Rebecca A. Davis ARAMARK Dietetic Internship RICHMOND UNIVERSTY MEDICAL CENTER

Clinical Case Report:Nutrition support Acute Respiratory

Failure On Mechanical Ventilation and End Stage Renal Disease Receiving

Hemodialysis

Rebecca A. DavisARAMARK Dietetic Internship

RICHMOND UNIVERSTY MEDICAL CENTER

Disease Description

What is Respiratory Failure?

Respiratory failure is a rapid decline in respiratory function due to fluid retention in the lungs air sacs.

transport of oxygen to the blood and removal of carbon dioxide becomes impaired.

Failure to conduct proper gas exchange.

It is considered a syndrome rather than a disease state

It can be diagnosed as acute or chronic

Description of Disease

Altered gas exchange Altered ventilation

ACUTE RESPIRATORY FAILURE

TYPE 1 HYPERCAPNIA

TYPE 2HYPERPOXEMIA

Etiology of Acute Respiratory failure (ARF)

• Ailments that damage breathing ability can give rise to ARF.

• It can effect nerves, tissue and muscle invovled in breathing as well as impacting the lungs in a direct manner.

• When breathing capacity is damaged oxygen cannot move freely into the blood and eliminate CO2


• Lung Ailments (COPD, Pneumonia, Pulmonary embolism, Cystic fibrosis, Acute respiratory distress syndrome)

• Damage to the chest or ribs and tissue surrounding the lungs can induce ARF.

• Damage to Muscles and Nerves regulate breathing (Muscular dystrophy, Spinal cord trauma, ALS, Stroke)


• Sudden onset of Lung damage

(inhalation of dangerous chemicals and smoke can impair lung functuion)

• Substance abuse/ OD

• Complications involving the spine specifically scoliosis.

1

Epidemiology of ARF

• ARF is a complex of symptoms rather than a specific disease state.

• Overall occurrence of ARF is not well documented.

• 2001 and 2009 the number of patients admitted to the hospital for ARF rose from 1,007,549 to 1,917,910 a 56% influx with a p value of 0.0001.

• In the United States, over 3 million patients admitted to the ICU for Acute Respiratory Failure require mechanical ventilation

Pathophysiology of ARF

• Respiratory failure can result irregularities found in the respiratory system:

1) the central nervous system 2) alveoli 3) peripheral nervous system 4) chest wall 5)respiratory 6) muscles and chest airways.

• overall low blood volume, reduced blood movement secondary to the bodies in ability to pump adequate blood to meet the bodies needs.

Clinical Signs and Symptoms

• There are no hallmark signs symptoms for Respiratory failure.

• signs and indicators are contingent on the volume of carbon dioxide and oxygen found in the blood stream as well as the underlying issue it’s related too.

Clinical Signs and symptoms

• REDUCED OXYGEN OUTPUT IN THE LUNGS

1) Shortness of breath

2) feeling that there isn’t enough air to inhale

• SEVERE OXYGEN DEPRIVATION 1) Drowsiness

2) abnormal heart rhythms

3) bluish tint to fingernails, lips and flesh.

Co-morbidities

• TYPE 2 DIABETES- 1) The most common form of diabetes

2) Defined as insulin resistance

3) progressive ailment and can go unnoticed for many years.

4) Uncontrolled diabetes is linked to raising the chance of developing micro and macrovascular challenges

Co-morbidities

• END STAGE RENAL DISEASE

1) loose ability to create hormones, maintain fluid/ electrolytes homeostasis and to filter out toxins that lead to symptoms of Uremia.

2) ESRD always progresses from Chronic kidney disease.

3) 90% of patients who develop ESRD have other comorbidities such as hypertension, Diabetes and Nephrotic syndrome 4) Patients who reach the final stage of kidney disease either require renal replacement therapy or transplantation.

Co-morbidities• SEPSIS 1) Serious bodily response bacterial infection causing widespread inflammation. also known as systemic inflammatory response syndrome (SIRS).

