CASE STUDY #1 - MPEmily SchlictmanB10ISpring 2016

PATIENT DEMOGRAPHICS 41 y.o. Haitian Female Language – Primary: French Creole, Secondary:

English Pt profile: 5’4”, 260# Lives in an apartment with significant other; 4

children Unemployed Wears glasses Baptist No known food allergies Never a smoker, no reported alcohol use, no illicit

substances Allergies: metformin

PAST MEDICAL HISTORY Peripartum cardiomyopathy (2013) CHF HTN DM - uncontrolled Hyperlipidemia, Hypertriglyceridemia Obesity Obstructive Sleep Apnea Asthma Acute hypoxic and hypercapnic respiratory failure Pulmonary edema GERD

MEDICAL HISTORY 01/17/16 – 01/24/16 : Backus Hospital Admitted for respiratory failure Intubated in the field At hospital: severe hypoxic and hypercapnic

respiratory failure with pulmonary edema Ejection fraction of 40%, Atrial fibrillation,

possible aspiration PNA Persantine MIBI: EKG normal, small reversible

lateral wall perfusion defect NG in place at some point

HH ADMISSION DIAGNOSIS: S/P VFIB/VT ARREST On 2/22 evening: pt had SOB, chest

discomfort, called EMS Upon EMS arrival, MP unconscious with heart

rate in 200s and lost pulse CPR initiated and 1 mg Epi given ROSC w/n 2 minutes, sent to Backus

At Backus, pt was intubated and then transferred to HH for therapeutic hypothermia

THERAPEUTIC HYPOTHERMIA Therapy to minimize hypoxic brain injury

after return of spontaneous circulation after cardiac arrest Brain death can occur 4-6 mins after cardiac

arrest Return of circulation associated with free radical

formation, leading to cell necrosis Hypothermia preserves tissue, decreases

intracranial pressure, decreases cerebral metabolic rate, and decreases cerebral oxygen demand

THERAPEUTIC HYPOTHERMIA Four phases:

Induction phase: normal temperature 32-34C w/n 4 hours

Maintenance phase: maintain 32-34C for 24 hours

Re-warming phase: 32-34C 38C at rate of 0.35C- 0.50C/hr

Post warming phase: maintain 37C for next 36 hrs

ICY catheter connected to CoolGard cooling device

No fluid infusion

HOSPITALIZATION COURSE 2/23 – admitted, in therapeutic hypothermia,

Nutrition consult 2/24 – Nutrition f/u 2/26 - Nutrition f/u 2/27 – Pulmonary consult, pt self- extubated 2/28 – SLP swallow evaluation 2/29 – Electrophysiology consult, Nutrition f/u 3/01 – Endocrine consult 3/02 – Nutrition f/u with DM and low sodium

education 3/03 – Wound Care consult

NUTRITION CONSULT 2/23 D/t therapeutic hypothermia protocol, automatic

consult received Bed scale wt: 260.1 MP sedated on propofol, intubated w/ OGT in place Baseline TG levels elevated (189), must monitor

d/t propofol FSBS very uncontrolled: 247-305 x12 hrs, likely d/t

clinical status and history of diabetes No elevation in cardiac enzymes by noon on 1st

day of admission

NUTRITION CONSULT 2/23 Nutritional Needs:

Based on ASPEN Critical Care Nutrition guidelines for BMI > 30

Kcal based on ABW (117.9kg) and protein based on IBW (54.5kg)

Kcal: 11-14 kcal/kg = 1300-1650 kcal/day Protein: 2-2.5g protein/kg = 108-130 g

protein/day Water: 20 ml/kg = 2300 ml/day

Nutritional Diagnosis: Inadequate oral intake related to decreased

ability to consume sufficient energy as evidenced by NPO/intubated

NUTRITION FOLLOW UP 2/24 Pt was still intubated, NPO, and on

hypothermic therapy, to begin the warm up process

FSBS: 69-322 x 24 hrs Still no increase in cardiac enzymes Propofol running at 53.1ml/hr, providing 1401

kcal/day, meeting pt minimum calorie needs If MP was not extubated, plan to start enteral

feeding via OGT once warmed up

NUTRITION FOLLOW UP 2/24 Nutrition needs remained the same Nutrition diagnosis changed from inadequate

oral intake to inadequate protein - energy intake as pt was NPO and intubated New diagnosis: Inadequate protein – energy

intake related to decreased ability to consume sufficient energy and/or protein as evidenced by estimated energy intake less than estimated levels/ NPO

