Case Study
An 80 year old female is admitted to the MICU with sepsis, pneumonia, stage 2 pressure wound on the sacrum and a weight loss of approximately 12 lb over the past month. She also has been experiencing intermittent nausea and vomiting coupled with loose stool. Due to hypoxia and hypotension, the patient is placed on mechanical ventilation.
Past History: HTN, NIDDM (non-insulin dependent diabetes mellitus), HFpEF, osteoporosis
Height: 5’3” (medium frame) IVF: D5 ½ NS @ 100 ml/hr – 50g dextrose /77mEq
Weight: 139# (on day of nutrition consult)
UBW: 111# (1 week PTA) Estimated. Kcal/d: 1500 – 1750
130# (1 year ago) Estimated. Protein/d: 75 – 85 g
Medications: ceftazidime (IV), clindamycin (IV), erythromycin (IV), milk of magnesia, Colace, Protonix, Fosamax,
Acetaminophen for temperature > 101 F, sliding scale insulin coverage-finger sticks Q 6 hr (beginning at 201 mg/dl)
Labs:
Na 149 mEq/L (H) BUN 30 mg/dl (H)
K 3.0 mEq/L (L) Crt 0.8 mg/dl
Cl 119 mEq/L (H) Glu 215 mg/dl (H)
CO2 18 mEq/L (L) Alb 2.0 g/dl (L)
Mg 1.4 mg/dl (L) Ca 8.3 mg/dl (L)
PO4 2.3 mg/dl (L) Trig 200 mg/dl
Prealb 3.6 mg/dl (L) Hgb A1C 9 % (H)
Be as complete as possible with your answers[Total Awarded Points 165]
1. What type of feeding access would you recommend for this patient and why? (4 pt.)
Naso Jejunum → high risk of aspiration
Protonix and vomiting
2. Which tube feeding (TF) would you recommend for this patient and why? (8 pt.)
(Specify > 3 attributes) Formulas available: Jevity 1.5, Glucerna 1.5, Two Cal HN, Nepro Carb Steady, Vital AF (semi-elemental), Pivot 1.5
Pivot 1.5
Fluid restriction -HF
Immune modulating- anti-inflammatory (sepsis)
Wound healing (stage 2 pressure wound)
Fiber (loose stool – normalize regularity)
Stimulates Insulin (helps with glucose level) – Hbg A1C of 9% and her Glu at 215mg/dL
3. Recommend a sample TF protocol to be followed by the medical team and nursing. Be specific. (12 pt.)
Intermittent → can stimulate a meal plan which can be useful for blood glucose levels in diabetes and permits more freedom for ambulatory pts.
Pump assisted
Closed system
Head of Bed at 30 degrees to decrease the risk of aspiration
Check to make sure the tube is still placed by using ultrasound – because of risk of migrating back into the stomach
MD responsible for entering orders
RN adjust run rate to assure full EN dose provided over 24 hours
Orders are written as a dose volume/ day
Flush between meds
Administer medication one at a time
125mL/hr for 2 hours every 6 hours → 1L per day is goal
When TF ends, turn off the pump. Prior to restarting feed, the nurse should zero out the memory, document the infuse and the restart rate over the next 24 hour period. In addition, when restarting the feeding, the nurse should confirm any changes to the TF dose in the pump.
Withhold TF until patient is hemodynamically stable
4. How many Kcal, protein, fiber, Na, K, calcium, B12, Fe, Zn, vitamin c, vitamin d and omega 3 fatty acids/ratio (if applicable) and % RDI for vitamins and minerals does this regimen supply per day? (12 pt.)
Providing 1L of formula
Kcal→ 1500 calories
Protein → 93.8 g
Fiber→ 7.5g
Na→ 1475 mg
K→ 1983 mg
Ca→ 1013 mg
B12→ 5.1 mcg (212.5%) RDI is 2.4
Fe→ 23.6 mg (295%) → RDI for women over 50 is 8mg
Zn→ 30.8 mg RDI=8mg (385%)
Vitamin C→ 304 mg RDI=75mL (405%)
Vitamin D→ 27.8 mcg RDI=600IU (15mcg) (185%)
Omega 3→ (EPA, 2.6 g; DHA, 1.1 g) omega 6:omega 3→ 1.7:1
5. How much free water does the patient require in addition to the TF and how should it be provided? Show all work (5 pt.)
Free water for the patient was calculated using 25mL/kg for total fluid needs and subtracting from the volume she is receiving for the IV solution.
25mL x 50.45kg =1.261L per day → 1261mL
Solution provides 750mL
1261mL-750mL= 511mL of free water
6. What other recommendations do you have for the MD to improve upon the nutritional prescription? Include a minimum of 3 and provide explanations. (6 pt.) [Extra 2 points will be awarded for each appropriate, additional recommendation.
Recommend assessing b12 (MMA), folate, serum ionized calcium, and iron labs and supplement any deficiencies because on PPI
Increasing protein needs to 101g of protein because the patient is under severe stress so 2.0g of pro per kg may be more appropriate
Possibly supplement glutamine and arginine??
