Case Study

Erin Kieser
51 YOM Admit date: 3/21/21

• Brought to ED by roommate after collapsing due to

drinking 4 shots and smoking marijuana which may
have had some substance with it
• Hyperkalemia, rhabdomyolysis, AKI, acidosis
• Coded after admission, ROSC, and was intubated
• CIKD consulted for CRRT & patient transferred to ICU
• PMH: alcohol use, hepatitis C, substance use, chronic
back pain, bipolar disorder
Nutrition Assessment #1 3/23/21
consult for tube feeding management
 Clinical Data Lab Value
Reference
Range
Na 134 mmol/L (L) 136 - 145 mmol/L

• CT abdomen: dilated small K 4.6 mmol/L 3.5 – 5.1 mmol/L

bowel representative of ileus BUN 32 mg/dL (H) 7 – 25 mg/dL
• Propofol at 13.1 mL/hr (346 Creatinine 2.2 mg/dL (H) 0.6 – 1.3 mg/dL
kcals/day) Ca 7.6 mg/dL (L) 8.6 – 10.3 mg/dL
• Levophed 5 mcg/min Mg 1.7 mg/dL (L) 1.9 – 2.7 mg/dL
• Folic acid and thiamine Glucose 162 mg/dL 140 – 180 mg/dL
• Pressure ulcer coccyx stage Albumin 2.8 g/dL (L) 3.5 – 5 g/dL
1 and multiple unstageable Phosphorus 1.7 mg/dL (L) 2.5 – 5.0 mg/dL
pressure ulcers on upper and
lower extremities
CRRT and Hypophosphatemia

“CRRT allows for

80% of patients on Common solutes in
slow, continuous
CRRT present with CRRT: Na, Cl, K, Ca,
removal of solutes
hypophosphatemia1 Mg, and glucose2
and fluid”1

Increased diaphragm Prolonged

weakness, cardiac mechanical
CRRT does not
arrhythmia, seizures, ventilation and
contain phosphorus2
rhabdomyolysis, and increased need for
hemolysis1 tracheostomy1
Anthropometric Data

• Admit weight: 73.1 kg

• Current weight: 74.1 kg
• Height: 5’ 11” (180.3 cm)
• BMI: 22.5 (normal weight)
• IBW: 78.2 kg
• Percent IBW: 93%
Food & Nutrition Related History

Diet Order: NPO

NKFA

Estimated Nutritional Needs: 1819-2319 kcals/day, 146-

193 g protein/day, 1819-2319 mL fluid/day
 Moderat Mild
e temple clavicle
Nutrition loss loss
Focused
Physical Severe
Assessment Severe
gastrocn
patellar
emius
loss
loss
Nutrition Diagnosis

1. Inadequate oral intake related to sedation as

evidenced by NPO diet order and consult for TF
management.
2. Increased nutrient need related to CRRT and
pressure ulcers as evidenced by increased
protein/energy and vitamin/mineral needs.
3. At risk for malnutrition.
 Vital AF at 20 mL/hr. Advance 15 mL/hr q4h to
goal rate of 70 mL/hr

2 pckts beneprotein TID

Nutrition
Intervention
100 mL FWF q4h

Vital AF + 2 pckts beneprotein TID + propofol + 100

mL FWF q4h to provide 2260 kcals, 146 g protein,
2150 ml free water
Nutrition Assessment #2 3/24/21
consult for parenteral nutrition orders
 Clinical Data

Reference
Did not tolerate TF- abd distended, NGT Lab Value
output >1 L, no BM since admit Range
K 3.7 mmol/L 3.5 – 5.1 mmol/L
Creatinine 1.5 mg/dL (H) 0.6 – 1.3 mg/dL
Intubated and sedated, general surgery
consulted, CRRT continued Mg 2.0 mg/dL 1.9 – 2.7 mg/dL
Glucose 100 mg/dL 140 – 180 mg/dL
Phosphorus 1.1 mg/dL (L) 2.5 – 5.0 mg/dL
Propofol 11 mL/hr (290 kcals/day) D10 at
50 mL/hr (480 kcals/day) Triglyceride 246 mg/dL (H) < 150 mg/dL

CT abdomen: distal SBO with potential for

ischemia
New Nutrition Diagnosis

Altered GI function related to small bowel obstruction as

evidenced by CT scan showing SBO, distended abdomen,
>1 L NGT output, and no BM since admission.
 1 L Clinimix 5/20 E

