Complex Case Study

Immaculata University Dietetic Internship

Caroline Collins
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Table of Contents
INTRODUCTION 3
REPORT ON ADMISSION 3
LABS, X-RAYS, TEST RESULTS 4
TABLE 1: LABS UPON ADMISSION 4
ADMITTING DIAGNOSIS 4
PHYSICIAN’S ORDERS 5
PAST MEDICAL HISTORY 5
SURGICAL HISTORY 6
SOCIAL HISTORY 6
HOME MEDICATIONS 7
PHYSICAL HISTORY 7
HYPERTENSIVE EMERGENCY: TREATMENT 7
HOSPITAL COURSE 9
DAY 2 9
DAY 5 9
TRANSVERSE MYELITIS: TREATMENT 10
DAY 6 10
DAY 9: NUTRITION ASSESSMENT 11
NUTRITION DIAGNOSIS STATEMENT 11
TABLE 2: LABS DAY 9 11
DAY 12 12
HEMICOLECTOMY AND ILEOSTOMY: TREATMENT 12
DAY 13 13
NUTRITION FOLLOW UP 13
TABLE 3: LABS DAY 13 14
DAY 14 14
DAY 18 15
NUTRITION FOLLOW UP 15
TABLE 4: LABS DAY 18 15
NUTRITION SUPPORT IN CRITICAL ILLNESS: TREATMENT 16
DAY 19 18
DAY 20 19
NUTRITION FOLLOW UP 19
TABLE 5: LABS DAY 20 19
DAY 21 NUTRITION FOLLOW UP 20
TABLE 6: LABS DAY 21 20
DAY 22 20
NUTRITION FOLLOW UP 20
TABLE 7: LABS DAY 22 21
TIME OF DEATH 21
REFERENCES 22
APPENDIX A 24
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Introduction

This case study focuses on a 39-year-old male, R.H., with a very complicated hospital

course. He has had recurrent hospitalizations, this being his fifth hospitalization in the past 6

months. R.H. He was admitted for hypertensive emergency. During his hospital course, R.H.

developed paraplegia of his lower extremities due to transverse myelitis. He developed MRSA

bacteremia with concerns for an aortic valve endocarditis, peritonitis, and had spiking fevers. He

had toxic megacolon and a perforated transverse colon for which he underwent a resection with

an end ileostomy. He also had a cardiac arrest, with subsequent acute renal failure, vent-

dependent respiratory failure, septic shock, and need for total parental nutrition (TPN).

Report on Admission

R.H. came in with shortness of breath and chest pain radiating to his back, which has

gotten progressively worse. He called EMS and was found by medics in severe distress with

diaphoresis. He was given three sublingual nitroglycerin tablets and said his pain was 8/10 and

associated with shortness of breath. The patient denies syncope, abdominal pain, pain radiating

to his arms, shoulders or jaw. He also denies pain in his lower extremities and recent congestion,

cough, or fever, urinary frequency or urgency. The patient was discharged from Crozer Chester

Medical Center three days ago after a new diagnosis of new onset atrial fibrillation with rapid

ventricular responses and endorses cardioversion via shock at this time. He states that he has not

been able to fill his new blood pressure prescription since discharge. He has been taking his old

blood pressure medications. The patient describes his chest pain as central and crushing. His

EKG in the ER is normal sinus rhythm with 95 beats per minute, and a prolonged QTC of 622.

He is currently taking Xarelto for his A-fib. His current blood pressure is 168/97.
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Labs, X-rays, Test Results

Chest X-Ray:

1. Central pulmonary venous congestion, no edema

2. Stable severe massive multi-chamber cardiomegaly

CTA Abdomen and Pelvis:

1. No evidence of thoracic abdominal aortic dissection or aneurysm

2. Severe multi-chamber cardiomegaly

3. Enlarged main pulmonary artery consistent with pulmonary artery

hypertension, severe anasarca noted, early liver cirrhosis

Table 1: Labs Upon Admission

Name Lab value Normal Range Assessment

WBC 5.7 4.8-10.8 10*3/uL WNL
HGB 15.4 (11.6-15.0) g/dL Increased
HCT 45.5 37.0-47.0 % WNL
PLT 113 145-400 10*3/uL Decreased
Sodium 139 135-146 mmol/L WNL
Potassium 3.4 3.5-5.1 mmolL/L Decreased
Chloride 103 96-106 mmol/L WNL
CO2 29 24-32 mmol/L WNL
Glucose 105 65-99 Increased
BUN 13 10-20 mg/dL WNL
Creatinine 1.0 0.6-1.1 mg/dL WNL
Magnesium 1.7 0.6-1.1 mg/dL Increased
Phosphorus 3.5 <5.0 mg/L WNL
Calcium 8.9 8.5-10.5 mg/dL WNL
Alk Phosphatase 105 30-120 U/L WNL
Albumin 3.8 3.4-5.0 g/dL WNL
Bilirubin, Total 0.9 0.3-1.0 mg/dL WNL

Admitting Diagnosis

Hypertensive Emergency, Chest Pain Unspecified

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Physician’s Orders

1. Hypertensive emergency. Goal mean arterial pressure reduction of 25%-30% within the

first few hours. Continue with nitro drip, transition to p.o. meds when goal is reached.