NUTRITION FOLLOW UP 2/24 Intervention: Recommendations for

appropriate TF or PO diet If extubated and able to consume PO diet: 75 g

CHO, 2g Na, low cholesterol/low saturated fat TF: Impact Peptide 1.5

Pt receiving 1401 kcal/day from Propofol, did not want to overfeed If continue on Propofol: 10 ml/hr ATC (360 kcal/day) If d/c propofol: 45 ml/hr ATC (1620 kcal/day) Free water flush every four hours for tube patency

Evaluate lactate, mean arterial pressures, and body temperature

NUTRITION FOLLOW UP 2/24 Monitoring and Evaluation

Formula rate and flush Weight Gastric residual volumes, when TF started Glucose Triglycerides

High level of risk

NUTRITION FOLLOW UP 2/26 Pt still intubated, completed hypothermia

therapy, working on vent weaning EEG was noted to be negative for seizures

and MRI head scan negative for acute findings

Propofol rate reduced to 24.8 ml/hr, providing 654 kcal/day

TF was started and running at rate of 40ml/hr at that time, providing 1440 kcal/day Blood sugars were fairly well controlled (133-

204x24 hrs), PC02 normal, and was maintaining hydration

NUTRITION FOLLOW UP 2/26 Previous nutrition diagnosis of inadequate

protein energy intake is resolved because TF was meeting estimated needs

Intervention: Continue TF with goal rate adjusted on Propofol until at 45ml/hr or recommend 75g CHO/meal, 2g Na+ diet, low cholesterol/low saturated fat

Monitoring and Evaluation: Formula, flush Weight Gastric residual volume Glucose Triglycerides

NUTRITION FOLLOW UP 2/29 Pt was transferred from ICU to SDU, alert, self-

extubated 2 days prior MD added Lantus as her blood sugars were still

elevated (152-320 x 24 hrs) SLP evaluation (2/28) indicated pt can tolerate

regular diet consistency with thin liquids Newly documented Stage 2 PU on posterior neck Updated wt: 25# loss r/t fluid status and diuresing New nutritional needs since no longer critically ill

and new wt 2/2 to diuresing (106 kg) 20-25 kcal/kg, 1.2 -1.5 g protein/kg, 20 mL water/kg

NPO for cardiac catheter, stated she was hungry Able to speak to pt at bedside

NUTRITION FOLLOW UP 2/29 Pt was able to tell me about food dislikes and she

cooks her food at home (sometimes with salt) Updated nutrition diagnosis: Altered nutrition related

laboratory values, plasma glucose, related to endocrine dysfunction as evidenced by elevated plasma glucose over course of stay.

Intervention: Carb control 75gm, 2gNa+, low cholesterol/low saturated fat, MVT

Monitoring and Evaluation: Amount of food Weight Glucose Skin (Stage 2 PU)

ENDOCRINE CONSULT 2/29 Pt reporting taking more insulin at home than

getting at hospital, MD questions pt compliance at home, states pt follows up with endocrinologist at Backus

Determined her Lantus and Humalog doses should be increased and will have correction scale coverages with meals, at bedtime, and at 3 a.m.

OTHER CONSULTS 2/29: Cardiac catheter results indicate mild

diffuse nonobstructive coronary disease, EF 55%, increased left ventricular end diastolic pressure

3/1: Electrophysiology notes since there was no EKG at time of arrest, unclear etiology; awaiting cardiac MRI; her EF has now recovered but she does have diastolic dysfunction; no indication for defibrillator at this time

NUTRITION FOLLOW UP 3/2 Pt on NCS, 2gNa+, Low saturated fat/ low

cholesterol diet FSBS: 177 -250 x 24 hrs Intake has been adequate, 50-100% of all

meals consumed since on PO diet MP went for cardiac MRI but became anxious at

start of procedure, was unable to complete test Sat with pt and educated about diabetes and

low salt diet with resources from NCM Referred to DLC for continued education and long

term management Pt was asking questions, making eye contact,

nodding head

INTERIM DISCHARGE SUMMARY – 3/2 MD thinks it’s more likely PEA arrest instead of VT/VF

PEA from hypoxia and maybe CHF acute decompensation Acute on chronic heart failure – still being diuresed on Lasix CAD – on aspirin HTN – on Lisinopril and Coreg Paroxysmal Atrial Fibrillation – on Xarelto Asthma – Breo, PRN DuoNeb Obstructive Sleep Apnea – BiPAP at bedtime, no O2 during

day, may need another sleep study before d/c Acute Hypoxic Respiratory Failure – resolved T2DM – being followed by Diabetes Service Constipation Plan: to transition to medical floor today, have MRI

completed, then transition to home when able

MEDICATIONS 3/3 Carvedilol – blood pressure Lisinopril – blood pressure Duoneb Neb Soln – PRN for SOB Docusate Sodium – constipation Miralax Powder – constipation Miconazole Powder – topical Protonix – prophylaxis Tylenol – PRN Chloraseptic spray – for throat, most likely r/t self- extubation Maalox Plus – PRN for GI upset Breo Inhaler Insulin – Humalog and Lantus Xarelto – A fib Lasix – d/t to high left ventricular pressure Ativan – to reduce anxiety before cardiac MRI 2nd attempt

