ICU Case StudyTalia Philippsborn

MSU Dietetic InternMarch 6, 2015

Patient Profile• Initials: R.M.

• Age: 55 years old

• Gender: Male

• Ethnicity: Caucasian

• Admission date: 2/25/2015

• Nutrition Assessment/Follow Ups: 2/26, 3/3, 3/4

• c/o: Heart burn, sore throat, difficulty swallowing

• Diagnosis: Barrett’s esophagus with high grade dysplasia, COPD (emphysema), GERD

• Surgical Procedure: Ivor-Lewis Esophagectomy

Barrett’s Esophagus with High Grade Dysplasia

• Barrett’s esophagus is a change in the lining of the esophagus from a normal, white lining known as squamous mucosa to a pink/red lining known as intestinal-type mucosa. This can result in precancerous cells.

•  Risk Factors: GERD, overweight/obesity, smoking

• High Grade Dysplasia: Higher risk for progression to cancer. Treatment options must be discussed, including endoscopic options: removal of tissue and/or ablation, and surgical options: esophagectomy. 

Source: http://www.massgeneral.org/digestive/faq/frequently-asked-questions-barretts-esophagus.aspx

Ivor-Lewis Esophagectomy

Commonly used approach for esophagectomy via laparotomy and right thoracotomy, with intrathoracic anastomosis.

•Benefits:• Less gastric tube needed• Avoid neck dissection and potential recurrent laryngeal nerve injury• Less aspiration risk

•Risks:• intrathoracic leak can be more difficult to manage

Signs and Symptoms

Problem Signs and Symptoms

Barrett’s Esophagus with high grade dysplasia

Heart Burn ✔Chest Pain ✔Difficulty swallowing ✔Abnormal/precancerous cells seen in endoscopy ✔

Possible complications of esophagectomy surgery

Pneumonia ✔Atelectasis✔Anastomotic Leak ✔

Possible problems after esophagectomy

Dumping syndromeDysphagia

COPD/Emphysema Short of breathWheezingCoughChest tightness ✔

Goal of Medical Treatment for Barrett’s Esophagus with High Grade

Dysplasia • The goal of medical treatment is to remove the abnormal

precancerous cells that developed in the esophagus.

• Treatments:• Endoscopic resections (cut out abnormal lesions)• Ablation (burn abnormal cells and replace with normal esophageal

cells)• Esophagectomy (surgical removal of all or part of the esophagus)

• Prognosis: If not treated, will likely lead to adenocarcinoma. Prognosis of esophagectomy is good if no complications arise.• For those who are surgical candidates, immediate esophagectomy

for high grade dysplasia extends life expectancy by an additional 5.5-9.8 years. (The Esophagogastric Junction Textbook, 2011)

Source: http://www.hon.ch/OESO/Vol_5_Eso_Junction/500_Chapters.html

Nutrition Assessment

Nutrition Focused Physical Findings

• Skin intact, pink, warm to touch

• No pressure ulcer

• Braden= 17

• NGT for suction, J-tube for feeding (Placed on 3/3)

• Chest tube for drainage

Anthropometric Measures• Height: 5’10” (70in)• Weight: 212# (96kg), 106% of UBW, 127% of IBW• BMI:30.4, obese • UBW: about 200# (90.9kg)• IBW: 166# (75.4kg)• History of weight changes: Per patient, recently gained

weight in the past few months

Nutrition Assessment: Lab DataLab Normal Range 2/27/15 3/1/15 3/4/15

Na 136-145 mmol/l 137 138 140

K+ 3.5-5.2 mmol/l 4.4 4.6 3.5

Chloride 96-110 mmol/l 108 105 107

CO2 22-32 mmol/l 21 28 28

BUN 5-25mg/dL 13 10 9

Creatinine 0.6-1.24 mg/dL 0.8 0.5 0. 58

GFR >60 ml/min/1.73m^2 >60 >60 >60

Glucose 70-110mg/dL 143 144 132

Calcium 8. 5-10. 5mg/dL 8.8(adj for alb)

