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Case Study #30 Metabolic Stress and Trauma

Understanding the Disease and Pathophysiology


1. (1 point one paragraph) The patient underwent gastric resection and repair, control of
liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity.
Describe the potential effect of surgery on this patients ability to meet his nutritional
needs.
There are many potential effects of surgery for this patient. When the patient goes in for
surgery, a systemic response will be activated. During this activation, the patient will
have physiologic and metabolic changes. The body will respond to the stress of the
surgery and the body will have a hypermetabolic, and catabolic response to the surgery.
During major surgeries such as a gastric resection and repair, liver hemorrhage, and
resection of the proximal jejunum, there is a chance that these changes can lead to septic
shock. Due to the extent of this patients surgery, his GI tract is now nonfunctional. This
will cause a potential effect on the patients ability to meet his nutritional needs because
of inadequate food intake and malabsorption of nutrients. Since the GI tract is
nonfunctional, we will set the patient up for TPN to meet his nutritional needs.
2. (1 points one paragraph) Define anasarca and describe how this condition may affect
interpretation of his nutritional status.
Anasarca is generalized edema with accumulation of serum in the connective tissue. This
condition may affect the interpretation of the patients nutritional status because anasarca
can interfere with accurate anthropometrics measurements such as weight history. Due to
the accumulation of serum that is found in the patients connective tissue, this will give an
inaccurate measurement and will limit the accuracy needed to assess the patient during
their nutrition assessment.
3. (3 points) The metabolic stress response to trauma has been described as a progression
through three phases: ebb phase, flow phase and recovery or resolution phase. Define
these three phases and how they may correspond to this patients hospital course
The first phase is the ebb phase, which is the immediate period after injury about 2-48
hours. During this shock phase, the results from injury could lead to hypovolemia and
decreased oxygen to the tissues. Due to the decrease in blood volume, there is also a
decrease in cardiac and urinary output. During the ebb phase, the doctors will need to
restore blood flow to organs, maintain oxygenation to tissues and stop bleeding. In this
patients case, we will see the decrease in cardiac and urinary output along with
decreased oxygen and lowered body temp when in surgery for the gastric reaction and
repair. The surgeon will monitor these decreases during this phase and other medical staff
while the patient is in surgery. In this phase, the Registered Dietician is not involved.
The second phase is the flow phase; this phase begins when the patient has become
stabilized hemodynamically. During this phase, the patient will begin to show the signs
and symptoms of metabolic stress. The signs and symptoms that may be present during
this phase are: hypermetabolism, catabolism, and altered immune and hormone

responses. In the flow phase, this is when a Registered Dietician will see the patient as a
consult and begin a Nutrition Assessment of the patient. In this phase, we will be able to
follow fluid resuscitation and see an increase in cardiac output, body temperature, energy
expenditure, and total body protein catabolism will begin. In this phase, we will begin to
determine how we will feed the patient and due to the GI tract not functioning, we will set
the patient up for TPN to make sure the patient is receiving the proper amounts nutrition
support.
The third stage is the recovery or resolution phase. During this stage, the patient will
return to anabolism and normal metabolic rate and restoration of lean body mass. During
this stage, we will continue to the monitor the patient and continue TPN while the patient
is still recovering.
4. (1 points- one paragraph) What is an acute phase protein? What is the role of C-reactive
protein in the nutritional assessment of critically ill trauma patients?
Acute phase proteins are secretory proteins, such as C-Reactive Protein and Fibrinogen,
that will increase or decrease in the blood when there is an inflammation response to
trauma or a major stress. C-reactive protein is an acute phase protein responder which
increases during a stress response. It triggers the catabolism of protein, through
gluconeogenesis, in response to inflammation due to trauma. To assess if the patient is
stabilizing, C-reactive protein should be weekly measured, providing metabolic status. A
decrease in serum C-reactive protein indicates homeostasis and protein anabolism, versus
the catabolism during trauma.
Nutrition Assessment
5. (1 point) Calculate and interpret the patients BMI.
102.2 kg/(1.778)2 = 32. This is classified as obese I, however BMI does not correctly
assess patient status as it does not account in variables such as lean body mass.
6. (1 points) What factors make assessing his actual weight difficult on a daily basis?
The patient is experiencing anasarca and therefore retaining fluid which will obscure his
actual weight. His use of mechanical ventilation, as well as drainage tubes, limits his
ability to be able to be weighed out of bed. He is also in and out of his room fairly often for
surgery or lab work.
7. (2 points) Calculate energy and protein requirements for Mr. Perez. Use two different
equations for estimating his energy needs and briefly explain you rational for using each.
(Use kcal/kg and Mifflin-St. Jeor formulas)
Kcal/Kg: 22-25
102.3kg x 22kcal/kg = 2250 102.3kg x 25kcal/kg = 2557
Range of 2250-2557 kcal/day
This equation was used as Mr.Perez is obese, and under metabolic stress so permissive
underfeeding is required to limit the risks of overfeeding.
Mifflin St Joer: 10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) + 5
Stress factor 1.5 indicating moderate stress, due to surgery and abdominal trauma
(10 x 102.3kg + 6.25 x 177.8 cm 5 x 29 + 5) * 1.5 = 2991 kcals/day