2. Chest pain secondary to hypertensive urgency versus cardioversion plus minus GERD.

Manage hypertension as above. Tylenol for chest pain. Protonix daily. Troponin 0.03,

that is now 0.04. Aortic dissection – rule out on CT.

3. Hypokalemia and hypomagnesemia, replete and follow up BMP.

4. Prolonged QTC. Avoid QTC prolonging meds.

5. Reduced ejection fraction. No decompensated or hypoxic, Lasix as needed based on

evaluation.

6. History of atrial fibrillation, status post cardioversion, normal sinus rhythm. Continue

with amiodarone daily. Restart Xarelto on day 2.

7. LOC of 1. Deep venous thrombosis prophylaxis, Xarelto.

8. Diet NPO.

Past Medical History

R.H.’s past medical history includes cardiac history, congestive heart failure, low ejection

fraction (25%-35%), hypertension, chronic lymphedema, obesity, pulmonary disease, sleep

apnea, and atrial fibrillation. The patient has a history of type 2 diabetes that he reports is now

resolved. His full past medical history is listed below.

1. Accelerated hypertension since 2002

2. Severe biventricular congestive heart failure

3. Atrial fibrillation

4. Hypercholesterolemia
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5. Morbid obesity

6. Lymphedema

7. Obstructive Sleep Apnea

8. Common bile duct stones status post cholecystectomy

9. Gastric umbilicated lesion and diverticulum, and gastritis

10. Anemia

11. Intermittent thrombocytopenia

12. Necrotizing RLE infection, status post multiple surgeries and skin grafting

13. Depression

14. Polysubstance abuse

15. Type 2 diabetes, now resolved

Surgical History

The patient had a cholecystectomy in 2008, right lower extremity orthopedic surgery

secondary to necrotizing fasciitis in 2013, and a cardioversion 1 week prior for atrial fibrillation.

Social History

R.H. lives at home with family. He has a history of smoking one pack of cigarettes per

day, but now reports he only smokes 1-2 cigarettes per day. He endorses alcohol, marijuana, and

denies illicit drugs. He resides in a two-story home with several steps to enter. The patient lives

with his father in-law and 17-year-old daughter. His father in-law has let several untrustworthy

people move in and the patient admits this is causing him stress. In addition to his living

situation, his daughter is pregnant. The patient’s mobility is very limited due to low endurance

and lymphedema. He admits he does not go out because of this. Although the patient sees benefit
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of homecare, he refuses due to living conditions. The patient is connected with Community

Transit for doctor visits.

Medication History

The patient's home medications are: Amlodipine, Clonidine, Hydralazine, Lisinopril,

Minoxidil, Norvasc (high blood pressure), Gabapentin (neuropathic pain), Lasix (congestive

heart failure), and Xarelto (blood thinner). R.H.’s inpatient medications from this admission are

listed in Appendix A.

Physical History

The patient is 165 centimeters tall and currently weighs 365 pounds. His body mass index

is 60.6kg/m2, which is classified as morbid obesity class IV. His ideal body weight (IBW) is 136

pounds. The patient reports a usual body weight of 280 pounds and reports his weight gain is

related to fluid fluctuations.

For his nutrient requirements, the standard formula for energy needs recommended for a

BMI >50 in the ICU, are 25-30 kcal/kg of his IBW. This comes out to 1550kcal to 1850kcal. For

protein, the equation for BMI >50 in the ICU is 1.5-2.0g/kg of his IBW. Using the Mifflin

equation, his calorie needs come out to 2494 calories. His fluid needs are 1200mL/day, per

physician orders.

Hypertensive Emergency: Treatment

Hypertensive emergencies are defined as severe elevations in blood pressure (BP)

(>180/120 mmHg), with evidence of impending or progressive end-organ damage (Shanahan,

Linas, & Iii, 2018). Patients with hypertensive emergencies should be admitted to an ICU and

started on parenteral antihypertensive medications to stop the progression of end-organ damage

(Shanahan, Linas, & Iii, 2018). The medical goal in hypertensive emergencies is to reduce the
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mean arterial pressure (MAP) by no more than 25% within the first hour. After the patient

stabilizes, the BP can then be lowered by 10% per hour until it reaches 160/100-110 mm Hg

(Shanahan, Linas, & Iii, 2018). After stabilization, a gradual reduction to the patient’s baseline

BP should be reached over the next 24 to 48 hours. Abrupt or excessive decreases in BP can

worsen renal, cerebral, or coronary ischemia (Shanahan, Linas, & Iii, 2018). It is important to

monitor intravascular volume to prevent quick falls in BP when antihypertensive agents are

started.

The type of pharmacologic agent differs for each patient. Medication choice is based on

pharmacologic properties, patient comorbidities, and end-organs involved (Shanahan, Linas, &

Iii, 2018). Once the patient has a stable BP and end-organ damage has ceased, patients can be

transitioned to oral medications. Possible pharmacologic agents are Nitroglycerin, Sodium

Nitroprusside (SNP), Labetalol, Esmolol, Nicardipin, Fenoldopam, Nitroglycerin, Hydralazine

(Shanahan, Linas, & Iii, 2018). R.H. was started on a nitroglycerin drip for his hypertensive

emergency. Nitroglycerin is a potent venodilator used for the treatment of acute coronary

syndromes and acute pulmonary edema.

