Question

Name: Fahad B                                  Word: Medical                       Bed: ICU bed #9

Age: 57 years                                     Physician: Mona, Khaled (unit A)

Fahad is a fit and healthy consultant surgeon. He arrived by ambulance to the ER unconscious after having a seizure in his house after a long sentry duty in the same hospital.

His wife reported that he experienced incomprehensible symptoms in the last two months like continues headaches, strange feeling in his head, imperiled vision, difficulty to recall his patient and colleges names and general weakness specially in his hands. Fahad was known of his linguistic ability but these days he lost the right words.

Neurosurgeon did MRI and found a big malignant Grade I (brain tumor). They put him under surgery and sedate him after that in the ICU by using benzodiazepines, opioid narcotics and propofol for 5 days to help him recovery. In the ICU the medical team monitor him closely. The ICU dietitian decided to start enteral nutrition as soon as possible. So, a gastrointestinal tube was fixed immediately.

Diagnosis:                   Malignant Grade I

Medical plan:             Brain surgery to remove the tumor followed intubation and sedation for 5 days. Radiation therapy is planned to be after the assessment.

Medical history:         No medical history

Smoking:                    Heavy smoker 3 backet/day   

Medication:                None  

Family history:          Mother (Breast cancer and Diabetes)

Marital status:           Married with 2 kids

           

Physical examination:

Abdomen:      Normal                       

Chest/lungs: Clear   

Skin:               Soft, normal bowel sounds, no-tender           

Edema:           Brain edema around the skull

Stool:             No

Urine:             Normal

Edema:           -ve      

Vital signs:

BP:                  140/80

Pulse:              70

Temperature:                                                37.2 ^OC

Height:                                                182 cm

Usual weight:                                     82 kg

Last weight before surgery:             79kg

Current weight after surgery:         unknown

Biochemical lab test (after surgery):

Chemistry
Glucose	18	20	15	5.6 to 6.9 mmol/L
HbA1C (%)	5.2			<5.7
Creatinine	0.9			0.6-1.2 mg/dL
Urea	5.3			2.5 to 7.1 mmol/L
BUN	11			7-18 mg/dL
Potassium	4.3			3.5-5.3 mEq/L
Phosphate	2.38			2.5-4.5 mg/dL
Sodium	138			133-143 mEq/L
Chloride	100			98-108 mEq/L
Calcium	10.5			9-11 mg/dL
Albumin	4.7			3.5-5.8 g/dL
WBC	3.2			4.5-11 x109/L
Platelets	200			150,000-450,000 microliter
Neutrophils	6			3–7 x 109/L
RBC	5			4.8-9.3 x109/L
Hb	12			12-16 g/dL
Hct	40%			36-46%
Ferritin	21			20-120 (mg/mL)
MCV	88			80-100 fL
CRP	2			<3 mg/L
Fibrinogen	230			150-400 mg/dL
ESR	20			0-22 mm/hr
Cholesterol	170			<200 (mg/dL)
LDL	110			<130
HDL	55			>59
Triglycerides	110			35-135 (mg/dL)

24hours recall (usual menu before diagnosis with cancer):

Breakfast: 1 cup Americano + 1 protein bar

Snack: 1 orange juice
Lunch: 1 cup laban+ 1 cup rice + grilled meat or chicken of fish +Dagoos (tomato sauce) + green salad (olive oil + lemon dressing)

Snack: 300ml Arabic coffee + 5 Dates

Dinner: 1 cup low fat yogurt + protein chips

Questions: (100 points)

1. What is the metabolic response to critical illness in human body? (10 point)

2. Write a PES statement according to his nutrition statues. (9 point)

3. Determine Mr. Fahad energy and protein requirements consider his stress and activity level. (Use BMR) (13 point)

4. Mr.Fahad can’t consume food while he is intubated, if you have 4 options of nutritional formulas, which one you would use and why? (10 point)
   1. Nutrition dense like Jevity (energy 1.5 Kcal/ml- protein 15g/235ml)
   2. Standard like Ensure (energy 1 Kcal/ml – protein 9g/220ml)
   3. Immune enhancing like Impact (energy 1 Kcal/ml- protein 14 g/250ml)
   4. Diabetes formula like Glucerna (energy 1 Kcal/ml- 9.9g/237ml)

5. How many cans (250ml) you will give Fahad in the nasogastric tube in 24h? (6 point)

6. What is the flow rate you will set the electronic pump on, in the first 48hr after surgery? (6 points)

7. Mr.fahad is intubated after surgery, what are the signs you have monitor to check his gastrointestinal tolerance. If you suspect a low tolerance how would you check it in the ICU? (10 points)

8. Mr. Fahad is not diabatic, what is the reason for the high blood glucose level? (10 points)

9. Radiation therapy is prescribed to Mr. Fahad, it known by its gastrointestinal side effects, list the effect and chose two side effect and write how to minimize it effect on him. (12 point)

10. If Mr.Fahad faced problem in breathing after the surgery and he is connected to ventilator, and his maximum temperature was 38.3C and his ventilation recorded is 10L/min. calculate Mr.Fahad energy needs by using penne state equation. (6 point)

11. In the recent year’s formula companies added omega-3 fatty acids, arginine, glutamine and antioxidants to the formula to promote healing after surgery. discuss what are the benefits? (8 point)

Answer 1

Answer: Metabolic response to Critical illness to human body

1)The Critical consequences of the metabolic response to stress include sequential changes in energy expenditure,stress hyperglycemia,changes in body composition,and psychological and behavioral problems.The loss of muscle proteins and function is a major long-term consequence of stress metabolism.

2) PES statement

Problem.

Mr Fahad is intubated after surgery,sedated,unable to consume  normal diet. So gastrointestinal tube was fixed.He is having stress induced hyperglycemia

Etiology: Tumor induced stress affects blood glucose levels

Symptoms: High blood glucose level

3) Mr Fahad nutritional formula to be choose is: (d)

Diabetes formula like glucerna(energy 1Kcal/ml-9.9g/237 ml).High risk ICU patients,both diabetes-specific formula lowers insulin requirements,improved glycemic control and reduce the risk of acquired infections relative to standard formula.

4)The reason for the High blood glucose level fo Mr.F ahead is due to the metabolic response to stress due to his Critical illness.