9.56(adj for alb) 9.56(adj for alb)

Albumin 3. 5-5.0g/dL 3.4 2.8 2.8

RBC 4. 5-5.3 M/CU.MM 4.64 3.99 3.72

Hemoglobin 13.2-17.5 g/dL 13.8 11.7 10.8

Hematocrit 40-53 % 42.1 35.8(MCV, MCH wnl) 33.2(MCV, MCH wnl)

Triglycerides

<150 35

Magnesium 1.3-2.5mg/dL 1.9

Phosphorus 2.5-4.6mg/dL 3.7

Anion Gap 10-20 12

Lab Data: Arterial Blood Gases

Blood Gases Normal Levels 3/4/15

pH 7.34-7.44 7.46

PCO2 35-45 MMHG 38.6

PO2 75-100MMHG 153

O2 Sat 95-100% 99.5

Bicarbonate 22-26 mmol/L 27.4

ABE 0.0-2.3 mmol/L

3.9

Vent Settings s/p pyloric dilation bronchoscopy and Jtube insertion

FIO2 % 50

PEEP CM/H2O 5

VENT ML 550

Assist Control 18

Intake and Output Analysis

Date Daily Intake (IV, ice chips)

Daily Output (NGT, Urine)

Daily Balance

3/5 3518 4420 -902

3/4 1167 1710 -543

3/3 2409 2725 -316

3/2 2079 2290 -210

3/1 2022 1900 122

2/28 3095 1650 1445

2/27 807 773 34

Nutrition Assessment: Hospital Medications

Medication Mechanism of Action Interactions

Humulin R (Sliding Scale)Insulin coverage

Helps manage blood glucose levels Caution with hypoglycemia

MetoprololBP management

Beta blocker. Metoprolol reduces the oxygen requirements of the heart at any given level of effort

Caution with hypoglycemia unawareness

ProtonixGERD

Antiulcer agent. Inhibits the action of histamine at the H2 receptor site primarily in gastric parietal cells. Inhibits gastric acid secretion.

May cause constipation, diarrhea, and nausea

HeparinPrevent DVT

Anticoagulant. Advise to keep vitamin K intake constant.

Vancomycin Antibiotic for suspected PNA May cause n/v/d

IV D5W/NS @125ml/hrx13.25h

IV fluids

IV morphine drip prn Pain management

MethylprednisoloneFor COPD and inflammation

Corticosteroid used to manage difficulty breathing as well as inflammation

Causes high BG levels

Nutrition Assessment: Client History

• Currently unemployed

• Single, lives alone

• Independent of ADLs

• 42 year hx of smoking (1 pack/day), recently quit 7 months ago

• Denies drug/alcohol use

• Patient’s insurance runs outs this month

• Has uncles and parents that visit often and are involved in his care

Nutrition Assessment: Food and Nutrition Related History

• Regular diet prior to admission

• Experienced heart burn often

• Patient reports he avoids spicy food

• Eats take out often

• H&P stated that he recently gained weight unintentionally

• Unable to obtain 24 hr recall, patient is NPO. Declined going through usual intake PTA

• Diet order: NPO, ice chips (7days), Jevity 1.2@10mL/hr per Jtube, with goal of 50mL/hr.

Estimated Requirements

• Energy: 25-30 kcal/kg IBW (75.4kg)• 1885-2200 calories

• Mifflin St. Jeor Equation (using actual weight)• 1839 calories x activity factor 1.2 (injury factor for surgery)=• 2206 calories

• Protein: 1.2-1.5g protein/kg IBW • 90-113g

• Fluid: 2200mL (30ml/kg), or based on fluid balance, daily I&O

Source: NCM and AND pocket guide to nutrition assessment.

