Intensive Care Unit: Cardiac Arrest – A Case Report Pamela C. Vickers Candler Hospital: Dietetic Internship Clinical Rotation Georgia Southern University

Intensive Care Unit: Cardiac Arrest – A Case Report

Pamela C. Vickers Candler Hospital: Dietetic Internship Clinical Rotation

Georgia Southern University April 14, 2015

Patient Data Name: Mr. X Sex: Male Age: 53 years old Height: 5’10” Weight: 156 lbs. BMI: 22.5 kg/m2, normal IBW: 166 lbs. % IBW: 94% Admit Date: 03/24/2015

Social, Diet, & Weight History Social History (per reports):

Happily married with children

Employed Former smoker: wife

unable to report how much he smoked or the duration of his smoking

Drinks 3-4 beers a day Urine tested positive for

benzodiazepines and marijuana

No significant medical history on file

Diet and Weight History (per reports): Due to the patient being

intubated, the patient’s diet and weight history were unable to be obtained.

Per MD reports, patient was well-nourished upon arrival with a normal body mass index and no signs of malnutrition

Currently nothing-by-mouth Nutrition provided enterally

through a percutaneous endoscopic gastrostomy (PEG) tube

Past Medical History (per reports)

Uncontrolled, systemic hypertension “High blood pressure in the systemic arteries – the vessels

that carry blood from the heart to the body’s tissues (other than the lungs)”1

Severe degenerative joint disease “form of arthritis that occurs when the protective cartilage on

the ends of the bones wear down over time”2

Iron deficiency anemia “type of anemia in relation to insufficient iron in the blood

stream.”3

History of Present Illness & Presenting Symptoms (per reports) Witnessed ventricular fibrillation, cardiac arrest on March 24,

2015 Colleagues performed CPR for 45 minutes before EMT arrived

and successfully resuscitated Mr. X on the way to the emergency department

Upon arrival to the emergency department, Mr. X was stabilized and placed on a central line. He is currently intubated and under mechanical ventilation.

Admitting & Current Diagnosis(es) (per reports) Cardiac arrest in coordination with uncontrolled hypertension

Cardiac arrest: “unexpected loss of heart function usually resulting from an electrical disturbance in the heart that disrupts the pumping action and stops blood flow to the rest of the body”. 4

Anoxic Encephalopathy (anoxic brain injury): “results in a patient remaining comatose or demonstrating neurological impairments”5

Cardiac arrest disrupts blood flow (oxygen) to the brain; “once oxygen is no longer supplied to the brain, the brain will begin to shut down, thus, causing brain damage or eventual death.”5

Current & Planned Medical Interventions (per reports) Ventricular fibrillation: currently on amiodarone drip which he will remain

on until current arrhythmias are stable Hypertension: anti-hypertensive medications Acute Respiratory Failure: ventilation support Per family request, Mr. X remains full code and will receive aggressive

care. Mr. X is receiving continuous tube feeding of Jevity 1.2 at 30 mL/hr

with a goal rate of 65 ml/hr through a PEG tube.

Estimated Energy Needs Penn State 2003B (used because patient is on mechanical ventilation, < 60 years old and is not obese)

Weight: 71 kg. Height: 177.8 cm. Age: 53 years

Equation: Mifflin (0.96) + VE (31) + Tmax (167) – 6212

Mifflin: [71 kg. x 10] + [177.8 cm x 6.25] – [53 years x 5] + 5

Resting Energy Expenditure (Mifflin): 1,561 kcals

Penn State: [1,561 kcals * 0.96] + [8.5 VE * 31] + [36.9°C *167] – 6212 = 1,715

kcals/day

Estimated Energy Needs: 1,715 kcals/day

Protein Needs: 1.2-1.5 actual body weight (used because patient is critically ill)

Estimated Protein Needs: 85-107 grams of protein/day

Fluid Needs: 1,715 mL (1 mL/kcal)

Estimated Fluid Needs: 1,715 mL/kcal

Penn State Compared to Mifflin St. Jeor Mifflin St. Jeor (extubation

status) Estimated Energy Needs:

1,873 – 2,029 kcals/day

Estimated Protein Needs: 57-71 grams of

protein/day Estimated Fluid Needs:

1,873 – 2,029 mL/kcal

Penn State is more appropriate for calculating Mr. X’s estimated needs Ventilation settings Maximum body

temperature in the past 24 hours to determine if a fever is present or not

Current Diet Order and Feeding Modality Mr. X is currently receiving nutritional support through a PEG

tube with continuous tube feedings. Currently on Jevity 1.2 at 30 mL/hr with a goal rate of 65

mL/hr Jevity 1.2 at 30 mL/hr. provides 864 kcals and 42 grams of protein, meeting 50% estimated energy needs and 49% estimated protein needs.