Protein: 102.3kg x 2.0-2.5 g/kg = 205-256g PRO/day


Protein requirements were estimated at a range of 2.0-2.5 g/kg due to the patients
trauma, the abdominal leak, and inadequate healing.
8. (3 points) What does indirect calorimetry measure? Interpret the RQ values from day 4 and
day 10. Compare the estimated energy needs calculated from the previous question with
those obtained by indirect calorimetry measurements.
An RQ of 0.82 indicates protein as the main energy source, while an RQ of 0.70 indicates
lipids as the primary energy source.
Day #4 RQ = 0.76, indicating a majority of energy obtained from fat oxidation
Day #10 RQ = 0.70, indicating all energy is being obtained from fat oxidation
The RQ observed on day 10 may be due to the medication propofol, which contains lipids.
It could also indicate that the patient is in a state of starvation and relying on fat
metabolism for energy.
Indirect calorimetry measures oxygen intake and carbon dioxide output to determine
energy output and caloric needs. This measurement dictates if the body is in a state of
homeostasis.
The REE from the indirect calorimetry was equal to 3,765 kcal. When compared to the 2
equations used, kcal/kg provided a range of 2250-2257 kcal, while the Mifflin St Joer
indicated a need of 2991 kcal. Both equations underestimated the actual needs. The
indirect calorimeter is the gold standard for determining patients energy requirements
during the metabolic state.
9. (4 points) List abnormal biochemical values and describe why they might be abnormal.
Biochemical Value

Patients Value
(Indicate high or
low)
1.9 g/dl (Day 10)
LOW

Reason for
Abnormality

Nutrition
Implication

Due to loss of
blood, and
Metabolic Stress

Glucose

140 mg/dl (Day 10)


HIGH

Due to Metabolic
Stress induced
insulin resistance

C-Reactive Protein

220 mg/dl (Day 10)


HIGH

Due to Metabolic
Stress induced
Catabolic State and
inflammation

Transferrin

160 mg/dl (Day 10)


LOW

Due to Infection
and inadequate
intake

Increase Protein
needs through an
increase in AA% in
TPN.
Provide the same
mL of
carbohydrates per
hour, providing a
constant source of
carbohydrates
Increase caloric
intake through an
increase in AA%,
Lipid and CHO%
TPN
Increase Protein
and Iron needs
through increasing
AA% in TPN

Albumin

Nutrition Monitoring and Evaluation


10.(2 points) List 4 standard recommendations for monitoring the nutritional status of a
patient receiving nutrition support.

The patients intake as well as tolerance should be monitored. Weight should be assessed
at least weekly, monitoring fluid status and weight loss. Fluid intake and output needs to
be watched. Lab values of prealbumin, glucose and BUN should be assessed for metabolic
state.
11.(1 points) Hyperglycemia was noted on the patient care monitoring sheet. Why is
hyperglycemia of concern in the critically ill patient? How was this handled for this patient?
Hyperglycemia is of concern because it indicates insulin resistance due to metabolic
stress. During metabolic stress, liver production of glucose increases, leading to insulin
resistance. This can eventually lead to mortality. To help reduce the risk of hyperglycemia,
Mr. Perez was placed on an insulin drip.
You were just assigned to review and re-evaluate this patients current nutrition support
intervention. Calculate total grams (protein, lipids and dextrose) and kcal the patient is
receiving from the TPN and EN as of day 13 and write your note based on you evaluation
of the patients current nutritional intake and needs. Attach a Nutrition Care Note to this
document: your assessment, diagnosis, intervention, monitoring and evaluation of your
patient. (10 points)
EN: 15 mL/hr x 24 hr = 360 mL
KCAL: 360 mL x 1.5 kcal/mL = 540 kcal
DX: .36L x 134g CHO/L = 48.24g CHO (/3.4 kcal/g = 164 kcal)
AA: .36L x 94g PRO/L =33.84g PRO (/4kcal/g = 135.36 kcal)
LIPID: .36L x 67g Fat/L = 24.12g LIPIDS (/10 kcal/g = 241.2 kcal)
TPN:
DX: 350g x 3.4 kcal/g = 1190 kcal
PRO: 180 g x 4 kcal/g = 720 kcal
LIPID: 250 mL x 1.1 = 275 kcal (/10 kcal/g = 27.5g LIPID)
Total:
KCAL: 540(EN) + 1190 (CHO-TPN) + 720 (PRO TPN) + 275 (LIPID-TPN) = 2725 kcal
PRO: 33.84g + 180g = 213.84g
LIPID: 24.12g + 27.5g = 51.62g
CHO: 48.24g + 350g = 398.24g
1st: Please compare the energy intake that the patient is receiving via TPN and EN to the
calorimetry REE kcal provided in the case study not to the kcal estimate that you come up
with from the equations. Remember you will be including the 250ml of lipids IVFE 10% in
your calculation when assessing total kcal intake.
The patient is currently receiving 2725 kcal total. His calorimetry indicates his needs at
3765 kcal per day. He is in deficit by ~1000 kcal. He is also currently receiving 214g PRO
total, about 2.1 g/kg of Protein. He should be receiving at least 2.5 g/kg, for a total of at
least 255g PRO, to provide for optimal healing.
2nd: For the intervention goal to make this assignment a little more straight forward come
up with your own TPN calculation using 1800ml for amino acids (choose from either 4%
4.5% or 5%) and dextrose (chose from 20% or 25%) plus 250ml of IVFE (10% or 20%). You
will keep the patient on the same enteral feeding until his status improves but I want you
to recommend a specific TPN order (rate/24hr and %aa, %dex with 250ml %IVFE).