Assessment of Risk for Malnutrition

• Patient is at moderate risk for malnutrition related to secondary to acute illness related to s/p esophagectomy requiring NPO and dependency on EN, AEB NPO and no EN x 8 days and expected suboptimal nutrition in the following days .

• Intake: NPO and no EN for 8 days (Severe)• Weight: No weight loss noted. • Muscle mass: No muscles mass loss noted on MR. Visible wasting.

Suspect muscle breakdown due to NPO status and healing process. • Body fat: No subcutaneous fat loss noted on MR. Visible wasting.• Fluid accumulation: No edema noted

NCM, 2014

Nutrition Diagnosis

• Inadequate intake related to status post esophagectomy, as evidenced by NPO status x 8 days with no nutrition support.

• Suboptimal enteral nutrition infusion related to specific MD orders, as evidenced by EN order with goal rate providing 72% of calorie needs and 66% of protein needs.

Goals• Short term:

• On assessment:• Patient will be able to advance to clear liquids in 7 days with no aspiration

and dumping syndrome• If patient is not able, will insert a Jtube for feeding within 7 days• Patient will not require TPN to meet nutritional needs

• After Jtube insertion:• Patient will tolerate tube feed well and reach goal• Patient will pass swallowing evaluation/MBS• Patient will be able to go home on tube feeds for optimal nutrition before

being able to tolerate a full PO diet.

• Long Term:• Patient will be able to progress to a clear liquids diet, full liquids diet, and then

soft solids with no s/s of aspiration.• Patient will not experience significant dumping syndrome once diet is progressed.• Patient will be able to resume a full PO diet meeting all his nutritional needs.• Patient will be able to adequately identify foods to avoid and foods he can

consume during this diet transition.

Evidence Based MNT Nutrition Care Manual Diet Instructions provided by

MD•Routine to place Jejunostomy tube during surgery due to need for extended NPO•For TF: use standard polymeric formula unless otherwise contraindicated. •One oral intake begins, cycle EN at overnight and encourage po intake during the day.•With PO intake: prevent dumping syndrome. Recommend:• Avoid all simple sugars• Consume liquids30min before and after

food.• Do not start clear liquids with simple

sugars as first feeding.• Patients may be initially lactose

intolerant. Avoid dairy initially.• When solids are reached: 6 to 8 small

meals. Educate on consuming adequate protein.

•Provide education for progression of diet.•Provide liquid MV to prevent nutrient deficiencies.•Risks include gastric stasis, dumping syndrome, and fat malabsorption. M/E for that.

•Clear liquid, full liquids, soft solids. •Eat toasted bread, avoid untoasted bread. •Avoid dry, hard foods.•Avoid nuts and seeds. •Avoid tough fibers (potato skins, dried peas, beans and lentils, all raw fruits and vegetables)•Avoid citrus foods and spicy foods•Avoid gas producing vegetables•Avoid tough meats with a lot of gristle•Add sauces and gravies to food for ease of swallowing. •Avoid fried foods, anything containing chocolate, coconut, and mint. •Avoid carbonated beverages•Per MD, po diet will resume in about 2 weeks. •Prevent complications: nausea, diarrhea, pain, gas, bloating, and obstruction.

MD instructions for home TF: cycle 3pm to 9pm.

Intervention at Initial Assessment

• Patient NPO, only ice chips. S/p sx day 1

• Received a TF consult

• Patient did not get Jtube during surgery due to insurance

• Unable to leave TF recommendations if patient doe not have enteral access.

• NGT only used for drainage

• Later found out that NG tube was placed in trachea instead of esophagus. NG tube was removed.

• M/E Labs, weight, and patient progress. F/U asap for further feeding plans and esophagram results.

Intervention on Follow Up 3/3

• Received TPN and EN consults from MD.