Overall medical goals for patients with hypertension are to reduce or control blood

pressure. Suggested nutrition interventions for individuals with hypertension are to reduce the

intake of salt excessive sodium, limit food sources of saturated fat, trans fat, cholesterol, and

total fat, limit sweets and added sugars, limit alcohol intake, and increase the consumption of

vegetables, fruits, low-fat dairy foods, and whole grains (Academy of Nutrition and Dietetics,

2020). The ideal dietary pattern for a patient with hypertension should emphasize vegetables,

fruits, and whole grains, while also incorporating low-fat dairy items, poultry, fish, legumes,

vegetable oils, and nuts; and minimize intake of red meats, sweets, and sugar-sweetened
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beverages (Academy of Nutrition and Dietetics, 2020). Patients should aim for a daily sodium

intake of no more than 2,400 mg. Patients should also be educated on ways to attain and

maintain a healthy weight.

Hospital Course

Day 2

R.H.’s blood pressure is now 150/84. He still complains of chest pain. He was ruled out

for aortic dissection, and troponins are very minimally elevated. He claims that his pain has now

migrated to his epigastric region at his back. Patient is now with hypertensive urgency,

secondary to pain and/or noncompliance to home medications. Nitro drip is off and is now on

Clonidine and Norvasc PO. Diet advanced to Heart Healthy.

Day 5

R.H.’s blood pressure is 150/88 today. The patient developed bilateral lower extremity

paralysis due to questionable transverse myelitis versus a spinal cord infarct. In the morning

while the patient was standing to use the urinal, he noted left foot numbness, which quickly

progressed to left leg and then bilateral lower extremity numbness. He also noted acute severe

worsening of his back pain. He states he was just standing and urinating with no acute

exacerbating event. He now reports complete paraplegia of his lower extremities stating he

cannot feel or move them. The patient denies any bowel or bladder incontinence, recent illnesses,

IV drug abuse, or recent trauma. He does report back pain, acute lower extremity paraplegia, and

diminished sensation. His thoracic spine imaging showed no significant abnormalities. An MRI

of his spine showed an expansion of the spinal cord T6-7 and subtle T2 hyperintense signal

within the spinal cord. This is consistent with transverse myelitis. Patient was transferred to the

Neuro ICU.
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Transverse Myelitis: Treatment

Transverse myelitis is an inflammation of the spinal cord. Causes include infections,

immune system disorders, or disorders that damage or destroy myelin, the fatty insulating

substance that covers nerve cell fibers in the spine (National Institute of Neurological Disorders

and Stroke). Symptoms include pain, sensory problems, weakness in the legs and possibly the

arms, and or bladder and bowel problems. These symptoms may develop suddenly or over days

or weeks. The treatments to prevent or minimize permanent deficits include antiviral medications

and corticosteroids or other medications that suppress the immune system (National Institute of

Neurological Disorders and Stroke). There is no cure for transverse myelitis, but treatments can

either address the infections that may cause the disorder, reduce spinal cord inflammation, or

manage and alleviate symptoms (National Institute of Neurological Disorders and Stroke).

Intravenous corticosteroid drugs may decrease swelling and inflammation in the spine and

reduce immune system activity. Such drugs may include methylprednisolone or dexamethasone.

(National Institute of Neurological Disorders and Stroke). R.H. was prescribed Solu-Medrol for

five days.

For nutrition therapy, a major area of concern with transverse myelitis is effective

management of bowel and bladder functions. Constipation is the most common bowel

elimination issue. Nutrition can help mediate constipation, through a high fiber diet, adequate

and timely fluid intake. Lifestyle changes such as regular exercise can also contribute to

gastrointestinal motility (National Institute of Neurological Disorders and Stroke). Patients with

transverse myelitis should be educated on ways to alleviate possible constipation through dietary

management.
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Day 6

R.H. had an infectious work up today, and his blood cultures were positive for MRSA

bacteremia. He began treatment with broad spectrum antibiotics, daptomycin and ceftaroline.

Patient is also on fentanyl for pain. He is still on a heart heathy diet.

Day 9: Nutrition Assessment

The RD conducted a nutrition assessment, as the patient met the screening criteria for

length of stay. At this time, he was on a heart healthy diet, and a 1200mL fluid restriction. He

reports eating only 25% of his meals over the last week. He says this is due to taste changes. At

this time, he has bilateral lower extremity lymphedema, +4 bilateral lower extremity edema. The

patient was agreeable to trying Ensure Complete with each meal. He will receive Ensure daily

while intakes remain poor. The RD will adjust supplement pending intakes. The patient reports

he has been educated on a CHF diet and fluid restrictions previously and declined additional

education at this time. The RD discussed increasing fruits and vegetables, lean proteins, and

whole grains for weight loss. The RD also added magic cup supplement once daily. The patient

is currently at risk for malnutrition in the context of acute illness per ASPEN criteria. Nutrition

will continue to monitor for diagnosis as appropriate. The dietitian will follow up in 3-5 days.

Nutrition Diagnosis Statement

1. Inadequate oral intake, related to taste changes, AEB by patient consuming 25%

intakes for 1 week per patient report.

