Critical Care Case Study: MVA

Annabel Biruete, PhD

Dietetic Intern
Learning Objectives
1. Recognize the three phases of metabolic response after trauma.
2. Recognize the physiological changes after a spinal cord injury leading to paraplegia.
3. Be familiar with the energy and protein requirements of a patient requiring
mechanical ventilation.
4. Assess the factors that may increase/decrease the nutritional requirements after
spinal cord injury/trauma.
5. Assess the trajectory of the components of the nutrition status and their association
with the nutrition support provided to the patient.
6. Evaluate the ideal tube feeding formula to be utilized for critical care patients
requiring mechanical ventilation.
7. Evaluate the areas of opportunity and critical points to assess and follow-up in a
critical care patient with spinal cord injury.
Spinal cord injury (SCI)
Acute traumatic lesion of neural
elements in the spinal canal
MVA (35-58%) and falls (22-37%)
Temporary or permanent
damage
Incidence of 13.1-52.2/million
Mortality of 3.1-17.5/million
High cost: hospitalization and
long-term care need ($9.7
billion/year)
Jia X et al., Journal of Intensive Care Medicine (2013)
Spinal cord injury: 2 phases
1. Primary injury
2. Immediately after trauma: days to
weeks
Vascular change (e.g., ischemia,
hypotension related to neurogenic
shock)
Inflammatory response (e.g.,
vascular permeability, edema,
activation of microglia)
Chemical change (e.g., ionic
derangement: intracellular Ca,
extracellular K, sodium permeability)
Cellular dysfunction (e.g.,
neurotransmitter accumulation, free
radicals, eicosanoid production and
lipid peroxidation, apoptosis)
Anatomic and functional change
(e.g., edema)

Jia X et al., Journal of Intensive Care Medicine (2013)

Phases of metabolic stress-trauma
Phase Nutritional consequences
EBB 24-48h
Catecholamines
Maintain blood volume
BMR, T, O2 consumption,
vasoconstriction, HR, acute-phase
proteins
Flow Catabolic Days-Weeks
Maintenance of energy
BMR, T, O2 consumption
Negative nitrogen balance
Anabolic Weeks-months
Tissue repair
Back to baseline

Walker et al. Respiratory care (2009)

Nutritional requirements in critical care

BMI <30: 25-30kcal/kg

Energy BMI >30: 11-14kcal/kg

BMI <30: 1.5 g/kg

Protein BMI >30: 1.5-2g/kg IBW

ASPEN, 2016
Case of SCI
AS 28y M with high-speed MVA: rollover and hit head (LOC) with complete
spinal cord injury on 07/28/17.
Per EMS head-on collision w/another car w/passenger passing away in other
car.
Complete fx. dislocation of T8/9 w/o neck fx. and ASIA A spinal cord injury BLE.
Moving BUE.
Intubated/sedated, with corneal reflex present.
Strong carotid pulses and red reflex is present (symmetrically bilaterally) and
showed good sensation.
Urgently to OR for reduction of fx. And pull his spine back into anatomic
alignment and then compress down upon this (may require a cage).
Summarized procedures
Date Intervention
07/29 T5-12 instrumented fusion and fx. Reduction w/decompression. R
pulmonary contusion; B pneumothorax; intubated/sedated w/full vent
support.
08/01 ORIF R clavicle
08/07 Respiratory decline. Paralyze with vecuronium. Intermittent tachycardia and
irregularity, possible atrial flutter. Intermittent fever.
08/09 Rotaprone bed
09/06 I&D of sacral wound; off vent.
09/08 Passed swallow test!
09/11 Waiting to decrease O2 consumption to go to rehab.
Rotoprone bed
MSI trajectory
R-pulmonary contusion, acute respiratory failure
Bi-CT
Bi-PTX
Sacral decubitus wound (requiring vac, MRSA)
Leukocytosis
C. diff
Pseudomonas
Nutrition diagnosis and PES statement

Inadequate oral intake r/t increased physiological needs (mechanical

ventilation, SCI) aeb NPO.
Nutritional requirements

25kcal/kg=1807kcal
Energy
1.5g/kg=108g (could be
Protein increased d/t sacral wound)

