CLINICAL

NUTRITION CASE
STUDY 2020
By: Tayler Blamer
 Introduction/Patient Profile
■ 68-year-old male admitted on 11/18/2019 for Multiple Myeloma not having achieved remission
■ Undergoing Melphalan 200 mg/m2 chemotherapy
■ Married with three children
■ Retired in 2008 from GM as a machine operator
■ Previous Medical History: Type 2 Diabetes Mellitus- long term use of insulin (Lantus 20 units), Chronic Kidney Disease
(CKD) Stage 3b/Aa, Acute kidney injury, Paroxysmal atrial fibrillation, Hypoparathyroidism, Central Sleep Apnea (CPAP
Machine), Dyslipidemia, Restless Legs Syndrome, Coronary artery disease, Hypertension, Adrenal insufficiency, Bilateral
sensorineural hearing loss, Gout, anemia of chronic disease, morbid obesity (body mass index of 40 – 44.9),
thrombocytopenia, Coronary-myocardial bridge (mild mLAD), Cardiomyopathy, Arthritis, Prostate carcinoma (1/2018)
■ Surgeries: Tracheostomy (12/30/2019), Vasectomy, Total thyroidectomy - goiter and Parathyroidectomy (2002)
■ Autologous bone marrow transplant (11/20/2019)
– Primary tube was leaking, approximately less than 1 ml of stem cell loss

■ Ongoing hospitalization due to Septic shock (septicemia), neutropenic fever, tachycardic and hypotensive starting on
11/27/2019, treated for Enterococcal Bacteremia with VRE bacteremia with blood cultures and SLED for AKI
■ Required a Percutaneous endoscopic gastrostomy (PEG)  to be placed and ongoing sedation and ventilation
Disease Background- Septic Shock
■ Septic Shock (septicemia): A body-wide infection, typically caused by bacteria, leads to dangerously low
blood pressure, tissue damage, and poor organ function due to the body’s strong inflammatory response to
toxins
■ Defined as sepsis with hyperlactatemia and concurrent hypotension requiring vasopressor therapy
■ Life-threatening
■ Most often occurs in the very old and the very young. Also occurs with weakened immune systems
■ Preventing infections is key
■ Sepsis symptoms:
Shivering, fever, or very cold
Extreme pain or discomfort (“worst ever”)
Pale or discolored skin
Sleepy, difficult to rouse, confused
“I feel like I might die”
Short of breath
■ Septic shock is a medical emergency. In most cases, people are admitted to the intensive care unit of the
hospital

■ Risk factors: Diabetes, Diseases of the genitourinary system, biliary system, or intestinal system, Diseases
that weaken the immune system, such as AIDS, Indwelling catheters (for extended periods, intravenous
lines, urinary catheters, plastic and metal stents used for drainage), Leukemia, Long-term use of antibiotics,
Lymphoma, Recent infection, Recent surgery or medical procedure, Recent or current use of steroid
medicines, Solid organ or bone marrow transplantation

■ Clinical manifestations: blood pressure (BP), heart rate, and oxygen monitoring, complete blood count
(CBC) with differential, electrolyte panel and creatinine, lactate, invasive central venous pressure (CVP),
PaO2, and central venous oxygen saturation (ScvO2) readings, cultures of blood, urine, and other potential
sites of infection, including wounds in surgical patients
■ Characterized by early massive catabolism, lean body mass (LBM) loss and escalating
hypermetabolism
■ Early enteral nutrition should attempt to correct micronutrient/vitamin deficiencies, deliver
adequate protein and calories
■ Increasing protein/calories are needed to reduce lean body mass loss and promote recovery
■ Malnutrition screening is essential and parenteral nutrition can be safely added when enteral
nutrition is failing based on pre-illness malnutrition
■ Following ICU discharge, significant protein/calorie delivery is required for months to years to
facilitate functional and lean body mass recovery, with high protein oral supplements being
essential to achieve adequate nutrition
■ Medical treatment: Breathing machine (mechanical ventilation), intensive insulin therapy,
antimicrobial agents, coagulation-modulating drugs, dialysis, drugs to treat low blood pressure,
infection, and nutrition support
■ High volume of fluids given intravenously, oxygen, sedatives, surgery to drain infected areas,
antibiotics if needed, the pressure in the heart and lungs may be checked - hemodynamic
monitoring
Nutrition Therapy for Sepsis

Critical step in the treatment and resolution of sepsis

Needed to assist with modulating the inflammatory response, maintain adequate immune response,
reduce skeletal catabolism, support wound healing, and assist the maintaining gastrointestinal and
pulmonary mucosal barriers to bacteria.
Challenges of meeting the needs of critically ill patients:
abnormalities of metabolism, difficulty, estimating and/or measuring nutritional requirements,
fluid/volume restrictions, and multisystem organ dysfunctions
Vital High Protein is an example of a good enteral formula used for patients in the ICU, also good in refeeding,
mechanical vented and for bariatric patients, It is low in fat however is not usually long term
Use caution with formulas containing Arginine with septic patients since it is immune modulating and could be
counter indicating due to the infection state of the blood
Disease Background- Type 2 Diabetes Mellitus
■ A combination of abnormal insulin secretion and insulin resistance, multiple factors contribute to its development
(polygenic) such as obesity, poor nutrition, and physical inactivity
■ Some insulin is produced but the tissues are resistant, this increases the need for insulin, so the pancreas increases
production. Over time the pancreas is not able to maintain such high insulin production levels.
■ When cells cannot respond to insulin be translocation glucose transporters to their outer membrane, they are unable to
take up glucose from the blood for fuel. Since insulin normally inhibits glycogenolysis and gluconeogenesis when blood
glucose is high, defective insulin secretory response results in excessive hepatic gluconeogenesis

Symptoms:
Excessive urination (polyuria), thirst (polydipsia) and hunger (polyphagia), weight loss, increased susceptibility to
infections, especially yeast or fungal infections, extremely low blood sugar levels – hypoglycemia, which can be deadly,
extremely high blood sugar levels also can lead to hyperosmolar syndrome which is a life-threatening form of dehydration
In some cases, hyperosmolar syndrome is the first sign that a person has type 2 diabetes, causes confusion, weakness, nausea
seizures and coma 

Diagnostic Criteria:
■ Fasting plasma glucose is greater than 125 mg/dL
■ 2 hour Plasma Glucose is greater than or equal to 200 mg/dL during Oral Glucose Tolerance Test
■ A1c > 6.5
■ Symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose > 200 mg/dL
Type 2 Diabetes Mellitus
Medical Nutrition Therapy:
★ Hit target plasma glucose and A1c while avoiding hypoglycemia, achieve & maintain body weight
★ Consume a variety of nutrient dense foods in appropriate portion sizes, with half of the plate being
vegetables, having a good, lean, source of protein and fruit, choosing whole grains and low-fat dairy options,
meals every 4-5 hours, achieve and maintain body weight goals, individualized glycemic, blood pressure and
lipid goals
★ Monitor plasma glucose to determine whether adjustments in eating patterns are sufficient to achieve blood
glucose goals or if medication needs to be combined or adjusted

Carbohydrate:
★ Fruits, starchy vegetables, whole grains, and low-fat milk are encouraged carbohydrates
★ Monitor carbohydrate intake, whether by carb-counting or exchanges, achieving glycemic control

Fat:
★ Limit saturated fat to <7% of total calories. minimize trans fat intake
★ lower dietary cholesterol to < 200 mg/day

Protein:
★ 15-20% of total calories
Type 2 Diabetes
Normal: HgbA1C <5.7%: Prediabetes: 5.7-6.4 % Diabetes: >6.4%