2) Most common areas for sepsis development is the skin, liver, lungs, bloodstream, Large intestine, bone, Kidneys, and brain. 3) Common indications are lethargy, elevated temperature, juddering, elevated heart beat, dizziness, fever and chills.

Co-morbidities • PRESSURE ULCERS

1) constant pressure that inhibits movement of blood away from the heart to the skin and tissue that lies underneath

2) The key components contribute to pressure ulcers: physical immobility and involuntary urination.

3) it develops in Geriatric patients with psychiatric problems, deeply sedated and those with dementia who cannot independently move.

4) There are four main stages for decubitus based on how deep the wound is and the amount of tissue affected. After stage 4 pressure ulcers considered unstageable

Co-morbidities

• HYPERTENTION1) Elevated blood pressure

2) Pushes blood to come in contact with the arterial wall causing pressure 3) Symptoms may not arise for many years.

4) Uncontrolled blood pressure can contribute to the onset of Strokes and heart attack

Evidence –Based Nutrition Recommendations

• Currently equations used to calculate REE are not reliable and make it difficult to truly identify the energy needs of ICU patients causing undernourishment especially among those mechanically ventilated

• Patients that are intubated and necessitate mechanical ventilation for extended periods of time are said to have great variation in the amount of energy needed over a 24 hour period also know as REE.

Faisy C., Lerolle N., Dachraoui F., Savard JF., Abboud Imad., Tadie JM., Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. 2009; British journal of Nutrition. 101: 1079-1087.


• In an observational/retrospective study by faisey et al, it was discovered that patients whose’ ICU stay ended in mortality had a much higher daily energy insufficiency compared to those ICU patients who survived with a p- value of 0.004.

• Additionally, Twenty-five of these patients had an average daily loss of 1200 calories and had a higher death rate (13 deaths) after a two week period compared to those patients in the ICU with a lower calorie deficit , a significant p- value of 0.01.


Evidence- Based Nutrition Recommendation

• Challenges with the research:

1) The observed patient population consisted of a small sample size

2) A large percentage of the patients observed had renal failure requiring feed and fluid volume constraints.

3) stops on enteral nutrition support related to serious enteral nutrition GI intolerances and medical procedures took place approximately 23% of time patients were observed and surveyed.



• Providing adequate nutrition is even more challenging among mechanically vented patients with ARF who also present with ESRD and require renal replacement therapy.

• Undernourishment is a occurs often among patients with chronic kidney disease.

• Malnutrition is prevalent in 9 to 72% of patients receiving dialysis.

Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

Evidence-Based Nutrition Recommendation

• Stratton et al (2005) reviewed 18 studies, 13 non-randomized control trials and 5 studies that were randomized in order to ascertain the advantages of enteral nutrition support among patients getting dialysis treatment. In one particular control trial, studying undernourished hemodialysis patients; a substantial 12% influx of post dialysis weight was discovered after a 3- month mediation of enteral nutrition support.


Evidence-Based Nutrition Recommendations

• Within the Systematic Review, Meta analysis of 1 Randomized Control Trial and 2 Control Trials uncovered a relationship between higher blood albumin levels and adequate Enteral nutrition feeds.

• 95% confidence interval (0.037 to 0.418 g/dL) without significantly effecting serum electrolytes.

• Stratton and colleagues also cited an international multicenter study in which albumin levels that were lower than 3.5 g/dL were linked to a 1.38 higher risk of mortality supporting there findings.


Combe C., McCullough KP., Asano Y. et al: Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and practice patterns Study (DOPPS): Nutrition guidelines, indicators and practices. Am J kidney Dis. 2004; 44(suppl 2): S39-S46.


• Sharma et el, found that standard formulas and those designed for specific disease states were similar in composition. No dissimilarities in protein and caloric intake were identified when comparing patients who received standard formulas against those catering to specific disease states



• Challenges with the research…….

1) Lack of supportive data to measure the effect of enteral nutrition support on clinical outcomes as well as the use of formulas catering to specific disease states.