Table 2: Labs Day 9

Name Lab value Normal Range Assessment

WBC 13.3 4.8-10.8 10*3/uL Increased
HGB 14.1 (11.6-15.0) g/dL WNL
HCT 42.2 37.0-47.0 % WNL
PLT 197 145-400 10*3/uL WNL
Sodium 137 135-146 mmol/L WNL
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Potassium 3.8 3.5-5.1 mmol/L WNL

Chloride 99 96-106 mmol/L WNL
CO2 32 24-32 mmol/L WNL
Glucose 102 65-99 Increased
BUN 15 10-20 mg/dL WNL
Creatinine 0.7 0.6-1.1 mg/dL WNL
Magnesium 1.8 0.6-1.1 mg/dL Increased
Phosphorus 3.2 <5.0 mg/L WNL
A1C 5.6% <6.0% WNL
Point of Care 100-146 65-99 mg/dL Increased

Day 12

R.H. expressed sudden onset of generalized abdominal pain over the past 24 hours. His

last recorded bowel movement was 2 days ago. He was noted to have colonic distension on his

CAT scan of his abdomen and was subsequently taken for an emergency exploratory laparotomy

surgery by General Surgery. He had a transverse colon bowel perforation which resulted in a

subtotal hemicolectomy and end ileostomy being performed. The patient was placed on

additional antibiotics for abdominal flora and fungal coverage. His diet is NPO. The patient was

transferred from the NEURO ICU to the ICU.

Hemicolectomy and Ileostomy: Treatment

The patient underwent an exploratory laparotomy, a surgical operation where the

abdomen is opened and the organs are examined for injury or disease. The surgeons found a

bowel perforation, which resulted in a subtotal hemicolectomy and end ileostomy. This requires

the development of a new path for feces to be excreted from the body by creating an artificial

stoma (Academy of Nutrition and Dietetics, 2020). An ileostomy is the procedure in which the

colon and rectum are removed, and the end of the ileum is surgically attached to the stoma. This

surgical resection of the intestines will cause changes in absorption, motility, and production of

waste products.
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Nutrition Interventions for those with ileostomies may include the following: progression

of an oral eating plan postoperatively to meet nutrition needs and optimize postoperative healing,

correction and prevention of deficiencies, provision of short-term or long-term enteral or

parenteral feeding, and provision of nutrition education for food choices (Academy of Nutrition

and Dietetics, 2020).

For initial oral intake after surgery, the patient should begin with clear liquids only. They

can then progress to a low-fiber nutrition therapy with adequate energy, protein, fluid, and

electrolytes which should be individualized for the patient (Academy of Nutrition and Dietetics,

2020). They should start with smaller, more frequent meals. If a patient is experiencing high

output, limiting fluids with meals may be helpful. Fat malabsorption and lactose tolerance should

be monitored. Patients should also restrict foods high in oxalate (Academy of Nutrition and

Dietetics, 2020). Rehydration beverages may also be of benefit, especially if the patient is

experiencing excessive fluid loss.

Enteral and or parenteral nutrition support are not normally required in patients after

surgery. Enteral nutrition support should be considered when progression to an oral diet is not

successful postoperatively or if complications arise that indicate the need for additional nutrition

support (Academy of Nutrition and Dietetics, 2020).

Day 13

Post-op day 1: R.H. needed multiple vasopressors to maintain his blood pressure. The

patient was unable to wean off the ventilator after surgery and became ventilator dependent with

respiratory failure. He was noted to have increasing fevers and white count. Repeat blood

cultures showed no infections.

Nutrition Follow Up
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The RD noted that the patient is currently NPO and on a D5W drip, receiving 306

calories, which meets only 20% of his calorie needs. Per chart, there will be an attempt to

extubate today. Patient has generalized +4 edema and an abdominal incision.

Nutrition Intervention:

1. If extubated, recommending trialing PO diet with clear liquids when medically

feasible. Recommend supplementing with Ensure clear and Protein-Jello. Advance as

tolerated to full liquid diet, then to a GI modified Heart Healthy diet.

2. If unable to extubate, recommend vital 1.5 @10mL per hour, advance by 10ml Q6

hours to goal of 55ml. Add 1 packet of Prosource. This will provide 1845kcal and 93g

protein. RD will follow-up in three to five days.

Table 3: Labs Day 13

Name Lab value Normal Range Assessment

Sodium 141 135-146 mmol/L WNL
Potassium 4.0 3.5-5.1 mmol/L WNL
Chloride 102 96-106 mmol/L WNL
CO2 31 24-32 mmol/L WNL
Glucose 88 65-99 mg/dL WNL
BUN 28 10-20 mg/dL Increased
Creatinine 1.0 0.6-1.1 mg/dL WNL
Magnesium 1.7 0.6-1.1 mg/dL Increased
Phosphorus 5.0 <5.0 mg/L WNL
AST 68 10-37 U/L (Males) WNL
Point of Care 91-113 65-99 mg/dL Increased

Day 14

R.H. was hypotensive and tachycardic initially. He coded and pulse was lost.

Resuscitation was performed and achieved return of spontaneous circulation (ROSC). Patient

became increasingly acidotic with worsening liver and renal function after his cardiac arrest.
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Leukocytosis increasing. Patient was started on continuous renal replacement therapy (CRRT).

