Major Case Study:

Jess Wittenauer
Mercy Hospital – Jefferson
April 13, 2021
 Patient Information

Patient Initials: SH Occupation: Retired

Age: 71 years old
Gender: Female Allergies: Wheat, Latex
Weight on Admit 190 lbs
Height : 5’3 Married: Spouse
BMI : 33.7
Date of Admission: 2/1 Attending Physician: Dr.
LOS : 23 days Bogachenchu

ED PCU ICU PCU ICU

Past Medical History

 Type 2 DM, HTN, Hyperlipidemia, CHF, recent

left Cataract surgery

 No history of tobacco use

 Alcoholic beverages: 2-3 x per week (on

average)

 No drug use
Initial Assessment (2/1- 2/2)
• Admitted for : Nausea, Vomiting, Fatigue, SOB, and general weakness after eating a
hazelnut cake
• Difficulty swallowing and dry mouth after falling d/t weakness
• Principle Problem: Hypercapnia, hypoxia respiratory failure
• Active problems: Aspiration pneumonia, GERD with esophagitis, hypocalcemia, colitis,
dysphagia, Type 2 DM
• Plan of Care
• CT scan on Abdomen and Pelvis – Lacunar Infarct in left thalamus
• Hypocalcemia/Hypophosphatemia- Replete vitamin stores
• Left sided weakness, speaking out of right side
• Bedside swallow- severe dysphagia and aspiration score
Cardiac Arrest – (2/2)

• Nurses reported increased weakness with concern for cardiac output- MRI
ordered
• Pt underwent cardiac arrest while being wheeled into the MRI- Code Blue
called
• No pulse, CPR was given, ROSC achieved
• Endotracheal Intubation- Dr. Iyer
• Sedation -Fentanyl and Propofol
Nutrition Assessment 2/3
• OG tube Placement
• Propofol infusing at 12.8 ml/hr ( 337 kcals) w/ OG suction
• Hypothermia Management

Labs reviewed: Pertinent Meds:

Na: 149 ( H) Humalog

Phos: 5.4 (H) Lantus
CL: 116 (H)
BUN : 30 (H)
Propofol
Ca: 7.8 (L) Fentanyl
Glucose: 126 ( H) Cyanocobalamin
HgbA1c : 7.8 ( H) Lipitor
Elevated MCV
Diagnosis, Intervention, Monitoring/Evaluation
Inadequate oral intake r/t inability to consume adequate nutrition - intubation as
evidenced by NPO status/ EN trickle feeds ordered

Nutrition Prescription:
• Estimated Energy Needs: 1372- 1716 kcals (16-20 kcal/kg ABW)
• Estimated Protein Needs: 77- 94g ( 0.9-1.1 g/kg ABW)
• Estimated Fluid Needs: 1372-1716 ml ( 1 ml/kcal)

Intervention:
• TF Vital AF (1.2) 10-20 ml/hr ~ Trickle Feeds, FWF 75 ml q2h
• Goal rate : 45 ml/hr (1080) ml/24 hr, providing 1296 calories and 81 g protein
• Total Calories: 1634 kcals, 81g Protein

Monitoring/ Evaluation: When medically appropriate, advance to goal rate.

Monitor Phos levels
• Goal: Tolerance and meeting nutrition goal or enteral nutrition
8
Vital AF 1.2 – Tube Feeding
Basic information:
• Elemental – hydrolyzed
• Contains MCT , Fish oils, Antioxidants
• Used to help manage inflammation, Promotes GI function
MCT oils
• Rapid/simple digestion
• Does not trigger cholecystokinin ( CCK) and Pancreatic
enzymes to be secreted
• Absorbs via passive diffusion
Fish Oil
• Anti-inflammatory
• DHA and EPA form Pro Anti-Inflammatory mediators
Vitamin C and Vitamin E
• Vitamin C = 422 mg/L
• Vitamin E = 253 IUs/L
Effectiveness of EPA/GLA and antioxidants
for Acute Respiratory Distress Syndrome
National Institute of Health: Critical Care Medicine