Calcium supplement because pivot only provides 1000mg of the 1200mg RDA and osteoporosis
Mg, ca, and k supplement to replenish electrolytes all commonly low together
Free fluid
Possibly estimated calories too high 1263-1515 (25-30kcal/kg) ** not sure with high catabolic state and loss of 12lbs in month… she possibly has higher energy needs.. Maybe include a 1.2 for TEE
7. After 2 ½ days at the TF goal, the nurse informs you that the patient is having diarrhea and the abdomen is distended. What preliminary step(s) should you take when evaluating this issue and why? (3 pt.)
Rule out
C.diff,
Bleeding,
Partial obstruction
Possible fluid accumulation
8. After a thorough evaluation (and concurring that the patient has diarrhea), what recommendations do you have for the MD and why? (> 6 possible recommendations) (18 pt.)
Switch vital AF → last resort
Remove IV meds switch to crushed meds
Remove milk magnesia because high in mg
Remove: Motility agents and Antibiotics
Remove stool softener
Supplement electrolytes
Add soluble fiber to tf like benefiber
Supplement zinc and copper because we lose a lot in stool
Upon further workup, the patient is found to have a partial SBO. Surgery is consulted and the plan of care is conservative treatment with gastric decompression and IV hydration. PN is to be initiated considering her age, severe weight loss PTA and expected length of time to be without enteral nutrition. The patient only has PIVs at this time.
The solution is to be 2400 ml of a 3 in 1 solution with 20% SMOF lipid, to run over 20 hours to start. Provide in the solution the average adult dosage for K, Ca, PO4 and Mg with Na in 1/4 NS concentration (1/3 from an acetate source). It should provide about 1500 total calories and 100g protein.
In addition, to be included in the solution is 1 mg of vitamin K, 2000 mg of vitamin C, 5 mg zinc, 200 mg thiamin, MVI, trace element mixture and 25 units of regular insulin. (See provided sheet for parenteral formulary.)
Answer the following questions using the provided fact sheets.
1. What is the maximum amount of dextrose and fat which can be provided based upon the patient’s preadmission weight and available standards? (4 pt.)
Preadmission weight was 111lbs.
Dextrose Max Dose: 7.2g/kg → 7.2 x 50.5kg= 364g of dextrose
Lipid Max Dose: 2.5g/kg → 2.5 x 50.5kg= 126g of lipid
2. How many grams of amino acids, dextrose and fat would you like to provide to fill the prescription of 1500 kcal? (6 pt.)
3% AA: .03 x 2400mL = 72g of AA
72gx3.4cals/g=244.8 cals
Lipid (1.5g/kg) = 76g of lipid
Lipid volume= 76gx100mL/2g = 380mL
Lipid Kcal= 380mL x 2cals/mL = 760cal
1500 cals – 244.8 cals (AA)-760 cal (ILE)= 495.2 cals from dextrose
dextrose= 495.2cals/3.4 cals/g = 145.6→ 146g of dextrose
3. How much volume (ml) of the base solutions for dextrose, amino acids, ILE, electrolytes, sterile water and other additives will be needed to fill the desired prescription? (29 pt.)
Amino Acids 15% Base solution provides 150 per L
150g/1000mL = 72g/x → 480mL
Dextrose 50% base solution provides 500g dextrose per L
500g/1000mL =146g/x → 292 mL
ILE 20% provides 200g lipid per L
200g/1000mL = 76g/x → 380mL
MVI: 10mL
TE: 1mL
Vitamin K (2mg/mL): 2mg/1mL = 1mg/x = .5 mL
Vitamin C (500mg/mL): 500mg/x = 200mg/mL → .4mL
Zinc (1mg/mL): 1mg/1mL = 5mg/x → 5mL
Thiamin (100mg/mL): 100mg/1mL = 200mg/x → 2mL
Insulin (100 units/mL): 100 units/mL = 25 units/x → .5mL
Sterile water: 480mL (AA) + 292mL (dextrose) + 380mL (ILE) + ~150-200mL (additional) =1302mL-1352mL
2400mL – 1302mL-1352mL = 1048mL-1098 mL sterile water
4. What is the final concentration of dextrose, ILE and amino acids in the desired volume? (8.pt.)
AA: 72g/2400mL x 100% = 3%
Dextrose: 146g/2400mL x 100% = 6%
Lipid: 76g/2400mL x 100% = 3.2%
5. Do all of the constituents fit in the desired volume? (2 pt.)
Yes, Amino acids are less than 4% and dextrose is less than 8%
6. Calculate the osmolarity of the 3 in 1 solution. Calculate the osmolarity of the individual electrolytes, and then using the general rule of thumb 2 mOsm/mEq (8 pt.)
