Case Study: Critical Illness

You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning, and
monitoring throughout his hospitalization.
Initial admission information available from the medical chart:
Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms, and back in
an accident at the chemical plant where he works. After emergency first aid at the plant, he was
transported by ambulance to the university hospital burn center. Mr. G was in shock when he
was admitted.
Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned skin is pale
and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-injury wt: 165#
Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem 20
screening panel, ABGs, and UA.
Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck, upper
back, arms, hands, and upper thighs.
Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted. Urinary
output, P, and BP monitored hourly. NPO x 24 hrs. NG tube placed for stomach decompression.
Maalox q 2 hrs through NG tube.
Initial hospital course:
As soon as the shock was under control, Mr. Gs wounds were washed, debrided, and
dressed with silver sufadiazine using fine-mesh gauze. He was given a tetanus shot and
600,000 units of procaine penicillin were administered q 12 hrs.
After 24 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned; patient is
responsive to pain, but limited alertness; breathing & respiration normal
By 36 hrs, a nasoduodenal tube was placed and position of the tip verified by radiology to
be past the ligament of Trietz.
On second day (~ 36 hours), a Nutrition Consult was ordered for feeding
recommendation
Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the initial
consult, on day 2 of admission.
1. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the following
methods. Show your work.
a. Quick shortcut as used by UCDMC burn unit [35-40 kcal/kg BW] (2 pts)
165lbs/2.2kg=75kg
75kg x (35-40kcalkg)= 2625-3000 kcal
*Pocket Resource Guide

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

(10x75kg) + (6.25x177.8cm) (5x32) + 5
510=70in x 2.54cm=177.8cm
750
+ 1111.25
- 160 + 5= 1706.25
1706.25 x (1.5-1.85IF)= 2559.375-3156.5625 x 1.1AF
2815.3125-3472.21875
= 2815-3472 kcal
*Pocket Resource Guide
c. Comment on whether these two estimates differ or are similar, and what you would
use as your actual energy recommendation for this patient. Provide justification for
why you selected this energy recommendation. (2 pts)
-These two estimates are somewhat similar, but the shortcut method gives a slightly
lower range, and the Mifflin St-Jeor formula provides a wider, higher range. I would
use the Mifflin St-Jeor formula to make recommendations for this patient, because he
is a burn patient, and needs a higher energy intake to help with wound healing, tissue
repair, and prevent breakdown of his muscle protein due to his high catabolic state
and overall increased metabolic rate.
*Critical Illness Lecture
2. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work. (2
pts)
1.5-2.0g/kg/d PRO for burn patients
1.5-2.0 x 75kg= 112.5-150g PRO =113g-150g PRO
*Pocket Resource Guide
3. Discuss the effects of trauma on macronutrient metabolism. (3 points.)
-For about the first two days after a traumatic event, the human body is in a state of shock.
Cardiac output, metabolic rate, and overall energy needs decrease, while respiratory rate and
heart rate increase. Most of the bodys energy is coming from the breakdown of stored fat in this
phase through a process called lipolysis, while the protein store in muscle tissues is protected,
and catabolism is minimal.
-After this state of shock, the body undergoes an acute response flow phase mediated by
circulating inflammatory cytokines for about 0 to 5 days after the injury. This includes increases
in metabolic rate, proteolysis (protein breakdown), lipolysis (lipid breakdown), and
gluconeogenesis (glucose production) particularly from the excess amino acids produced from
the proteolysis, resulting in hyperglycemia. In this phase, the body is undergoing a state of rapid
catabolism, particularly from protein breakdown for wound healing and tissue repair.
-Lastly, the body undergoes an adaptive response flow phase for about 7 to 10 days after the
injury. This occurs when the body is becoming more stable, and is characterized by decreases in
metabolic rate, proteolysis, lipolysis, and gluconeogenesis as the body attempts to stabilize and
reach a state of homeostasis and balanced metabolic processes.
*Critical Illness Lecture
4. Based on the patients needs, consider the enteral formula to recommend.
a. Describe two desirable features or characteristics of the type of formula you
would select and recommend. (refer to the UCD TF lecture) (2 pt)