Patient’s 7.3% (8/16/2019), obtained again on (04/22/2020) 5.4%

➢ Increased due to poorly controlled diabetes, decreased with sickle cell anemia due to increased red blood cell turnover
Complications: 
■ Atherosclerosis - fat buildup in the artery walls, can impair blood flow to the all the organs. The heart, brain and
legs are most often affected
■ Retinopathy - Tiny blood vessels in the retina can become damaged by high blood sugar levels. The damage can
block blood. Caught early, retinopathy damage can be minimized by tightly controlling blood sugar and using
laser therapy. Untreated retinopathy can lead to blindness 
■ Neuropathy - Nerve damage. The most common type is peripheral neuropathy. The nerves to the legs are
damaged first, causing pain and numbness in the feet. Damage to the nerves that control digestion, sexual function
and urination can also occur
■ Foot problems - Sores and blisters occur for two reasons: 
– If peripheral neuropathy causes numbness, the person may not feel irritation in the foot. The skin can break
down, form an ulcer, and the ulcer can become infected
– Blood circulation can be poor, leading to slow healing
■ Nephropathy - Damage to the kidneys. More likely if blood sugars remain elevated and high blood pressure is not
treated aggressively
Acute Kidney Injury (AKI)
Acute renal failure - The rapid breakdown of renal kidney function that occurs when high levels of uremic toxins (waste
products of the body’s metabolism accumulate in the blood.
- When the kidneys are unable to excrete the toxins in the urine
- Causes impaired glucose use and protein synthesis
- Associated with the degree of hypercatabolism and infection
Risk factors:
>75 years old, CKD, cardiac failure, liver, disease, diabetes mellitus, nephrotoxic medication use, sepsis, and
hypovolemia (increased blood volume).
3 types:

Prerenal- Caused by severe blood loss, prolonged poor nutrient intake, volume depletion (hemorrhage, renal losses (diuretics,
osmotic diuresis), fluid losses from the GI tract or extensive wounds, burns, severe dehydration, GI losses (vomiting, diarrhea,
nasogastric suction), Impaired cardiac efficiency (myocardial infarction, heart failure, dysrhythmias, cardiogenic shock),
vasodilation (sepsis, anaphylaxis, antihypertensive medications, vasodilation medication

Intrinsic (parenchymal) - damage within the kidney cells

Exposure to toxins such as antibiotics, chemotherapy, sepsis, contrast dyes, acute glomerulonephritis, or inflammation from
conditions such as Sjogren's syndrome (immune disorder that usually causes dry eyes and mouth.

Postrenal- Ureter or neck of the bladder blockage- kidney stones, tumors, blood clots

Four phases of AKI: Initiation (when GFR declines), extension (when ischemia and inflammatory damage continue)
maintenance (when GFr is at its lowest level) and recovery (when epithelial cells regenerate)
Acute Kidney Injury (AKI)
Clinical Manifestations:
Normal urine output is 1-1.5 L per day, during the period when GFR declines, < 5oo mL (Oliguric)
Likely to develop fluid and electrolyte disorders, azotemia, and wasting
Azotemia may cause nausea and vomiting, weight loss may result from negative nitrogen balance
serum levels of Potassium, Magnesium, Phosphorus are generally elevated because of decreased renal clearance
and marked net protein breakdown, although could be decreased as a result of intracellular shifts associated with
carbohydrate delivery and anabolism.
Serum phosphorus may be decreased secondary to severe respiratory alkalosis with continuous renal replacement
therapy (CRRT) or intracellular shifts
Hypophosphatemia also occurs in refeeding syndrome, malnutrition, and diuretic therapy
Potassium, magnesium, and phosphorus should be monitored frequently to assess the need for supplementation and
should be individualized
Elevated Blood urea nitrogen (BUN) and creatinine, aim to maintain BUN 80-100 mg/dL
insufficient kilocalories and protein contribute to high levels of protein catabolism
Dialysis may be required to remove metabolic wastes and excess water
Acute Kidney Injury (AKI)- Nutrition Therapy
Nitrogen losses (up to 30 g per day) contribute to a nutritional decline in a short period of time causing:
lean body mass loss, toxicity-related symptoms (nausea, vomiting, bleeding, poor oral intake), loss of essential and non-essential amino
acids, and plasma proteins during dialysis therapy and impaired glucose utilization and protein synthesis from uremia
Protein - energy malnutrition often results and contributes to the high mortality rate
If necessary, specialized formulas with lower electrolyte levels should be used when a patient is not able to consume foods orally and
requires enteral nutrition such as Nepro with Carb Steady
Protein: .8-1.0 g/kg/day in non-catabolic patients who are not dialyzed, 1.0-1.5 g/kg/day for patients on renal replacement therapy, and up
to 2.0 g/kg/day when receiving CRRT or are hypercatabolic
Energy: 30-35 kcal/kg
ASPEN guidelines: All ICU patients receiving parenteral nutrition (PN), mild permissive underfeeding should be considered at
least initially
Total fluid intake depends on the amount of residual renal function, fluid, and sodium status, recommended to equal output from urine
and other measured sources (nasogastric aspirate or fistula drainage) plus 400-500 mL per day, which takes the contributions of
endogenous water production fro metabolism and insensible water losses in breath and perspiration into consideration
Fluid and mineral balance need to be carefully monitored to prevent overhydration and electrolyte disorders
Records of daily intake and output, weight changes, electrolyte levels and blood pressure are useful for assessment of fluid tolerance and
requirements
Supplementation of minerals, electrolytes, and trace elements is regulated by monitoring serum and urine levels to prevent excess or
deficiency
Hypertension
■ Consistently elevated blood pressure where systolic pressure is > 130 mm Hg and/or diastolic pressure is >
80 mm Hg
– Elevated: >= 120-129 over < 80
– stage I: >= 130-139 over 80-89
– stage II: >= 140 over >= 90

■ Risk factors:
– Alcohol intake
– Obesity
– Family history
– Excessive salt intake
– Physical inactivity
– African American ancestry

Medical Nutrition Therapy: Dietary Approaches to Stop Hypertension (DASH)

– Eating vegetables, fruits, and whole grains
– Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
– Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and oils such
as coconut and palm oil.
– Limiting sugar-sweetened beverages and sweets
 Morbid Obesity
Excess of adipose tissue or body fat
Adult males are considered obese > 25% body fat, adult females > 33%
BMI = weight in kg / (height in meters)^2
30<35 is Class I, 35<40 Class II, 40 and greater Class III

■ When the body’s chronic energy intake exceeds its energy expenditure
■ Obesogenic environment: promote weight gain and act as barriers to weight loss, promotes the consumption of energy-dense, high
fat, high-sugar foods, sedentary behaviors
■ Genetics affects body weight and composition by influencing appetite, taste preferences, energy intake resting energy expenditure,
thermic effect of food, non-exercise activity thermogenesis (NEAT), and the body’s efficiency in storing energy.

Treatment: energy deficit with diet, physical activity, and behavioral therapy, consider pharmacotherapy (lipase inhibitors and appetite
suppressants- anorectics) and bariatric surgery if appropriate.
Lipase inhibitors work by blocking the action of pancreatic and gastric lipases, reducing the digestion of triglyceride.
Appetite suppressants act on the central nervous system to decrease appetite and increase satiety

Obesity increases the risk of developing: Type 2 diabetes (three times as prevalent among the obese), hypertension (twice as prevalent in
both men and women with BMI > equal to 30) or , stroke, coronary heart disease, osteoarthritis, cancers of the endometrium, breast,
prostate, and colon.

Most common surgical procedures for weight loss: Adjustable gastric banding, Vertical sleeve gastrectomy, Roux-en-Y gastric bypass
(RYGB), and Duodenal switch with biliopancreatic diversion

