Question

Nutrition Support of the Critically Ill Trauma Patient

Lab Assignment

Pt is a 25 year-old man admitted to the ER secondary to multiple gunshot wounds to the left flank, right buttock, and right thigh. He was taken to the operating room for an exploratory laparotomy, extensive lysis of adhesions, small bowel resection, repair of the third portion of the duodenum, and repair of the duodenal wall. Pt is transferred to ICU. TPN will be initiated rather than enteral feedings due to the patient’s hemodynamic instability. A jejunostomy tube is placed. The RD is consulted for an initial assessment.

The patient was intubated and sedated. Some diet history was given by his mother. On hospital day 10 his WBC count was elevated and he presented with a fever. Abdominal distention was noted and he was taken back to the operating room. He had an abscess in the right upper quadrant area which was drained. Day 15, enteral feeding was initiated.

Biochemical Data upon admission (Which are high, low and normal?)

Na+ 139 mEq/L

K+ 3.9 mEq/L

Chloride 111 mEq/L

CO2 25 mEq/L

BUN 20 mg/dL

Creatinine 0.8 mg/dL

Glucose 115 mg/dL

Hemoglobin 9.5 g/dL

Hematocrit 29%

Phosphorus 4.0 mg/dL

Albumin 2.2 g/dL

Prealbumin 9.8 mg/dL

Alkaline phosphatase 66 U/L

Aspartate aminotransferase 24 U/L

Alanine transaminase 30 U/L

Triglycerides 130 mg/dL

Anthropometrics:

Height 182.9 cm

Weight 96.8 kg

UBW 86 kg

Nutrition-focused physical findings:

No obvious signs of nutrient deficiencies

Social History:

Lives with mother and two younger siblings

                                             

Food/Nutrition-Related History:

Patient’s mother reports that her son does not follow any special diet. NKFA

Questions:

1. Which weight would you use to determine his calorie needs and why?

2. Determine the patient’s initial calorie and protein requirements. What is your recommendation for grams of protein, dextrose and lipids?

3. What is the reason why his albumin and prealbumin levels are lower than normal? Before admission, he was well-nourished.

4. Which type of enteral formula would be appropriate to recommend for this patient?

5. The patients prealbumin dropped from 9.8- 8.0 in one week. The TPN formula was providing 2.0 g/kg of body weight per day. Should you adjust the protein goal for the enteral feeding? What other lab test can be done to help you determine if more protein is justified?

6. What is another way to determine if your nutrition prescription for enteral or parenteral nutrition is meeting his needs?

7. Recommend a goal rate for the enteral feeding. Include total calories, grams of CHO, protein, and fat.

8. Would you recommend continuous, intermittent, or bolus feedings? When should the TPN be discontinued?

9. The patient was receiving continuous jejunal tube feeding at a rate of 50 mL/hour, gastric residuals were noted to be 100 mL/hour. Is this an indication of an intolerance to the feeding?

10. Identify an appropriate nutrition diagnosis for this patient, write two PES statements

11. What are some nutrition-related outcomes you would like to see for this patient?

Answer 1

Normal values

serum sodium, potassium, glucose, creatinine, phosphorus, alkaline phosphatase, aspartase amino transferase,alanine transaminase, triglycerides, carbondioxide

High values

Chloride - 111 mEq/L( normal value- 90-106 mEq/L)

Low values

Albumin-2.2 g/dL (normal 3.4-5.4 g/dL), Prealbumin- 9.8 mg/dL (normal 15-36 mg/dL),Hematocrit-29%( normal 41-50%), Hb-9.5g/dL ( normal 13.5-17.5 g/dL)

1. UBW or Usual Body Weight : the body weight value used to compare the patient's current weight with his or her own baseline weight. This is the weight the client weighed most of his adult life time . This is a crucial piece of information because most of the adults never weighed within their ideal body weight . Hence , for this patient his UBW 86 kg should be used to determine his calorie needs

2. The recommended dietry allowance (RDA) for energy is about sedentary men 40 Kcal/Kg so his energy requirement=3440 Kcal per day. Moderately active men-48 Kcal/kg, heavy activity= 63 Kcal/kg

RDA for protein is based on 1g/kg body weight.It does not vary with activity, so his protein requirement= 86 g/day

Fat 20 g/day

3.Most of the protein digestion takes place in duodenum. By the time food reaches jejunum almost all the proteins are absorbed Protein digestive enzymes are mainly secreted by the mucosal lining of duodenal wall. In this scenario, he underwent small bowel resection with duodenal wall repair which impairs protein absorption. Because of impaired protein absorption he has low albumin and pre-albumin value