NUT 116BL Name: ______________Karina

Almanza__

Major Case Study: Critical Illness & Nutrition Support

(11 questions; 60 points total)

Due 2/17/17 by 11 am
Submit Case Study online;
Turn in typed hard copy of ADIME note

You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning, and
monitoring throughout his hospitalization.

Initial admission information available from the medical chart:

Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms, and
back in an accident at the chemical plant where he works. After emergency first aid at the
plant, he was transported by ambulance to the university hospital burn center. Mr. G was in
shock when he was admitted.

Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned skin
is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-injury wt:
165#

Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem 20
screening panel, ABGs (arterial blood gas), and UA (urinalysis).

Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck,
upper back, arms, hands, and upper thighs.

Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted. Urinary
output, P, and BP monitored hourly. NPO x 12 hrs or until hemodynamic stability achieved.
NG tube placed for stomach decompression. Maalox q 2 hrs through NG tube.

Initial hospital course:

As soon as the shock was under control, Mr. Gs wounds were washed, debrided,
and dressed with silver sufadiazine using fine-mesh gauze. He was given a tetanus
shot and 600,000 units of procaine penicillin were administered q 12 hrs.
After 18 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned; patient
is responsive to pain, but limited alertness; breathing & respiration normal
By 24 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On morning of second day (~ 30 hours), a Nutrition Consult was ordered for feeding
recommendation

Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the initial
consult, on day 2 of admission.

1. Which of the following statements best describes your nutrition screening of Mr. Gs risk
level? (1 pt)
BMI= 23.67 normal

_____ Minimal risk (patient is at or above IBW, no weight loss prior to admission); no
specialized nutrition therapy over the first week of hospitalization is required.

_____ Moderate risk (patient is at or above IBW, no weight loss prior to admission);
limited alertness duration likely > 72 hours; trophic feeds recommended to be started
within 48 hours of admission and continued through first week of hospitalization.

___X__ High risk (patient is at or above IBW, no weight loss prior to admission) with
high injury severity; enteral feeds recommended to be started within 48 hours of
admission; enteral nutrition support recommended to provide >80% of goal energy &
protein needs.

_____ High risk (patient is at or above IBW, no weight loss prior to admission) with high
injury severity; trophic feeds recommended to be started within 48 hours of admission;
parenteral nutrition support recommended to provide >80% of goal energy & protein
needs.

2. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the

following methods. Show your work.
a. Quick shortcut per the ASPEN Critical Care Guidelines [25-35 kcal/kg BW] (2
pts)
(75 kg)(25 kcal/kg)= 1,875 kcal
(75 kg)(35 kcal/kg)= 2,625 kcal
Range 1,875 to 2,625 kcal/ D

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

IF= 1.505to 1.85 (assuming 40% TBS); AF= 1.1 (confined to bed)
[(10* 75kg) + (6.25*177.8 cm) - (5*32 yo) + 5] = 750 +1111.25 -160 + 5 = 1,706.25 kcal
2,815.3125 to 3,472.22 kcal/ D = 2,815 to 3,472 kcal/D

c. Comment on whether these two estimates differ or are similar, and what you
would use as your actual energy recommendation for this patient. Provide
justification for why you selected this energy recommendation. (2 pts)

When comparing the ASPEN method versus the Mifflin St-Jeor method, there was a
significant difference of a substantial amountl. of calories seen in Mifflin St. Jeor. Although
thisant difference, i Mifflin St. Jeor ASPEN method for Mr. Gs second day because he is a
patient in critical care that needs to transition to tube feeding in a and more conscience
caloric valuepersonalization; Mifflin St. Jeor is not best suited foeints and would surge an
abundant amount of calories into a highly catabolic and stressed statebest suited for this
personalizatiause ieight.
ASPEN is not as personalized for Mr. Gs needs and gives a general value for caloric per
kilogram of weight.
mnia,fd rch protein is provided and pridesit causes nextra workload onto the eys.