2) Large percentage of the results were inconclusive



• The evidence-based nutrition recommendations for patients with acute respiratory failure with End stage renal disease receiving mechanical ventilation and renal replacement therapy.

• However, it is clear that malnutrition contributes to patient mortality and that it is vital for patients to receive adequate calories and protein to increase the chances of survival in the medical ICU.

• Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.

Case Presentation

• An 87 year old black male presented to the ER with altered mental status and decreased arousability.

• Hospital course was complicated by cardiac arrest, primarily due to acute respiratory failure.

• Patient stabilized, intubated and admitted to the medical ICU.

Case presentation

COMORBIDITIES

• Septic shock likely due to stage III sacral pressure ulcer

• chronic anemia

• Dehydration

INITIAL TREATMENT

• Intravenous vasopressors, Norepinephrine, Vancomycin and Zosyn for septic shock

• aggressive IV hydration, (Normal saline 2 liters bolus)

• FeSO4 for anemia.

Nutrition Care: Assessment

• The American Dietetic Association advocates that Registered Dietitians utilize the Nutrition Care Process as a primary step in the provision of Medical Nutrition Therapy and should be an essential constituent of medical therapeutics and management of specific ailments. The nutrition care process was applied for the current case subject.

Client History

The patients’ personal, family, social and immunization history could not be obtained as well as his history and physical due to the fact that the patient is unresponsive and has no family.

RUMC Previous Admission:

recurrent hypernatremia, AKI, E-coli in the urine, elevated LFT’scalcium and Blood Urea Nitrogen, sepsis, and hyperkalemia. According to the nursing home assessment the patients Past Medical History :

Diabetes, GERD, Hyperlipidemia, Hypertension, Schizophrenia, DVT, BPH, Glaucoma, blindness, hypothermia, PEG placement, suprapubic catheter placement, neurogenic bladder, sepsis due to UTI, dysphagia, anemia and Chronic Kidney Disease.

Food/Nutrition-Related History

Data could not be obtained from Patient due to intubated and mechanical ventilation. Nursing home assessment note:

1. Diet: Glucerna 1.2 @ 160 ml/hr

2. Daily MVI and 4 Prostat to assist in wound healing.

3. Daily dose of FeSO4 to treat chronic anemia.

4. Medication: Novolog Aspart – low dose algorithm + Lantus

Nutrition- Focused Physical Findings

Assessment DiagnosticTerminology

1. breathing over vent, intubated with bilateralcourse breath sounds plus corneal reflex and spontaneous eye movements (PD-1.1.6, PD-1.1.3)

Appears to be within normal weight limits, was edematous with slight fluid retentionrelated to Chronic Kidney disease (PD-1.1.1)

2 deep tissue injuries (DTI) stage III pressure ulcers (PD-1.1.8)

Nutrition Focused Physical Findings

Assessment Diagnostic Terminology

Abdomen was soft, no distention and presented with Suprpubic catheter (PD-1.1.5)

Attending physician, reported that the patient’s initial temperature was 86.1, blood pressure of 115/71 and a heart rate of 55 (PD-1.1.9).

Enteral feedings administered via PEG tube, negative gag reflex was documented and at time of assessment patient was NPO for medical observation. (PD-1.1.5)

Anthropometric Measurements

• height is 5’ 11”(AD-1.1.1).

• weight upon admission was 163lbs or 74kg

• BMI of 22.75 - weight within normal limits.

• IBW of 172 lbs. +/- 10% (AD-1.1.2, AD-1.1.5)

• Pre and post dialysis weight was also documented.

Biomedical Data, Medical Tests and Procedures

Abnormal Laboratory values upon admission

Normal Patients value

Sodium 136-145 133

Potassium 3.5-5.1 5.7

CO2 98-107 14

BUN 7-18 107

Creat 0.6-1.3 4.2

Glucose 74-106 175

Phosphorus 2.5-4.9 2.3

Magnesium 1.8-2.4 1.6

Biomedical Data, Medical Tests and Procedures

Pertinent medical tests and procedures

1. Tunneled hemodialysis catheter place 2. PEG Tube replacement3. Tracheostomy4. Intubation and mechanical ventilaion5. Urine analysis

Nutrient Needs – Upon admission

• Macronutrient requirements were estimated to be at a range of 2000-2200 calories.

