Case Report: Medical Nutrition
Therapy for Septic Shock
ANGELA GASBARRE
ARAMARK DIETETIC INTERNSHIP
UPPER CHESAPEAKE MEDICAL CENTER
JANUARY 4, 2013
Objectives
Disease Description
Evidence-Based Nutrition
Recommendations
Case Presentation
NCP: Assessment, Diagnosis,
Interventions, Monitoring and Evaluation
Conclusion
Disease Description
Sepsis
• Systemic
Infection
• SIRS
Severe
Sepsis
• Decreased
urine
output
• Change in
mental
status
Septic
Shock
• Drop in
Blood
Pressure
• Organ
Failure
Evidence-Based Nutrition Recommendations
Early vs. Late Initiation of PN
Participants
•2312 patients: early-initiation
group began PN on day 3 of
insufficient enteral feeding.
Intervention
•The EPaNIC study gathered
patients admitted to the ICU
between April 2007 and November
2010.
• Exclusion criteria for this study
•2328 patients: late-initiation group included patients <18 years of age,
began PN on day 8 of insufficient
those with DNR code status, those
enteral feeding.
patients who were pregnant or
lactation, and those receiving oral
nutrition.
Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-517
Early vs. Late Initiation of PN
Results
p value
(respectively)
•Length of stay in the late-initiation group was one
day shorter than the early-initiation group.
•3 vs. 4 days
•p=0.02
•Late-initiation group had significantly less new
infections than the early-initiation group.
•22.8% vs. 26.2%
•p=0.008
Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-517
Early vs. Late Initiation of EN in Hemodynamically
Instable Patients
PARTICIPANTS
Mechanically
ventilated >2 days
on vasopressors
707 pts earlyinitiated (within
48 hrs of
ventilation)
467 pts lateinitiated (>2 days
after ventilation)
Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19:261-268
Early vs. Late Initiation of EN in Hemodynamically
Instable Patients
Results
p values
(respectively)
•Days in the ICU were higher in the
early-initiated group than the lateinitiated group.
•8.6% vs. 7.7%
•p=0.39
•Hospital mortality was lower in the •33.9% vs. 42.6%
early-initiated group than the late- •p=0.01
initiated group
Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care. 2010;19:261-268
Case Presentation
64 year old male
Rheumatoid arthritis
• Humira and
Methotrexate
• Cholangitis
Septic Shock
• Vasopressors
• Mechanical
ventilation
• TPN
• EN
• Pureed, nectar
thickened liquids
NCP: Assessment
64 year old male
Hx of
rheumatoid
arthritis
• Humira and
Methotraxate
Well
nourished,
intubated
• BMI 29.2
• 5’ 11”
• 95.2 kg
Monitored
- 2024
for
kcal/day
electrolyte
- 1.5-1.8 g
and nutrient
protein/day
changes,
and organ - Fluids per
MD
function
ARAMARK
NSC
• Diarrhea
Vomiting
Intubation
Sepsis
Does not
meet
criteria of
DRG
NCP: Nutrition Diagnosis
Inadequate oral intake (NI-2.1) related to intubation
and initiation of vasopressors as evidence by a need
for parenteral nutrition support.
Swallowing difficulty (NC-1.1) related to prolonged
intubation as evidence by speech language pathology
report and recommendation of a pureed diet, nectar
consistency liquids.
NCP: Interventions
Medical
Drainage of
gallbladder
Intubation
Vasopressors
CRRT
Hemodialysis
Nutritional
PN: 2 L of Clinimix
5/15 with 250 ml of
20% lipid at 83.33
ml/hour over
Q24H (ND-2.2.1)
EN: Vivonex at 85
ml/hour Q24H
with 200 ml water
flushes Q4H (ND2.1.1, ND-2.1.4)
NCP: Monitoring and Evaluation
Food/Nutrientrelated history (FH)
• Enteral nutrition order (FH-2.1.1.3)
• Modified diet (FH-2.1.1.2)
Anthropometric
Measurements (AD)
• Weight (AD-1.1.1)
• Weight change (AD-1.1.4)
Biochemical Data,
Medical Tests, and
Procedures (BD)
• BUN (BD-1.2.1), Creatinine (BD-1.2.2)
• Sodium (BD-1.2.5), Potassium (BD-1.2.7)
• Magnesium (BD-1.2.8), Calcium, ionized (BD-1.2.10),
Phosphorus (BD-1.2.11)
• Glucose, casual (BD-1.5.2)
Nutrition-focused
Physical Findings
(PD)
• Digestive system (PD-1.1.5)
Conclusion
Septic Shock is a life threatening condition.
Vasopressors, intubation, and sedation as medical treatment
indicates need for nutritional support.
TPN was initiated to maintain nutritional status of patient.
As patients became hemodynamically stable, EN became route of
nutrition therapy.
Upon extubation and regain of strength, patient began oral
intake.
Length of hospital stay: November 12-December 18.
References

Sepsis. A.D.A.M Medical Encyclopedia. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001687/. Updated August 23, 2012. Accessed
December 28, 2012.

Siner, JM. Sepsis: Definitions, Etiology, Epidemiology, and Pathogensis. Chest. 2009; 4. http://www.chestnet.org/accp/pccsu/sepsis-definitionsepidemiology-etiology-and-pathogenesis?page=0,3. Accessed December 23, 2012.

Septic Shock. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/000668.htm. Updated January 14, 2010. Accessed December 28, 2012.

Pinsky MR, Mink S, Sharma S, et al. Septic Shock: Epidemiology. Medscape Reference. http://emedicine.medscape.com/article/168402-overview#a0156.
Updated August 13, 2012. Accessed December 28, 2012.

Shock. A.D.A.M Medical Encyclopedia. Pubmed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001106/. Updated January 10, 2012.
Accessed December 23, 2012.

Casaer MP, Mesotten D, Hermans G, et al. Early versus later parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-517.

Khalid I, Pratik D, DiGiovine. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit
Care. 2010;19:261-268.

McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patients. J
Parenter Enteral Nutr. 2009;33:279-285.

American Dietetic Association. International Dietetics and NutritionTerminology (IDNT) Reference Manual. 3rd ed. Chicago, Il: American Dietetic
Association; 2011.

Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition Practice Guidelines. A.N.D. Evidence Analysis Library website.
http://andevidencelibrary.com/template.cfm?key=1309. Accessed 2 Jan 2013.

Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010.

ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures,
Volume IV; 2010.
QUESTIONS?