(116B Critical Illness, Slide 17)

3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work
and provide a goal range. (2 pts)
Burn: 1.5 - 2.0 g PRO/ kg
(1.5 g PRO/kg)(75 kg)= 112.5 g PRO/D
(2.0 g PRO/ kg)(75 kg)= 150 g PRO/ D
Goal Range: 113 to 150 g PRO/ D

4. Based on the patients needs, consider the enteral formula to recommend

a. Describe two desirable features or characteristics of the type of formula you
would select and recommend. (refer to the UCD TF lecture) (2 pt)
1. Formula best meeting caloric needs of Mr. G (within the range of 1875 to 2625 kcal/
D)
2. Adequate protein, icronutrient and electrolytes needs (increased demand for
glutamine, arginine and omega-3)
-

(Lecture 5, Enteral Nutrition Support: Slide 19)

(MNT-PG p. 96)
b. Give one example of an appropriate enteral formula meeting these
characteristics, using the UCDMC formulary provided on the course web site.
(2pt)
- Osmolite 1.5 Cal (Abbot)
- Whole protein, high calorie and fiber-free RTH bottle
- Meets demand for caloric and protein needs

5. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetodine liquid to
be put down the feeding tube? (Use the FMI text for this question) (2 pts)
Famotidine (Pepcid) is a Histamine H2 Receptor Antagonist. A Histamine H2 Receptor
Antagonist is being used because histamine acts as a vasoactive amine that contributes to
inflammation and IgE-mediated allergic reaction through inflammation of local blood
vessels furthermore provoking dilation of local blood vessels and smooth muscle
contraction. Furthermore Famotidine will reduce gastric acid secretion which is crucial for
Mr. G since there ill be minimal movement and he will be in a laying down position while
obtaining food through TB regimen; this can ultimately result in gastric acids impacting the
lower esophageal sphincter, resulting in GERD.
Pepcid was used instead of Cimetodine
for a number of reasons including precipitation of feeding tube as well as the symptoms
seen in Cimetodine supplementation. btheThe toms posed in Cimetodine could act as
more of a threat to Mr. G who is already in a stressed-induced state where catabolism is
high, and there is degradation of lean body mass and threat of function to vital organs.
Symptoms of Cimetidine include rare pancreatitis, and an increase in prolactin after IV
bolus. Prolactin, a hormone released from the anterior pituitary gland, can further induce
stress responses by increasing the already stimulated cascade of stress provided from the
HPA axis. Conclusively, the s
tomach is not being used as much as it was prior to the accident and therefore, the
medication being used would want to bypass the stomach through IV instead of adding
medication to Mr. Gs feeding supply. Adding medication to Mr. Gs feeding tube regimen
can further increase bid secretions to prevent tooucand induce furer imbalances and GI
complications than those already being expressed through Mr. Gs stress response.

(Lennartsson, Anna-Karin, and Ingibjrg H. Jonsdottir. "Prolactin in response to acute

psychosocial stress in healthy men and women." Psychoneuroendocrinology 36.10 (2011):
1530-539. Web.)
(NTP p. 159) (FMI p. 166-167)

6. Describe 3 ways you could determine the adequacy of your recommendations for
energy and protein intake for this burn patient. (In other words, what will you monitor to
decide if your recommendations are adequate, and why?) (3 points)
Three ways I will determine the adequacy of my recommendations for energy will be:
(1) maintenance of body weight to be within 10% of pre-injury wt. if possible and
measure nutrient intake including caloric intake and I/Os
- During the response to critical illness, there is an increase in catabolic and
counter-regulatory hormones such as cortisol, epinephrine and glucagon;
increasing BMR, catabolism of skeletal muscle and fat stores which ultimately
increase gluconeogenesis and hyperglycemia. This degradation of fat stores and
skeletal muscle will be evident in body weight loss. When there is no longer an
extreme or consistent weight loss seen in Mr. Gs progress in healing, there will
be indication of an adequate energy and protein intake.
(2) (easure balance daily losses of nitrogen in urine; can be done through
measurement of Nitrogen Balance,
- When there is a critical illness response, there is a highly catabolic nature to the
body, an imbalance of electrolytes and degradation of lean muscle mass to
release a surplus of nitrogen. The nitrogen is then being excreted out of the
 body and there is usually and increased loss of weight and lean muscle mass. If
Mr. G is being adequately supplied energy and protein intake, then his Nitrogen
Balance will be closer to a value of 0 instead of a negative value.
(3) 3easure CRP
(4)
- When there is a critical illness response there is an increased synthesis of
positive acute phase responder proteins. Measuring CRP values will indicate
adequate adjustments to diet (specifically protein metabolism and absorption),
the higher the value, the more inadequate the body is in responding to the stress
and illness.