RYGB is the most common in the United States (60-70% overall) and the gold standard of surgical procedures due to its high degree of
effectiveness and durability.
Hypoparathyroidism
Decreased production and secretion of thyroid hormones, most common pathologic hormone deficiency.
Many medical conditions may directly or indirectly affect the thyroid gland
Thyroid hormone influences growth, development, and many cellular processes, insufficient thyroid hormone has extensive
consequences on the body
The most frequent cause of hypothyroidism is iodine deficiency
Consequences of Thyroid hormone deficiency:
■ Myxedematous infiltration of heart tissue results in decreased contractility, cardiac enlargement, pericardial effusion, decreased
pulse rate, and decreased cardiac output.
■ Infiltration of the GI tract can cause achlorhydria (reduction in gastric acid production) and increased intestinal transit time with
gastric stasis.
■ Delayed puberty, anovulation, menstrual irregularities, and infertility, increased levels of total cholesterol, and LDL cholesterol,
and increased insulin resistance
Symptoms: Reduced basal metabolic rate, intolerance of cold, weight gain, easily fatigued, bradycardia, slow reflexes and movement,
slow mental responsiveness, pitting edema of lower extremities, periorbital puffiness, myxedema, goiter, loss of scalp hair, axillary
hair, pubic hair, abdominal distension
Treatment: Exogenous thyroid hormone to supplement or replace endogenous thyroid hormone production unless caused by iodine
deficiency which can be remedied through adequate intake of dietary iodine
Clinical benefits of either treatment begin in 3-5 days and level off after 4-6 weeks, monitor for overtreatment- tachycardia,
palpitations, nervousness, tiredness, headache, increased excitability, sleeplessness, tremors possible angina
Iron, calcium, and magnesium supplements should be taken at least 4 hours before or after Synthroid
Hypocalcemia
Serum Calcium <9 ml/dL or ionized Calcium < 4.5 ml/dL
Results from a deficit of PTH or abnormal vitamin D metabolism, seen in patients with renal or liver failure
Activated vitamin D requires normal function of both liver and kidneys, abnormalities of organ function are
common causes of hypocalcemia
Alkalosis can cause a decrease in ionized calcium in the extracellular fluid (ECF) causing symptoms consistent
with hypocalcemia
Calcium and phosphorus levels are closely linked so changes in serum phosphorus levels can result in subsequent
changes in serum calcium levels
Hypomagnesemia or hypermagnesemia and hungry bone syndrome post parathyroidectomy can also cause
hypocalcemia
Symptoms are a result of altered nerve transmission and electrical activity of the cell
Neuromuscular symptoms include muscle spasms, tetany, and cardiac dysrhythmias
Untreated hypocalcemia is life threatening
Treatment: Treatment of the underlying cause is crucial for long term control, intravenous administration of
calcium is given, replaced, in extreme cases due to potential side effects
Hypercalcemia
Stems from either hyperparathyroidism or malignancy

Malignant tumors of the breast, prostate, and cervix commonly metastasize to the bone. Resulting bone resorption
can lead to hypercalcemia, other malignancies can produce factors that act like parathyroid hormone (PTH)
and cause an increase in bone resorption

Clinical manifestations:
Fatigue, weakness, bone pain, confusion, cardiac dysrhythmias

■ Diagnosed when serum calcium levels are > 11 mg/dL

Treatment: Dependent on the underlying cause

■ Surgical removal of the parathyroid gland, calcium binding agents
■ Intravenous fluids, diuretics, and dialysis can be used to dilute serum calcium and increase its excretion
Calcium

❏ Most calcium is located within the bones and teeth, the remaining 1% in the body fluids, is highly regulated
due to its function in muscle contraction
❏ Normal serum calcium: 9-11 mg/dL, either protein (albumin) bound (40%), complexed (13%), or ionized
(47%) which is essential for cellular process
❏ Plasma homeostasis is maintained through the interaction of three hormones: Parathyroid hormone (PTH),
Calcitonin, and 1, 25-dihydroxycholecalciferol (activated vitamin D)
❏ When serum calcium levels fall, PTH is released. PTH decreases bone resorption of calcium, decrease
calcium excretion, and increase calcium absorption in the gastrointestinal tract.
❏ Activated vitamin D acts to increase absorption of calcium by increasing production of the protein needed for
calcium absorption in the GI tract.
❏ Vitamin D also effects the uptake of calcium by the bone
❏ Calcitonin, produced by the thyroid gland, inhibits osteoclast activity, reducing bone resorption
 Multiple Myeloma
A tumor composed of cells derived from hemopoietic tissues of the bone marrow, a plasma cell tumor
The malignant plasma cells produce an abnormal antibody called M protein which is detected in high levels as an indicator of Multiple Myeloma
As the cancerous cells multiply, there is less space in the bone marrow for normal blood cells decreasing the number of red blood cells, white blood cells and
platelets
Clinical manifestations: CRAB

● Calcium - High levels in the blood come from affected bones leaking calcium. Too much calcium can cause extreme thirst, nausea, vomiting, GI
problems, loss of appetite, confusion, and constipation
● Renal failure - due to the buildup of M protein in the blood and urine
● Anemia - due to decreased red blood cells to carry oxygen to the rest of the body from cancerous cells outnumbering red blood cells in the bone
marrow, causes fatigue, dizziness, irritability, decreased ability to fight infection
● Bone damage -can cause bone pain and osteolytic lesions, increased risk of fractures, and hypercalcemia

● Additional symptoms: weakness or numbness, especially in the legs, unintentional weight loss, confusion, problems with urination, nausea, vomiting,
repeated infections, vision loss or vision problems

Higher risk of developing multiple myeloma: Male, over age 50, African-American, overweight or obese, exposed to radiation, employed in the petroleum
industry

Treatment: Chemotherapy, Radiation, targeted therapy, Stem Cell Transplant, Corticosteroids, Biological therapy

- The decision to perform an Autologous Hematopoietic Cell Transplant (AHCT) depends on the physician assessment of patient’s eligibility, assessing
co-morbidities, performance status and age of patients
Medical Treatment Summarized

■ 11/20/2019: Bone marrow transplant. ~1 ml of stem cell loss due to leaking primary tube. Persistently hypotensive while
on P2. Transferred to the MICU for septic shock and neutropenia.
■ 11/29 Intubated for respiratory failure
■ Experienced acute respiratory infection and septic shock
■ Had Vancomycin-resistant enterococci (VRE) - treated with Vancomycin and Meropenem
■ 12/03 -12/16 on Sustained low efficiency dialysis (SLED) for Acute respiratory Infection (ARI)
■ 12/10: A CT head without contrast was ordered and showed no structural lesions or intracranial hemorrhages
■ Intubated 11/29-12/30. Tracheostomy on 12/30 which was changed on 1/6 to cuffed in setting of trach bleed and hypoxia
due to granulation tissue at the distal tip of the tracheal stoma, ball-valving into the trach tube lumen and causing 90%
obstruction of the tracheostomy tube 
■ 12/20/19 Percutaneous endoscopic gastrostomy placed
■ Prolonged Mechanical Ventilation trial was not appropriate as patient was unable to produce voicing with digital
occlusion and produced noticeable back pressure with removal of digital occlusion per chart review
■ 1/8: Clinical swallow evaluation completed revealed oropharyngeal dysphagia and aphonia Recommendations were to
continue NPO with PEG and to complete a a fiberoptic endoscopic evaluation test
■ 1/10: Discharged to Sparrow Specialty Hospital
Present Illness and Medical Treatment

■ Admitted on 11/18/2019 for Multiple Myeloma not having achieved remission

■ Received Autologous bone marrow transplant on 11/20/2019
– Primary tube was leaking, approximately less than 1 ml of stem cell loss
– Primary tube was replaced and stem cell infusion restarted without further incidents
■ Septic Shock (septicemia) (11/27/2019)
– Neutropenic fever of 38.1, IV Vancomycin and Aztreonam started.
– Tachycardic and hypotensive, 1 liter IV Bolus of NS given, Tylenol and ice packs
■ Transferred to MICU for septic shock- diarrhea despite Imodium, fever, hypotensive, abdominal pain in left
upper quadrant. Negative for C.Diff, Placed NPO, Intubated
■ Critical Care Nurse Practitioner described case as life-threatening deterioration
■ 11/30: Became oliguric, AKI and metabolic acidosis, last Creatinine was 3.57, bicarbonate 10 – Nephrology
was consulted, Patient sedated on fentanyl, propofol and restrained for line integrity and patient safety
■ Initially NPO for nausea and abdominal pain, now intubated
■ tube feed change to Vital HP; initial goal of 80 ml/hr as tolerated providing 1920 kcals, 168 g of protein,
1605 free water
Present Illness and Medical Treatment

■ 12/01: Not following commands, not opening eyes to stimulation, Sedations paused for better assessment of neuro
status, able to open eyes to verbal stimulation, withdrawal in all extremities.
– Current Diet Order: NPO, Tube Feeding through Orogastric Tube (OGT) Glucerna 1.5 Cal with goal of 10
ml/hr not infusing/placed on hold
– Sedation restarted as heart rate elevated, blood pressure elevated, coughing excessively. Dark green output.
Foley Catheter placed, Parenteral vancomycin being initiated for lower respiratory tract infection
■ 12/02: Registered Dietitian: PES: Predicted inadequate nutrient intake (calories, protein)- not improving Related to
medical/respiratory status as evidence by NPO/ intubated; NG tube to low-intermittent suction (LIS)
■ Recommendations (follow up): As soon as medically appropriate resume enteral feedings, consider tube feed change to
Vital HP; initial goal of 80 ml/hr as tolerated providing 1920 kcals, 168 g of protein, 1605 free water
■ 12/03: Sustained low efficiency dialysis (SLED) initiated for AKI (100 ml/hr).
■ Trickle feeds of Nepro with Carb Steady @10 ml/hr; VRE bacteremia with blood cultures to grow gram positive cocci
in blood culture
■ 12/05: SLED @ 150 ml/hr, Amio, insulin, propofol, fentanyl drip
Present Illness and Medical Treatment Continued