-I would select a formula with a high protein composition to promote wound

healing and assist in providing adequate protein to the patient, especially since he
is in a highly catabolic state, and burn patients require higher protein intake to
heal properly and prevent loss of lean body mass. I would also select a formula
with a high kcal composition, since his body is undergoing an increased metabolic
rate, and a lot of energy is required for tissue repair and wound healing.
*Tube Feeding Lecture
b. Give one example of an appropriate enteral formula meeting these characteristics,
using the formulary provided on the course Smartsite.(1pt)
-Two Cal HN (Abbott) contains 2.0kcal/mL and 84g of PRO per 1,000mL, so it
meets both the high kcal and high protein characteristics mentioned above.
5. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being used?
Why do you think this was used instead of the alternative Cimetodine liquid to be put down
the feeding tube? (Use the FMI text for this question) (2 pts)
-Famotidine is a histamine H2 receptor antagonist. It is used as an antiulcer/antigerd
medication to prevent acid indigestion.
-Cimetodine liquid medication precipitates tube feeding, which could disrupt the delivery of
nutrients to the patient and possibly even cause harm, so Famotidine was used instead, in
order to prevent that from happening.
*FMI Book
6. Describe 3 ways you could determine the adequacy of your recommendations for energy and
protein intake for this burn patient. (In other words, what will you monitor to decide if your
recommendations are adequate, and why?) (3 points)
-Monitor weight status to make sure patient isnt losing weight and is consuming enough energy
and protein to prevent muscle wasting.
-Monitor nitrogen balance to get it as close to neutral as possible, and get an idea of whether his
protein needs are adequate or not.
-Monitor wound healing progress to make sure patient is getting enough protein and energy to
help with tissue repair and wound healing.
*Critical Illness Lecture
Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin grafting
is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.5 @ 60 ml/hr, plus
PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking 100
kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full TF volume
is being delivered each day.
The patient tells you it is difficult for him to eat by mouth due to pain, and that he doesnt
have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current information
available.
a. Energy: (1 pt)
(10x70kg) + (6.25x177.8cm) (5x32) + 5
*Pocket Resource Guide
700
+ 1111.25
- 160 + 5= 1656.25
1656.25 x (1.0-1.50IF)= (1656.25-2484.375) x 1.1AF
= 1821.875-2732.8125
= 1822-2733 kcal
b. Protein: (1 pt)
70kg x (1.5-2.0g PRO/d)= 105-140g PRO

*Pocket Resource Guide

c. Fluid: (1 pt)
*Pocket Resource Guide
1mL fluid/kcal = 1mL fluid= 1mL kcal = 1822-2733 kcal
8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show
your work
a. Energy: (1 pt)
60mL/hr x 24 hr= 1440mL of Tube Feed (TF) being given
1440mL x 1.5kcal/mL in Jevity 1.5= 2160 kcal
*Pocket Resource Guide
b. Protein: (1 pt)
64g PRO/1000mL of TF = x g of PRO/1440mL of provided TF
1.44 x 64g PRO= 92.16g =92g PRO
*Pocket Resource Guide
c. Fluid: (1 pt)
-1440mL of TF being given -H2O%=76%= 0.76
1440mL x 0.76= 1094.4mL= 1094mL of H2O

*Pocket Resource Guide

9. Calculate Mr. Gs nitrogen balance at day 10. (1 point)

Dietary intake= 92.16g
(92.16g/6.25) (UUN+4)
(92.16g/6.25) (23+4)
14.7456-27= -12.25
*Pocket Resource Guide
10. Interpret the results of the nitrogen balance study. Is current TF order adequate to meet
estimated protein needs? (2 points)
-A negative nitrogen balance means the nitrogen loss or output is greater than the nitrogen
intake or input. His current TF order is inadequate in meeting his protein needs, which is
evidenced by his 92g of PRO he is receiving from the current TF order, although his needs
should lie between 105g and 140g of PRO. His nitrogen balance of -12.25 indicates that his
nitrogen output is higher than his input, which makes sense, since his protein needs are not
being met. Additionally, he is still recovering from his burn incident, and is still 15%
TBSAB, so his body is still at an increased metabolic rate and is still breaking down protein
at a higher rate due to his increased catabolic state.
*Pocket Resource Guide
11. Write one PES statement that you will use in your note below: (3 pts)

