Nutrition Support for Morbidly Obese in Critical Care
Introduction:
Patient: JK
Admitting Dx: Septic shock, acute renal failure, anemia, chronic respiratory failure,
healthcare-acquired pneumonia
Medical Hx: COPD, CHF, Pulmonary hypertension, Chronic respiratory failure, DVT s/p
IVC filter placement, CKD, HTN, GI bleeding on Coumadin, Diverticular disease, OSA,
morbid obesity, breast cancer (s/p mastectomy), endometrial cancer (s/p hysterectomy)
Surgical Hx: S/p tracheostomy tube placement, s/p PEG tube placement, s/p inferior
vena cava filter placement, hysterectomy, mastectomy
Height: 157cm (5’2”)
Weight: 184.1kg (405lbs)
Age: 68 yo
Sex: Female
Objective: This patient was chosen for this case study due to her nutrition diagnosis
requiring nutrition support, in addition to her critical care status complicated by comorbid
conditions.
Duration of study: 3 weeks
Focus: Nutrition support for patients with morbid obesity in critical care
Social History:
Marital status: Married
Residence: RML Specialty care hospital, prior bed bound in nursing home
Religion: Unknown
Ethnicity:
African American
Health Insurance: Medicare
Tobacco / alcohol use: negative / negative
Pathophysiology:
1
JK was admitted to the ICU with the diagnosis of septic shock and acute renal
failure. JK presented with additional comorbid conditions including: morbid obesity,
chronic respiratory failure, HCAP, CHF, CKD. JK’s critical medical status required
ventilator support, IV fluids, hemodialysis, and nutrition support.
Past Medical History:
Hospitalization at Central DuPage for atrial fibrillation and respiratory distress.
There, the patient was not tolerating CPAP and was started on Cardizem infusion. The
patient developed a GI bleed and was taken off Coumadin. The patient was ventilated
and developed healthcare-acquired pneumonia / ventilator associated pneumonia. The
patient was diagnosed with chronic respiratory failure with difficulty weaning from the
ventilator. A tracheostomy was placed and the patient was transferred to RML for
ventilary weaning.
At RML, JK had diuretic therapy for continued issues with fluid overload. JK was
given Bumex, a potent diuretic, and despite the interventions, had worsening renal
failure associated with oliguria. JK also developed hematuria and was transferred to
Adventist Hinsdale for acute renal failure with septic shock.
Present Medical Status and Treatment:
Theoretical Discussion of Disease Condition:
Septic shock is a widespread infection that leads to dangerously low blood
pressure. It is often caused by bacteria, and JK tested positive for MRSA. Fungi may
also cause the condition. Septic shock leads to low blood pressure when toxins from
the bacteria or fungi cause tissue damage and poor organ function. The body has a
strong inflammatory response to these toxins, and inflammation may contribute to organ
damage. Septic shock can affect any part of the body, including the heart, brain,
kidneys, liver, and intestines. JK had several risk factors for septic shock, including: an
indwelling catheter, long-term use of antibiotics, recent infection, and recent steroid use.
Symptoms of septic shock are listed below and bolded symptoms were known to
be present in JK.
● Cool, pale arms and legs
● High or very low temperature, chills
● Light-headedness
● Little or no urine
● Low blood pressure
● Palpitations
● Rapid heart rate
● Restlessness, agitation, lethargy, or confusion
2
● Shortness of breath
● Skin rash or discoloration
Treatment for the condition:
Treatment for septic shock needs to be immediate as it is a medical emergency.
People are often admitted to the intensive care unit and treatments include: mechanical
ventilation, dialysis, drugs to treat low blood pressure, infection, or blood clotting, IV
fluids, oxygen, sedatives, and surgery.
The general prognosis for patients with septic show is poor with a high death
rate. The death rate depends on the patient’s age, overall health, the cause of infection,
the number of failed organs, and how quickly medical therapy is initiated. (1)
Patient’s Symptoms upon admission:
Patient came from RML with chief complaint of difficulty urinating. Additional
symptoms include fluid overload, oliguria, hematuria, and acute renal failure with septic
shock. JK was hypotensive and required ventilator support.