1ml/kcal=1807kcal
Fluids
Formulas suitable for SCI, trauma, vented patients

Immunonutrition: arginine, Peptide-based, MCT/fish oil Peptide-based

glutamine, EPA, DHA. (EPA/DHA), scFOS. For high protein requirements
Metabolically stressed Inflammation, GI tolerance Inflammation, GI tolerance
surgical, trauma, H&N ca.
Interventions and goals of care
Date Intervention
07/29 Pivot 1.5 @ 50ml/h: 1800kcal, 113g of protein, 911ml of free water.
08/01 Pivot 1.5 @ 45ml/h: 1620kcal, 101g of protein, 820ml of free water.
08/03 Vital AF 1.2 @ 60ml/h + 1 AWC prostat: 1828kcal, 125g of protein, 1168ml
of free water.
08/07 Pivot 1.5 @45ml/h: 1620kcal, 101g of protein, 820ml of free water.
08/18 Vital AF 1.2 @60ml/h: 1728kcal, 108g of protein, 1169ml of free water.
08/22 Trach and PEG, same recommendation
09/05 Jevity 1.2 @ 75ml/h: 1800kcal, 100g of protein, 1453ml of free water.
09/08 Passed swallow test. Nocturnal TF (8PM-5AM) Jevity 1.2 @ 75ml/h:
810kcal, 37.5g of protein, 545ml of free water (consuming PO: )
09/11 Nutrition education: high-energy and high-protein foods
Outcomes monitored
Weight change
Nutrition support
Lab values
Medication change
 Total Energy: TF + propofol
2200
2000
1800 Energy requirement was
covered in ~60% of days.
1600
1400
Energy (kcal)

Reasons for not covering energy

1200 requirements:
1000 Tests/surgeries
TF stopped and not restarted
800
Goal rate not advanced
600 SBT
400 Energy
Propofol
200
0
11-Aug
13-Aug
15-Aug
17-Aug
19-Aug
21-Aug
23-Aug
25-Aug
27-Aug
29-Aug
31-Aug
2-Sep
4-Sep
6-Sep
8-Sep
10-Sep
12-Sep
1-Aug
3-Aug
5-Aug
7-Aug
9-Aug
28-Jul
30-Jul
 Protein (g)

10
20
30
40
50
60
70
90
100
120
130

80
110

0
28-Jul
30-Jul
1-Aug
3-Aug
Protein

5-Aug
7-Aug
9-Aug
11-Aug
13-Aug
15-Aug
17-Aug
19-Aug
21-Aug
23-Aug
25-Aug
27-Aug
29-Aug
31-Aug
2-Sep
4-Sep
6-Sep
8-Sep
10-Sep
12-Sep
covered in ~66% of days.
Protein requirement was
 40
50
60
80
90
100
110
120

70
28-Jul
30-Jul
1-Aug
3-Aug
5-Aug
7-Aug
9-Aug
11-Aug
13-Aug
15-Aug

Vented
17-Aug
Weight trajectory

19-Aug
08/02-08/31 Edema +

21-Aug
23-Aug
25-Aug
27-Aug
29-Aug
31-Aug
2-Sep
4-Sep
6-Sep
Wt

8-Sep
%UBW

10-Sep
12-Sep
% wt loss: 17.2%
Nutrition-related laboratory values
200

Vented
150

100

D Albumin
% Change

50 D Prealbumin
D CRP

0
31-Jul 7-Aug 14-Aug 21-Aug 28-Aug 4-Sep 11-Sep

-50

-100
 mEq or mg/dl

0.5
1.5
2.5
3.5
4.5

0
1
2
3
4
5

28-Jul
30-Jul
1-Aug
3-Aug
5-Aug
7-Aug
9-Aug
11-Aug
13-Aug
15-Aug
17-Aug
19-Aug
21-Aug
Intracellular ions: K, Mg, P

23-Aug
25-Aug
27-Aug
29-Aug
31-Aug
2-Sep
4-Sep
6-Sep
8-Sep
10-Sep
P
K
Mg
What can be improved in critical care patients?
GRV: is NOT a sole indication of d/c TF (if 250-500: other exams, such as
CXR)
TF advancement as planned
Immunonutrition formulas for: trauma and sacral wound
Steroids?
Fermentable fiber?
Conclusions
Patients w/SCI have fluctuating requirements d/t phases of metabolic
stress related to injury
Nutritional requirements are hard to meet d/t hemodynamic instability,
procedures (NPO), TF advancement, etc.
Despite meeting energy and protein requirements in >60% of the LOS,
there was a 17% wt. loss in 6wks.
Immunonutrition formulas can be provided in trauma patients (good for
wound healing too)
Fermentable fiber in the ICU?