Metabolic Stress Case Study

35 year old female admitted to ICU after Motor Vehicle Accident.

Height: 65”         Weight: 120 lbs.              PMH: not available

Dx: Multitrauma, Skull Fracture, Intracranial Bleed, s/p craniotomy, Rib Fracture, Left Femur Fracture

Patient is receiving full ventilator support with sedation. NGT in place to suction with no further output documented. Blood pressure is now stable. She is unable to provide any diet history, but as per family, patient had a good appetite and stable weight prior to her accident. You have been consulted to provide instructions for starting EN.

Nutrition Needs:

1650-1925 kcal/day

83-110 g Pro/day

1650-1925 mL Fluid/day

1. Choose an appropriate formula from your EN formulary (provided in class) and discuss your rational for this choice.

• Calculate the total volume required to meet this patient’s needs.

• How many calories, protein, and fluids does this provide?

• At what rate would you infuse this feeding to provide the total volume continuously over 24 hours?

After providing EN for 24 hours, you receive a new consult to re-evaluate this patient’s feedings. Patient has been having increased residuals of >500mL on multiple occasions throughout the day. Also noted is severe diarrhea that has a foamy/oily appearance and foul odor. Stool studies confirm that this patient has steatorrhea. After retrieval of this patient’s medical record from her primary physician, it is revealed that this patient has a PMH of Crohn’s disease and has had multiple intestinal resections in the past.

1. What would be your next course of action for this patient? Should we consider PN (explain you’re rational)?

• If EN is to be continued, what formula would you provide and what is your rational?

After 5 days of feedings, the patient has developed an ileus. There have been multiple interruptions in this patients feeding due to high gastric residuals and severe diarrhea. She only managed to receive ~30% of her total estimated nutrition needs since her admit to the ICU as per your calculations. The surgeon states that this patient will require a resection of her small bowel. She will be required to be NPO for the next 3 days until the surgery and will likely be NPO for up to a week following her surgery.

1. Is PN appropriate for this patient? If so, when should it be started?

• Calculate an appropriate PN prescription using the TPN example provided in class and the nutrition needs provided in this case.

Nutrition Needs:

1650-1925 kcal/day

83-110 g Pro/day

1650-1925 mL Fluid/day

Stock Solutions:  10% AA             D70W (70%) Dextrose                 20% Lipid

Step 1:  Determine Nutrient Needs  

Kcal:

Protein:

Fat :

Fluid:

Step 2: Determine Protein Kcals & Volume of AA Solution

Determine Protein Kcals Required

How many mL of ?? % solution meets est. protein needs?

Step 3: Determine Volume of Lipid Solution

Step 4: Determine Dextrose Kcal, Grams of Dextrose, & Volume of Dextrose Solution

To determine dextrose kcal:

To determine dextrose gm:

How many mL of ??% solution meets est. dextrose needs?

Step 5: Determine Additional Free H2O

Final Volume = mL AA + mL Lipids + mL Dextrose + mL MVI + mL Free H2O

Step 6: Determine Glucose Infusion Rate (GIR) & Lipid Infusion Rate (LIR)

Determine GIR  (*Max: < 5mg/kg/min)

Determine LIR (*Max: <1gm/kg/day)