He is on fentanyl and versed drips. He is also on dopamine and phenylephrine. Patient is NPO.

Day 18

Patient is still sedated and ventilated. He is currently on four different vasopressors. He is

in acute renal failure and septic shock, status post cardiac arrest. His hemoglobin dropped and he

was transfused packed red blood cells (PRBC). He is still on CRRT. He has multiorgan failure,

septic shock, shocked liver, and severe metabolic acidosis. LFTS are extremely high. Patient is

NPO. There is a plan for TPN to be initiated. The physician consulted the dietitian for TPN

recommendations. TPN will be ordered today and start tonight at 10pm. Patient has met 0%

nutrition goals met over 24 hours. The dietetic intern provided the TPN recommendations and

the RD approved the recommendations.

Nutrition Follow Up

Nutrition Diagnosis

1. PES: Inadequate Oral Intake – ongoing.

2. NEW PES: Altered GI Function, related to perforated bowel, AEB NPO/Need for TPN

Nutrition Intervention:

1. 120g Amino Acids, 150g Dextrose, 40g Lipids, minimum volume –provides 1390

kcals. This meets 87% of the patient’s needs. Starting lipids at a low level, as

patient’s LFTs are elevated.

2. Custom electrolytes – No potassium, no phosphate, add 63MeQ NaCl. Patient with

metabolic acidosis, hyperphosphatemia, hyperkalemia, and hyponatremia.

3. Check triglyceride level and monitor LFTS.

Table 4: Labs Day 18

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Name Lab value Normal Range Assessment

WBC 40.1 4.8-10.8 10*3/uL Increased
Sodium 133 135-146 mmol/L Decreased
Potassium 5.5 3.5-5.1 mmol/L Increased
Chloride 102 96-106 mmol/L WNL
CO2 21 24-32 mmol/L WNL
Glucose 91 65-99 mg/dL Increased
BUN 71 10-20 mg/dL Increased
Creatinine 3.8 0.6-1.1 mg/dL Increased
Magnesium 2.1 0.6-1.1 mg/dL Increased
Phosphorus 7.7 <5.0 mg/L Increased
AST 4934 10-37 U/L (Males) Increased
ALT 2573 4-40 U/L (Males) Increased
Alk Phos 202 30-120 U/L Increased
Lactic Acid 3.1 0.5-1 mmol/L. Increased
Troponin 2.94 0-0.4 ng/mL Increased

Nutrition Support in Critical Illness: Treatment

Nutrition support is part of the standard of care in critically ill patients, and is of

significant importance in the hospital setting, especially the ICU. Critically ill patients often have

sepsis or systemic inflammatory response syndrome, which leads to hypermetabolism, lipolysis,

insulin resistance, and protein catabolism (Cotogni, 2017). Likewise, these patients often have

increased infectious morbidity, multiple organ dysfunction, prolonged hospitalization, and

mortality (Cotogni, 2017)). Such complications are often associated with the lack of nutritional

intake and can lead to malnutrition. Artificial nutrition does not reverse metabolic complications

but can help decrease or slow the depletion of lean body mass and improve clinical outcomes

(Grau, et al., 2007). Critically ill patients are usually unable to maintain adequate nutritional

intake to meet their increased metabolic demands (Singer, et al., 2019). Therefore, provision of

nutrition support is an important part of the medical care of these patients. Nutrition support in

the intensive care setting must be monitored closely.

ASPEN guidelines suggest the use of enteral nutrition (EN) over parenteral nutrition (PN)

in critically ill patients who require nutrition support therapy (Warren, et al. 2016). PN is the
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alternative approach when enteral routes are either not successful, not possible, or unsafe

(Singer, et al., 2019). Diseases and conditions where PN are indicated include short bowel

syndrome, GI fistulas, bowel obstructions, critically ill patients, and severe acute pancreatitis

(Singer, et al., 2019). For patients such as these, ASPEN guidelines suggest that, for patients at a

low nutrition risk, exclusive PN should be held over the first seven days following ICU

admission, even if the patient cannot maintain nutritional intake or if early EN is not possible

(Singer, et al., 2019). There is no benefit to starting TPN in the first week after impaired gut

function occurs. Early TPN may increase the risk for infections (Warren, et al. 2016). Therefore,

providing no nutritional support or providing only dextrose infusions is more beneficial than

early TPN for critically ill patients who cannot tolerate EN (Warren, et al. 2016).

Parenteral nutrition is the intravenous administration of nutrition for patients who cannot

eat or absorb nutrition through tube feeding formulas or by mouth (Warren, et al. 2016). The

contents of TPN solutions are individualized for each patient, and is determined by age, weight,

height, and medical condition. PN regimens contain more than forty different components,

including water, macronutrients (dextrose, lipids, amino acids), electrolytes, micronutrients

(trace elements, vitamins) and other additives (glutamine, insulin, heparin) (Warren, et al. 2016).

Safe and successful TPN requires daily monitoring of the patient’s glucose level, blood count,

blood gasses, fluid balance, urine output, and electrolytes. Liver and kidney function tests may

also need to be routinely performed. The contents of the solution are modified based on the

results of these tests.