• TPN recommendations:

• Day 1: 80gm AA, 150gm Dextrose, 40gm Lipids

• Provides: 1230 calories, 80gm protein (16kcal/kg, 1g/kg protein)

• If tolerated well, no signs of refeeding syndrome:

• Day 2 (goal): 150gm AA, 300gm dextrose, 40gm lipids

• Provides: 2020kcal, 150gm protein (27kcal/kg, 1.9g protein/kg)

• Goal GIR= 2.7

• Monitor and evaluate: CBC, magnesium, phosphorus daily, and baseline TG, then TG 1xweek. Skin integrity and pt. progress.

• TPN 3 in 1 solution running at 75ml/hr x 24 hrs:• D20W: 366gm, 1244 calories

• 8.5%AA: 153gm, 612 calories

• 10% lipids: 40g, 440 calories

• Total: 2,296 calories, 153gm protein, 1800mL fluid.

Follow Up 3/4• Patient went for pyloric dilation bronchoscopy and Jtube insertion.

• Received TF consult.

• EN recommendations: (initially)• Jevity 1.2@ 10mL/hr continuous x24h with goal rate of 70mL/hr per

Jtube. Increase by 10mL to goal Q6h if tolerating well. Provides total of:• 1680mL, 2016 calories, 93g protein, 1355mL free H2O• 150mL free water flushes Q6h for total of 1955mL. • 27kcal/kg, 1.2g pro/kg, 26mL fluid/kg.

• MD orders: Max goal rate 50mL/hr. This provides 1440 calories, 66.6g protein, 72 percent of energy needs and 66 percent protein needs.

• Monitor/Evaluate: tolerance (n/v/d), labs, skin, weight, and patient progress.

Future Plans for R.M.• Per MD, if patient goes home on TF, will cycle TF from 3pm to 9pm.

• This provides: 300mL, 360 calories, 16.6g protein, 242mL of free water.

• Instruct 300mL free H2O water flushes Q4h for adequate hydration.

• Provides 5kcal/kg and 0.2g protein/kg.

• If patient is tolerating feed well, recommend cycling overnight 7pm to 6am and increase rate to 70ml/hr x11 to better meet nutrition demands for healing, and to promote PO intake:• 770mL, 924 calories, 42g of protein, meeting 50 percent of need

• If patient’s diet is progressed, patient would need to be consuming 50 percent of needs PO.• 1. Perform swallow evaluation. 2. Educate on diet progression and post esophagectomy MNT.

• To transfer from EN to full PO feeds, conduct 3 day calorie count. If patient is meeting 75 percent of needs PO, EN can be stopped.

• When patient is on PO diet with no s/s of dumping syndrome, recommend Ensure Plus TID (350kcal, 13g protein, 8oz) to better meet needs.

• Introduction: Malnutrition and underfeeding are major challenges in caring for critically ill patients. Tube feedings are often put on hold for procedures, resulting in suboptimal nutrition support.

• Objective: To characterize interruptions in enteral nutrition delivery and their impact on caloric debt in the surgical intensive care unit. To propose ways in which enteral nutrition interruptions can be minimized. 

• Methods: EN interruptions were categorized as “unavoidable” vs “avoidable” and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality.

• Results: The cohort was composed of 94 patients. Twenty-six percent of interruptions were deemed “avoidable.” Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03–8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14–1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41–1.67) vs group 2. 

• Conclusion: Within the cohort of critically ill surgical patients, EN interruption was frequent, largely “unavoidable,” and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.

Peev, M.P., Yeh, D.D., Quraishi, S.A., Osler, P., Albano, C.E., Darak, S., Velmahos, G.C. Causes and consequences of interrupted enteral nutrition: A prospective observational study in critically ill surgical patients. Journal of Enteral and Parenteral Nutrition. 2015. 39(1). 21–27.

• Objective: Cervical anastomotic leak rates are high after esophagectomy. The aim was to examine the effect of a purposeful delay in institution of oral diet after esophagectomy on the leak rate and hospital length of stay.