■ 12/06: Registered Dietitian: PES: Predicted inadequate nutrient intake (calories, protein)- not improving related to medical ventilation,
eternal feeding on hold per RN secondary to high residual as evidence by per Registered Nurse 2 liter output from NGT on admission to
medical ICU, residual today at 300 ml and then 125 ml 2 hours later
■ Nutrition Diagnosis #2: Altered nutrition related lab values related to acute kidney injury, diabetes mellitus II as evidence by 12/05/2019:
Sodium 130, BUN 53, Creatinine 2.74, Phosphorus 5.2, Glucose 169 mg/dl
■ Recommendations: Restart enteral feeding with an elemental (predigested) formula. 2. Vital HP start at 10 ml/hr and increase to goal of 70
ml/hr as tolerated. (enteral feeding calculated for 22 hours with Synthroid= 1540 calories, 134 g protein and 1287 ml free water)  Propofol
calories 280 calories/day. 3. When propofol weaned off goal rate of Vital HP increases to 80 ml/hr.
■ Pertinent medications: Synthroid, Levophed, Oscal, Pepcid, Fentanyl, Glycolax, Propofol 10.6 ml/hr 280 kcals
■ Weight 398 lbs (180.5 kg), edematous, 425 ml gastric residual in 3 hours
■ Estimated needs: 1958-2225 kcals, 178-223 g protein (2-2.5 g/kg IBW)
■ Tube feeding Vital HP started as trickle, 12/09 Tube feeding advanced, SLED continued, 12/10: Sedation placed off for neuro exam, then
placed back on full respiratory support due to increased respiratory rate. Vital HP @ 50 ml/hr, oliguric, stopped due to marginal blood
pressure then continued, Vital Hp increased to 70 ml/hr then to goal @ 80 ml/hr on 12/12
■ 12/13: Registered Dietitian recommended an increase in Vital HP to 90 ml/hr =2160 calories, 189 g protein and 1806 ml free water.
Nutrition Intervention: nutrition assessment, patient requires formula (Vital HP) with lower calorie to nitrogen ratio
■ Nutrition Diagnosis: Predicted inadequate nutrient intake (calories, protein)- Improving related to tolerating enteral feeding well at this
time as evidence by at initial goal rate
■ Nutrition Diagnosis #2: altered nutrition related lab values-improving related to acute kidney injury, diabetes II as evidence by BUN 29,
Creatinine 1.31, glucose 165 mg/dl, replacing magnesium and potassium as needed
Present Illness and Medical Treatment
■ 12/16: SLED stopped.
■ 12/17: Recommendations: 1. Change enteral nutrition to Vital 1.2 @ 75 mL/hr x 24 hours with
2160 kcal and 162gm protein 2. Monitor stool output and tolerance to decreased enteral infusion
rate 3. Medically manage glucose 4. If SLED resumes, please add one packet of Prosource plus
daily to provide additional 15 gm protein and 100 kcal.
– Patient noted to have 1.1L stool output (12/16)
– Per chart review, SLED currently held to assess for renal recovery. While SLED is held,
estimated needs are decreased. 
– BUN 55, Cr 1.94, Glucose 214
– Pertinent Medications: IV Synthroid, Oscal, fentanyl, Senokot, potassium phosphate,
prednisone
– PES: Predicted inadequate nutrient intake (calories, protein) –improving related to
Tolerating enteral feeding well at this time as evidence by at initial goal rate
– Nutrition Diagnosis #2: altered nutrition related lab values-improving related to acute
kidney injury, diabetes II as evidence by BUN 55, Cr 1.94, Glucose 214
Present Illness and Medical Treatment - Continued
■ 12/18: Catheter removed without complications, still encephalopathic (acute)
■ 12/19: Putting out adequate urine and copious feces from rectal table
■ 12/22: G tube placed, DNR signed 12/23: Minimal vent settings, able to open eyes, stick out tongue, wiggle
toes, unable to move extremities, hypotension continues, Tube feeding tolerated @ goal via PEG, daughter
switched to spokesperson upon wife’s hospitalization, ongoing loose brown stool
■ 12/25: Follows commands intermittently, flicker of contraction to extremities X4, intubated, stool:
liquid/watery/brown. Electrolytes continue to be monitored and replaced, GI: 1.9 L output
■ 12/26: Registered Dietitian: Recommendations: Change enteral feeding to Vital AF 1.2 Cal at 80 mL/hour
for 22 hours - hold one hour before, one hour after Synthroid administration, Continue to monitor blood
glucose and control as medically appropriate
■ Nutrition Diagnosis: Predicted inadequate nutrient intake (calories, protein) -improving related to enteral
order as evidence by tolerating enteral order at goal rate 
■ Nutrition Diagnosis 2: altered nutrition related lab values-improving related to acute kidney injury, diabetes
II as evidence by BUN and Cr improved, blood glucose elevated since 12/22
■ Pertinent Medications: Calcitriol, Os-Cal, Nexium, Lantus, Humalog, Synthroid oral, Mag-ox, Effer-K,
Prednisone, Senokot-s
■ Edema: 3+ generalized and dependent
Present Illness and Medical Treatment - Continued
■ 12/30: Tracheostomy
■ 1/03: RD Recommendations: Continue Vital AF 1.2 @ 80 mL/hr x 22 hours as tolerated
– Nutrition Diagnosis 1: Predicted inadequate nutrient intake (calories, protein) –improving
related to enteral order as evidence by tolerating enteral order at goal rate
– Nutrition Diagnosis 2: altered nutrition related lab values-improving related to by acute
kidney injury, diabetes II as evidence by BUN 27, Glu 176
Factors Affecting Nutritional Intake: compromised airway, Labs: Mg 1.6, BUN 27, Glu 176. Pertinent
Medications: Calcitriol, Os-Cal, Nexium, Lantus, Humalog, Synthroid oral, Mag-ox, Effer-K,
Prednisone, Senokot-s
1/06: Chest tube placed by ACS for pneumothorax, pigtail drain- removed 1/09
1/10: Discharged to Sparrow Specialty Hospital
Drug Drug Class Action Possible Adverse Effects Nutrition
Implications
Decadron Corticosteroid Anti-inflammatory, Grapefruit/related citrus Increases/stimulates
immunosuppressant, hormone, interactions appetite, weight except
glucocorticoid Increased risk for steroid anorexia, helps with
induced diabetes nausea and vomiting

Zofran Serotonin/5HT3 Antiemetic, anti-nauseant Dry Mouth, abdominal pain, Prevents vomiting,
Antagonist diarrhea, constipation reduces nausea
Antiemetics/anti-
nauseant

Cinvanti Substance Antiemetic, prevents and reduce Fatigue, diarrhea, neutropenia, Diarrhea, dyspepsia
P/NK1 receptor chemotherapy-induced nausea and asthenia, anemia, peripheral
antagonist vomiting neuropathy, leukopenia,
dyspepsia, urinary tract
infection, pain in extremity

Melphalan bifunctional Interstrand cross-linking with DNA,
alkylating agent treatment prior to an autologous
stem-cell transplant in patients with
multiple myeloma and for the
palliative treatment of patients with
multiple myeloma for whom oral
therapy is not appropriate
Bleeding, infection, anemia,
neutropenia, white blood cell
(WBC) count
decreased/leukopenia,
nausea, vomiting, diarrhea,
mucositis/oral ulceration,
decreased appetite/anorexia,
constipation, stomatitis,
abdominal pain, dysgeusia,
dyspepsia
Nausea, vomiting, diarrhea,
mucositis/oral ulceration,
decreased
appetite/anorexia,
constipation, stomatitis,
abdominal pain, dysgeusia,
dyspepsia
Drug Drug Class Action Possible Adverse Effects Nutrition
Implications
Diflucan Ergosterol Antifungal, used to treat fungal Nausea, vomiting, diarrhea, Loss of appetite,
synthesis infections stomach discomfort, headache, stomach pain, diarrhea,
inhibitor dizziness, or hair loss  nausea, vomiting