Electrolyte management is essential while TPN is administered. Abnormal electrolytes

levels are common among critically ill patients due to underlying and severe medical conditions

(Warren, et al. 2016). Since these patients are more prone to electrolyte imbalances, TPN
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electrolyte adjustments are necessary to help balance the abnormalities. There are no specific

guidelines for the use of electrolytes based on body weight or as a fixed element of parenteral

nutrition. The requirements should be determined on an individual basis and through electrolyte

monitoring (Singer et al., 2019).

R.H. has multiple electrolyte abnormalities. The patient has metabolic acidosis, a disorder

of acid-base balance when too much acid builds up in the body. He is also on CRRT. Both of

these factors often result in significant influences on electrolyte and nutrient balance (Dounousi

et al., 2015). R.H. had hyperphosphatemia, which was likely related to decreased phosphate

excretion and his acute renal failure. To remedy this, the dietetic intern recommended phosphate

to be held from the TPN solution. The patient also had hyponatremia, which could be related to

multiple medical complications such as his renal failure, depletion of extracellular fluid volume,

CHF. The hyponatremia could be treated by increasing the sodium content of the TPN solution.

Sodium in PN is combined with either chloride, acetate, phosphate, or lactate salt (Fessler,

2011). At this time, sodium chloride was ordered for the TPN solution, which can also aid acid

base balance. The administration of free water should also be limited to treat hyponatremia,

therefor minimum volume was recommended for the TPN bag. The patient also had

hyperkalemia, likely related to decreased potassium excretion due to renal failure and metabolic

acidosis. Metabolic acidosis can pull potassium out of the cells. For this, the dietetic intern

ordered potassium to be held from the TPN solution.

Day 19

R.H. underwent a bedside laparotomy with evacuation of a hematoma and washout.

Surgery found an intact bowel with no necrotic tissue. A hematoma was removed and sent for

cultures. The patient had a temporary abdomen closure.

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Day 20

Patient with an open abdomen and septic shock. He continues to have worsening

acidosis, minimally responding to bicarb. Pressor requirements are increasing. LFTs still high

but trending down. TPN and CRRT running.

Nutrition Follow Up

The patient is meeting 100% of his needs from TPN. The dietetic intern provided the

TPN recommendations.

Nutrition Intervention:

1. 120g Amino Acids, 200g Dextrose, 45g Lipids, minimum volume – provides 1610

kcal

2. Custom electrolytes, No K, No Phos, 43MeQ Nacl, 50MeQ Sodium Acetate.

Dextrose is increased as patient’s blood sugar is stable. Lipids increased as LFTS are

trending down. Sodium Acetate was added to the TPN bag since the patient still has

hyponatremia, but has worsening acidosis, and is minimally responding to bicarb. The amounts

of acetate and chloride in PN can be adjusted in cases of metabolic acid-base disorders to assist

the physician’s efforts to correct abnormalities (Fessler, 2011). Bicarbonate is not used in PN

formulas because it is not a stable additive; thus, the metabolic precursor acetate is used Acetate

serves as an alternate source of bicarbonate by metabolic conversion in the liver (Fessler, 2011).

Table 5: Labs Day 20

Name Lab value Normal Range Assessment

WBC 52.7 4.8-10.8 10*3/uL Increased
Sodium 133 135-146 mmol/L Decreased
Potassium 3.7 3.5-5.1 mmol/L WNL
Chloride 101 96-106 mmol/L WNL
CO2 19 24-32 mmol/L Low
Glucose 122 65-99 mg/dL Increased
BUN 37 10-20 mg/dL Increased
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Creatinine 2.0 0.6-1.1 mg/dL Increased

Phosphorus 3.0 <5.0 mg/L WNL
Lactic Acid 5.8 0.5-1 mmol/L Increased
Trigylcerides 105 150-200 mg/dL Decreased

Day 21: Nutrition Follow Up

Patient is currently meeting 100% needs from TPN over the last 24 hours. The dietetic

intern provided the TPN recommendations.

Nutrition Intervention:

1. 130g AA, 200g Dex, 50g Lipids, Min volume – 1700 kcal

2. Custom lytes: NaCl 63meq, 65 meq Sodium Acetate

Table 6: Labs Day 21

Name Lab value Normal Range Assessment

WBC 50.7 4.8-10.8 10*3/uL Increased
Sodium 132 135-146 mmol/L WNL
Potassium 3.5 3.5-5.1 mmol/L WNL
Chloride 101 96-106 mmol/L WNL
CO2 21 24-32 mmol/L Low
Glucose 158 65-99 mg/dL Increased
BUN 39 10-20 mg/dL Increased
Creatinine 1.9 0.6-1.1 mg/dL Increased
Phosphorus 2.1 <5.0 mg/L WNL
Lactic Acid 4.4 0.5-1 mmol/L Increased

Day 22

TPN is running, CRRT running, wound vac with output 1 liter. Ventilator setting

requirements increased over night due to hypoxia and decreased oxygen saturation levels. The

patient’s vasopressor requirements also increased. There is a possible return to the OR today for

an abdominal washout and possible abdominal closure. He is still in septic with metabolic

acidosis. Patient has a poor prognosis.

Nutrition Follow Up
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RUNNING HEAD: COMPLEX CASE STUDY

Patient is meeting 100% of his needs from TPN over the last 24 hours. The RD provided

the TPN recommendations.