Present disease condition: Deceased after planned extubation due to septic shock
IPOC Treatment Timeline:
Date
AIM
Hospital
Renal
Cardiac /
Pulmonary
Temp cath
placed for
hemodialysis
Fluid bolus for
hypotension,
correct before
initiating dialysis.
Monitor volume
status and
electrolytes
1/18
Poor
prognosis.
Plan for family
meeting
pending
results of
echo and
cultures.
Unclear if pt
will tolerate
dialysis
Dialysis today
EKG.
A-fib.
Hold betablockers for now.
Supportive care
w/ vasopressin
and Levophed
1/19
Complicated
Dialysis today.
Afib w/
1/17
(admit
from
RML)
3
Infectious
Disease
Nutrition
R sided VAP
Consult -
Pallative
Care
UTI.
Urine culture
with growth of
candida,
MRSA culture
positive.
Contineue
abx covergae
as above.
begin iv bumex.
begin iv diuril
contraindication
to systemic
anticoagulation
with GI bleeding.
Rate acceptable.
Trach/vent.
Hope to wean
pressor
(Levophed)
today
(cxMRSA/PSAR
) treated,
antibiotics
completed
1/15/2015.
Restarted
here.
Metabolic
acidosis.
Nutrition
Score,
Previous TF
EN ordered:
Nepro @
10mls /hr,
advance to
goal rate
30mls / hr
PEG
clogged in
PM
1/20
1/21
Pt more alert
today, follows
simple
commands.
Discussed
case with
sister/mother
at bedside,
desired
continued
maximal
support for
now
Tolerating dialysis.
Responding to IV
diuretics,
nonoliguric.
Back on pressors,
wean off.
Will start
midodrine 5 mg.
If no sign of renal
recovery will need
permcath
placement
wean pressors d/c Vasopressin
today
Afib More
rapid this
morning on
CPAP and
getting ABG.
Will restart
lopressor
when able.
Dialysis again
today
Still appears fluid
overloaded on
exam
Placed tunneled
catheter
wean pressors.
Duoneb q6h
PEG no
longer
clogged, TF
resumed at
20mls/hr
Abdominal
distention
noted
TF reached
goal rate,
but on hold
today d/t pt
vomiting in
AM.
Intervention:
restart
Nepro @ 15
mls/hr; if
tolerated,
raise TF 15
mls to 30
mls/hr goal
rate 8 hrs
thereafter
Thrombocytop
enia. Repeat
CBC ordered,
will test for
heparin
induced
thrombocytop
enia if
persistently
depressed.
Family
desires Full
Code for now
RN noted
TF to
resume s/p
bowel
movement
4
1/22
1/23
1/24
Resume TF
today
Midodrine
noted (started
1/20)
Dialysis again
today
permcath by IR
OK with ID.
Progressive acute
renal failure that
may be due to
cardiorenal
syndrome,
hypotension and
perhaps acute
tubular necrosisdialysis dependent
Continue
cipro,
vancomycin,
meropenem
at this
time,day #4
after
completing
recent course
of abx at
RML
Cultures: so
far neg.
TF resumed
for 3 hrs @
30mls / hr
Pt more alert
today.
Pt has been
intermittently
requiring
pressor
support with
HD
Tunneled catheter
for HD.
Dialysis today.
Still levophed dep.
1/22 HIPA
negative
Volume and lytes
per renal.
Permacath
placed.
Midodrine noted.
Fluid Overloadimproving.Hypona
tremia-stable
Continue
cipro,
vancomycin,
meropenem
at this
time,day #5
Per RN, TF
to resume
today after
permacath
placement.
TF on hold,
pt NPO for
permacath
placement
tomorrow
TF resumed
@ 30mls/hr
at 17:00
GI consult:
PEG became
clogged 1/24.