• 109-117 g protein

• 2000 mL / day

Nutrient Needs –B4 dialysis

Calories – 2160

Protein 87g

Fluid 783 mL H20

Nutrition Status Classification

• ARAMARK Nutrition status:Nutrition Care Indicator Category Highest Points Assigned

Nutrition History 3Feeding Modality/Nutrition Care Order

4

Unintentional Weight Loss 0

Weight Status 0

*Serum Albumin or Pre-albumin 3

Dx/Condition 34

TOTAL POINTS 44 points

Nutrition Status Classification

Nutrition Status Classification Points

Severely compromised (Status 4) > 12

*FOLLOW UP ASSESSENTS TOOK PLACE EVERY 4 DAYS AFTER INITIAL CONSULTTILL THE DAY OF DISCHARGE

Nutrition Care Process: Nutrition Diagnoses

#1. Increased nutrient needs (NI-5.1) related to skin integrity, wound healing as evidence by skin break down. (4 x unstageable decubiti, 2x stage II Deep Tissue Injury and excoriated scrotum).

#2. Inadequate intake of enteral nutrition (NI-1.2) related to estimated calorie needs, new admission, s/p intubation as evidence by feeds not at goal.

#3. Altered GI function (NC-1.3) related to C-DIFF as evidence by severe diarrhea

Date Energy Intake

Status

Formula Indication

9/5 NPO X S/P intubation 9/6-9/11 Enteral Nutrition

Replete Plus Fiber 30mL/hr to goal 70 mL/hr

Slow progression of feeds related to abdominal distention

9/12- 9/29 Enteral Nutrition

Nepro 45 mL/hr

Deteriorating kidney function. Possible dialysis.

10/1-10/13

Enteral Nutrition

Nepro 50 mL/ht

Increased to meat caloric needs: 2160 kcal, 97g protein, 870ml H20

10/14-10/15

Enteral Nutrition Replete Plus Fiber 50 mL/hr

Electrolytes are within normal limits. Patient is receiving dialysis

10/16 – 10/20 NPO X

Abdominal distention, PEG tube is disconnected. Possibly due to pressure ulcers. Suggested TPN with Prolonged NPO.

10/21- 11/5


Peg Tube replaced, safe to restart feeding regimen. It was suggested to increased feed to 90 mL/her

11/6- 12/13


Patient received Replete at 90 mL/hr till the day of discharge

Nutrition Care Process: Interventions

#1. Enteral Nutrition, (ND-2.1). Recommend substituting current enteral nutrition order for Replete Plus Fiber at 90mL/hr x 24 hours. This will provide 2160 kcal, 127g proteins, and 1703 mL H20.

#2. Nutrition-related medication management; (ND-6.1). Recommend modifying insulin dose per MD.

#3. Vitamin and mineral supplements; Multivitamin/mineral, magnesium (ND-3.2.1).

#4. Nutrition-Related Medication Management (ND-6), Nutrition related complementary medicine. Recommend Probiotic.


• Short-term goals

1. Prevent further skin breakdown

2. Advance EN to Goal

3. Achieve better control over blood Glucose


• Long-term goals

1. Meet 100% of the patients energy and protein need via enteral nutrition support.

2. The patient will present will less pressure ulcers and will heal in a timely manner.

3. The patient will maintain normal blood glucose levels.

Nutrition Care Process: Monitoring and Evaluation

#1. Food /Nutrition-Related History (FH). Enteral nutrition intake (1.3.1) Tolerance and rate of enteral nutrition support were monitored during every follow up.

#2. Biochemical Data, Medical Tests, and Procedures (BD). Electrolyte and renal profile. The patient’s laboratory values and electrolyte were closely monitored and addressed if abnormal.