Nutrition Intervention:

1. Consider palliative care to determine plan and level of care.

2. If TPN renewed, recommend 130g Amino Acids, 200g Dextrose, 50g Lipids,

minimum volume – provides 1700 calories and meets 100% of needs.

3. Custom electrolytes, increase Sodium Acetate to 130meq.

Table 7: Labs Day 22

Name Lab value Normal Range Assessment

WBC 59.6 4.8-10.8 10*3/uL Increased
Sodium 131 135-146 mmol/L Decreased
Potassium 4.5 3.5-5.1 mmol/L WNL
Chloride 102 96-106 mmol/L WNL
CO2 16 24-32 mmol/L Low
Glucose 150 65-99 mg/dL Increased
BUN 39 10-20 mg/dL Increased
Creatinine 1.9 0.6-1.1 mg/dL Increased
Phosphorus 2.7 <5.0 mg/L WNL

Time of Death

Family met with palliative care in the afternoon. Family understood patient’s poor

prognosis and changed the patient’s level of care. In the evening, the patient was noted to be

asystole. Upon examination, no carotid pulses or peripheral pulses appreciated, and no heart

sounds or breath sounds. Time of death was called at 1951.

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References

Academy of Nutrition and Dietetics. Nutrition Care Manual. Hypertension Nutrition

Intervention. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=2

72984&lv2=8480&lv3=267342&ncm_toc_id=267342&ncm_heading=Nutrition%20Care

. Accessed March 21, 2020.

Academy of Nutrition and Dietetics. Nutrition Care Manual. Ileostomy Nutrition Intervention.

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=1

729&lv3=268576&ncm_toc_id=268576&ncm_heading=Nutrition%20Care. Accessed

March 21, 2020.

Academy of Nutrition and Dietetics. Nutrition Care Manual. Ileostomy Nutrition Support.

https://www.nutritioncaremanual.org/topic.cfm?

ncm_category_id=1&lv1=5522&lv2=19

729&lv3=268583&ncm_toc_id=268583&ncm_heading=Nutrition%20Care. Accessed

March 21, 2020.

Cotogni P. (2017). Management of parenteral nutrition in critically ill patients. World journal of

critical care medicine, 6(1), 13–20. https://doi.org/10.5492/wjccm.v6.i1.13

Dounousi, E., Zikou, X., Koulouras, V., & Katopodis, K. (2015). Metabolic acidosis during

parenteral nutrition: Pathophysiological mechanisms. Indian journal of critical care

medicine : peer-reviewed, official publication of Indian Society of Critical Care

Medicine, 19(5), 270–274. https://doi.org/10.4103/0972-5229.156473

Druml, W., Kierdorf, H. P., & Working group for developing the guidelines for parenteral

nutrition of The German Association for Nutritional Medicine (2009). Parenteral

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nutrition in patients with renal failure - Guidelines on Parenteral Nutrition, Chapter

17. German medical science : GMS e-journal, 7, Doc11. https://doi.org/10.3205/000070

Fessler, T. (2011, September 12). Fluid and Electrolytes in Adult Parenteral Nutrition. Retrieved

from https://www.todaysdietitian.com/pdf/courses/FesslerelecrolytesinPN.pdf

Grau, T., Bonet, A., Rubio, M., Mateo, D., Farré, M., Acosta, J. A., … Working Group on

Nutrition and Metabolism of the Spanish Society of Critical Care. (2007). Liver

dysfunction associated with artificial nutrition in critically ill patients. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2147066/

Shanahan, A., Linas, S., & Iii, M. A. (2018). How Should Hypertensive Emergencies Be

Managed? Retrieved from https://www.the-hospitalist.org/hospitalist/article/124244/how-

should-hypertensive-emergencies-be-managed.

Singer, P., Blaser, A. R., Berger, M. M., Alhazzani, W., Calder, P. C., Casaer, M. P., …

Bischoff, S. C. (2019). ESPEN guideline on clinical nutrition in the intensive care

unit. Clinical Nutrition, 38(1), 48–79. doi: 10.1016/j.clnu.2018.08.037

Warren, M., Mccarthy, M. S., & Roberts, P. R. (2016). Practical Application of the Revised

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult

Critically Ill Patient. Nutrition in Clinical Practice, 31(3), 334–341. doi:

10.1177/0884533616640451
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APPENDIX A. R.H. Inpatient Medication List

