NUT 116BL Name: Britt Robinson

Major Case Study: Critical Illness & Nutrition Support

(11 questions; 60 points total)

Due 2/17/17 by 11 am
Submit Case Study online;
Turn in typed hard copy of ADIME note

You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning, and
monitoring throughout his hospitalization.

Initial admission information available from the medical chart:

Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms, and
back in an accident at the chemical plant where he works. After emergency first aid at the
plant, he was transported by ambulance to the university hospital burn center. Mr. G was in
shock when he was admitted.

Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned skin
is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-injury wt:
165#

Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem 20
screening panel, ABGs, and UA.

Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck,
upper back, arms, hands, and upper thighs.

**Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted.
Urinary output, P, and BP monitored hourly. NPO x 12 hrs or until hemodynamic stability
achieved. NG tube placed for stomach decompression. Maalox q 2 hrs through NG tube
and IV Famotidine.**

Initial hospital course:

As soon as the shock was under control, Mr. Gs wounds were washed, debrided,
and dressed with silver sufadiazine using fine-mesh gauze. He was given a tetanus
shot and 600,000 units of procaine penicillin were administered q 12 hrs.
After 18 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned; patient
is responsive to pain, but limited alertness; breathing & respiration normal
By 24 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
 On morning of second day (~ 30 hours), a Nutrition Consult was ordered for feeding
recommendation

Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the initial
consult, on day 2 of admission.

1. Which of the following statements best describes your nutrition screening of Mr. Gs risk
level? (1 pt)

_____ Minimal risk (patient is at or above IBW, no weight loss prior to admission); no
specialized nutrition therapy over the first week of hospitalization is required.

_____ Moderate risk (patient is at or above IBW, no weight loss prior to admission);
limited alertness duration likely > 72 hours; trophic feeds recommended to be started
within 48 hours of admission and continued through first week of hospitalization.

__x__ High risk (patient is at or above IBW, no weight loss prior to admission) with high
injury severity; enteral feeds recommended to be started within 48 hours of admission;
enteral nutrition support recommended to provide >80% of goal energy & protein
needs.

____ High risk (patient is at or above IBW, no weight loss prior to admission) with high
injury severity; trophic feeds recommended to be started within 48 hours of admission;
parenteral nutrition support recommended to provide >80% of goal energy & protein
needs.

2. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the

following methods. Show your work.
a. Quick shortcut per the ASPEN Critical Care Guidelines [25-35 kcal/kg BW] (2
pts)

75 kg x 25-35 kcal/kg = 1875 2625 kcal/day

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

165# / 2.2 kg/# = 75 kg

10 x weight (75) + 6.25 x height (177.8) - 5 x age (32) + 5 = 1706.25 x 1.1 AF =
1876.875 x 1.5-1.85 IF = 2815 3472 kcal/day

c. Comment on whether these two estimates differ or are similar, and what you
would use as your actual energy recommendation for this patient. Provide
justification for why you selected this energy recommendation. (2 pts)

These estimates are very different, by over 1000 kcals on either side of the
range. If we used the ASPEN shortcut on the higher end of the range, it would
 almost meet the minimum of the MSJ with AF/IF adjustment. Given the extent of
his wounds (20-40% TBSA) it is appropriate to use the MSJ estimate, especially
after only two days. He will likely begin to experience a net lean mass/protein
loss (Critical Illness, slide 5, 9, 10) as he moves from the ebb to flow phase of
acute injury, and so in order to save his tissues from excessive catabolism,
giving him the necessary resources to avoid malnutrition is critical.