*[Crucial 1.5: 1.5kcal/ml; 94g Protein/L; 134g Carbohydrate/L; 67g Fat/L; 772ml
Water/L]

Nutrition Care Form (Total = 10 Points)


1 Point:
Age: __29_____Gender: ____M_____ Height: ____510_______ Weight: ___102.3 kg____
Medical Diagnosis: __GSW Abdomen_ Consult: Trauma surgeon requested after Day 1 and asked
to review and re-evaluate patient current nutrition intake and needs at Day 13
ASESSMENT
Weight History: Edema- currently 109 kg Ideal Weight: 135% Ideal Weight: 160# +/- 16#
Activity Level: Sedentary Medications: Morphine, Lorazepam, Esomeprazole, Meropenum,
Vancomycin
Current Diet Order: TPN/EN

Education Needs: _none

1 Point:
Past History: Smoker, Family History CAD, drinks beer daily per brother
Lab Values: 7/11 - Alb 1.9, Total Pro 5.1, Prealb 5.0, Transferrin 160, Magnesium 1.5, Osmolality
305, Glucose 140, BUN 25, Creatine 1.6 C-Pro 220, TG 265
1 Point:
Energy Needs: 3,765 kcal Protein Needs: 205 256 g Fluid Needs: __3.7 L
1 Point:
Energy Intake: 2,725 kcal Protein Intake: 214g

Fluid Intake: None

NUTRITION DIAGNOSIS 2 Points:


Problem: Altered GI Function (NC -1.4) and Inadequate enteral/parenteral nutrition infusion NI2.3 & NI-2.6)
Related To:
state

Gunshot wound to abdomen resulting in decreased GI status and hypermetabolic

As Evidence by: EN fluids draining from anastomotic leak resulting in decreased energy intake.
NUTRITION INTERVENTION 2 Points:
Parenteral Nutrition Formula/solution (ND-2.2.1) & Initiate Glutamine and Arginine Supplement
(ND-3.3.1)
Goal: Provide TPN of 25% dextrose, 5% amino acids at a rate of 75 mL/hr for 24 hours and 15
mL/hr of 10% Lipids for 12 hours and continue to provide EN at rate of 15 mL/hr to meet protein
and caloric needs and promote optimal healing and recovery of gut function. Increase EN to 20
mL/hr as tolerated to meet the kcal and protein needs until patient is out of metabolic stress.
Reassess nutrient needs once out of metabolic state. Add glutamine and arginine supplement
for ample protein production to help with healing the site of the wound resulting in improved
localized immunity. Give 200 mL of flushes every 6 hours.
NUTRITION MONITORING 2 Points:
Monitor: Total Energy Intake (FH-1.2.1.1), Rate of Enteric Nutrition (FH-1.3.1.1) and Monitor Creactive Protein (FH-1.6.1.13)
Goal: Increase EN slowly by 5 mL/hr as anastomic leak heals and EN is tolerated to bring PT to
full EN support followed by complete PO. Once patient meeting 75% of nutrient needs by new
route, old method of feeding can be discontinued. Feedings stable at goal rate for at least 2-3
days. Check C-reactive Protein to make sure levels are dropping. Check Nitrogen balance daily
until it is positive. Check Residuals every 4-6 hours, fluid status, abdominal distention, frequency
and volume of stools, and daily weight to check for reduction in edema.
RD Signature: Christina Taalla, RD Date: 2/21/2013