(Dr. Francene Steinberg- Lec 4: Nutrition Care Critical Illness Slides 8; 14- 20)
(NUT 116B, Lecture 10: Critical Illness, Slide 3)

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.2 @ 60 ml/hr,
plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking 100
kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full TF
volume is being delivered each day.
The patient tells you it is difficult for him to eat by mouth due to pain, and that he
doesnt have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current
information available.
BMI: (70 kg)/ ((1.778 m)^2)= 22.14 kg/ m^2 Normal BMI
(only 7.14% of change from Normal BW)

a. Energy: (2 pt)
IF: 1.0 to 1.5
AF: 1.1
[(10* 70 kg) + (6.25*177.8 cm) - (5*32 yo) + 5] = +1111.25 -160 + 5 =1651.25
kcal/D
b. = 1,822 to 2,73325cal/ D

c. Protein: (2 pt)
(70 kg)(1.5-2.5 g PRO/ kg)= 105 to 140 g PRO/ D
 d. Fluid: (2 pt) (assuming 1 mL/ kcal= 1,822 to 2,733 mL)
(1,822 to 2,733 kcal/D)(1 mL/D)= 1,822 to 2,733750 / D

8. Calculate the energy, protein, and fluid provided by the current TF regimen.
Show your work
a. Energy: (2 pt)
(60mL/hr)(24 hr)(1.2 kcal/ mL)= 1,728 kcal/ D

kcal2 kcal/L)

b. Protein: (2 pt)
[(1,440 mL)(1,000 mL)](55.5 g PRO/ L)= 79.92 g/D= 8081 g PRO/D

c. Fluid: (2 pt)
d.
80.7% H2O
= (1440 mL)(0.807)= 1,162.08 mL(450 m= 648 mL

9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.

N balance = g protein (UUN + 4) = 92 g pro (23 g + 4) = - 12.3 g N/d

6.25 6.25

(1)Interpret the results of the nitrogen balance study above. (2)Is the current TF order
adequate to meet estimated protein needs? (2 points)
(1) The negative nitrogen balance of 12.3 g N/D is a suggestion that Mr. G is not meeting
the protein need required, as well as an indicator that there is an inadequacy of whole
body protein delivery. Furthermore, until Mr. G is in an anabolic state, nitrogen balance
will be difficult to obtain due to dysregulation and catabolistic nature of metabolism.
(2) The current TF order of Jevity 1.2 would not meet the adequate protein needs for Mr. G
to obtain nitrogen balance and meet the daily recommended amount of protein. This is
noted from the calculation being done from the previous TF used, providing 92 grams
of protein a day and still having an overall (substantially) negative nitrogen balance.
The newly prescribed TF established 80 grams of protein a day, a lower supply of
protein than what was initially used and will more than likely proceed to give a greater
negative value when nitrogen balance is tested.

