Be Well Solutions Clinical Rotation

Case Study
Olivia Alexander, Dietetic Intern
Overview
● Patient presents with pneumonia on 10/16
● 70 y/o male
● Active problems: ● Past Medical History:
○ HTN ○ Stroke
○ HLD ○ Hypernatremia
○ Tracheostomy dependence ○ Chronic respiratory failure
○ CKD stage 3 ○ CAD
○ Severe protein-calorie malnutrition ○ Acute renal failure
○ Diabetes
○ CHF
○ PEG tube in place

MD consult to write orders for enteral nutrition

Malnutrition
● Undernutrition, overnutrition, micronutrient-related
● Recent studies show 35-40% prevalence in hospitals
● Can develop as a consequence of:
○ Deficiency in dietary intake
○ Increased requirements in particular disease state
○ Complications of an underlying illness
● Can lead to other adverse health effects:
○ Decreased immune system
○ Impair wound healing
○ Muscle wasting
○ Longer LOS
○ Increased mortality
● At risk for refeeding syndrome
Malnutrition in the Hospital
Nutrition Focused Physical Exam
● Muscle wasting
○ Temples
○ Clavicle
○ Acromion
○ Interosseous

● Subcutaneous fat loss

○ Orbital fat pads
○ Triceps
Malnutrition Characteristics
What is refeeding syndrome?
● When someone who is starved or severely malnourished begins to eat too much food
or receives too much liquid nutrition support
● Causes drastic imbalance of electrolytes and fluids
● Reintroducing food too quickly causes rapid increase in glucose -> rise of insulin ->
uptake of glucose, phosphate, potassium, magnesium from extracellular stores
Refeeding Syndrome
Refeeding Syndrome- Electrolytes

Cardiac arrest
Neuromuscular complications
Respiratory dysfunction
Who is at risk of refeeding syndrome?
● At high risk if one or more:
○ BMI < 16 kg/m2
○ Unintentional weight loss > 15% in the past 3-6 months
○ Little or no nutritional intake for > 10 days
○ Low levels of potassium, phosphate, or magnesium before feeding
● Or, two or more of the following:
○ BMI < 18.5 kg/m2
○ Unintentional weight loss >10% in the past 3-6 months
○ Little or no nutritional intake for > 5 days
○ History of alcohol/drug abuse
Subjective
● Patient is non-verbal at baseline
● No family present to gather
information
● Tracheostomy tube in place
● Hemiplegia s/p stroke
● Physical signs of severe
protein-calorie malnutrition
PEG Tube
● Feeding tube that goes
directly from abdomen into
stomach
● Possible aspiration risk
Assessment- Malnutrition
● Assessment suggestive of severe protein calorie malnutrition: present on admit
● Physical findings:
○ Subcutaneous fat loss
■ Orbital region: hollow look
■ Upper arm region- Triceps: very little space between folds
○ Muscle loss
■ Temple region: hollowing
■ Clavicle bone region: protruding, prominent bone
■ Clavicle and acromion bone: shoulder to arm joint looks square
○ Severe Malnutrition Chronic Illness
■ Severe depletion of body fat
■ Severe depletion of muscle mass
Assessment- Medications
● Insulin glargine
● Insulin lispro
● Lactobacillus acidophilus
● Multivitamin
● Thiamine
● Zinc sulfate
● Ascorbic acid
 Assessment- Abnormal Labs

Value on 10/16 Potential Reason for abnormal

value

BUN (8-18 mg/dL) 79 ↑ Elevated: Renal disease,

excessive protein catabolism,
dehydration

Creatinine (0.6-1.2 mg/dL) 1.72 ↑ Elevated: Renal disease,

severe dehydration

Calcium (9-11 mg/dL) 7.8 ↓ Low: Renal failure,

rickets/Vitamin D deficiency
Assessment- Skin
● Breakdown location/integrity: pressure injury sacrum (stage 3)
● Extremities/Edema: WDL
Assessment- Anthropometric
Measurements
● Current height: 72 inches; 182 cm
● Current weight: 55.3 kg (121 lb 14.6 oz)
● IBW: 178 lb (81 kg)
● UBW: UTA
● BMI: 16.53
● 27% weight loss x 1 year
Assessment- Comparative Standards
● Calories: 1659-1936 (30-35 cal/kg) (1798 cal average)
● Protein: 66-83 g (1.2-1.5 g/kg) (75 g average)
● Fluid: 30 mL/kg (1659 mL) for maintenance or per MD
Nutrition Diagnosis