Lantus  long-acting To improve glycemic control Hypoglycemia, allergic Inability to manage

human insulin  reactions, injection site blood glucose levels
reactions, lipodystrophy, rash, due to improper
edema and weight gain production of insulin

Synthroid Hormone treats hypothyroidism, headache, hyperactivity, Hold feedings 1 hour

goiters, thyroid cancer
nervousness, anxiety, irritability,
emotional lability, insomnia,
palpitations, tachycardia,
arrhythmias,
increased pulse and blood
pressure, heart
failure, angina, myocardial
infarction, cardiac arrest,
dyspnea, menstrual
irregularities, impaired fertility,
decreased bone mineral density
before and 1 hour after
administration. Can
cause diarrhea,
nausea, increased
appetite, weight loss,
abdominal cramps and
elevations in liver
function tests

Oscal Vitamin/mineral Treat or prevent low calcium Gastric hypersecretion acid Low blood calcium
supplement levels, calcium deficiency, rebound, flatulence, gastric levels, insufficient
osteoporosis, distension, constipation calcium from diet
hypoparathyroidism,
osteomalacia/rickets
Drug Drug Action Possible Adverse Nutrition
Class Effects Implications
Senokot Laxative Treats constipation, used to clean out Stomach/abdominal pain, Bowel function
the intestines before a bowel cramping, nausea, diarrhe
examination/surgery. Work by keeping a, or weakness
water in the intestines, which causes
movement of the intestines.

Prilosec Proton  Treats gastroesophageal reflux disease Headache, nausea, Diarrhea, gas, nausea
pump (GERD), gastric ulcers, and other vomiting, stomach pain, Needed when there is
inhibitors (P conditions caused by excess stomach diarrhea, gas. excess stomach acid
PIs) acid. Decreasing the amount of acid Fever (in children)
the stomach makes. Relieves symptoms Respiratory system
such as heartburn, difficulty swallowing, symptoms
and persistent cough

Zantac histamine-2 Treats and prevents recurrent ulcers of Headache, constipation, Relieves difficulty
blockers the stomach and intestines and, treats diarrhea, nausea, stomach swallowing, stomach pain,
certain stomach and esophagus pain, vomiting needed when there is too
problems (such as erosive esophagitis, much stomach acid
gastroesophageal reflux disease-
GERD, Zollinger-Ellison syndrome)
Relieves symptoms such
as cough, stomach pain, heartburn, and
difficulty swallowing
Drug Drug Class Action Possible Adverse Nutrition
Effects Implications
Vancomycin Glycopeptide Treats infections caused by Allergic reactions Diarrhea, nausea,
antibiotic bacteria, also used in patients (anaphylactoid vomiting, loss of
with heart valve disease (eg, reactions),  low blood appetite, indigestion
rheumatic fever) or prosthetic pressure, 
(artificial) heart valves who are wheezing, 
allergic to penicillin indigestion, 
hives, or 
itching. 
flushing of the upper body
(called "redneck" or "red man
syndrome"), 
dizziness, 
pain and muscle spasm of
the chest and back

Calcitriol Vitamin D Analog Treats kidney disease with low
blood calcium,
hyperparathyroidism due to
kidney disease, low blood
calcium due to
hypoparathyroidism,
osteoporosis, osteomalacia, and
hypophosphatemia.
Abdominal pain, bone pain, When calcium levels are
BUN and creatinine low, deficient
increased, cardiac
arrhythmia, constipation,
dehydration, drowsiness, dry
mouth, loss of appetite,
metallic taste,
nausea/vomiting, weight
loss, urinating more than
normal, heart rate changes,
hypercalcemia,
hypertension,
hypercholesterolemia,
hyperphosphatemia,
hypermagnesemia
Drug Drug Class Action Possible Adverse Effects Nutrition
Implications
Propofol Intravenous Sedative, used Hypotension, hypertension, apnea, rash, Provides 1.1 kcal/mg
anesthetic for pain itching hypertriglyceridemia, movement, Important to calculate
the kcals coming from
the rate of propofol
Calcium Antacid Reducing the Constipation, gas, and bloating, belching, Used to raise calcium
effect of acid in dry mouth levels, can cause
carbonate the stomach. constipation, gas,
Relieve the bloating, belching, dry
symptoms of mouth
heartburn, acid
indigestion, and
upset stomach.
Used to prevent
osteoporosis.
Magnesium Mineral, Maintain Abdominal cramps, diarrhea Take fiber and iron
Antacid, magnesium supplements
Oxide Laxative levels, separately
decreases
stomach acid,
promotes
laxative effects
Maxiprime Cephalosporin Antibiotic, Abdominal cramps, back, leg, or stomach Nausea, vomiting, loss of
treats bacterial pains, bleeding gums/nose, confusion, appetite, Avoid taking at
infections Convulsions, dark urine, difficulty breathing, the same time as
fever, headache, irregular heartbeats, muscle Warfarin
numbness/ tingling around mouth, fingertips,
or feet, yellowing eyes or skin
Nutrition Care Process- Nutrition Assessment
■ Anthropometric Measurements-
■ Weight: 361 lbs, 164 kg
■ Height: 6’3”, 190.5 cm
■ Ideal Body Weight (IBW): 89 kg
– 106 + (6 x 15) =196/2.2

■ %Ideal Body Weight: 184%

– 164/89 = 1.84 x 100

■ Usual Body Weight: 184 kg (405 lb) 

■ Weight Loss: unintentional
■ BMI: 45 kg/m^2 BMI 40 or greater: obesity grade III

11/14/2019: 362.6 lb
1/3/2020: 348 lb
-14.6 lb or ~4 % weight loss in approximately 3 weeks
Food/Nutrition-Related History
▪ Previous Nutrition Education: Carbohydrate Controlled Diet related to diagnosis of Diabetes
▪ Met with Henry Ford weight management clinic in 2015
▪ Not following any type of diet for Diabetes, continues to eat foods high in added sugar
▪ Nutrition Plan/Recommendation by outpatient Dietitian:
▪ Encouraged patient to follow a healthy diet with fruits, vegetables, whole grains and high-quality protein
sources. Stressed importance of a good source of protein at every meal.
▪ Reviewed Low-Microbial Diet and food safety precautions after transplant and coordination of care with IPD
Registered Dietitian team
▪ Described as minimal understanding of diet education, needing further diet reinforcement

– Meal/Snack Patterns: 1 Ensure Clear, ~3 Premier Protein shakes per day, 2 side portions of foods like mashed
potatoes, oatmeal, burgers
– Low Microbial diet. Good Oral intake upon visit
– Patient tolerating diet order without any gastrointestinal side effects during initial visit
– Reviewed low microbial diet, patient and spouse demonstrated understanding
– Provided educational handout from Nutrition Care Manual with Nutrition consult number for additional questions
– Discussed symptom management if side effects such as dysgeusia worsen as well as the importance of choosing
high protein food sources
Needs
Calorie
– Estimated kcal needs: ~2600-3100 kcals
(30-35 kcals/kg) (Ideal body weight) (89 kg)

Protein:
– Estimated Protein Needs: ~133-178g
(1.5-2 g/kg) (89kg) (Ideal body weight) (89 kg)

Fluid:
– Estimated Fluid needs: ~2600-3100 ml
(1 ml/kg) (89kg) (Ideal body weight)
30ml/kg (Ideal body weight)(89 kg) = 2670 ml
 Biochemical Data

