Name: _Miles Hirata__________

Case Study: Enteral and Parenteral Nutrition

Mr. R, a 35 yo drug user, is hospitalized after a motor vehicle accident (MVA). He is currently suffering from a severe concussion and lapses of consciousness, a broken jaw, multiple broken bones, and possible internal injuries. He had not eaten anything for several days PTA because he was overdosing on drugs. Enteral feeding has been recommended in order to improve his nutritional status and given his decreased level of alertness. The patient will be bedridden until his mental status improves. A nasogastric feeding tube has been inserted and the physician has asked for your recommendation regarding the type of formula and amounts of kcal/protein needed for this patient. Ht: 511 Current wt: 156 # UBW: 167 # Serum albumin: 3.0 mg/dL

1. Write 1 PES statement for this patient. (2 pts) NI-2.1 Inadequate oral intake related to MVA as evidenced by broken jaw and nothing consumed for several days.

2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts)
The nasogastric feeding route is appropriate for this patient. Feeding tube should be temporary and due to his broken jaw, will be unable to masticate any food. The nasogastric tube will provide a route for macro and micronutrients to be metabolized and absorbed by the patient.

3. What daily intake of kcals, protein, and fluids would you recommend for this patient and why? Show calculations for estimated needs, give recommendations as kcal/d, g protein/d, ml fluid/d. (6 pts) MSJ: REE=10W+6.25H-5A+5 10(70.9kg)+6.25(180.34cm)-5(35)+5 709+1127.125-175+5 =1,666kcal x 1.2AF x 1.5IF = 2,999kcal/d Protein: 1.3-1.5g protein/kg/day Current Body weight: 70.9kg 1.3g x 70.9kg = 92.17 grams protein 1.5g x 70.9kg = 106.35 grams protein Protein: 92g-106g protein/day Fluids: 1ml/kcal Total kcals = 2,999kcal Fluid Recommendation: 2,999ml fluid/d Kcal Recommendations NTP pg.60

Protein Recommendations NTP pg.61 Fluid Recommendations NTP pg.123

4. Based on the needs of this patient, describe three desirable characteristics for the type of formula you would recommend. Give one example of an appropriate enteral formula meeting these characteristics. Use Appendix C2 in NTP text or websites of formula companies, such as Nestlenutrition.com/us or Abbottnutrition.com. (4 pts)
Since the patient has no specific requirements such as a lactose free formula, the main requirement in a formula would pertain to satisfying the patient s protein and carbohydrate recommendations. A formula with adequate protein and carbohydrates will assist in healing from his multiple injuries. The selected formula should also contain vitamins and minerals, specifically vitamin D and calcium to aid in bone growth/healing. One formula that would meet these recommendations is Ensure (Abbott).

5. a) Based on the enteral formula you selected in question 3 above, what daily total volume of formula would meet Mr. Rs estimated kcal and protein needs? Show calculations. (3 pts) Ensure : 1.06kcal/ml Kcal: 2,999kcal/1.06kcal/ml =2,829.25ml =2,800 ml Protein range: 92-106g/d 44 grams of protein in 1,000ml of Ensure 44 grams of protein/1000ml x 2,800ml = 103.6 grams of protein b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr infusion? Show calculations. (1 pt) 2,800ml/24 hours = 116.67ml/hour =115ml/hour (goal rate) Start at 30 ml/hour and increase by 30 ml every 4 hours as tolerated, to goal rate of (115ml/hour) c) Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what else is needed and how it would be added to the current tube feeding. Show calculations. (4 pts)
Ensure: 83% water Fluid Recommendations: 2,999 ml 2,800ml x 0.83 = 2,324ml of fluid provided by formula 2,999ml-2,324=675ml of extra fluids needed provided by water flushes 675ml/6 water flushes @ every 4 hours = 112.5ml This volume of tube feeding is not adequate to meet his fluid needs. In order to meet his needs, 115ml water flushes will be completed every 4 hours.

6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts)

Albumin should be monitored to indicate amount of protein stored which will be needed in wound healing. Blood Urea Nitrogen should also be measured in order to monitor the indicated protein catabolism required for wound healing and assuring that urea/nitrogen is being safely removed from the body. Hematocrit and Hemoglobin levels should be monitored for signs of anemia since the patient has many injuries including possible internal injuries.

7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts)
I would monitor the total urinary output to check for any signs of dehydration and to ensure his fluid needs are being met.

