FN 418/618: Medical Nutrition Therapy II Spring 2017

Nutrition Support in Sepsis and Morbid Obesity

Dakota Cossairt

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kcal recommendations are too low for someone who is on a vent and has sepsis.

Remember protein intake and levels of albumin and prealbumin are not correlated especially in someone wh

We discussed in class that you can not provide a tube feeding rate of 77. You either need to round down to 7
to state what tube feeding product you are going to recommend in your intervention. We discussed this exte

Can't educate a patient who is on a vent and likely unconscious due to his illness.

Follow-up daily not as needed. Again I was very specific about stating this in class.

A Patient is a 37 yo obese white male recently admitted to the MICU with

severe sepsis, pneumonia, 4 months after undergoing Roux-en-Y gastric
bypass. Medical history includes type 2 DM, hyperlipidemia, Htn, and
osteoarthritis. Initial weight loss of 24# prior to surgery. Has lost 100# total,
since surgery. Medications at home include Lovastatin. Medications given in
MICU include vancomycin, Zosyn, Versed, and fentanyl. Family medical
history includes father with type 2 DM, CAT, Htn, COPD, and mother with
type 2 DM, CAD, and osteoporosis.
Physical findings include rash under skin folds, ecchymosis, abrasions,
petechiae, and 2+ pitting edema on extremities. Lab values indicate
increased levels of potassium, CO2, glucose, bilirubin, ammonia, ALT, AST,
CRP, CPK, fibrinogen, lactate, cholesterol, LDL, LDL/HDL ratio, triglycerides,
HbA1C, WBC, and transferrin, and decreased levels of phosphate, protein,
albumin, HDL, Hgb, Hct, and ferritin.
Urinalysis indicated increased levels of protein, glucose, Bact and ketones.
Patient was NPO upon admission. Orders for feeding tube inserted and
enteral feeding initiated per nutrition consult.

Highest wt. = 425# CBW = 325# %UBW = 77% Ht. = 70

BMI = 46.8

Recommended kcals = 1350-1650 kcal/day

Recommended protein = 125-150 grams/day

Fluid Requirements = 1800-2000 mL/day

D Inadequate protein intake R/T septic state and malnutrition AEB
decreased levels of albumin and total protein, as well as 2+ pitting edema

I Start continuous tube feeding at 20 mL/hr. RD recommends increasing

feeding 10-20 mL/8-12 hours as tolerated, to eventually meet goal rate of 77
mL/hr (1500 kcal; 198 g of CHO; 140g of protein; 17g of fat). Will educate
patient on enteral feeding, refeeding syndrome, and effects of bypass
surgery.

ME Will f/u with patient as needed while patient is in MICU. Will

asses/monitor fluid intake and out take, weight, and pertinent lab values.

