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1. The patient has suffered a gunshot wound to the abdomen. This has resulted in an open abdomen.
Define open abdomen. The medical record describes the use of a wound “vac.” Describe this procedure and its connection to the diagnosis for open abdomen.
An open abdomen is defined as an injury defined by open abdominal walls and specifically the inability to close abdominal fascia post-laparotomy. A wound vac is a procedure where the wound is covered with a sheet of bandages connected to a vacuum via tube. This vac collects any discharge from the wound while also implementing negative charge on the wound to promote wound healing.
2. The patient underwent gastric resection and repair, control of liver hemorrhage, and resection of gproximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on this patient’s ability to meet his nutritional needs.
Mr. Perez’s GI discontinuity results in malabsorption of nutrients from macro and micronutrients, inadequate energy intake, and potential anemia from liver hemorrhaging. This jejunum is the primary site of nutrient absorption and will therefore prevent him from obtaining energy/nutrients from food when it is compromised. This surgery therefore limits his ability to meet nutritional needs.
3. The metabolic stress response to trauma has been described as a progression through three phases: the ebb phase, the flow phase, and finally the recovery or resolution. Define each of these and determine how they may correspond to this patient’s hospital course.
Ebb phase: This phase is defined as the initial reaction to stress and trauma. Vasodilatation and increased permeability occur as well as blood clotting and phagocytizing by neutrophils to rid of bacteria. This phase lasts for 4-6 days.
Flow phase : The flow or proliferative phase begins on the third or fifth day and lasts for 2-3 weeks. A protective covering formed by epithelial cells covers the wound and collagen deposition and crosslinking begin to strengthen the wound. Myofibril blasts induce wound contraction and the wound begins to close.
Recovery phase: This phase begins at 2-3 weeks after the time of injury and lasts up to two years.
Collagen maturation and stabilization occur and the fibrous scar tissue matures.
4. Acute-phase proteins are often used as a marker of the stress response. What is an acute-phase protein? What is the role of C-reactive protein in the nutritional assessment of critically ill trauma patients? What other acute-phase proteins may be followed to assess the inflammatory stress response?
Acute-phase proteins are secreted by the liver in response to trauma. The c-reactive protein is a positive acute-phase protein and increases in concentration during stress response. Pro-inflammatory cytokines promote growth of inflammatory tissue fibroblasts and macrophages in the incidence of trauma. They are responsible for the induction of fever and muscle catabolism after injury as well in response to metabolic stress.

5. Metabolic stress and trauma significantly affect nutritional requirements. Describe the changes in nutrient metabolism that occur in metabolic stress. Specifically address energy requirements and changes in carbohydrate, protein, and lipid metabolism.
Systematic inflammation response syndrome and multiple organ dysfunction syndromes can occur after trauma. Indirect calorimetry should be used to calculate nutrient needs and should be used on the higher end, as the patient will need lots of calories to suffice for the trauma their systems are going through. Protein is calculated at 1.2-2 g/kg/d, carbohydrates at about 53% of daily energy, and fat at
25%. Metabolism of these nutrients is altered because lipid metabolism is preferred until protein becomes the main substrate due to hypermetabolism Carbohydrates are digested and glucose uptake is limited because of the catabolic stress hormones and suppression of insulin receptors. Lipids in the diet should consist of medium chain triglycerides that are easily digested. Fiber should be avoided in this diet.
6. Are there specific nutrients that should be considered when designing nutrition support for a trauma patient? Explain the rationale and current recommendations regarding glutamine, arginine, and omega-3 fatty acids for this patient population.
Specific nutrient needs include consuming more B vitamins including thiamin and niacin. Potassium, magnesium, phosphorus, and zinc should be increased in the diet to prevent loss of lean body mass.
Arginine benefits include increasing collagen deposition, improving nitrogen balance, and enhancing the immune system to promote wound healing. The recommended intake is unknown. Glutamine is converted to glucose in the liver and is used as a fuel source and precursor for macrophages, fibroblasts, lymphocyte proliferation, and the inflammatory immune response for early wound healing.
The recommended daily intake is .57 mg/kg/d for adults. Omega-3 fatty acids are essential for recovery with 1.6 grams recommended/day.
7. Using current evidence-based guidelines, explain the decision-making process that would be applied in determining the route for nutrition support for the trauma patient.
Parenteral nutrition is the best choice for this patient as his jejenum is compromised post operation. His GI is tract is currently discontinuous and so TPN will be administered first. As Mr. Perez recovers, bouts of EN will be administered in small amounts and assessed as needed based on the integrity of his GI tract.
8. Calculate and interpret the patient’s BMI.
Weight: 102.7 kg
Height: 1.78 m BMI = 32.4 kg/m 2
9. What factors make assessing his actual weight difficult on a daily basis?
Fluid plays a major factor in difficulties for measuring his actual weight. During this time, his weight will fluctuate because of fluid resuscitation, loss of blood, and swelling in certain areas causing edema.
10. Calculate energy and protein requirements for Mr. Perez. Use at least two methods (including the
Penn State) to estimate his energy needs. Explain your rationale for using each one. For the Penn
State calculation, the minute ventilation is 3.5 L/minute and the maximum temperature is 39.2.