#3. Biochemical Data, Medical Tests, and Procedures (BD). Gastrointestinal (BD1.4) patient had C-Diff. During the patient’s diarrhea episodes it was recommended to put a hold on the laxatives and to administer a probiotic.

Conclusion

The clinical case subject was complex in nature requiring-long term mechanical ventilation and presented with many comorbidities.

He was initially diagnosed with acute respiratory failure secondary to cardiac arrest that eventually advance to chronic respiratory failure.

Conclusion

His hospital course was complicated:

1.Intubation2. Sepsis3. uncontrolled blood glucose4.multiple deep wound pressure ulcers5. C-DIFF induced diarrhea6. Constipation7. PEG tub infection8. electrolyte abnormalities9. placement of a tunneled catheter for dialysis treatment.

Conclusion

• Main interventions:

1. Enteral nutrition support- received different formulas and rates over the course of his hospital stay depending on his clinical state at the time.

2. The patient was recommended 1.4-1.5 grams per kg or protein. He was also recommended an MVI to aid in wound healing.

3. Adjustments were made to the patient’s insulin regimen when blood glucose was significantly out of range

4. The patient was also administered a probiotic to help alleviate C-DIFF induced diarrhea.

Conclusion

• During final follow- up assessment Phosphorus was trending up.

• Before discharge it was recommended to switch enteral feeding once more back to Nepro@50mLx24.

• • It was also suggested to continue administering a MVI

supplement and to adjust his insulin dose as needed.

• patient was stable before discharge and was sent to a nursing home in Brooklyn where he will receive long-term care