Questions
1. Mr. McKinleys admission orders indicate he is being treated
for probable sepsis and systemic inflammatory response
(SIRS). Define these conditions.
a. Sepsis
i. Bodys response to infection. It can lead to tissue damage,
organ failure, and death.
ii. Immunosuppressive process
iii. Signs include hypoxemia, oliguria, lactic acidosis, elevated
liver enzymes, and altered cerebral function.
b. SIRS
i. A response to infection, trauma, burns, pancreatitis, or a
variety of other injuries.
ii. Considered sepsis when resulted by infection
iii. Can occur after major trauma, surgery, or heart attacks
iv. Systemic meltdown
v. Occurs in sepsis
2. Describe the metabolic alterations that occur as a result of
sepsis and the systemic inflammatory response (SIRS). Using
the medical record information, identify the specific criteria
that are consistent with the diagnosis of sepsis.
a. Sepsis
i. Elevated WBC levels
ii. Increased heart rate >90 beats/min
iii. Increased respiration >20 breaths/min
iv. Edema
v. Fever
vi. Increased C-reactive protein levels
vii. Increased glucose
viii. Increased lactate
 b. SIRS
i. Temperatures > 38oC or < 36oC
ii. Increased heart rate >90 beats/min
iii. Increased respiration >20 breaths/min
iv. CO2 < 33mmHg
c. Mr. McKinleys signs include
i. Elevated heart rate 98 beats/min
ii. Elevated respiration 23 breaths/min
iii. Increased WBC levels
iv. Temperature of 39.2 oC
v. 2+ pitting edema
3. Mr. McKinley had a Roux-en-Y gastric bypass 4 months ago and
has lost approximately 100 lbs. Describe this procedure.
Identify the most probable nutritional concerns associated
with this specific procedure and rapid weight loss.
a. Vitamin and mineral deficiencies
b. Absence or reduction of intrinsic factor secretions
c. Iron deficiency
d. Decreased energy intake
e. Malabsorption
f. Dumping syndrome
4. Using evidenced-based guidelines, determine whether Mr.
McKinley should receive nutrition support. Explain the
rationale for your decisions.
a. Mr. McKinley is NPO and critically ill. These factors alone provide
evidence for him to receive nutritional support through enteral
tube feedings.
b. He is on a mechanical ventilator. This means oral intake is not an
option, but his gut is still fully functional.
5. How will Mr. McKinleys bariatric surgery affect your
recommendations for nutrition support?
a. Having bariatric surgery results in many changes, which patients
can often be oblivious to, resulting in rapid weight loss. These
changes include
i. Increased energy expenditure
ii. Decreased appetite
iii. Altered GI function
iv. Inadequate protein and carbohydrate intake
b. Knowing about these changes will greatly affect
recommendations for nutrition support.
6. Define refeeding syndrome. How will Mr. McKinleys recent
100-lb weight loss affect your nutrition support
recommendations?
a. Refeeding Syndrome = A set of metabolic alterations due to
nutritional repletion for malnourished patients. It can often
appear in starved and obese patients.
b. Mr. McKinleys recent 100# weight loss affects my nutrition
support recommendations, as it could be a result of
malabsorption, deficiencies, and decreased intake. It is important
to consider these factors to avoid refeeding syndrome. When
 beginning a tube feeding on a patient, you should start off slow
to see how the patient tolerates it. Once you have assessed that,
you can gradually increase the rate.
c. Overfeeding can lead to hyperglycemia, which could exacerbate
his diabetes. It can also result in hepatic steatosis, as well as
increased CO2 production.
7. Assess Mr. McKinleys height and weight. Calculate his BMI and
% usual body weight.
Wt. = 325# 148 kg Highest wt. = 425# 193 kg
Ht. = 5 10 70 177.8 cm 1.778 m 3.161 m2
BMI = 148 kg / 3.161m2 = 46.8 47
%UBW = (148 kg / 193 kg) x 100 = 76.7% 77%
8. After reading the physicians history and physical, identify any
signs or symptoms that are most likely a consequence of Mr.
McKinleys admitting critical illness.
a. Hyperlipidemia
b. Flu-like symptoms
c. Bariatric surgery
d. Mechanical ventilation
e. Increased respiratory rate
f. Elevated heart rate
g. 2+ pitting edema
9. Identify any abnormal biochemical indices and discuss the
probable underlying etiology.
a. Increased levels of
i. Potassium altered cellular metabolism; acidosis
ii. CO2 respiratory failure; inadequate alveolar ventilation
iii. Glucose insulin resistance; stress; uncontrolled diabetes
iv. Bilirubin sepsis; liver function; acute hemolytic anemia
v. Ammonia ineffective metabolism
vi. ALT, AST sepsis; acute hemolytic anemia
vii. CRP inflammation in body due to infection
viii. CPK pulmonary infraction; injury to lungs
ix. Fibrinogen protein for blood clot formation; inflammatory
reaction; pneumonia
x. Lactate releasing lactic acid due to decreased blood flow
causing a decrease in O2 to tissues
xi. Cholesterol hyperlipidemia
xii. LDL & LDL/HDL ratio hyperlipidemia
xiii. Triglycerides hyperlipidemia
xiv. HbA1C average blood glucose level
xv. WBC signifies infection; anemia; bacteria; physical stress
xvi. Transferrin iron deficiency from altered GI function
b. Decreased levels of
i. Phosphate altered GI metabolism; acidosis
ii. Protein malnutrition
iii. Albumin protein inflammatory cytokines; malnutrition;
liver dysfunction
iv. HDL hyperlipidemia
 v. Hgb & Hct anemia or deficiency from altered GI function;
malnutrition; acute hemolytic anemia
vi. Ferritin iron deficiency; altered GI function
10. Assess Mr. McKinleys current hydration status using the
first 24 hours of I/O and the nursing assessment.
a. Daily I/O daily total = +1430 mL
b. Daily Total Intake = 4700 mL/kg
c. Daily Total Output = 3270 mL/kg
d. Could be dehydrated as a result of sepsis, temperature, and
edema
11. Determine Mr. McKinleys energy and protein
requirements. Explain the rationale for the method you used to
calculate these requirements.
Wt. = 325# 148 kg
IBW = 106 + 60 = 166# 75 kg

Calories 1350-1650 kcal/day

18-22 kcal/kg BW
18 kcal * 75 kg = 1350 kcal
22 kcal * 75 kg = 1650 kcal

Protein 130-150 g/day 150 g/day

A= 1.75-2.0 g/kg BW
1.75 g * 75 kg = 131 g
2.0 g * 75 kg = 150 g
12. Identify the pertinent nutrition problems and the
corresponding nutrition diagnoses.
a. Mr. McKinley has sepsis and his total protein levels are low. He
needs to increase his protein intake to help speed up his
recovery. Selecting a tube feeding that is high in protein will help
Mr. McKinley reach his protein needs.
b. Mr. McKinley is obese and had undergone a Roux-en-Y gastric
bypass. It is crucial that he is not overfed by the enteral feeding,
so his energy intake should be low in calories and high in protein.
c. He also has a high BMI of 46.8, which is another reason his
energy intake should be lower.
d. Also, with having the bypass surgery, he is at risk for
malabsorption of vitamins and minerals. With that being said, his
levels should be monitored and repleted as needed/if necessary.
13. Are you able to diagnose Mr. McKinley using the etiology-
based malnutrition criteria? If so, describe the information you
used to make the diagnosis.
a. Yes, I am able to diagnose Mr. McKinley using etiology-based
malnutrition criteria
b. I used the following information to make the diagnosis
i. Admitted for sepsis
ii. Lab values indicating malnutrition
iii. Lab values corresponding with acute illness and
inflammatory response
iv. SP bypass surgery
 v. Lack of supplementation
14. Outline the nutrition support regimen you would
recommend for Mr. McKinley. This should include formula
choice (and rationale), rate initiation, rate advancement, and
goal rate.
a. Initiate continuous enteral tube feeding on osmolite at 20 mL/hr
b. Increase as tolerated by 10-20 mL every 812 hours until goal
rate of 77 mL/hr to provide 1500 kcal
i. 198 g of CHO
ii. 140g of protein
iii. 17g of fat
c. ICU patient continuous feed over 22 hours.
15. Identify the steps you would take to monitor Mr.
McKinleys nutritional status in the intensive care unit.
a. Monitor/review daily I/O
b. Monitor weight
c. Asses hydration status
d. Check vitals
e. Asses GI function
16. What factors may affect his tolerance to enteral feeding?
a. Bypass surgery
b. Sepsis
c. SIRS
17. Write a note for your initial inpatient nutrition
assessment with nutrition support recommendations.
a. ADIME provided above