IJEE: 1784-(11*29)+(5*102kg)+244+239 = 2458 kcal/d
- This one is used for ventilator-dependent male pt c trauma. UBW is used to calculate his energy needs most closely related to his current weight and what his body is used to.
Penn state: (0.85 * 2173 kcals)+ (175*39.2) + (33*3.5) – 6,433 = 2,389.6 kcals/d * 1.3-1.4 = 3106-3345 kcal/d
Protein Requirements: 3106-3345* .2-.25 = 621-669 kcal/ 4kcal/g = 155.25-167.25 g protein
11. What does indirect calorimetry measure?
Indirect calorimetry is used to “determine the amount of calories an individual burns over a certain period of time.” It is used to calculate an individual’s resting metabolic rate and the amount of calories burned when they are active.
12. Compare the estimated energy needs calculated using the predictive equations with each other and with those obtained by indirect calorimetry measurements.
The IJEE and the Penn State formulas differed in comparison to the indirect calorimetry recommendation.
IJEE was the lowest amount, whereas the caloric intake based on the metabolic cart sat slightly above the Penn State equation at about 3,657 kcals.
13. Interpret the RQ value. What does it indicate?
RQ is a measurement that shows which energy substrate the pt is using currently for their energy needs.
The patient’s RQ value of 0.76 indicates that the substrate being used is currently fatty acid metabolism.
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14. What factors contribute to the elevated energy expenditure in this patient?
Mr. Perez is experiencing hypermetabolism because he has undergone multiple surgeries dealing with trauma n the form of a gunshot wound. The pt is experiencing increased energy needs due to the stress from surgery. 25-30% of his energy needs are being used to account for his wound on top of the catabolic stress from surgery.
15. Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and grams of protein are provided with his prescription. Read the nutrition consult follow-up and the I/O record.
What was the total volume of PN provided that day?
Pt was prescribed: Dextrose: 140, AA: 60, IL: 20, Goal rate of 135 mL/hr.
Prescription provides 2448 kcal/day and 194.4 g protein.
Total energy + propofol is 3372 kcal/day.
Total volume on the follow-up day 7 was 3.312 L based on the pt’s I/O for this day.
Calculated total volume was 3.24 L, additional amounts come from added micronutrients and possible amounts of added carbohydrates, protein, and lipids.
Calculations:
135 mL/day x 24hr = 3.24 L/day
• 3.24L x 20g/L lipid = 64.8 g lipids x 10 kcal/g= 648 kcal lipids
+ 924 kcal lipids via Propofol

• 3.24L x 60g protein=194.4g x 4 kcal/g = 778 kcal from protein
• 140g CHO/L x 3.24L = 453.6g CHO x 3.4 kcal/g = 1540.2 kcal from
CHO
(648 + 778 + 1540.2 kcal + 924 kcal = 3,890 kcal)
16. Compare this nutrition support to his measured energy requirements obtained by the metabolic cart on day 4. Based on the metabolic cart results, what changes would you recommend be made to the
TPN regimen, if any? What are the limitations that prevent the health care team from making significant changes to the nutrition support regimen?
On day 4, the metabolic cart measured the pt’s energy requirements to be 3657 kcal, which is an adequate amount in comparison to what he is provided through TPN. Propofol is a limitation in this calculation, which contributes a significant amount to calories and total protein. Propofol increases the risk for overfeeding and adjustment of nutrition support goal rates can be difficult because of the adjustment from this medication.
17. The patient was also receiving propofol. What is this, and why should it be included in an assessment of his nutritional intake? How much energy did it provide?
Propofol is a sedative that helps reduce anxiety and promotes relaxation, and is used during short diagnostic tests and consciousness after surgery. It should be included because it has a fat content similar to a
10% lipid solution. It was administered at a rate of 35 ml/hr, so in a 24hr period it provided around 924 kcals/d of lipid. This adds a large amount to the total kcals that are being administered in a day. If the calories coming from propofol are not considered, it could result in excessive energy intake.
18. The RD recommended that trickle feeds be initiated. What is this and what is the rationale? The RD recommended the formula Pivot 1.5 for these trickle feeds. What type of formula is this, and what would be the rationale for choosing this formula?
Trickle feeding means incorporating small doses of enteral nutrition (~10-20 ml/hr to provide 15-30% of pt needs) to the small bowel of a patient receiving TPN. This EN is not included in calculations because it provides an insignificant amount for alteration. Initiation of trickle feeding provides stimulation to the gut in order to preserve some GI function in patients receiving TPN. This will transition the pt to enteral and oral nutrition efficiently and affectively.
19. List abnormal biochemical values for 3/29, describe why they might be abnormal, and explain any nutrition-related implications.
HbA1C: 7.1% Elevated Indicative of diabetes, carbohydrates need to be assessed.
ALT/AST: 435 U/L / 190 U/L Elevated Due to liver hemorrhage – pt has increased protein needs.
C-reactive protein : 245 mg/dL Elevated Due to inflammatory response to his abdominal trauma –
Prealbumin: 3.0 mg/dL could be related to excess glucose levels
Elevated Inflammatory response due to abdominal trauma
Albumin: 1.4 g/dL Decreased Due to protein losses with open abdomen – need to increase delivery through PN