The patient, Mr. R, is now 5 days s/p his MVA. He did not tolerate the enteral feedings well (diarrhea and pain) and now has been diagnosed with acute pancreatitis. The MD has ordered a nutrition consult for evaluation of parenteral nutrition (PN) support. For the purposes of answering questions 7-12, assume that your current estimated kcal and protein needs for Mr. R are: 2600 kcal/day and 110 g protein/day. 8. Write a PES statement. (2 pts) NI-2.3 Inadequate intake from enteral/parenteral nutrition related to acute pancreatitis as evidenced by diarrhea and pain. 9. Which type of PN support do you recommend central or peripheral? Justify your answer. (2 pts)
I would recommend using central parenteral nutrition since patient was unable to tolerate enteral nutrition for 5 days. While peripheral parenteral nutrition would be ideal for using parenteral nutrition short term, the main goal is to make sure the patient is receiving adequate nutrition. Furthermore, taking into consideration the patients estimated kcal requirements are on the higher side, central parenteral nutrition will be utilized more effectively than peripheral.

10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of Mr. Rs total kcal needs. Show calculations. (2 pts) 2600kcal x 0.2=520kcals 520kcal/10kcal/gm=52 grams of fat 520kcals/1.1kcal/ml = 472.72ml =500ml (Common bag size)

11. The MD wants the dextrose and amino acid solution to be a total volume of 2 L/day. (The volume of lipid emulsion is separate from this 2 L.) a) Determine the final amino acid concentration of this solution, which would supply 110 g protein/day. Show calculations. (2 pts)

110grams protein/2000ml = 0.055g/ml 0.055g/ml x 100 = 5.5%

b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals from CHO and as grams of dextrose. Show calculations. (3 pts)
kcals from fat = 520kcal kcals from protein = 110 grams x 4 kcal/gram = 440kcal Total kcal =2,600 Kcal from CHO = 2,600-520-440=1,640kcal Grams of Dextrose: 1,640kcal/3.4kcal/gm =482.35grams =482 grams of dextrose

c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts)
482 grams dextrose/2000ml = 24.1%

d) If the PN solution had to be made from a starting stock solution of D 50W (500 g dextrose in 1 L of water), what volume of this stock D50W would be needed to provide the grams of dextrose that you calculated in question 9b above? Show calculations. (2 pts)
482 grams dextrose/500g/L = 0.964L =964ml of stock D50W

e) Compare the grams of dextrose to be provided in this solution with the maximum glucose infusion rate for Mr. R of 5 mg/kg BW/min. Would you make any changes to the PN solution based on this information? If so, how would you change it? (2 pts)
482 grams of dextrose Infusion rate: 5mg/kg Body weight: 70.9kg 70.9kg x 5mg = 354.5 mg/min 354.5mg/min x 60min/1hour x 24 hours/day = 510,480 mg/day =510.48 grams/day No, I would not make any changes since the grams of dextrose provided is lower than the maximum infusion rate of 510 grams/day.

12. List three lab values that you would monitor for this patient and the reasons why. (6 pts)
Because of the acute pancreatitis diagnosis, b12 absorption may be inhibited. Due to this, I would monitor B12 levels for any signs of deficiencies and development of anemia. Blood glucose should also be monitored to determine glucose uptake and carbohydrate absorption. A lipid panel should also be generated to look at triglyceride levels for measuring the severity of acute pancreatitis.

13. Mr. R develops hyperglycemia while on PN support. Describe two actions you would recommend to help lower blood glucose and achieve metabolic control of the patient. (2 pts)
To help lower the blood glucose, I would initiate insulin therapy and provide synthetic insulin to the patient. Also, I would possibly reduce the amount of dextrose given to the patient provided by the parenteral nutrition.

14. What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a severely malnourished patient who is started on PN? (4 pts)
Refeeding syndrome is defined as metabolic alterations that may occur during nutritional repletion of starved patients. When a person has been starved for several days, the body produces energy in the form of ketones. When nutrients are re-introduced to the body, glucose metabolism begins again and requires a large amount of electrolytes, leading to a sudden and dramatic decline in blood levels. This drop can lead to inhibited respiratory functions, cardiac arrhythmias, and death. It is important to monitor for refeeding syndrome in a severely malnourished patient who is started on parenteral nutrition since refeeding syndrome can occur in any malnourished patient, whether from oral intake, enteral nutrition, or parenteral nutrition. Refeeding syndrome definition NTP pg.81