-Inadequate enteral nutrition infusion (NI-2.3) r/t inappropriate diet order recommendation
of TF regimen by MD AEB severe weight loss of 7% in 10 days, and a negative nitrogen
balance of -12.25.
12. Write an ADIME note for your day 10 follow-up assessment of Mr. G. Hints: Be sure to
evaluate his current anthropometrics (and any trends seen), current kcal/pro needs, adequacy of
the current diet order (including both the TF and PO intake), and current labs. What do the
anthropometric and biochemical data reveal? Is the current diet order adequate and realistic for
the patient? Write two PES statements that reflect your assessment. In addition to the PES
statement in Q 11, write one more PES statement and include both in your note. In the Plan
section, make very specific nutrition support and monitoring recommendations for this patient at
this point in time. (23 points)
Assessment:
-Patient Hx: 32yo male admitted to burn unit with a 30% TBSA chemical burn, currently 10
day-post injury with a 15% TBSAB. Pt. awaits skin grafting surgery scheduled in the next week,
as some wounds are still open. Noted MD consult for nutrition recommendation for TF per RD.
-MD Diet Order: Jevity 1.5 @ 60mL/hr, plus PO intake as tolerated.
Volume: 1440mL; Kcal: 2160 kcal; Protein: 92g; Fluid: 1094mL
-Anthropometrics:
Ht: 70in/177.8cm
UBW (pre-injury): 75kg
CBW: 70kg
IBW: 75.45kg
%IBW: 92.8%
BMI: 22.14 (Normal)
-Weight Hx: Severe wt. loss of 7% in 10 days.
-Biomedical Data/Labs: -UUN 23g/24 hr (High relative to protein intake. Negative nitrogen
balance of -12.25). Prealbumin 8mg/dL (low, associated with trauma and high inflammation).
-Medications: IV Famotidine (Pepcid), Maalox
-Estimated Nutrient Needs (based on 70kg wt):
Kcal [x] Mifflin St-Jeor Equation: 1822-2733kcal
Protein: 105-140g PRO
Fluid: 1822-2733mL
-Food and Nutrition Hx: Inappropriate current TF regimen indicated by insufficient protein
needs. 92g of protein consumed, while recommended needs include 105-140, although 100% of
TF is being provided. Calorie intake being monitored via kcal counts. Pt. experiencing
difficulties with oral intake due to pain and poor appetite and refuses to attempt eating for now.
Diagnosis:

1. Inadequate enteral nutrition infusion (NI-2.3) r/t inappropriate diet order recommendation of
TF regimen by MD AEB severe weight loss of 7% in 10 days, and a negative nitrogen balance of
-12.25.
2. Inadequate protein intake (NI-5.7.1) r/t high catabolic response from having 15% TBSAB
AEB negative nitrogen balance of -12.25.
Intervention:
-Overall MNT goal: To prevent further weight loss and neutralize nitrogen balance by adjusting
TF regimen to meet patient energy and protein needs, and gradually increase oral intake while
reducing and eventually eliminating TF regimen.
-Specific Recommendations:
1. Recommend TF regimen that meets pt. energy and protein needs.
-Jevity 1.5 @ 75mL/hr should provide pt. with adequate kcal and protein needs.
-Energy: 2700kcal
-Protein: 115g
-Fluids: 1368mL
Free Water: 250mL q 6hrs: 4 flushes of 1000mL each
2. Recommend gradual PO intake of tolerable foods.
-Pt. compliance to new tf regimen good, as patient is still receiving continuous TF. Compliance
to gradual PO intake may be difficult, as pt. experiences pain when eating by mouth, and has a
decreased appetite.
M/E:
1. Monitor pt. weight, nitrogen balance, wound healing, tolerance to nutrition support, and oral
intake progress.
2. Follow-up with pt. every 1-2 days to monitor status.
February 12, 2016
Nutrition Student
13. It is now 3 weeks since admission and he is now in a transitional care unit. Mr. Gs wounds
are closed and healing well. He is interested in trying to eat more foods orally and his appetite is
returning. How could his current continuous TF regimen (the one recommended in your note
above) be modified to provide approximately 1000 kcal/day and not interfere with his intake at
meal times? Make recommendations for an appropriate transitional TF plan/order and how to
monitor. Make a specific recommendation for both the TF plan and monitoring. (6 points)
-Mr. Gs current TF regimen could be modified by providing a continuous TF overnight, so that
he can try to eat more foods orally during the day, and not interfere with his intake at meal times.
I would recommend Jevity 1.5 @ 60mL/hr for 12 hours overnight for him to receive 1080kcal
from the TF. For an appropriate transition TF plan, I would adjust the enteral feeds and energy
based on Mr. Gs oral intake, consider his swallow evaluation, recommend oral supplements or
snacks to help him meet his oral caloric needs, and lastly discontinue the TF once he meets 5075% of his energy needs orally. I would monitor both his oral and TF plan by assessing actual
oral intake of food, doing a diet analysis and counting his calorie intake. Lastly, I would monitor
the rate by which the TF is administered, whether protein and fluid needs are sufficient, and if
cycled TF at night is the best course of action.