UPDATE 3/4 Pt still on floor care, awaiting MRI scan Wound care evaluation noted pressure ulcer

on neck to only be abrasion MP ready to get home

REVIEW OF LITERATURE

Descriptive study to examine whether early enteral nutrition is tolerated by hypothermic patients following cardiac arrest

BACKGROUND National Institute for Health and Care Excellence

identify critically ill patients as at risk of malnutrition due to inadequate oral intake, poor gastrointestional absorption or increased nutritional requirements

Early enteral feeding advocated in many cases Recommendations for patients undergoing

therapeutic hypothermia are less clear Some authors advise nutrition should not be provided

during therapy at any phase Other authors imply nutrition can be provided but a

reduced volume

BACKGROUND Ischemic injury initiates cascade of free radicals

on reperfusion, which can exacerbate tissue injury During cardiac arrest, severe intestinal ischemia

occurs, causing translocation of bacteria and endotoxins and early intestinal dysfunction ensues

Critical illness and hypothermia reported to delay gastric emptying and decrease peristalsis, both contributing to intolerance of enteral feed

No published data addressing tolerance of enteral feed by patients undergoing TH after cardiac arrest

METHODS Setting: single mixed ICU in a district general

hospital in United Kingdom between April 2006 and December 2010

Pt exclusions: pre-existing internal bleeding, pregnancy, established multi organ failure, severe systemic infection

All pts sedated with propofol and alfentanil until return to normothermia

Enteral formula was Nutricia Nutrison standard and delivered via continuous pump 1 kcal/ml, 40g protein/1000ml, low lactose, MCT oil

METHODS Retrospective access to nursing notes and EMR,

identified 55 pts Had to have core temperature </= 34C, Glasgow coma

score <8, records of CPR, underwent TH, and completed 72 hr period of TH

Volume of enteral feed delivered was recorded as: volume administered – discarded residuals Some pts had large gastric residuals that exceeded

volume of enteral feed given, which were included as it couldn’t be determined if was formula, bile, or mixture

The volume of formula tolerated during each of three phases was recorded Failure to tolerate was assumed if volume of gastric

residuals exceeded volume delivered or it patient vomited

RESULTS Sample: 55 pts, 20-85 y.o. (median 68), 35 males, 20

females All patients fed nasogastrically No correlation between volume of formula tolerated and age

or gender

1 (cooling) 2 (rewarming) 3 (normothermia)0

5

10

15

20

25

30

35

40

45

50

43 43 43

9 9

4

ToleratedNegative gastric aspirates

Phases

Num

ber

of p

atie

nts

RESULTS

DISCUSSION At core temperatures of 32-34C during Day 1, pts

tolerated median of 72% of administered tube feed, which was ~10ml/hr or 240 kcal/day Five pts vomited 1/5th of pts produced gastric residuals that exceed input

During rewarming, most pts tolerated almost all of their feed 10 pts vomited 1/5th of pts still had high gastric residual volumes

Suggests pts are intolerant of feeding at this time

DISCUSSION Underfeeding limits the benefits of early enteral

feeding In this population at this hospital, the feeding protocol

was noted to not be followed as strictly Many nursing staff provided TF at reduced rate and

few appropriately increased the rate by 30 ml when residuals were minimal Unable to evaluate tolerance to higher volume reliably

LIMITATIONS Study was retrospective, no control over feeding

practices No way of knowing whether the formula was

actually absorbed No data on other variables like PMH or technique

used when aspirating gastric contents Alfentanil for sedation may also have reduced

tolerance to enteral feeding Still need to understand metabolic requirements

of cooled patients

STUDY CONCLUSION Most post cardiac arrest patients treated with

TH tolerate a least a proportion of administered formula and is better tolerated as patients are rewarmed

Reduced rate should be considered when pts are at target temp of 32-34C and increased incrementally once temp has increased to normal

Earlier, routine use of prokinetics may improve the tolerance of larger volumes of formula

REFERENCES Williams, Marie-Louise, and Jerry P. Nolan. "Is

enteral feeding tolerated during therapeutic hypothermia?." Resuscitation 85.11 (2014): 1469-1472.

WHAT I WOULD DO DIFFERENTLY If there was more time, continue DM

education Use visuals and food models

Follow up on diet order sooner after her cardiac catheter to make sure she was on proper diet

QUESTIONS?