(NUT 116B- Dr. Zivowack- Lec 9, Nutrition in Critical Care, Slide 37)

10. Write an ADIME note for your day 10 follow-up assessment of Mr. G. (22 points)
Hints: Follow the ADIME note guidelines provided on the course web site. Use
subheadings. Be sure to evaluate his current anthropometrics (and any trends seen),
current kcal/pro needs, adequacy of the current diet order (including both the TF and PO
intake), and current labs. What do the anthropometric and biochemical data reveal? Is the
current diet order adequate and realistic for the patient? Write a PES statement that
reflects your assessment and include it in your note. In the Plan section, make very
specific nutrition support and monitoring recommendations for this patient at this point in
time.
.
*REMEMBER to turn in hard copy of your typed ADIME note & attach a calculations sheet
to your note; remainder of the assignment is to be submitted online

11. It is now 3 weeks since admission and Mr. G is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is finally interested in trying to eat more foods
orally and his appetite is returning.
(1) How could his current continuous TF regimen (the one recommended in your note
above) be modified to provide a total of approximately 1000 kcal/day and not interfere with
his intake at meal times?
(2) Make recommendations for an appropriate transitional TF plan/order and how to
monitor.
(3) Make a specific recommendation for both the TF plan and monitoring. (6 points total)

(4 pts) Recommended transitional feeding plan

(1) Transition into feeding EN during the night when Mr. G is asleep, adapting the
dripping to 60 mL for 121hours throughout the night , 9:00 pm to 9:00 am and
avoiding interference of his meal intake during the day, 9:00 am to 9:00 pm.
Throughout the course of the day, Mr. G will consume food P/O, fulfilling the
adequate 2048.3 kcal/ D that is recommended for Mr. Gs daily intake. Throughout
the night, there will be 60 mL of Osmolite 1.5 released every hour. Over time, there
will be transition of 75 mL/ hr to 60 mL/ hr throughout the 9:00 pm to 9:00 pm
duration, eventually eeting the 1000 kcal/ D needs during the night and meeting the
estimated addition 1000 kcal during the day P/O.

increase rate,

Mifflin St Jeor
AF: 1.1
IF: 1.2
[(10* 75 kg) + (6.25*177.8 cm) - (5*32 yo) + 5]= 1,706 kcal
= 2048.3 kcal/ D

PRO: (70 kg)(1.5-2.5 g PRO/ kg)= 105 to 140 g PRO/ D

Use enteral feeding for 8 hours in which Mr G is resting to night while during the day DAT
P/O.

Feed: Osmolite 1.5 @ 75 mL

75 mL/ hr for 12 hrs/ D

Energy: (75 mL)(12 hr)(1.5 kcal/ mL)= 1,350 kcal/ D

PRO: [(75 g)(12 hr)]/(1,000 mL)(62.7 g PRO/ L)= 56.43 g/D= 57 g PRO/D
Fluid: (76.2%)(1080 kcal/ D)= 1028.7 mL= 1,029 mL

Jevity Osmolite 1.5 @ 60 80 mL

60 mL/ hr for 128 rs/ D

Energy: (60 mL)(120 r)(1.5 kcal/ mL)= 1080960al/ D

PRO: [(60 g)(12 hr)]/(1,000 mL)(62.755 PRO/ L)= 45.1224.4 g/D= 4550 PRO/D
Fluid: (76.2%)(1080 kcal/ D)= 822.92 mL= 823 mL

(2) Once Mr. G has established a steady intake of 60% of needs through oral intake, it
would be an appropriate time to wean off of nutrition support. Mr. G will be
monitored at each meal during the day and throughout the night, especially the first
few nights when feeding regiments are adjusted to ensure there are no negative
responses to this change in feeding, including inability for GI to metabolize TF
regimen.

(2 pts) (3) Monitoring plan

- Monitor nausea, constipation, vomiting, diarrhea, abdominal pain or

distention
- Monitor daily to see if tube feeding is working efficiently and that there is a
tolerance to feeds
- Monitor desired results:
o Weight increase and stability, avoiding further weight loss
o Adequate and normal albumin, prealbumin and CRP levels
o Nitrogen Balance
o Adequate wound healing
o Weaning off of ventilator

(NUT 116BL, Lecture 5: Enteral Nutrition Support Slide 65 and 67)