Labs Normal Value 11/20 11/30 12/08 12/11 12/16 12/20 12/30 Reasons for abnormal

Calcium 8.6 - 10.4 mg/dL 8.7 6.9 7.8 8.1 7.5 7 7.3 Vitamin D deficiency, hypoparathyroidism,
osteomalacia, kidney failure, low
magnesium levels
Magnesium 1.8-2.3 mg/dL 2.4 2.5 1.8 1.7 1.7 1.9 1.9 Electrolyte disturbance, Proton Pump
Inhibitors
Phosphorus 2.5-4.5 mg/dL 4.9 6.0 5.1 4.6 3.7 3.1 4.5 Antacids, kidney failure,
hypoparathyroidism
Glucose 50-140 mg/dL 175 173 150 157 204 118 145 Acute stress response, dehydration,
Serum corticosteroid therapy
Platelet 150-450 k/uL 256 14 80 94 99 102 116 Heparin-induced thrombocytopenia
Count
Sodium 135-145 mmol/L 138 135 133 138 141 147 141 High due to: Dehydration, Excessive Na+ in
IV fluids
Low due to: overhydration, peripheral
edema
Potassium 3.5-5.0 mmol/L 4.7 4.1 4.8 4.1 3.5 3.9 4.0 WNL
BUN 10-25 mg/dL 36 63 36 30 48 47 22 ^ due to impaired renal function, increased
protein catabolism (stress, starvation,
fever), dehydration
 Biochemical data

Labs Normal Value 11/20 11/30 12/08 12/11 12/16 12/20 12/30 Reasons for abnormal
Creatinine <1.28 mg/dL 1.46 4.36 2 1.45 1.95 1.35 .69 Increased due to: Kidneys
Males: .6-1.2 not functioning properly,
ml/dL muscle breakdown/loss
Females: .5-
1.1 mg/dL
Hematocrit 41-53% 27.2 26.8 29.3 27.4 23.3 24.4 22.2 Iron deficiency anemia,
malnutrition
Hemoglobin 13.5-17 g/dL 9.1 9.1 9.5 8.7 7.6 8.1 7.4 Iron deficiency anemia,
malnutrition, kidney
disease
GFR >60 49 13 33 49 34 54 98 Kidneys are not working
(glomerular ml/min/1.732^ properly
filtration 2
rate)
Nutrition-Related Physical Findings
■ Patient appears overweight, morbidly obese, not tolerating very low-calorie diet weight
management program
■ Patient has poor dentition (4 teeth extracted) however has no difficulty with regular
consistency foods
■ Bilateral lower extremity edema
Nutrition Timeline
11/19/2019: Low Microbial Diet
11/25/2019: Low microbial diet(consuming Enure HP/Premier protein from home) Ensure Enlive ordered
twice daily
12/02/2019:  NPO; Tube Feed of Glucerna 1.5 cal with a goal of 10mL/hour not infusing; placed on hold 
12/03/2019: Trickle feeds of Nepro with Carb Steady @10 ml/hr
12/06/2019: NPO
12/13/2019: Vital HP @ 80 ml/hr for 24 hours(1920 calories, 168 gms protein and 1605 mls free water)
12/13/2019: Vital HP to 90 ml/hr=2160 calories, 189 gms protein and 1806 mls free water
12/26/2019: Vital AF 1.2 Cal; Continuous; 30; 10; 75; 400; Every 4 hours
1/03/2020: Vital AF 1.2 @ 80 mL/hr x 22 hours
Discharged with tube feeding however currently tolerating oral diet with Ensure Enlive twice daily, can feed
self, no issues chewing or swallowing.
Client History
■ Central sleep apnea – Uses a Continuous positive airway pressure machine (CPAP)
– CPAP machines use mild air pressure to keep the airways open, makes sure that the airway doesn't collapse when one breathes while asleep
■ Poor dentition, 4 teeth extracted
■ Bilateral lower limb edema with venous stasis present
■ Motor strength is 5/5 to upper and lower extremities
■ Dysgeusia and fluctuating bowels between diarrhea and constipation while on treatment but improved appetite after
Melphalan treatment finished (11/2019): pre-initial assessment for autologous bone marrow transplant
■ Former smoker- 1 pack of cigarettes per day for 15 years, quit 8/20/1979
■ Multiple myeloma in remission- admitted for autologous bone marrow transplant on 11/28/2019, Was on
Prophylactic Acyclovir, Fluconazole prior to transfer to MICU
■ Educated by outpatient dietitian: low microbial diet, safety precautions after transplant, encouraged to follow
a healthy diet with fruits, vegetables, whole grains and high-quality protein sources, importance of a good source of
protein at every meal was stressed
■ Upon initial admission, reported consuming: 1 Ensure Clear, ~3 Premier Protein shakes per day and 2 side size
portions of foods like mashed potatoes, oatmeal, and burgers
■ Patient and wife were well informed of the safety precautions however were not aware of ways to troubleshoot certain
nutrition related side effects such as choosing cold foods over hot foods when experiencing dysgeusia until we had
discussed it during initial admission visit as well as we reviewed the importance of choosing high protein foods to
prevent cachexia. Both expressed understanding
Nutrition Diagnosis
■ Problem (P) Predicted inadequate nutrient intake (calories, protein)
■ Related to: Etiology (E) Autologous bone marrow transplant planned for
11/20/2019, currently receiving melphalan chemotherapy
■ As Evidenced by (AEB): Signs/Symptoms (S) Denies nutrient related side
effects, other than occasional dysgeusia at this time, currently consuming 100%
of one documented meal, however possibility for nutrition related side effects
exist

Hematopoietic transplant - Autologous – Patients receive their own cells

Conditioning chemotherapy prior to transplant to eradicate malignant cells; immune system is nearly
destroyed to prepare
Nutrition Intervention
■ 1. Continue low microbial diet order as tolerated
■ 2. Order Glucerna Shake twice daily if intake falls below 75% consistently
■ 3. Obtain updated Hemoglobin A1c. Last updated 8/16/2019
Patient tolerating diet order without any gastrointestinal side effects at this time.
Reviewed low microbial diet, patient previously educated per outpatient Dietitian. Patient and spouse
demonstrated understanding.
Provided educational handout from Nutrition Care Manual with Nutrition consult number for
additional questions.
Discussed symptom management if side effects such as dysgeusia worsen as well as the importance
of choosing high protein food sources.
Continue to monitor for malnutrition despite good oral intake.
 Low Microbial Diet
Designed to prevent foodborne illness an immunocompromised patients
Restricts:
❖ Unpasteurized juice, dairy products (Pasteurized cheeses are allowed)
❖ Unwashed fruits and vegetables
❖ Salad bars or buffets
❖ Strawberries, raspberries, and blackberries (washed or not)
❖ Due to their small seeds, too difficult to ensure proper cleaning
❖ Untreated honey
❖ Undercooked meats, not proper cooking temperatures - allowed to reheat packaged lunch meats in a
microwave
❖ Raw fish/sushi
❖ Black pepper – added, (cooked in foods is okay)
❖ Grows from Aspergillus mold and can cause fungal infection
■ Implemented in January 2019, replacing the “Neutropenic” diet (Much more restrictive)
■ Neutropenia measured by ANC (absolute neutrophil count) which is typically low in chemotherapy
patients and drops to 0 in Peripheral Stem Cell Transplant (PSCT) patients
Nutrition Monitoring and Evaluation
■ Monitor for any taste changes (dysgeusia), reduced appetite, nausea, vomiting, diarrhea, mucositis,
odynophagia- sore throat/painful swallowing, radiation esophagitis, esophageal strictures, steroid induced
hyperglycemia, weight loss, and muscle wasting which can be evaluated with an open line of communication
between the patient and the interdisciplinary team as well as visually and if appropriate with a nutrition
focused physical exam
■ Nutrition management of side effects:
Upon initial visit, 1 day before BMT, patient was not experiencing any symptoms but had experienced dysgeusia
previously due to cancer treatment. We discussed symptom management if it were to re occur
– Dysgeusia (altered taste): If experiencing foods tasting metallic, too sweet, no taste, or just different
than they normally taste: Saline rinses and lidocaine for numbing, choosing colder foods over hot
foods, using plastic instead of metal utensils, consuming lemon candies, lemon packets, lemon ice,
ginger/ginger ale to promote saliva production.