Medication Treatment/Use Nutrition Related Side

Effects
Tylenol Aches and pains, and reduces fever Nausea, stomach pain,
decreased appetite
Alteplase Thrombolytic medication: Treats conditions Nausea, vomiting,
caused by arterial blood clots: heart attacks, gastrointestinal bleeding
strokes, unstable angina, pulmonary
thrombosis or embolus, and other less
common conditions involving blood clots
Amiodarone Anti-arrhythmic: Treats certain types of Nausea, vomiting,
serious irregular heartbeat (i.e. persistent constipation
ventricular fibrillation/tachycardia), restores
normal heart rhythm and maintains regular,
steady heartbeat
Norvasc Calcium channel blocker: hypertension and Nausea, abdominal pain,
agina edema of the ankles or feet
Coreg Beta blocker: treats hypertension and heart Diarrhea, nausea,
failure, reduces risk of death after heart vomiting
attack
Ceftaroline Antibiotic: anti-MRSA activity, active Nausea, vomiting,
against methicillin-resistant Staphylococcus constipation, diarrhea.
aureus and other Gram-positive bacteria dizziness
Catapres Sedative and antihypertensive: treats Dry mouth, constipation,
hypertension, pain loss of appetite,
Flexeril Muscle relaxant: treats pain and stiffness Dry mouth or throat, loss of
caused by muscle spasms appetite, stomach pain.
Daptomycin Antibiotic: treats bacterial infections of the Severe stomach pain,
skin and underlying tissues, and infections diarrhea that is watery or
that have entered the bloodstream bloody
Colace Stool softener Bitter taste, bloating,
cramping, diarrhea, gas,
throat irritation
Lasix Diuretic: treats fluid retention (edema) and Increased thirst, diarrhea,
swelling caused by congestive heart failure, stomach pain, and
liver disease, kidney disease, and other constipation, dehydration,
conditions electrolyte abnormalities,
loss of appetite
Glycerin Relieves occasional constipation Nausea, stomach cramps,
Suppositories gas, diarrhea
Hydralazine Vasodilator: treats hypertension Loss of appetite, nausea,
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vomiting, diarrhea
Hydromorphone Narcotic: treats moderate to severe pain Nausea, vomiting,
Dilaudid constipation, dry mouth
Sliding Scale Blood sugar control
Insulin
Isosorbide Treats heart-related chest pain, heart failure, Nausea
Mononitrate and esophageal spasms
Lisinopril ACE inhibitor: treats hypertension and heart High potassium levels,
failure, reduces the risk of death after a heart nausea, diarrhea
attack
Oxycodone/Acet Narcotic: treats moderate to moderately Nausea, vomiting,
aminophen severe pain. constipation
Pantoprazole Proton-pump inhibitor: treats GERD and a Stomach pain, gas, nausea,
damaged esophagus, treats high levels of vomiting, diarrhea
stomach acid caused by tumors
Prednisone Steroid: treats many diseases and conditions, Increased appetite, gradual
especially those associated with weight gain, nausea,
inflammation stomach pain, bloating,
swelling, bloody or tarry
stools, low potassium, high
blood pressure 
Xarelto Blood thinners: treat and prevent blood clots. Bloody stools, bowel or
This may lower the risk of stroke, deep vein bladder dysfunction,
thrombosis (DVT), pulmonary embolism vomiting of blood or
(PE), and similar conditions. material that looks like
coffee grounds
Senna Treats constipation and can empty the large Nausea, abdominal pain or
intestine prior to surgery discomfort, cramps,
diarrhea. electrolyte
abnormalities, including low
potassium (hypokalemia),
excessive bowel activity
Spironolactone Potassium-sparing diuretic: prevents your Vomiting, diarrhea, stomach
body from absorbing too much salt and pain or cramps, dry mouth
prevents potassium levels from getting too and thirst
low
Flomax Urinary retention medication: relaxes the Nausea, diarrhea
muscles in the prostate and bladder neck,
making it easier to urinate
Mupirocin Antibiotics: treats skin infections Nausea
Morphine Narcotic: treats moderate to severe pain Nausea, vomiting,
Sulfate constipation
Labetalol Beta blocker: treats hypertension, controls Nausea
congestive heart failure in patients who have
had a heart attack, can be used to produce
hypotension during surgery
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Nitroglycerin Vasodilator: treats and prevents agina in its Vomiting

oral form
Lorazepam Sedative: treats seizure disorders, such as NA
epilepsy, can be used before surgery and
medical procedures to relieve anxiety

K-Phos Neutral Acidify the urine and lower urinary calcium Nausea, vomiting, stomach
concentration, may increase the antibiotic pain, diarrhea, unusual
effect of methenamine, also used as a weight gain, swelling of the
phosphorus supplement to prevent and/or feet or lower legs
treat a phosphorus deficiency.
Tramadol HCL Narcotic: It can treat moderate to severe Nausea, vomiting,
pain. constipation, dry mouth
Aldactone Diuretic: treats hypertension, treat fluid Mild nausea or vomiting,
retention, and high levels of the hormone diarrhea
aldosterone
Methylpredniso Steroid Fluid retention, weight gain,
ne Solu-Medrol It can treat inflammation, severe allergies, high blood pressure,
flares of chronic illnesses, and many other potassium loss, nausea,
medical problems. It can also decrease some vomiting, heart burn,
symptoms of cancer. appetite changes
Fentanyl Narcotic: treats severe pain Constipation, dry mouth,
nausea
Norepinephrine Blood pressure support: treats low blood Nausea and vomiting
pressure and heart failure, improve organ
perfusion during cardiopulmonary
resuscitation
Epinephrine Blood pressure support and vasoconstrictor: Nausea and vomiting
used for cardiopulmonary resuscitation to
reverse cardiac arrest treats
Vasopressin Increase blood pressure in patients with Gas or stomach, cramps,
vasodilatory shock, helps return of nausea and vomiting, low
spontaneous circulation during cardiac arrest blood sodium levels
Dopamine Blood pressure support: treat symptoms of Nausea, vomiting
shock by improving blood flow, used in the
treatment of very low blood pressure
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