3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work
and provide a goal range. (2 pts)

75 kg x 1.5-2.0 g Pro/kg/day = 112.5 150 g Pro

4. Based on the patients needs, consider the enteral formula to recommend

a. Describe two desirable features or characteristics of the type of formula you
would select and recommend. (refer to the UCD TF lecture) (2 pt)

I would want a formula that provides plenty of fluid to make up for losses and
also high protein such that lean tissue is not catabolized to provide nutrients
(ie muscle tissue being degraded to go through gluconeogenesis)(Critical
Illness, slide 21). Additionally, I would want to look for a formula for wound
healing, including Perative, which uses arginine, Vit.s A/C/E and zinc (Enteral
Support, slide 37).

b. Give one example of an appropriate enteral formula meeting these

characteristics, using the UCDMC formulary provided on the course web site.
(2pt)

TwoCalHN provides 2 kcal/mL, 83.5 g Pro/L, and is still 70.0% water. Taking
in approximately 3100 kcal/day, Mr. G would need to consume 1.55 L, which
would provide 129.425 g protein, and 1085 mL fluid (which would have to be
supplemented with an additional 1915 mL water per day).

5. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetidine liquid to be
put down the feeding tube? (Use the FMI text for this question) (2 pts)

Famotidine and Cimetidine are acid reducers/anti-ulcer meds (histamine-2 blockers) in

the stomach. Cimetidine is not to be used in TF due to precipitating formulas (likely due
to alcohol suspension)(FMI, p 167).

6. Describe 3 ways you could determine the adequacy of your recommendations for
energy and protein intake for this burn patient. (In other words, what will you monitor to
decide if your recommendations are adequate, and why?) (3 points)

I would monitor weight and nitrogen balance to monitor catabolism weight to be

sure that he is not losing mass, and nitrogen balance to make sure he is not in
continuous negative balance. Additionally, I would monitor blood glucose to check
 for hyperglycemia. He could become hyperglycemic if gluconeogenesis continued
past his needs for glucose in a catabolic state (Critical Illness, slide 10).

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.2 @ 60 ml/hr,
plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking 100
kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full TF
volume is being delivered each day.
The patient tells you it is difficult for him to eat by mouth due to pain, and that he
doesnt have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr
**Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted.
Urinary output, P, and BP monitored hourly. NPO x 12 hrs or until hemodynamic
stability achieved. NG tube placed for stomach decompression. Maalox q 2 hrs
through NG tube and IV Famotidine.**

7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current
information available.

a. Energy: (2 pt)
10 x weight (70) + 6.25 x height (177.8) - 5 x age (32) + 5 = 1656.25 x 1.1 AF =
1821.875 x 1.5-1.85 IF = 2733 3370 kcal/day Given that this reflects a
severe unintentional weight loss (6.7% in just 10 days), I would be more inclined
to use his preinjury weight for his needs to get his weight back up.

b. Protein: (2 pt)
70 kg x 1.5-2.0g = 105 140 g/day

c. Fluid: (2 pt)
2733 3370 kcal x 1 mL/kcal = 2733 3370 mL

8. Calculate the energy, protein, and fluid provided by the current TF regimen.
Show your work
a. Energy: (2 pt)
Jevity 1.2 @ 60 ml/hr: 1.2 kcal x 60mL/hr = 72 kcal/hr x 24 hr/day = 1728
kcal/day

b. Protein: (2 pt)
Jevity 1.2 @ 55.5 g/L x 1.44 L (60 mL/hr x 24 hr) = 79.92 g/day
 c. Fluid: (2 pt)
Jevity 1.2 @ 80.7% water x 1440mL = 1162 mL/day

9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.

N balance = g protein (UUN + 4) = 92 g pro (23 g + 4) = - 12.3 g N/d

6.25 6.25

Interpret the results of the nitrogen balance study above. Is the current TF order adequate
to meet estimated protein needs? (2 points)

At a value of -12.3 g N/d, Mr. G is in negative protein balance at 79.92 g/day, he is

not taking in enough protein to meet his metabolic needs.