– Nausea/vomiting: Examining what medications are ordered and if they are scheduled or PRN
(antiemetics), any food intolerances, bowel regimen. Encouraging small frequent meals, discourage
foods with strong odors (use an enclosed cup/lid if patient dislikes odor of supplemental drinks like
Ensure, avoid high fat/greasy foods, spicy foods. Choose bland, easy to digest foods. If patient is being
fed enterally: reduce bolus volume, adjust rate of continuous feed, or change formula, possibly to a
more concentrated regimen.
– Diarrhea: Stem cell patients almost always have diarrhea regardless of their oral diet. Rule out C.
difficile, check medications for stool softener, multiple antibiotics, and for food intolerances.
Increase fluids, avoid concentrated sweets, decrease fiber, increase insoluble fiber foods
(applesauce, bananas, Banatrol supplement. Increase probiotic foods like yogurt. Enterally fed
patients could try switching to Osmolite 1.5 or Vital 1.2 AF

– Odynophagia: If due to mucositis, find out grading, higher the grading, more possible need for
TPN. Avoid acidic foods/drinks and high fat foods that will sit in the stomach longer. Concentrate
supplements to get more calories and protein in one bite/sip. Vital 1.2 AF for severe mucositis
and/or Gut Versus Host Disease

– Steroid Induced Hyperglycemia: Examine trending blood glucose levels and oral intake. Avoid
juices except Ensure Clear or ProSource Plus, choose higher protein/calorie foods, avoid simple
sugars. Avoid restrictions, however, if patient is malnourished or an extensive surgery planned.

– Radiation esophagitis/ Esophageal strictures: Small frequent meals, high protein soft foods/liquids,
supplementation
■ Unfortunately, the patient’s health drastically declined requiring:
■ Tube feeding: Monitoring and checking residuals, free water flushes, the tube feeding is titrated at the
appropriate rate, checking the abdomen for destination, bloating, proper neutropenic precautions were
being used, proper elevated head positioning (at least 30 degrees) checking electrolyte levels,
bowels/output, blood glucose levels, Synthroid administration to ensure proper holding of tube feeding
(one hour before, one hour after), and weight
■ Continue to monitor after discharge
■ Significant protein/calorie delivery is required for months to years to facilitate functional and lean body
mass recovery, with high protein oral supplements being essential to achieve adequate nutrition
■ Patient was transferred to Sparrow Specialty Hospital
Article 1: Autologous hematopoietic cell transplantation for multiple myeloma patients
with renal insufficiency: A Center for International Blood and Marrow Transplant
Research Analysis Bone Marrow Transplant.
Background: Autologous hematopoietic cell transplantation (AHCT) in multiple myeloma patients with renal insufficiency (RI)
has been controversial.
Renal insufficiency is common (20-50%) of multiple myeloma patients
- Considered a risk factor for early death and traditionally associated with an unfavorable prognosis
- Contributing factors of RI in multiple myeloma patients are light chain- induced proximal tubular damage, cast nephropathy,
interstitial nephritis, hypercalcemia, dehydration, hyperuricemia, amyloid deposition and plasma cell infiltration
~5% of multiple myeloma patients are dialysis dependent

■ Method- data was collected pre-transplantation, 100 days and 6 months post transplantation, and annually until death or last
follow up using the Center for International Blood and Marrow Transplant Research (CIBMTR) registry from over 450
centers worldwide. The data was submitted to the Statistical Center at the Medical College of Wisconsin in Milwaukee where
computerized checks for discrepancies, physicians’ review of submitted data and on-site audits of participating enters ensure
data quality.
■ Population- All patients from US/Canada who underwent AHCT for multiple myeloma and reported to the CIBMTR from
2008-2013 and had a reported creatinine at AHCT. N=1492. Grouped by GFR using the Modification of Diet in Renal Disease
(MDRD) equation (study equation analyzing whether protein restriction and control of blood pressure had an effect on the
progression of chronic kidney disease) normal/mild (> or equal to 60 ml/min, moderate (30-60) and severe RI (<30)
■ Results: 1240 patients had normal/mild, 185 had moderate and 67 had severe Renal insufficiency. Thirty-five patients were on dialysis prior to
Autologous Hematopoietic Cell Transplantation. Induction chemotherapies included bortezomib based treatments in 73% of normal/mild, 81%
of moderate and 80% of severe RI and 2 or greater lines of chemotherapy in 20% normal/mild, 22% moderate and 45% severe RI. Median
time from diagnosis to AHCT was < 6 months in 38% of normal/mild, 36% of moderate and 25% of patients with severe RI. Pre- transplant
disease status was similar between the groups with > Very Good Partial Response (VGPR) in 49% normal/mild, 49% moderate, and
50% severe RI. Melphalan does was 200 mg/m^2 in 92% of patients with normal/milk, 75% moderate, 33% severe RI. Remaining
patients received Melphalan 140 mg/m^2.
■ The median inpatient hospital stay was 14 days in patients with normal/mild, ranging from 1-90; 16 days for moderate, ranging
from 3-77 days, and 17 days in patients with severe RI ranging form 4-70 days.
■ Analysis of outcomes: IgA or light chain subtypes, International staging system (ISS) Stage III, 2 or more lines of chemotherapy,
lack of sensitivity to treatment, and lack of planned post-transplant therapy were significantly associated with higher relapse and
lower progression-free survival and overall survival. Renal function at AHCT was not a significant factor for predicting higher
frequency of relapse.
■ Hemodialysis patients at time of transplant: 34 out of 35 patients with severe RI who were on dialysis at time of transplant
achieved post-transplant dialysis independence. All dialysis patients at time of transplant received Melphalan 140 ml/m^2.
Average hospital stay was 18 days (0-63 days), Median time to platelet engraftment was 18 days and median time to neutrophil
engraftment was 11.5 days. The probability of progression-free survival was 70% after 1 year, at 5 years was 26%. The probability
of overall survival at 1 year was 88%, at 5 years: 49%
■ The probability of progression-free survival at 5 years for those who received maintenance therapy (n=935) was 40% and overall
survival at 5 years was 74%, those who did not receive maintenance therapy progression-free survival at 5 years was 26%
(n=548) and overall survival was 58%
■ 386 deaths were seen during follow up, very similar between the three groups, cause of death being relapse in 225 patients (82%,
73%, 73%) in normal/mild, moderate, and severe RI. Cause of death being infection in (3%) normal/mild, 2% moderate, and 0%
of severe. Cause of death being organ failure in 9 (3%) normal/mild (including 2 renal), 2 (6%) moderate, 2 (9%) of severe
(including 1 renal).
 Conclusion
❏ Autologous Hematopoietic Cell Transplant can be performed safely in patients with severe renal insufficiency including those on
dialysis with good outcomes
❏ High dose melphalan with AHCT is safe and effective in patients with Multiple Myeloma with renal insufficiency at the time of a
transplant with with 0 treatment related mortality at 100 days in patients with moderate and severe RI
❏ Patients with moderate RI appeared to benefit from Melphalan 200 mg/m2
❏ Post-transplant therapies improved outcomes and had much higher progression-free survival and overall survival rates
❏ The majority of patients were reported to achieve dialysis
independence
❏ Relapse/progressive disease remained the primary cause
of death for multiple myeloma patients, regardless of the
degree of renal insufficiency

Limitations:

- Study was limited by the absence of detailed data on

consolidation/maintenance post-transplant therapies and the
duration of use

- The retrospective nature and reliance on center-reported

dated reported to the CIBMTR

- Cannot exclude reporting bias

Article #2: Validation of Self-Reported Complications by Bone Marrow Transplantation
Survivors
❏ Self-reported data are commonly used in epidemiological and clinical research studies as the sole or primary source of exposure and
outcome information and need good validity
❏ With retrospective cohorts of BMT survivors it is not possible to do a physical examination or abstract data from the survivors
❏ The accuracy of self reporting complications was evaluated

Methods: A medical record validation of patient-reported complications following bone marrow transplantation (BMT) was performed using a
self-administered questionnaire, the Bone Marrow Transplant Survivor Study (BMTSS) questionnaire, was mailed to the patients along with
consent forms and a cover letter explaining the study and encouraged patients to call with any questions
❏ The questionnaire examined topics such as demographics, access to and use of medical care, and post-BMT complications (hearing, vision,
speech, endocrine, central nervous, cardiopulmonary system, gastrointestinal, genitourinary systems, graft-versus-host disease, and
psychological dysfunction) and included a detailed family history, reproductive history, health habits, physical activity, and
sociodemographic factors such as education, marital status, employment, and insurance.

❏ Self-reported complications were validated using medical records (gold standard): ocular, endocrine, cardiovascular, musculoskeletal,
pulmonary, gastrointestinal, neurological, graft-versus-host disease, and subsequent cancers.