Glucose:
BUN:
164 mg/dL
23 mg/dL
Elevated Insufficient glycemic control –need to decrease amount of carbs given through PN,also elevated due to trauma
Elevated Due to excessive protein catabolism, increased protein needs
Alkaline phosphatase: 540 U/L Elevated Due to gunshot wound and open abdomen
20. Current guidelines recommend using a nitrogen balance study to assess the adequacy of nutrition support. a. According to the Powell (2012) article (see bibliography below), what adjustments should be made to assess for nitrogen losses through fistulas, drains, or wound output? b. A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42 g. Calculate his nitrogen balance.
A primary goal of nutrition support is the maintenance of a positive nitrogen balance. This goal is difficult to attain because the pt is experiencing hypermetabolic stress resulting in an increased catabolism and using ketones as an energy source. In addition, the maintenance of an open abdomen relies on extra fluid, protein, and overall energy requirements. Protein losses through abdominal fluid is an estimated 15-30 g/L. When the increased protein loss of these patients is not considered in calculation of nitrogen balance, the result is underestimation of the total nitrogen loss and overestimation of sufficient protein administration to meet patient needs. This lapse leads to underfeeding and inadequate nutrition support. In critically ill patients, underfeeding consequently decreases wound healing, increases the occurrence of infection, and decreases the patient’s survival outcomes.
Nitrogen Balance:
NB = [Protein intake (g) / 6.25] – (UUN x 1.2) + 2 – 4
[194.4 g / 6.25] – (42 g x 1.2) - 20
NB = -39.36
21. Identify the nutrition diagnosis you would use in your follow-up note. Complete the PES statement.
- Altered GI function RT abdominal trauma from GSW and resection of proximal jejunum AEB enteral formula draining from anastomic leak and compromised GI tract. (NC 1.4)
- Inadequate intake of amino acids RT increased protein needs due to severe trauma and compromised GI tract AEB insufficient lab values of transferrin (160 mg/dL), prealbumin (5 mg/dL), and total protein
(5.1 g/dL). (NI-5.7.3)
22. For the PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).
--EN formula (ND 2.1.1)
• Maintain current EN recommendations of continuous 15mL/hr Crucial formula

• Add glutamine/arginine supplement to the EN
• Increase EN doses as leak heals to an increase of 5 cc/hr
Goals: full recovery of GI tract and additions of arginine and glutamine; bring Mr. Perez onto full EN nutrition gradually
--PN formula/solution (ND 2.2.1)
• Maintain current TPN recommendations of 180g AA solution (720kcals/day of protein), 350g of dextrose
(1190kcal/day of CHO), and 250mL of 20% lipid solution 3 days/week (appx. 214kcal/day of lipid) giving a total of 2124kcal/day and 180g P/day
• Glucose oxidation rate of 4.86mg/kg/min
Goals: to promote full recovery of GI tract and stabilize lab values; High protein recommendations will promote wound healing and meet body needs due to trauma; Low lipid intake will raise the RQ to the normal 0.85.
23. What are the standard recommendations for monitoring the nutritional status of a patient receiving nutrition support?
The standard recommendations for monitoring Mr. Perez as he receives nutrition support include watching his reaction to nutritional support. His weight, fluid status, and biochemical values should be monitored weekly to make sure that he is hemodynamically stable
24. Hyperglycemia was noted in the laboratory results. Why is hyperglycemia of concern in the critically ill patient? How was this handled for this patient?
JP’s glucose levels on day 4 were between 107 and 185 mg/dL. Hyperglycemia occurs from insulin resistance from stress. Exogenous insulin can be administered but is not as effective as natural insulin.
Pts undergoing TPN and with hyperglycemia should be watched closely because of the detrimental effects.
25. What would be the standard guidelines and subsequent recommendations to begin weaning TPN and increasing enteral feeds?
In order to properly wean Mr. Perez off of TPN, conditions such as hypo and hyperglycemia need to be considered. EN should be reduced gradually at a rate of 20 cc/hr. Throughout this process the pt should be monitored to watch for any side effects including high residuals and how they respond to overall TPN reduction.