The tube feed at goal rate of 65 mL/hr will provide 1,872 kcals and 87 grams of protein, meeting 109% estimated energy needs and 100% estimated protein needs.

Continuing to advance to goal rate and patient is tolerating at this moment

Parameter Normal Value Range

Patient’s Value (High or Low)

Reason for Abnormality

Nutrition Implication

Potassium 3.7-5.2 mEq/L 3.4 (L) Use of diuretics for treating high blood pressure6

When medically feasible, consume a diet high in

potassium rich foods to help increase potassium levels in the

blood and lower high blood pressure.7

Consume potassium

supplements either orally or through an IV drip.7

Glucose 70-110 mg/dL 128 (H) Stress response from injury6 Monitor blood glucose levels daily to ensure they do not

come within hyperglycemic ranges which can result in

slower healing and dehydration.7

AST 10-34 IU/L 42 (H) Cardiac arrest and lack of blood flow to the liver6

Consume a low-protein diet and avoid alcohol intake to improve

AST levels.7

Total Protein 5.9-8.4 g/dL 5.1 (L) Stress response from injury6 Total protein should be monitored as an indicator of the

healing process7

Albumin 3.5-5.2 g/dL 2.3 (L) Stress response from injury6 Though not used as a nutrition indicator, still monitor as an

indicator of the healing process.7

Medications (brand name & generic)

Used to treat? Mechanism of Action Nutritional Implications/Interactions

Ondansetron HCL (Zofran)

Used to treat nausea and vomiting caused by cancer drug treatment or after surgery8

Inhibition of serotonin 5-HT3 receptors in turn inhibits the visceral afferent stimulation of the vomiting center, likely at the level of the area postrema, as well as through direct inhibition of serotonin activity within the area postrema

and the chemoreceptor trigger zone.9

May cause constipation, diarrhea, or headache9

Can take medication with or without food9

May contain phenylalanine; those with phenylketonuria should not take this

medication.9

Clonidine HCL (Catapres)

Treats high blood pressure8 Stimulates receptors on nerves in the brain to reduce the transmission of messages from

nerves in the brain to nerves in other areas of the body. As a result, clonidine slows heart rate

and reduces blood pressure.9

May cause constipation, dry mouth, dizziness, or weakness9

Can take medication with or without food.9

Avoid or minimize alcohol intake because side

effects from drinking alcohol may worsen when taking this medicine.9

Hydralazine HCL(Apresoline)

Treats high blood pressure8 The precise mechanism of action of hydralazine is not fully understood, the major

effects are on the cardiovascular system. Hydralazine apparently lowers blood pressure

by exerting a peripheral vasodilating effect through a direct relaxation of vascular smooth

muscle9

May cause nausea, vomiting, loss of appetite, diarrhea, constipation, or dizziness.9



Can be taken with or without food9



Labetalol HCL(Normodyne)

Treats high blood pressure.8 Labetalol blocks receptors of the adrenergic nervous system. When labetalol attaches to and blocks the receptors, arteries expand, resulting

in a fall in blood pressure.9

May cause dizziness, nausea, vomiting, diarrhea, or constipation.9




Atorvastatin Calcium(Lipitor)

Treats high cholesterol.8 Prevents the production of cholesterol in the liver by blocking HMG-CoA reductase, an

enzyme that makes cholesterol.9

May cause diarrhea, upset stomach, confusion, dizziness, and tiredness.9

Avoid or minimize grapefruit juice because it

can increase blood levels of atorvastatin which can increase the risk of liver damage.9

Can be taken with or without food.9

Metoprolol Tartrate (Lopressor)