Population: 100 English speaking patients who had undergone BMT at the City of Hope and had survived at least 2 years from the date of
transplant without evidence of persistent or recurrent cancer.
- 212 were randomly selected from cohort of 3667 patients, the first 100 to respond were used
- Sixty-one patients had received an allogeneic BMT, while 39 received an autologous BMT
Results:
❏ High validation values were found for avascular necrosis, osteoporosis, hypothyroidism, hypogonadism.
❏ Moderate validity and reliability values were found for hypertension, myocardial infarction, cataracts, xerophthalmia, and
subsequent cancers excluding skin cancers
❏ Sensitivities (the proportion of those with the complication (as defined by the medical records) who are correctly classified by the
questionnaire) ranged from 52.9% for subsequent cancers to 100% for avascular necrosis and hypothyroidism.
❏ Specificities (the proportion of the study population that truly does not have the complication and is correctly classified by the
questionnaire) ranged from 75.4% for ocular complications to 100% for avascular necrosis.
Conclusions:
❏ Cancer survivors can self-report serious complications with an acceptable level of accuracy in epidemiological research
❏ The results indicated a good overall agreement between self-report and medical records for post-BMT complications, which are in
agreement with the reports in the literature for a variety of medical conditions
❏ The agreement between self-reported data and medical records was good for well-known complications that have clear diagnostic
criteria and are easily communicated to the patient
❏ The agreement was lower for complications with non-established diagnostic criteria or a fluctuating course like peripheral
neuropathies and hypertension
 Infections post-transplant
Article #3:
Infectious complications after high-dose chemotherapy and autologous stem cell transplantation:
comparison between patients with lymphoma or multiple myeloma and patients with solid tumors
Retrospectively analyzed the infectious complications that occurred after Autologous Stem Cell Transplantation (ASCT)

Population: 117 patients (66 with solid tumor, 36 with lymphoma, 14 with multiple myeloma, one with acute leukemia) underwent 178 cycles of high-
dose chemotherapy and autologous stem cell transplantation (ASCT)

Results: Median duration of neutropenia was 8 days, patients with fever requiring antimicrobial treatment was 63%, 35.4% of patients had fever of
unknown origin (FUO), primary bacteremia occurred in 21.3%, pneumonia in 3.4% and severe skin infection in 1.1% of patients. Three patients had
invasive fungal infections occur, one patient experienced enterocolitis, and infection was fatal in three patients (2.6%), all due to septic shock.

- The most frequently isolated pathogens were Gram- positive cocci. Median time to decrease the fever with antimicrobial therapy was 4 days (6
days in patients with bacteremia or other severe infection, and 3 days in patients with FUO).
- First-line antimicrobial therapy was successful in 65% of patients with FUO and 30.6% of patients with documented infections
- With respect to the incidence, type and clinical course of infection, no significant differences between patients with lymphoma or multiple
myeloma and those with solid tumors were detected which most patients with hematologic malignancies had received multiple cycles of intensive
chemotherapy prior to autologous stem cell transplant

Conclusion: The majority of patients undergoing high- dose chemotherapy and ASCT can be regarded as low-risk with respect to infectious
complications during neutropenia

- A significant proportion of patients with febrile episodes after high-dose chemotherapy and ASCT might be managed on an outpatient basis due
to the high success rates of patients receiving ciprofloxacin plus amoxicillin-clavulanate and patients receiving ceftriaxone plus amikacin
Conclusion
■ The medical status of a patient can change drastically in a short amount of time
■ Septic Shock is a serious life- threatening condition that can drastically affect many different aspects of a
person ranging from prolonged inflammation, immune suppression, organ injury and lean tissue wasting.
■ Patients who survive sepsis have continuing risk of mortality after discharge, as well as long-term cognitive
and functional deficits.
■ Patients who undergo treatment for Bone Marrow Transplants are easy targets for becoming septic as their
immune systems are wiped out in preparation for BMT procedure.
■ Typically patients receiving ALLO transplants are at higher risk for side effects as they are receiving related to
or unrelated donor cells.
– The risk is even higher when the patient has poor nutritional status prior to transplant
– The most ideal match is that coming from a brother donor
– Graft vs. Host Disease (GVHD) is a potential complication of an ALLO transplant where the donor’s T-
cells attack the patient’s healthy cells when they mistake them for being foreign
– GVHD can affect the mouth, gastrointestinal tract, lungs, liver, muscles and joints, skin, nails, scalp,
and hair
■ Patients who undergo Autologous Hematopoietic Cell Transplants and receive Post-transplant therapies including consolidation and
maintenance have higher progression-free survival as well as overall survival rates up to 5 years post transplant.

■ Although there has been controversy with renal insufficiency and undergoing autologous hematopoietic cell transplantation in multiple
myeloma patients, studies have concluded that it is safe and effective in patients with multiple myeloma with renal insufficiency.

■ Patients with moderate renal insufficiency appear to benefit from Melphalan 200 mg/m2

■ Although patients receive high-dose chemotherapy and Autologous Stem Cell Transplantation once they experience infectious
complications they still may be able to be managed on an outpatient basis due to the high success rates of the various antibiotic therapies

■ Cancer survivors can self-report serious complications with an acceptable level of accuracy in epidemiological research especially for
well-known complications that have clear diagnostic criteria and are easily communicated to the patient

■ Being a man, over 50 years old, overweight or obese, African American, and/or exposed to radiation increases your risk of developing
Multiple myeloma in which can negatively affect one’s kidneys due to the abnormally elevated levels of M protein in the bone marrow,
bones, calcium levels, rate of healing from infection, cause unintentional weight loss, nausea, vomiting, upset stomach, numbness
(especially in the legs), vision problems, and anemia
Impressions
❖ Careful and continued monitoring (electrolytes, fluids, organ function, weight changes, skin integrity,
tolerance) is crucial for patients to reach optimal health and avoid further complications, and initiation of
early interventions

❖ The medical status of a patient is ever changing and evolving requiring change and adjustment of
interventions

❖ Medical Nutrition Therapy is important in acute and chronic diseases for maintaining health and avoiding
complications

❖ Critical thinking skills are required to use clinical judgement that results in effective nutritional care for
individualized patients

I would like to know more about…

❖ The percentage of failed or complications such as tube leaks, spills, and other unforeseen incidents with Bone
Marrow Transplantation resulting in declining medical status

❖ What effect a disruption in consistent infusion of one’s cells has during a bone marrow transplant can have

Readmitted for acute on chronic exacerbation of systolic and diastolic heart failure and pulmonary edema
7/23/2020
References
Nelms, M., Sucher, K. P., & Lacey, K. (2016). Nutrition Therapy and Pathophysiology (3rd ed.). Boston, MA: Cengage Learning.

Neviere, Remi. "Pathophysiology of Sepsis." UptoDate, May 2020, doi:https://www.uptodate.com/contents/pathophysiology-of-sepsis?search=septic

%20shock&source=search_result&selectedTitle=9~150&usage_type=default&display_rank=9#

Reich, G., Mapara, M. Y., Reichardt, P., Dörken, B., & Maschmeyer, G. (2001). Infectious complications after high-dose chemotherapy and
autologous stem cell transplantation: comparison between patients with lymphoma or multiple myeloma and patients with solid tumors. Bone marrow
transplantation, 27(5), 525–529. https://doi.org/10.1038/sj.bmt.1702822

https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults/print?search=septic%20shock&sou
rce=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Evaluation and management of suspected sepsis and septic shock in adults

Authors:Gregory A Schmidt, MDJess Mandel, MD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859934/pdf/nihms887917.pdf Autologous hematopoietic cell transplantation for multiple myeloma
patients with renal insufficiency: A Center for International Blood and Marrow Transplant Research Analysis Bone Marrow Transplant. 2017
December ; 52(12): 1616–1622. doi:10.1038/bmt.2017.198. Authors: Anuj Mahindra, Parameswaran Hari, Raphael Fraser, Mingwei Fei, Anita
D’Souza

Louie, A., Robison, L., Bogue, M. et al. Validation of self-reported complications by bone marrow transplantation survivors. Bone Marrow Transplant
25, 1191–1196 (2000). https://doi-org.sladenlibrary.hfhs.org/10.1038/sj.bmt.1702419

https://www.uptodate.com

https://www-clinicalkey-com.sladenlibrary.hfhs.org/pharmacology/