10. Write an ADIME note for your day 10 follow-up assessment of Mr. G. (22 points)
Hints: Follow the ADIME note guidelines provided on the course web site. Use
subheadings. Be sure to evaluate his current anthropometrics (and any trends seen),
current kcal/pro needs, adequacy of the current diet order (including both the TF and PO
intake), and current labs. What do the anthropometric and biochemical data reveal? Is the
current diet order adequate and realistic for the patient? Write a PES statement that
reflects your assessment and include it in your note. In the Plan section, make very
specific nutrition support and monitoring recommendations for this patient at this point in
time.

A:
Patient History: 32 yo male, admitted to burn unit after full thickness burns to trunk and
arms. Current open wound estimate at 15% TBSAB.

MD Diet Order/Rx: Jevity 1.2 @ 60 ml/hr, plus PO intake as tolerated, current intake
measured by I/O at 100 kcal/day PO.

Anthropometrics: 510, 165# (75 kg) pre-injury wt at admission, 99% IBW, BMI 23.7, CBW
70 kg (6.7% loss in 10 days), no significant edema.

Cognition: Alert and oriented

Skin: Severe burns on torso and arms, current estimate of open wounds at 15% TBSAB

Biomedical data/labs: Alb 2.7 g/dL (Low), PAlb 8 mg/dL (Low), UUN 23 g/24 hr

Medications: Maalox q 2 hrs through NG tube and IV Famotidine

Estimated Nutrient Needs (based on pre-injury 75 kg wt):

Energy: (10 x 75 kg) + (6.25 x 177.8 cm) (5 x 32 yrs) + 5 = 1706.25 x 1.1 AF = 1876.875
x 1.5-1.85 IF = 2815 3472 kcal/day

Protein: 1.5-2.0 g/75 kg = 112.5 150 g/d

Fluid: 1 mL/kcal x 2815 3472 kcal = 2815 3472 mL

D: Inadequate protein-energy intake (NI 5.3) R/T increased protein and energy needs AEB
full thickness burns over torso and arms (15% TBSAB), unintentional weight loss of 6.7%
body weight over ten days in hospital, and negative nitrogen balance.

I: Increase intake to meet approximately 3100 kcal/day by replacing Jevity 1.2 to TwoCal
HN. Advance by 5 mL to goal of 65 mL/hr as tolerated to meet calculated energy needs
Provide pt with additional 2008 mL fluid to meet needs. If pt unable to drink fluids, provide
335 mL water flush Q 4 hrs.

TwoCal HN @ 65 mL/hr x 24 hr/day = 1560 mL/day

1520 mL/day x 2 kcal/mL = 3120 kcal/day
1.52 L/day x 83.5 g Pro/L = 126.92 g pro/day
1560 mL x 70.0% fluid = 1092 mL fluid

M/E: Monitor I/Os to ensure proper energy and fluid intake. Monitor which continuous TF
is provided and weigh daily to monitor any further weight change. Monitor nitrogen balance
and correct TF regimen (increase) if nitrogen balance remains negative.

11. It is now 3 weeks since admission and Mr. G is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is finally interested in trying to eat more foods
orally and his appetite is returning. How could his current continuous TF regimen (the one
recommended in your note above) be modified to provide a total of approximately 1000
kcal/day and not interfere with his intake at meal times? Make recommendations for an
appropriate transitional TF plan/order and how to monitor. Make a specific
recommendation for both the TF plan and monitoring. (6 points total)

(4 pts) Recommended transitional feeding plan :

Begin cycle feeding at night:
TwoCal HN 40 mL/hr x 12 hr from 20:00-08:00 (Enteral Support, slide 57).
TwoCal HN x 45 mL/hr x 12 hr = 540 mL x 2 kcal/mL = 1080 kcal provided during cycle
feeding.

(2 pts) Monitoring plan: Monitor pt report of N/V or diarrhea/constipation, or abdominal

pain. Monitor volume delivered compared to volume ordered this has already been
seen to be a problem. Monitor weight to ensure no further loss. Monitor intake during
the day to being transitioning away from TF, when pt is able to eat 75% of calories
while eating during day, discontinue TF (Enteral Support, slide 53).