-Double blind , randomized controlled trial

Design:
• 146 patients with ARDS
• Continuously received Tube Feed of either (1) EPA/GLA + Antioxidant rich
formula or (2) Standard formula
• 4 -7 days w/ meeting 75% of Estimated Energy needs
Results:
• Improved gas exchange, decreased need for mechanical ventilation and
reduction in new organ failure
Nutrition Follow Ups

2/5
• Intubated/sedated; increased propofol
• New Goal rate: 40 ml/hr + 1 Prosource, FWF 100 ml q2
• Last BM: -5 days

2/8
• Off propofol – increase goal rate to 50 ml/hr (1200 ml) – 1440 kcals and
90 gms protein
• Hypernatremia – Increase FWF to 80 ml/hr qh
• Elevated Glucose ( 214-160), Triglycerides: 206
Nutrition Follow Ups
2/9
• Extubated, re-intubated d/t decreased respiratory status
• No propofol
• TF on hold d/t possible bowel obstruction
• Glucose 299 ; POC glucose: 235-298
• Last BM: 2/9

2/10
• Trach/ PEG placement d/t worsening respiratory
• Plan to resume TF at 50 ml/hr (1200 ml) FWF 60 ml q2h
PEG Feeding Tube
What is a PEG tube?
• Percutaneous endoscopic gastrostomy
• Used to allow nutrition, fluids, and/or medications to
bypass the mouth/esophagus into the stomach

Why would a person need a

PEG?
• Appropriate for anyone who cannot consume nutrition by mouth at risk for aspiration, or have
increased nutrition needs
• Indicated for patients requiring medium to long enteral feeding (>30 days)
• Examples:
• Esophageal cancer, oral surgery, stroke, burns, anorexia, irritable bowel disease,
pancreatitis, radiation therapy, cystic fibrosis
How is a PEG tube inserted?
Pull method
1. Sedative and Local Anesthesia
2. Endoscopic inserted into the mouth
3. Gastronomy site selected :
• Applying pressure on abdomen to bring gastric wall in
position with abdominal wall, no other tissue or organ
lay between
• Tip of endoscope illuminates through abdominal wall,
spot marked
4. Incision into stomach
5. Wire passed through needle
6. Wire and endoscope are pulled back through the mouth
7. Bumper attached to wire, pulled back through esophagus
into stomach
How is a PEG tube inserted?
cont.
Push Method

1. Site selected
2. Incision made into stomach
3. Wire inserted through needle
4. PEG tube is pushed through abdominal wall into
stomach over the wire
Pull vs Push Methodology

Push Method Pull Method

• Higher rates of • Less Complications

complications • Increased placement
• Increased dislocations accuracy
and occlusions • Decreased rates of
• Increased rates of infections
infections • Primarily used by
• Used less often by physicians
physicians
Possible Complications w/ PEG

Perforation – Gastric or Esophageal

Gastric obstruction
Buried Bump Syndrome
Hemorrhage
Wound Infection
Peritonitis
Care and Maintenance of PEG Tubes
Cleaning
• Use mild soap and water to clean skin around PEG
tube 1-3 x per day
• Remove any drainage or secretions around the skin
• Dry skin well with gauze or clean towel

Placement
• Use medical tape to secure PEG tube to abdomen
• Wear loose fitting clothes
• Replace PEG tube every 6-8 months to prevent
infection

PEG tracts can shrink in several hours or a few days if

tube is not replaced
Nutrition Follow Up- S/p Trach and PEG
placement
2/12
• No discomfort with PEG/Trach placement. Push Method used
• Last BM: 2/11
• POC Glucose : 145-120, HgbA1c 7.8
• Current wt 190 lbs
• TF Vital AF 1.2 infusing at 20 ml/hr

2/15
• Last BM: 2/11
• Glucerna 1.2 , Goal rate= 50 ml/hr + 1 Prosource, FWF 75 q4
• Wt: 193 lbs ( +3 lbs in 2 days ) Fluid?
 Nutrition Follow Up (2/22)
Subjective:

• Pt remains on Oxygen therapy with trach

• Increases mucus secretion produced from lungs
• Wt: +34 lbs in 3 days ( 2/19- 2/22)
• IBW: 68 kg
• POC Glucose : 197-205

• Estimated Energy Needs: 1404-1664 kcals ( 27-32 kcal/kg IBW)

• Estimated Protein Needs: 83- 99 g ( 1.6-1.9 g kg IBW)
• Estimated Fluid Needs: 1404-1664 ml ( 1 ml/kcal)

• TF Glucerna 1.2 - New goal rate: 55 ml/hr ( 1320 ml) and 1 prosource to
provide 1644 kcals and 94 g protein
• FWF 60 ml q4 h
Nutrition Diagnosis (2)
Inadequate oral intake r/t inability to consume
adequate nutrition as evidence by NPO status

Increased protein needs r/t physiological causes

increasing nutrition needs as evidenced by
tracheostomy and pressure ulcer on neck
Discharge Summary
Improved Respiratory status and Hemodynamically stable

Tracheostomy wound site

• 4 L/hr Nasal Cannula

Home Health – LTACH placement at Kindred Hospital

Discharged on 2/24 ( LOS 23 days)

Kindred  Scenic Nursing Home

Future Plan of Care
Continuation of Enteral Nutrition via
PEG Tube
• Recommend Glucerna 1.2 TF Bolus

Proper care of PEG Tube

care/maintenance

Routine Physical Therapy, return of

motor function
Reflection
What did I learn?
Tube Feeding selection in critically ill
patients
• GI absorption, anti-inflammation,
Osmolality, hydrolyzed formulas
Nutrition Care Process – ICU
• Daily monitoring of Fluid status,
Labs, vasopressors, TF tolerance
PEG Tube placement/ Process
What would I have done differently?
Gathered SGA information for
complete Nutrition Assessment
Communicated PEG tube
care/maintenance with clear feeding
regimen with husband before
discharge
 Sources
Cook medical g56403 - Set, flow 20, PERC, ENDO, GASTRO, PULL, EACH. (n.d.). Retrieved April 08, 2021,
from https://www.ciamedical.com/cook- medical-g56403-each-set-flow-20- perc-endo-gastro-pull
Hegazi, R., & Wischmeyer, P. (2011). Clinical review: Optimizing enteral nutrition for critically ill
patients--a simple data-driven formula. Retrieved April 08, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3388694/
Pontes-Arruda, A., Martins, L., De Lima, S., Isola, A., Toledo, D., Rezende, E., . . . Investigating Nutritional
Therapy with EPA, GLA and Antioxidants Role in Sepsis Treatment (INTERSEPT) Study Group. (2011, June
9). Enteral nutrition with eicosapentaenoic Acid, γ-linolenic acid and antioxidants in the early treatment
of SEPSIS: Results from A multicenter, prospective, randomized, double-blinded, controlled study: The
INTERSEPT study. Retrieved April 13, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219016/
Shah, N., & Limketkai, B. (2017, February). Https://med.virginia.edu/ginutrition/wp-
content/uploads/sites/199/2014/06/Parrish-February-17.pdf. Retrieved April 07, 2021, from
https://med.virginia.edu/ginutrition/wp- content/uploads/sites/199/2014/06/Parrish-February-17.pdf
Tang, S., & Wu, R. (2014, April 05). Percutaneous endoscopic GASTROSTOMY (pull method) and Jejunal
extension tube placement. Retrieved April 08, 2021, from
https://www.sciencedirect.com/science/article/pii/S2212097114000284
Tucker, A., Gourin, C., Ghegan, M., Porubsky, E., Martindale, R., & Terns, D. (2010, September 09).
'Push' versus 'PULL' percutaneous endoscopic GASTROSTOMY tube placement in patients with
Advanced head and neck cancer. Retrieved April 08, 2021, from
https://onlinelibrary.wiley.com/doi/abs/10.1097/00005537-200311000-00007
 Thank you !

Questions & Answers