Also noted on
exam was a
distended
abdomen and
no BM X >2
days. KUB
showed
significant gas
distention.
Today at
bedside, PEG
was
unclogged
and >1L out of
feculent
material. Will
get CT scan
for further
evaluation to
rule out
TF on hold
at 16:00
(23hrs
continuous)
5
obstruction.
Rec surgical
consult.
Would
consider
alternate
forms of
nutrition
(TPN) as
patient may
not be able to
get tube feeds
for awhile.
Bowel
obstruction.
Started on
Diltiazem drip
on 1/24 in
PM.
1/25
1/26
No obvious
bowel
obstruction on
imaging. n
CT, can't tell if
g tube is just
inside gastric
wall, or pulled
out. Will
check with
fluoro
tomorrow
abd wall fluid
collection.
She has
mesh.
Possibility of
infected fluid.
No HD today
CVP if can be
measured via port
check cortisol
level
cont levo for BP
support, diltiazem
for HR control
Will inc D20 for
now, D50 1 amp.
Start TPN w bowel
obstruction, surg
on consult, CT
abd today wo
contrast
Nutrition
consult TPN
Poor
prognosis.
Have
discussed
case and
code status
with multiple
family
members on
multiple
occasions,
pt remains
full code.
Requested
palliative
consult to
facilitate this
discussion
No signs of renal
recovery
Electrolytes and
acid base status
No HD today,Next
HD likely in am
Will decrease
bumex and diurel
to bid
TPN
initiated @
21:00 @ 70
g AA, 250 g
dextrose, 40
g lipids
(1530 kcal,
70 g
d/w husband
on 1/26, 27.
Code status
Full;
Husband is
struggling
with end of
life
decisions.
6
cont levo for BP
support, diltiazem
for HR control
Will start TPN
after PICC
placement
D/c dextrose
10/50 after TPN is
started
protein, 250
g CHO)
'Can't let
go'.
TF held d/t
possible
SBO.
Continue
TPN.
Family
meeting
held today;
they now
realize the
futility of
aggressive
treatments
in the face
of multi
organ
failure. Code
status DNRso ordered.
No further
HD
TPN
discontinue
d, DNR
Family
meeting,
decided on
extubation
and
withdraw
aggressive
care
1/27
Patient
started on
TPN y/d. Had
abdominal
fluid drained.
Gtube
checked per
IR, no
leakage
PEG is to
gravity today.
Still no BM
No significant
change in renal
function but has
improved urine
output ( > 2 liters
Continue iv bumex
2 mg and diurel
500mg bid
Wean levo as
tolerated, Keep
MAP >60
1/28
Comfort
measures,
withdrawal of
care,
morphine on
board.
Patient
deceased
16:15 on
1/28/15.
No significant
change in renal
function.urine
output > 2 liters
Has hyponatremia
now. Will d/c diuril
Continue bumex 2
mg bid
Dr Kumar's input
noted. Family
does not want
further dialysis
and is considering
withdrawing care
Wean levo as
tolerated, Keep
MAP >60
TPN ordered ,
electrolytes
adjusted
Abdominal
fluid cultures
negative.
·
Lab Values:
7
Lab
1/17
1/20
1/22
1/24
1/25
1/26
1/27
Sodium
119
124
131
132
130
130
131
Potassium
4.7
3.7
3.6
3.6
3.7
3.6
3.6
Glucose
132
93
96
122
175
146
140
BUN
9.2
72
37
20
24
25
28
Creatinine
2.7
2.23
1.4
1.35
1.8
1.97
2.07
Calcium
10
9.1
9.0
9.7
9.6
9.8
9.7
GFR
21.