Treats high blood pressure.8 Blocks the action of certain natural chemicals in your body, such as epinephrine, on the heart and blood vessels. This effect lowers the heart rate, blood pressure, and strain on the heart.9







Benazepril HCL (Benazepril HCL)

Treats high blood pressure.8 ACE inhibitors such as benazepril lower blood pressure by inhibiting the formation of

angiotensin II, thus relaxing the arteries. Relaxing the arteries not only lowers blood

pressure, but also improves the pumping efficiency of a failing heart and thereby

benefits patients with heart failure.9





Chlorthalidone (Hygroton)

Treats high blood pressure.8 Reduces the kidneys' ability to hold on to salt and water and increases the kidneys' production

of urine (diuresis). It is used to eliminate excess salt and water from the body and to treat

high blood pressure.9





Docusate Sodium(Colace)

Treats occasional constipation and is often used when straining to have a bowel movement

should be avoided8

Reduces surface tension of the oil-water interface of the stool resulting in enhanced incorporation of water and fat allowing for

stool softening9

May cause diarrhea, nausea, stomach cramps, or throat irritation9

Take with a full glass of water9

Avoid consuming mineral oil as it leads to

mentioned side effects9



Polyethylene Glycol (Miralax)

Treats occasional constipation and is used in bowel preparation for colonoscopies8

Causes water retention in stool, producing a laxative effect9

May cause diarrhea, severe bloating, distention of the stomach, vomiting, nausea, lower

abdominal discomfort, or cramps9

Add powder to full glass of water, juice, soda,

coffee or tea.9

Doxazosin Mesylate (Cardura)

Treats high blood pressure8 Prevents norepinephrine that is released by nerves from binding to alpha-1 receptors on

smooth muscle surrounding blood vessels and in the prostate and bladder. By blocking the

effect of norepinephrine, doxazosin relaxes the smooth muscle.9





Physical Exam (per reports) Abdomen: soft, rounded, distended GI: active bowel sounds, but has diarrhea; last bowel movement

occurred on April 2, 2015; has a PEG placement for tube feedings Skin: no edema or wounds Eyes: can open his eyes but they are deviated to the right when

stimulated Oral: excessive secretions/drooling from one corner of his mouth Respiratory: artificially ventilated and has diminished inspirations and

expirations. There is a small amount of white, thick sputum present and he is having difficulty clearing these secretions.

Behavior: not oriented to his surroundings and has difficulty waking. He will respond to sternal rubs by opening his eyes but he cannot move any of his extremities.

Vital Signs: uncontrolled hypertension. His most recent blood pressure was 134/97 on April 2, 2015.

PES Statement Goal Intervention Monitoring Evaluation Inadequate energy

intake related to current TF regimen as

evidenced by TF meeting < 90% of

estimated energy needs.

Short-Term: Advance TF to goal rate

of 65 mL/hr.

Long-Term:Maintain weight within

2% throughout hospitalization.

Advance to goal rate of 65 ml/hr. to provide 1872

kcals and 87 grams of protein, meeting 109%

estimated energy needs and 100% estimated

protein needs

Increase to goal rate within 24 hours.

Meet 90-110% of estimated needs

Maintain weight within

2% throughout hospitalization

Short-Term: Tube feed goal rate of 65 mL/hr. is met within 24 hours, thus meeting 90-

110% of the patients estimated energy needs.

Long-Term:

Patient maintains weight within 2% throughout

hospitalization.

Inadequate oral intake related to mechanical

ventilation as evidenced by reliance on tube

feedings for nutritional support.

Short-Term: Advance TF to goal rate of 65 mL/hr to meet 90-

110% of estimated needs.

Long-Term:

Wean dependence on tube feedings once medically feasible.


2% throughout hospitalization.

Advance to goal rate of 65 ml/hr. to provide 1872

kcals and 87 grams of protein, meeting 109%

estimated energy needs and 100% estimated

protein needs

Increase to goal rate within 24 hours.

Meet 90-110% of estimated needs


2% throughout hospitalization

Short-Term:Tube feed goal rate of 65 mL/hr. is met within 24 hours, thus meeting 90-

110% of the patients estimated energy needs.