AA: 100mOsm x 3%= 300 mOsm/L x 2.4L → 720mOsm/2.4L
Dextrose 50mOsm x 6%=300 mOsm/L → 720mOsm/2.4L
Lipid 3.2% x 14 = 44.8 mOsm/L → 107.5 mOsm/2.4L
Sodium ¼ NS = 38.5 MeQ x 2.4L= 92mEq
K 1.5mEq/kg → 75.75 mEq
PO4→ 30mmol → 45mEq
mg→ 14mEq
Ca→ 12.5 mEq
(92mEq (Na) + 75.75 mEq (k) + 45mEq (PO4) + 14 mEq (mg) + 12.5 mEq (ca) x 2 = 478.5mOsm/2.4L
7. Is the osmolarity appropriate for a PIV access? (2 pt.)
MAX 900mOms/L x 2.4L → 2160mOms
720+720+107.5+478.5 = 2026 mOms
YES
MAX 900mOms
8. Complete the provided sample parenteral nutrition order form (completed worksheets included). (2 pt.)
See attached.
A PICC is placed due to poor venous access and multiple IV therapies. Change the above prescription to a CPN solution. (The volume of the 3 in 1 solution can be changed as deemed necessary to a maximum of 2 liters.) The sodium concentration is to remain ~ ¼ NS with 1/3 from an acetate source. Show all work and complete a new order form.
9. How much volume (ml) of the base solutions for dextrose, amino acids, ILE, electrolytes, sterile water and other additives will be needed to fill the desired prescription? (The quantity of individual macronutrients may be changed to better meet patient demands.) (30 pt.)
100 pro/.83g amino acids = 120g of AA
120g x 3.4cals/g = 408
1750cals -408 cals AA= 1342 cals
Lipid (1.5g/kg) = 76g of lipid
Lipid volume= 76gx100mL/2g = 380mL
Lipid Kcal= 380mL x 2cals/mL = 760cal
1342 cals – 760 cals ILE = 582cals
582 cals/ 3.4cal/g = 171 g of dextrose
Amino Acids 15% Base solution provides 150 per L
150g/1000mL = 120g/x → 800mL
Dextrose 50% base solution provides 500g dextrose per L
500g/1000mL = 171g/x → 342mL
ILE 20% provides 200g lipid per L
200g/1000mL = 76g/x → 380mL
MVI: 10mL
TE: 1mL
Vitamin K (2mg/mL): 2mg/1mL = 1mg/x = .5 mL
Vitamin C (500mg/mL): 500mg/x = 200mg/mL → .4mL
Zinc (1mg/mL): 1mg/1mL = 5mg/x → 5mL
Thiamin (100mg/mL): 100mg/1mL = 200mg/x → 2mL
Insulin (100 units/mL): 100 units/mL = 25 units/x → .5mL
Sterile water: 800mL (AA) + 342mL (dextrose) + 380mL (ILE) + ~150mL (additional) =1672mL
2000mL – 1672mL = 328 mL sterile water
10. What is the final concentration of dextrose, ILE and amino acids in the desired volume? (12 pt.)
AA: 120g/2000mL x 100%= 6%
Dextrose: 171g/2000mL x 100%=8.55%
ILE: 76g/2000mL x 100% = 3.8%
11. Calculate the osmolarity of the CPN (3 in 1) solution. (8 pt.)
Dextrose 8.55% x 50mOsm = 427.5mOsm
AA: 6% x 100mOsm = 600mOsm
Lipid: 3.8% x 14mOsm= 53.2mOsm
Sodium ¼ NS = 38.5 MeQ/L
K 1.5mEq/kg → 75.75 mEq
PO4→ 30mmol → 45mEq
mg→ 14mEq
Ca→ 12.5 mEq
(75.75 mEq (k)+ 45mEq (PO4) +12.5mEq (Ca) + 14mEq (mg))/2L = 73.6 + 38.5 mEq (Na)= 112.125 mEq
112.125mEq x 2mOsm= 224.3mOsm
427.5mOsm (dextrose) + 600mOsm(AA) + 53.2mOsm (ILE) + 224.3mOsm (electrolytes) = 1305mOsm/L
1305mOsm/L x 2 L = 2610mOsm total
12. Complete the provided sample order form. (2 pt.)
See attached.
The patient has been successfully weaned from mechanical ventilation and the partial SBO has resolved. The patient now agrees to have a feeding tube placed to supplement an extremely poor oral intake on her present diet.
13. What type of feeding access would you recommend and why? (4 pt.)
Nasogastric tube feeding.
Since she has been weaned from mechanical ventilation and the partial SBO has been resolved, and she is no longer at an increased risk of aspiration, a Nasogastric tube feeding would be an ideal tube feeding. Anticipated to be short term less than 4-6 weeks.
Motility to stimulate the gut
14. Provide a sample transition protocol from PN back to TF assuming po intake is presently negligible. (6 pt.)
Begin TF at 50% goal PO intake with good tolerance decrease PN components to 50%
When EN provides 75-80% of estimated requirements discontinue PN
Consider fluid needs once PN is discontinued
15. What type of TF regimen and access would you recommend for this patient at discharge and why (assuming further deterioration in nutritional status and newly diagnosed severe dysphagia)? (4 pt.)
PEG because she will require long term access considering her deteriorating nutritional status and newly diagnosed dysphagia
Regimen: bolus gravity bag to stimulate meal times
