days following surgery, most patients are on a clear liquid diet, which may include:
apple juice
beef broth
chicken broth
cranberry juice
decaffeinated tea
grape juice
Jell-O
 After the clear liquid diet, most patients are put on a full liquid diet for an additional three days. This diet consists of anything on the clear liquid diet plus the following:
Carnation instant breakfast (not chocolate)
creamed soups (strained, no broccoli or tomato)
cream of wheat (or cream of rice)
ice cream (vanilla or strawberry)
milk (no chocolate milk)
sherbet
yogurt (plain, blended, or custard with fruit or seeds)
Seven days after surgery, most patients are able to tolerate a soft food diet. However, to heal properly, patients must keep their stomach from stretching. This will require them to eat small, frequent meals six to eight times per day
This slide is fine for basic points; however, use Charlton and Tobey Diets, explain the differences. Remember to mention no carbonated beverages, Also; no bread—especially in stage 1

6. hiatal hernia
 A hiatal hernia is what doctors call it when a part of the stomach moves up into the chest area. Normally, the stomach sits below the diaphragm, the layer of muscle that separates the organs in the chest from the organs in the belly. The esophagus, the tube that carries food from the mouth to the stomach, passes through a hole in the diaphragm. In people with a hiatal hernia, the stomach pushes up through that hole, too.

7. symptoms of hiatal hernia
Burning in the chest, known as heartburn
Burning in the throat or an acid taste in the throat
Stomach or chest pain
Trouble swallowing
A raspy voice or a sore throat
Unexplained cough

8. Patient JH 91 YO female Dry weight – 121# (55kg) Height- 66” BMI-19.5
Admission diagnosis: POD#3Hiatal hernia repair, Nissen fundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

9. Initiating CMH RD- K.A.
TPN initiated with Day 1 bag- 50g/AA, 100g/dextrose, and no lipids
Recommendations Day 2/goal- 80g/AA, 250g/dextrose, providing 1170 calories
50 g lipids Monday and Thursday ( lipid shortage at the time) with lipids, provides 1670 calories
Recommendations based on 25 kcal to
30 kcal per Kg for CCU Patient, not vented.

10. Nutrition Care – Nate DI
Patient required intubation post op day exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes
Day 1 nutrition intervention followed initiating
RD care plan:
50g AA, 100g dextrose, no lipids
Day 2 Nutrition plan based on dry wt-121
Kcals (22-25kcal/kg--intubated)
Protein g ( ) wound healing
Fluid – Per Intensivist
Needs remained constant during care
IVF point should be removed, it is on the nutrition intervention-Day 2 slide

11. Day 2
POD #1 S/P exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes
POD #5 hiatal hernia repair, Nissen fundoplication
patient continued on mechanical ventilation without sedation, but high doses of neosynephrine
lab values include: WBC 17.3 trending up (TU), total bilirubin TU, urine output- approximately 10 – 33 cc/hr

12. nutritional intervention– Day 2
(intubated) Custom TPN- 1500ml-80gm/AA, 115gm/dextrose + 90 gm dextrose from D5 containing IVF, no lipids. Total: calories
Reviewed with Intensivist and asked if IVF would be adjusted
Plan moving forward: increase dextrose in TPN because D5 1/2NS was transitioned to NS
lipids would be added Monday and Thursday due to national shortage
nutritional monitoring and evaluation:
tolerance of TPN with goal of 80gm/AA, 200gm/dextrose, transition to jejunal tube feeding when appropriate per surgery recommendations

13. Day 2 of Care
PES
P-Inadequate energy intake(improvement shown- unresolved)
E- S/P exploratory laparotomy (2/18)
S-TPN prescribed
GI assessment
abdomen-distended and soft
Bowel Sounds-hypoactive
Emesis color- tan
Skin
2+ General edema
wounds-six total wounds including surgical wounds, Jackson Pratt, and G tube
fluid balance ml
pharmacy-calcium chloride repletion

14. Day 3 of care
POD#2 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity 1 10ml/hr (254kcal, 11gm/protein) prescribed by Thoracic surgeon (jevity 1 cal was MD preferred)
labs included: phosphorus 3.0 trending down (TD), potassium 4.1 stable, calcium 7.6 stable, magnesium 2.0 (TD), CO2/PCO2 38 (TD)
TPN order and discussed with Intensivist ml, amino acids-80gm (320kcal), dextrose- 140gm (476kcal), lipids-40gm (400kcal)- no MVI, no trace elements, with trophic feeding, total calories/protein: 1450 total kcals, 91 gm protein
Custom electrolytes K acetate 40mEq (potassium stable), Na phosphate 25 mEq ( repletion), Na acetate 22, Ca gluconate 9(stable), Mg sulfate 7(repletion)

15. Learning experience
the original electrolyte plan - K acetate 40mEq , Na phosphate 25 mEq , Na acetate 22, Ca gluconate 9, Mg sulfate 7
Plan changed following a discussion with the Intensivist - concern was- Although; CO2 was TD, pH Slightly more Acetate would possibly increase pH over 7.38
Acetate is added to correct Acidosis; Intensivist felt that the Patient was not trending toward acidosis at the time

16. Day 4 – Patient declining
POD#3 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity 1 10ml/hr (254kcal, 11gm/protein)
patient continued on mechanical ventilation with propofol sedation and Neo-Synephrine weaned to lower dose
50ml/hr continued
Labs include: Ca 8.0, Cl 112, Mg 2.0, Phos 1.8, and Potassium 3.7
nutritional intervention-TPN – 1500ml:
80gm/amino acids (320kcal),
165 gm /Dextrose (561kcal)
6 ml/hr propofol (158 calories )
trophic TF (254 calories, 11 gm protein)
D5 carriers with multiple antibiotics (127 kcal)
Total ~1420 calories, 91 gm protein
TPN electrolytes 40mEq K acetate, 15 mEq K phosphate, 25 mEq Na phosphate, 9 mEq Ca gluconate, 7 mEq Mg sulfate. TPN discussed with Intensivist
Promote with fiber was recommended in note—no renal problems at the time; thoracic surgeon paged by RD. MD still preferred Jevity 1 cal

17. Conclusion
JH was in poor condition toward the end of my nutritional care rotation:
Patient was requiring multiple antibiotics, including zyvox
LFTs/renal labs were elevating, multisytem organ failure ensued
I found out that JH soon expired due to poor condition and advanced age
I would not have changed anything with my nutritional plan of care

18. What I learned What I learned: TPN and electrolyte needs
pH and acid/base balance
Intensivists are approachable and a great information source
RD’s recommendations can show direct results in lab work

19. Sources http://www.healthline.com/health/gerd/nis sen-fundoplication#2
hernia-the- basics?source=search_result&search=Hiatal+h ernia&selectedTitle=2%7E75