Long-Term:

Once medically feasible, initiate PO diet with clear liquids and advance diet

as tolerated.

Patient maintains weight within 2% throughout

hospitalization.

Prognosis (per reports) Mr. X is stable but unresponsive due to anoxic encephalopathy.

Neurology: grim prognosis due to brain damage caused by oxygen deprivation

Scheduled to receive a trach-collar and be weaned from mechanical ventilation Mifflin St. Jeor will be used to determine his estimated needs, once

extubated, which should be around 1,873 – 2,029 kcals/day and 57-71 grams of protein/day.

Tube feedings will remain unchanged because Jevity 1.2 at 65 mL/hr will provide 1,872 kcals and 87 grams of protein, meeting 100% estimated energy needs and 102% estimated protein needs

If Mr. X regains motor skills and the ability to feed himself, his needs will remain within Mifflin ranges and dietary intake will be closely monitored to determine if he can successfully meet his nutritional needs through a PO diet.

Literature Review

Lee HK, Lee H, No JM, Jeon YT, Hwang JW, Lim JY, Park, HP. Factors influencing outcome in patients with cardiac arrest in the ICU. International Journal of Anesthesiology and Intensive Care, Pain and Emergency Medicine. 2013; 57: 784-792.

Where: Seoul National University Hospital, Seoul, Korea Objective: Identify pre- and intra- arrest factors associated with survival 3 months after

CPR in ICU patients and to identify post-arrest factors associated with long-term survival in those who survived 24 hrs after CPR

Who: 131 ICU patients from Seoul National University Hospital who underwent CPR When: January 2009 – June 2010 Methodology: Data was collected retrospectively by one anesthesiologist and categorized

into pre- and intra- arrest variables. Pre-arrest variables included age, sex, location, probable cause of CPA, reason for ICU admission, APACHE II score, and Glasgow Coma Scale score. Intra-arrest variables included electrocardiogram rhythm at time of CPR, duration of CPR, response time, time to epinephrine injection, total dose of administered epinephrine, and body temperature prior to CPR. Neurological outcomes were measured in patients who survived 3 months after CPR was performed.

Results: Early enteral nutrition within 48 hours and maintenance of normoxia after return of spontaneous circulation was predictive of 3-month survival in patients who survived 24 hours after CPR. 22 out of 57 patients were started on early enteral nutrition; their survival rate at 1 and 3 months was 81.8%.

Applications: Early initiation of enteral feeding in critically-ill patients, such as those suffering from cardiac arrest, enhances the probability of survival and better quality of life.

Parikh M, Webb ST. Cations: potassium, calcium, and magnesium. Continuing Education in Anesthesia, Critical Care & Pain. 2012; 12: 195-198. Where: Cambridge, United Kingdom Objective: Inform the reader of the role potassium, calcium, and

magnesium play in the body and how too much or too little of these minerals can affect the human body.

Who: Educational article for the general public When: August, 2012 Summary: Potassium functions include heart and skeletal contraction,

thus, hypokalemia and hyperkalemia can cause cardiac arrhythmias and changes in electrocardiographic abnormalities. Calcium is responsible for exocrine, endocrine, and neurocrine function; hypercalacaemia can cause cardiac arrest, anorexia, nausea, vomiting, and constipation. Magnesium is involved in energy metabolism; hypomagnesium is directly correlated with hypertension, angina, and cardiac arrhythmias.

Applications: Maintaining appropriate mineral levels in critically-ill individuals can help ensure proper care throughout the patient’s hospital stay.

Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia? Resuscitations. 2014; 85: 1469-1472.

Where: Intensive Therapy Unit, Royal United Hospital, Combe Park, United Kingdom Objective: To determine whether patients undergoing therapeutic hypothermia following

cardiac arrest could tolerate early enteral nutrition. Who: 55 patients treated with therapeutic hypothermia following resuscitation from cardiac

arrest When: April 2006 – December 2010 Methodology: A single-centre longitudinal cohort analysis was performed. The therapeutic

hypothermia treatment was separated into three different phases: 24 hours at target temperature (32-34ºC), 24 hours rewarming to 36.5ºC, and 24 hours maintained at core temperature below 37.5ºC. Demographic information was collected from the local database; data on enteral feedings and body temperature were collected from nursing observation charts. Data extraction occurred when the patient reached the target temperature of 32-34ºC.