Inadequate protein-energy intake

related to decreased ability to consume adequate nutrition

as evidenced by NPO, feeding tube for EN

Intervention
Initiate Diabetisource AC at 15 mL/hour and titrate by 10 mL every 6 hours until goal rate of
65 mL/hour is achieved/as tolerated via G-tube
Nutrition Goal

EN tolerated, meeting greater than 85%

nutrition needs within 24-72 hours
Monitoring and Evaluation
● Food/nutrition-related history: Enteral nutrition intake and medications
● Anthropometrics: weight
● Biochemical data/medical tests/procedures: electrolytes, glucose, feeding tube
placement
● Nutrition-focused physical findings: muscle/fat wasting, skin integrity, I&O fluid
balance, and GI
● Comparative standards
Re-assessment 1 (10/18)
● Aspiration on residuals occurred overnight
● Patient was tolerating 55 mL/hour with 0 residuals
● More calorie dense formula due to volume intolerance
● Patient now receiving dextrose 5%- providing additional 204 kcal/day
New Intervention
● Initiate Nutren 2.0 at 20 mL/hr and titrate by 10 mL every 4 hours until goal rate of 40
mL is achieved/tolerated via G-tube + 1 packet of ProSource daily
● Provides 1760 cal, 82 g protein, 1089 free water (TF + water flush), 190 g CHO
Re-assessment 2 (10/21)
● Patient tolerated new TF regimen at goal rate
● Will not increase water flushes due to volume overload per MD orders
● Monitoring Na trends
Re-assessment 3 (10/23)
● TF put on hold (10/22) due to aspiration event, resumed that afternoon
● S/p thoracentesis (10/22) with 1.4 L removed
○ Fluid attributed to 4.4% wt loss x 1 day
● Na levels trending up - increased water flushes to 110 free water every 4 hour
Continued...
● Another aspiration event
● Patient transferred to Prince William Medical Center
● TF flushes adjusted for Na levels
● Procedure to transfer to J-Tube (Percutaneous Endoscopic Jejunostomy Tube) due to
aspiration events
● Initial TF regimen initiated after J-tube placement: Diabetisource AC at goal rate of 65
mL/hour
PEG Tube vs PEJ Tube
Nutrition D/C Recommendations
● Concentration/rate/route: initiate 1.15 bolus (cartons) 3x/day via J tube; total 6 cans
daily (1500 mL)
● Feeding tube flush: 175 mL before and after each bolus (6x/day); total 480 mL
additional water
● Composition: 1750 kcal, 73.5 g protein, and 1656 mL fluid per day
Summary
● Malnutrition
● Refeeding Syndrome
● PEG tube vs. PEJ tube
Questions?
Current Research
Argáez C, Brett K. Gastrostomy versus Gastrojejunostomy and/or Jejunostomy Feeding Tubes: A Review of Clinical Effectiveness, Cost-Effectiveness and
Guidelines. Ottawa (ON): CADTH. 2018. https://www.ncbi.nlm.nih.gov/books/NBK538736/

Barker LA, Crowe TC, Gout BS. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. Int J Environ Res Public
Health. 2011;8(2):514-527. doi:10.3390/ijerph8020514.

Blumenstein I, Stein J, Shastri YM. Gastroenteric tube feeding: Techniques, problems and solutions. World Journal of Gastroenterology.
2014;20(26):8505-8517. doi:10.3748/wjg.v20.i26.8505

Brooke J, Ojo O. The Use of Enteral Nutrition in the Management of Stroke. Nutrients. 2016;8(827):1-6. doi:10.3390/nu8120827.

Dziewas R, Jäger M, Leischker AH, Smoliner C, Warnecke T, Wirth R. Guideline clinical nutrition in patients with stroke. Exp Transl Stroke Med. 2013;5(14).
doi:10.1186/2040-7378-5-14.

Lochs H, Allison S, Meier R, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clinical Nutrition. 2016;25(2):49-62.
https://www.espen.org/files/ESPEN-guidelines-on-definitions-and-terminology-of-clinical-nutrition.pdf.

McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG clinical guideline: nutrition therapy in the adult hospitalized patient. Am J Gastroenterol.
2016;111(3):315–334.

Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008;336(7659):1495-1498.
doi:10.1136/bmj.a301.

Nutrition Care Manual. https://www.nutritioncaremanual.org/. Accessed November 2019.

Sobotka, L. (2010). Basics in Clinical nutrition: Refeeding Syndrome. e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 5(3). doi:
10.1016/j.eclnm.2009.06.01

What is malnutrition? World Health Organization. https://www.who.int/features/qa/malnutrition/en/. Published February 6, 2017. Accessed October
2019.