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

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

3. 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

4. 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:

5. 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

6. 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

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

8. 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

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

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

11. Nutrition Assessment Nutrient Needs: Mifflin St-Jeor
(10 x 73.4) + (6.25 x 149.8) - (5 x 88) -161= kcals
Stress Factor: 1.3 x = 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

12. 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.

13. 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

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

15. 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
Acid-based balance 1.1
Partial pressure of carbon dioxide in arterial blood PaCO2 BD-1.1.4

16. 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: doi: /ajcc

17. 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: doi: /ajcc

18. 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): doi: /CCM.0b013e31820a905a

19. 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): doi: /CCM.0b013e31820a905a

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

21. Thank You!
Questions?

22. References
Mahan LK. Escott-Stump S. Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Saunders, Elsevier; 2012: p
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: doi: /ajcc
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): doi: /CCM.0b013e31820a905a
Academy of Nutrition and Dietetics. Evidence Analysis Library. Executive summary of recommendations. Accessed January 1, 2013