Results: During period 1,patients tolerated 72% of administered feed. During period 2, patients tolerated 95% of administered feed. During period 3, patients tolerated 100% of administered feed. Feedings are tolerated better as patients are rewarmed.

Applications: Understanding the proper feeding methods for patients undergoing specific treatments can enhances the probability of survival and better quality of life.

References 1. Cove Point Foundation. Systemic Hypertension. May 2011. Available at

http://www.pted.org/?id=syshypertension1, Accessed April 5, 2015. 2. Mayo Clinic. Diseases and Conditions: Osteoarthritis. January 2015. Available at

http://www.mayoclinic.org/diseases-conditions/osteoarthritis/basics/definition/con-20014749, Accessed April 5, 2015.

3. Mayo Clinic. Diseases and Conditions: Iron Deficiency Anemia. January 2015. Available at http://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/basics/definition/con-20019327, Accessed April 5, 2015.

4. Mayo Clinic. Diseases and Conditions: Sudden Cardiac Arrest. January 2015. Available at http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/definition/con-20042982, Accessed April 5, 2015.

5. Fausto J. Center to Advance Palliative Care. Prognosis of Anoxic-Ischemic Encephalopathy. January 2015. Available at https://www.capc.org/fast-facts/234-prognosis-anoxic-ischemic-encephalopathy/, Accessed April 6, 2015.

6. U.S. National Library of Medicine. Medicine Plus. February 2015. Available at http://www.nlm.nih.gov/medlineplus/, Accessed February 25 2015.

7. American Association for Clinical Chemistry. Lab Tests Online. Inside the Lab. January 2015. Available at http://labtestsonline.org/, Accessed February 25, 2015.

8. Canadian Institutes of Health Research. DrugBank. Drugs. January 2015. Available at http://www.drugbank.ca/drugs, Accessed February 24, 2015.

9. HealthLine Networks. HealthLine. Drug Interaction Checker. January 2015. Available at http://www.healthline.com/druginteractions, Accessed February 26, 2015.

http://www.pted.org/?id=syshypertension1

http://www.mayoclinic.org/diseases-conditions/osteoarthritis/basics/definition/con-20014749

http://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/basics/definition/con-20019327

http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/definition/con-20042982

https://www.capc.org/fast-facts/234-prognosis-anoxic-ischemic-encephalopathy/

http://www.nlm.nih.gov/medlineplus/

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http://www.healthline.com/druginteractions

References Cont. 10. Lee HK, Lee H, No JM, Jeon YT, Hwang JW, Lim JY, Park, HP. Factors influencing outcome

in patients with cardiac arrest in the ICU. International Journal of Anesthesiology and Intensive Care, Pain and Emergency Medicine. 2013; 57: 784-792.

11. Parikh M, Webb ST. Cations: potassium, calcium, and magnesium. Continuing Education in Anesthesia, Critical Care & Pain. 2012; 12: 195-198.

12. Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia? Resuscitations. 2014; 85: 1469-1472.

13. Adam. HWCRC. Health Illustrations. January 2015. Available at http://www.hwcrc.org/Health/illustrations%20of%20human%20anatomy/picture1.htm, Accessed April 6, 2015.

14. McKenzie County Healthcare Systems. Cardiac Arrest or Heart Attack? January 2015. Available at https://plus.google.com/+Mckenziehealth/posts, Accessed April 6, 2015.

15. Reyst H. Rainbow Rehabilitation Centers. Neuroplasticity after Acquired Brain Injury. February 2015. Available at http://www.rainbowrehab.com/neuroplasticity-aquired-brain-injury/, Accessed April 6, 2015.

http://www.hwcrc.org/Health/illustrations%20of%20human%20anatomy/picture1.htm

https://plus.google.com/+Mckenziehealth/posts

http://www.rainbowrehab.com/neuroplasticity-aquired-brain-injury/

Documents

Intensive Care Unit: Cardiac Arrest – A Case Report Pamela C. Vickers Candler Hospital: Dietetic Internship Clinical Rotation Georgia Southern University