26.4
45.2
47
33.9
30.5
28.8
Albumin
3.0
2.4
2.5
2.4
2.3
2.3
Magnesium
2.2
1.9
1.8
2.6
1.9
1.9
Phosphorus
5.8
3.9
2.9
3.3
3.5
Home Medications (RML):
Medication
Dosage
Use
Side Effects
Interactions
acetaminophen 500mg every
4 hrs PRN
pain reliever,
fever reducer
nausea, upper
stomach pain,
itching, loss of
appetite, dark
urine, claycolored stools,
jaundice
antibiotic,
antifungal,
sulfa drug,
tuberculosis
medicine, birth
control,
NSAIDs
albuterol
sulfate
inhalation
2.5mg every
2 hrs PRN
Asthma,
bronchospasm
increased
intraocular
pressure, high
BP,
painful/difficult
urination
Alcohol
beta-blockers
(inhibitory)
albuterolipratropium
0.5mg-2.5mg
every 4hrs
Tx
bronchospams
in pt with
COPD
increased
intraocular
pressure, high
BP,
May decrease
serum K+
8
painful/difficult
urination
bisacodyl
(Bisac-Evac)
10mg daily
PRN
bumetanide
constipation
nausea,
cramps,
electrolyte
depletion
diuretics
12.5mg via IV Loop diuretic to
piggyback
tx edema in
CHF, hepatic,
and renal
disease
Anuria, hepatic
coma, severe
electrolyte
depletion
Drugs w/
nephrotoxic
potential
docusate
100mg
constipation
rectal bleedings
mineral oil
glucose
25 GM PRN
(BG<80)
hypoglycemia
hyperglycemia
none
glucose rescue
1 tube PRN
hypoglycemia
hyperglycemia
none
heparin
5000 units
every 8hrs
Glycosaminogl
ycan, for
prophylaxis of
peripheral
arterial
embolism
Hemorrhage
metoprolol
50mg every
12hrs
Selective betablocker to tx
HTN, pectoral
angina
bradycardia,
SOB, heart
failure
nystatin
500,000 unit
5ml every 6
hrs (swish
and spit)
Antifungal Candida
albicans
oral irritation, GI
upset, diarrhea
sodium
biphosphatesodium
phosphate
133ml rectal
PRN
constipation, if
30ml milk of
magnesium
and bisacodyl
diarrhea
9
active bleeding
moderate to
severe cardiac
failure
(contraindicator)
supp not
effective
sodium
chloride
10ml every
8hrs
central line
flush
Clinical Medications
Medication
Dosage
Use
Side Effects
albuterolipratropium
(DuoNeb)
3ml q4h
Tx bronchospams in
pt with COPD
bumetanide
(Bumex)
2mg, Q8h
Bumetanide is a
loop diuretic with a
rapid onset and
short duration of
action
diuresis with
water and
electrolyte
depletion,
dehydration,
reduction in
blood volume
and circulatory
collapse with the
possibility of
vascular
thrombosis and
embolism,
particularly in
elderly patients
Diuretics
chlorothiazide
(Diuril)
500mg, q8h
benzothiadiazide
diuretic and
antihypertensive
agent
Metabolic
alkalosis,
hyponatremia,
hypomagnesemi
a,
hypophosphate
mia,
hypercalcemia,
hyperglycemia,
hypercholesterol
emia, and
hyperuricemia
contraindicated in
pt’s with anuria,
severe liver
disease
10
Interactions
May decrease
serum K+
tx Vit D deficiency
hypercalemia
cholecalciferol
5000 IU, daily
ciprofloxacin
(Cipro)
400mg, 200mL, Synthetic
fluoroquinolone
q24h
fluconazole
200mL q48h
antifungal
abdominal pain,
chills, n/v
acetaminophen
heparin
5000 unit, q8h
anticoagulation
hemorrhage,
hematoma,
hepatic,
elevated liver
enzymes
active bleeding
insulin lispro
(Humalog)
medium dose
q4h
fast acting insulin,
lower blood sugar
hypoglycemia,
hypokalemia,
weight gain,
edema
thiazolidinediones
(cause fluid
retention),
albuterol, beta
blcokers
lactulose
20GM, once
chronic constipation
diarrhea,
hyperglycemia
n/a
lansoprazole
(Prevacid)
30mg DIS
tablet, BID
PPI (proton pump
inhibitor) to reduce
gastric acid
hypomagnesemi
a (from
prolonged use
>1yr)
n/a
meropenem
(Merrem)
1 GM q24h
Carbapenem
antibiotic
renal impairment
overgrowth of C.