100 mL 20% lipids

Nutrition
Intervention TPN + 100 mL 20% lipids + propofol to
provide 1370 kcals, 50 g protein (75%
kcals needs, 33% protein needs)

Contacted MD to discuss SSI, d/c IV

fluids, replete electrolytes outside of
TPN,
Nutrition Assessment #3 3/25/21
consult for parenteral nutrition management
Clinical Data

Reference
Intubated and sedated Lab Value
Range
K 3.7 mmol/L 3.5 – 5.1 mmol/L
Propofol discontinued due to high triglycerides Creatinine 1.2 mg/dL 0.6 – 1.3 mg/dL
Mg 2.1 mg/dL 1.9 – 2.7 mg/dL
Glucose 143 mg/dL 140 – 180 mg/dL
No levophed, CRRT continued
Phosphorus 1.2 mg/dL (L) 2.5 – 5.0 mg/dL
Triglyceride 206 mg/dL (H) < 150 mg/dL
SBO continued—no BM but decreased NGT
output AST 395 units/L (H) 7 – 52 units/L
ALT 121 units/L (H) 7 – 56 units/L
MG and Na phos repleted, BG controlled
Nutrition Diagnosis & Intervention

Severe, acute on social malnutrition related to acute illness as

evidenced by <50% of EEE for >5 days, moderate temple loss, mild
clavicle loss, severe patellar loss, severe gastrocnemius loss.

1.5 L Clinimix 5/20 E

100 mL 20% lipids

TPN + 100 mL 20% lipids to provide 1520 kcals, 75 g protein (83%

kcal needs, 51% protein needs)
 Nutrition Assessment & Intervention
3/26/21 - 3/28/21

• Assessment: CRRT discontinued. HD started on 3/27. Normalizing

electrolytes. Still NPO with abdomen distended and >2L NGT
output. TAG still elevated with 100 mL lipids given 
• Intervention: advanced to 2L Clinimix 5/20 + 100 mL 20% lipids to
provide 1960 kcal, 100 gm protein 
 Nutrition Assessment & Intervention
3/29/21 – 3/31/21
3/29/21: 
• TG 211 will give 100 mL lipids. NG output > 2 L and abdomen still distended. Small, liquid
BM today. Continue current TPN prescription. 
3/30/21: 
• Several BMs last night. Vit A lab low. TG improved. 2 L Clinimix 5/20 E + 250 mL 20% lipids.
3/31/21:
• Several BMs, abdomen still slightly distended, NGT clamp trial today. Potential for initiating
TFs. Swallow eval before diet advancement. HD today. Zinc low. Phos high. Current TPN
prescription without electrolytes.
• Altered nutrition-related laboratory values related to wounds as evidenced by retinol lab
value of 0.16 mg/dL and zinc lab value of 39.5 ug/dL.
 Formula: Jevity 1.2

Goal rate: 90 mL/hr to provide

TF 100 mL FWF q4h
Recommendations
Provides: 2268 kcals/day, 105 g protein/day,
and 2125 mL water/day (100% of kcal needs and
95% of protein needs) 

Start at 20 mL/hr and advance by 10 mL/hr q4h as

tolerated
 Predictors of Hypophosphatemia and Outcomes
during Continuous Renal Replacement Therapy1

Purpose: “to evaluate predictors of development of hypophosphatemia in patients undergoing CRRT and
determine if a preemptive approach to phosphate replacement is warranted in certain patients”

Participants: 72 patients on CRRT for >12 hours from a hospital in Memphis, TN

63% of participants developed hypophosphatemia

Patients who developed hypophosphatemia received longer durations of CRRT, had a diet order, presented with
lower P and K levels at baseline

Hypophosphatemia was associated with increased duration of ICU stay

60% of patients with hypophosphatemia received P supplementation with only 38% achieving normal levels while
on CRRT
References

1. Hendrix, R. J., Hastings, M. C., Samarin, M., & Hudson, J. Q.

(2020). Predictors of hypophosphatemia and outcomes during
continuous renal replacement therapy. Blood Purification, 49(6),
700-707. doi: 10.1159/000507421
2. Yessayan, L., Yee, J., Frinak, S., & Szamosfalvi B. (2016).
Continuous renal replacement therapy for the management of
acid-base and electrolyte imbalances in acute kidney injury.
Advances in Chronic Kidney Disease, 23(3), 203-210. doi:
10.1053/j.ackd.2016.02.005