• Methods: retrospective analysis of 120 patients submitted to esophagectomy with cervical esophagogastric anastomosis was conducted. Eighty-seven resumed diet within 7 days of surgery (early eaters), and 33 had delayed diet until a mean of 12 days after surgery (late eaters). Mean age was 62.3 years; 98 patients were male. 101 resections were for cancer, and 49 % of cancer patients received neoadjuvant therapy. The overall leak rate was 17.5 %, and hospital length of stay was 10.9 days.

• Results: Anastomotic leak rate was 3 % for late eaters versus 23 % for early eaters (OR of 9.57, p = 0.010). Hospital length of stay was 6 days for late eaters versus 11.8 days for early eaters (p < 0.001). Anastomotic leak was significantly associated with increased length of stay (p < 0.001), adding an average of 7.6 days to hospital stay. Respiratory complications (p < 0.001) and delayed gastric emptying (p = 0.014) were also independent predictors of increased length of stay, but early eater status was not.

• Conclusion: Delayed resumption of oral diet after esophagectomy significantly reduces cervical anastomotic leak rate and avoids the increased length of stay associated with leak. Enteral nutrition is indicated as the nutrition source prior to resuming oral diet, especially if delaying oral diet is being recommended.

Bolton, J.S., Conway, W.C., Abbas, A.E. Planned delay of oral intake after esophagectomy reduces the cervical anastomotic leak rate and hospital length of stay. J Gastrointest Surg. 2014. 18:304–309.

• Objective: Pulmonary complications after esophagectomy are still common and are a major cause of mortality. The aim of this study was to clarify the risk factors for the occurrence of pulmonary complications after esophagectomy.

• Methods: 299 patients who underwent elective subtotal esophagectomy with lymph node dissection for esophageal cancer were retrospectively analyzed. Group I included patients who had pulmonary complications (n = 53), and group II included patients who did not (n = 246). The clinicopathological factors, surgical procedures and surgical results were compared between the groups.

• Results: The frequency of any pulmonary complication was 17.7 %. Pneumonia (n = 26; 8.7 %) and respiratory failure that needed initial ventilatory support for 48 h or reintubation (n = 16; 5.4 %) were the major morbidities. The results of the logistic regression analysis suggested that smoking with a Brinkman index C800, salvage esophagectomy after definitive chemoradiotherapy and the amount of blood loss/body weight were independent factors associated with the occurrence of pulmonary complications.

• Conclusion: Pulmonary complications after esophagectomy remain common despite advances in perioperative management. Cases with a history of heavy smoking, and high blood loss during surgery require more careful postoperative pulmonary care.

Yoshida, N., Watanabe, M., Baba, Y., Iwagami, S., Ishimoto, T., Sakamoto, Y., Miyamoto, Y., Ozaki, N., Baba, H. Risk factors for pulmonary complications after esophagectomy for esophageal cancer. Surg Today. 2014. 44:526–532.

References• Bolton, J.S., Conway, W.C., Abbas, A.E. Planned delay of oral intake after esophagectomy reduces

the cervical anastomotic leak rate and hospital length of stay. J Gastrointest Surg. 2014. 18:304–309.

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• Peev, M.P., Yeh, D.D., Quraishi, S.A., Osler, P., Albano, C.E., Darak, S., Velmahos, G.C. Causes and consequences of interrupted enteral nutrition: A prospective observational study in critically ill surgical patients. Journal of Enteral and Parenteral Nutrition. 2015. 39(1). 21–27.

• The Merck Manual. Barrett’s Esophagus. 2014.. http://www.merckmanuals.com/professional/multimedia/v891252.html?Ref=n&ItemId=v891252&RefID=x&Speed=256&Plugin=WMP

• Yoshida, N., Watanabe, M., Baba, Y., Iwagami, S., Ishimoto, T., Sakamoto, Y., Miyamoto, Y., Ozaki, N., Baba, H. Risk factors for pulmonary complications after esophagectomy for esophageal cancer. Surg Today. 2014. 44:526–532. ]