diff
nystatin
Antifungal - Candida oral irritation, GI
500,000 unit
upset, diarrhea
5ml every 6 hrs albicans
(swish and spit)
omeprazole
20mg every 12
hrs
PPI (proton pump
inhibitor) to reduce
gastric acid
hypomagnesemi
a (from
prolonged use
>1yr)
pantoprazole
(Protonix)
40mg daily
short-term treatment
of erosive
esophagitis
associated with
gastroesophageal
reflux disease
(GERD)
hypomagnesemi
a (from
prolonged use
>1yr)
antibiotic
11
vancomycin
1500mg IV,
once
bactericidal
glycopeptide
antibiotic; for gram +
organisms
nephrotoxicity,
less urination,
fever, chills,
dizziness, skin
rash, stomach
pain, diarrhea,
low potassium,
severe skin
reaction,
nausea, back
pain,
muscle pain
renal dysfunction
Medical Nutrition Therapy:
Nutrition history: Enteral nutrition via G-tube pta
Current prescribed diet: TPN s/p EN intolerance
Patient’s response to the diet: EN failed to achieve goal rate due to intolerance and
altered GI function. TPN was initiated, but discontinued before reaching goal rate when
pt’s status changed to comfort care and was extubated. See IPOC Treatment Timeline
for details of MNT.
Nutrition related problems:
1. Swallowing difficulty related to chronic respiratory failure and COPD, as
evidenced by NPO, ventilated, PEG in place for nutrition support.
2. Altered GI function related to SBO, as evidenced by NPO, abdominal distention,
TPN.
Nutrition goals:
1. Initiate Enteral nutrition: Nepro @ 15mls/hr and advance by 15mls/hr q 8 hrs, if
tolerated, advance to 30mls/hr goal rate. This will provide 1296 kcal, 58g protein,
which basically met pt’s est needs.
2. Achieve/maintain goal rate via parenteral nutrition: 70g AA, 250g dextrose, 40g
lipids (1530 kcal, 70g protein, 250g CHO) which basically meets pt’s reassessed
needs.
Nutrition Intervention: JK was evaluated for enteral nutrition support via G-tube. JK’s
energy and protein requirements were estimated to be 1144-1300 kcal / day and 57-73g
protein / day. These calories were calculated using 22-25 kcal / kg IBW based on the
JK’s ICU status and BMI > 30. The protein requirements were calculated using 1.1-1.4
g / kg IBW based on JK’s renal status of ESRD on dialysis.
12
Nutrition Monitoring and Evaluation: The MNT goals were monitored and re-evaluated
daily. Tube feedings were first held due to a clogged G-tube and then due to vomiting
and abdominal distention. Tube feedings were discontinued when a SBO was
suspected. A 29 # weight loss in 7 days was noted. JK was reassessed for TPN and
caloric needs were estimated to be 1100 - 1250 - 2565 kcal based on 22-25 kcal / kg
IBW and 14 kcal / kg actual wt. TPN was initiated 48 hours after TF was held, and
administered for two days. Feedings were increased gradually to reduce the risk of
refeeding syndrome, and labs were followed to assess tolerance.
Present nutritional status: TPN was discontinued after two days when comfort care
and extubation were decided upon.
Prognosis: JK deceased from septic shock after extubation.
Summary and Conclusion:
I learned a significant amount about nutrition support in doing this case study. I
reviewed the MNT guidelines for both enteral and parenteral nutrition since both were
utilized in this case study. The patient I chose had a very complicated medical history,
which was overwhelming, but I am glad that I challenged myself with investigating this
case.
13