References:1. National Heart, Lung, and Blood Institute. Explore Respiratory Failure. http://www.nhlbi.nih.gov /health/health- topics/topics/rf/. Retreived December 19, 2011. 2. Deo R., Albert CM. Sudden Cardiac Death: Epidemiology and genetics of Sudden Cardiac Death. American Heart Association. 2012;125:620-637.3. Stefan, MS., Shieh, MS., Pekow PS., Rothberg, MB., Steingrub, JS., Lagu T. and Lindenauer, PK. Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: A national survey. J. Hosp. Med. 2013;8: 76-82.4.Kaynar AM., Pinsky MR. Respiratory failure. http://emedicine.medscape.com/article/167981-overview#a0104. Updated January 5, 2012. 5. Mahan LK, ed, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, Missouri: Saunders Elsevier; 2008: 655-672. 6. Sepsis. PubMed Health Web Site. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001687/. September 15, 2010. Accessed March 20, 20127. Mayo Clinic. High blood pressure(hypertension). http://www.mayoclinic.com/health/high-blood-pressure/DS00100. Accessed August 3, 2012. 8. Rice Tw., Morgan S., Hays MA., Bernard GR., Jensen GL., Wheeler AP. A Randomized Trial of Initial Trophic versus Full-Energy Enteral Nutrition in Mechanical Ventilated Patients with Acute Respiratory Failure. Crit Care Med. 2011; 39(5): 967-974. 9.Stefan, MS., Shieh, MS., Pekow PS., Rothberg, MB., Steingrub, JS., Lagu T and Lindenauer, PK. Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: A national survey. J. Hosp. Med. 2013;8: 76-82.10. Deo R., Albert CM. Sudden Cardiac Death: Epidemiology and genetics of Sudden CardiacDeath. American Heart Association. 2012;125:620-637.11. Siscovik DS., Sotodehnia Nona., Rea TD, Raghunathan TE., Jouven X., Lemaitre RN. Type 2 diabetes mellitus and the risk of sudden cardiac arrest in the community. Rev Endocr Metab Disord. 2010; 11(1): 53 -59.12. Mann, J.F.E. et al. Renal insufficiency as a predictor of cardiovascular outcomes and the impact of remipril: the HOPE randomized trial. ANN. Int13. Mann. JFE., Gerstein HC., Dulau-Florea I., & Lonn E. Cardiovascular risk in patients with milld renal insufficiency. Kidney int. 63 (suppl. 84). 2003S 14. Medline plus resource page. Glaucoma. http://www.nlm.nih.gov/medlineplus/glaucoma.html. U.S National Library of Medicine. Updated on December 6 2013.15. Shrishrimal K., Hart P., Michota F. Managing diabetes in hemodialysis patients: Observations and recommendations. 2009;76(11):649- 655.16. Sepsis. PubMed Health Web Site. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001687/. September 15, 2010. Accessed March 20, 2012. 17. Ramprasad R., Chandra Kapoor M. Nutrition in intensive care. J Anaesthesiol clinPharmacol. 2012;28(1): 1-3.18. Arbeloa CS.,Elson MZ., Monzon LL., Bonet TM. Enteral Nutrition in Critical Care. J Clin Res. 2013; 5(1):1-11.19. Codner PA. Enteral Nutrition in the Critically Ill Patient. Surg Clin N Am. 2012; 92: 1485- 1501. 20. Faisy C., Lerolle N., Dachraoui F., Savard JF., Abboud I., Tadie JM., Fagon JY. Impact of Energy deficit calculated by a predictive method on outcome in medical patients requiring prolonger acute mechanical ventilation. British Journal of Nutrition. 2009; 101: 1079-1087.21. Stratton RJ., Bircher G., Fougue D., Stenvinkle P., Mutsert RD., Engfer M.,Elia M. Multinutrient Oral Supplements and Tube Feedings in Maintenance Dialysis: A Systematic Review and Meta- Analysis. 2005;Am J Kidney Dis. 46:387-405.22. Combe C., McCullough KP., Asano Y. et al: Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and practice patterns Study(DOPPS):Nutrition guidelines, indicators and practices. Am J kidney Dis. 2004;44(suppl 2): S39-S46.23. Sharma M., Rao M., Jacob S., Jacob CK: A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients. J Ren Nutr.2002;12:229- 237.24. Position of the American Dietetic Association: Integration of Medical Nutrition Therapy and Pharmacotherapy. J Am Diet Assoc. 2010; 110: 950-956. 25. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd ed. Chicago, Il: American Dietetic Association; 2009. 26. K JL. Handbook of laboratory and diagnostic tests. 4th ed. Upper Saddle River, NJ. Prentice- Hall inc. 200127. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2007.28. Crowe T., Brockbank C. Nutrition therapy in the prevention and treatment of pressure ulcers. Wound practice research. 2009;17.( 2):90-99. 29. Vrese MD and Marteay PR. Probiotics and Prebiotics: Effects on diarrhea. J. Nutr. March 2007;137(3). 803S-811S.30. Parrish CR. Enteral Formula Selection: A review of Selected Product Categories. Practical Gastroenterology. 2005; 28:46-74.31.Stefan MS., Shieh MS., Pekow PS., Rothberg MB., Steingrub JS., Lagu T., Lindenauer PK. Epidemiology and outcome of acute respiratory failure in the United states , 2001 to 2009: A national survey. J Hosp Med. 2013; 8(2): 76-82.32. Miller AL., MacKay D. Nutritional support for wound healing. 2003;8(4):359-377.33. Hempel S., Newberry SJ., Maher AR., Wang Z., Miles J., Shanman R., Johnsen B., Shekelle PG. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: Systematic review and meta-analysis.2012;307(18):1959-1969

http://www.nhlbi.nih.gov/health/health-topics/topics/rf/

http://emedicine.medscape.com/article/167981-overview

http://emedicine.medscape.com/article/167981-overview

http://www.mayoclinic.com/health/high-blood-pressure/DS00100

http://www.mayoclinic.com/health/high-blood-pressure/DS00100

http://www.nlm.nih.gov/medlineplus/glaucoma.html.%20U.S

Rebecca A. Davis ARAMARK Dietetic Internship RICHMOND UNIVERSTY MEDICAL CENTER

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