clinical case report: nutrition management for left aspect ......8. mahan l, escott-stump s, raymond...

Clinical Case Report:Nutrition Management for

Left Aspect Medulla Oblongata Infarction

Alisha MukadamARAMARK Dietetic Internship

Lafayette General Medical Center December 19, 2016

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http://www.youtube.com/watch?v=Mkp_hxZCE7k

Disease Description

❏ Also known as Wallenberg Syndrome❏ A rare condition in which an infarction (stroke) occurs in

the lateral medulla. ❏ The lateral medulla is a part of the brain stem. ❏ Oxygenated blood does not reach to the medulla when

the arteries that lead to it are blocked. ❏ A stroke can occur due to this blockage. This condition is

also sometimes called lateral medullary infarction.

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Disease Description: Etiology

❏ It's not known what initially causes Wallenberg's syndrome.

❏ However, some researchers have found a connection between people who have the syndrome and who have peripheral artery disease, heart disease, blood clots, or minor neck trauma.

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Disease Description: Epidemiology

❏ Rare Disease❏ Affects less than 200,000 people in the US❏ Overall occurrence of Wallenberg’s Syndrome is not very

well documented.

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Disease Description: Pathology

Since there is no cure for Wallenberg's syndrome, treatment usually involves relieving the symptoms a person is experiencing, which may include the following:

❏ A feeding tube to help with swallowing complications❏ Speech therapy to help with talking and swallowing❏ Medication to help alleviate pain, such as the anti-epileptic

drug gabapentin (Neurontin)❏ Blood thinner medication, such as heparin or warfarin, to

help reduce or dissolve the blockage in the artery

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Disease Description:Clinical Signs and Symptoms

❏ Difficulty swallowing (dysphagia)

❏ Hoarseness❏ Nausea❏ Vomiting❏ Hiccups❏ Difficulty Walking &

Maintaining Balance (ataxia)

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Case Presentation64 year old African American male was admitted to the hospital from the Emergency Room for shortness of breath, respiratory failure with an O2 saturation of 84%, and dizziness.

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Diagnoses: 1. Left aspect medulla

oblongata infraction2. Thyroid Mass3. GI Bleed4. Severe Dysphagia with

tracheal aspiration5. Sepsis 2/2 Pneumonia6. Ataxia

Nutrition Care Process

❖ Assessment

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Client History

Medical History: ❏ Pt has not seen a PCP

in over 30 years❏ HTN

Social History:❏ Drinks alcohol socially

once in a month ❏ Smokes 1 ½ - 2 packs

of cigarettes a day 10

Food and Nutrition Related History: ❏ N/A

Anthropometric Physical Findings

❏ Height: 167 cm, 5 ft 6 in

❏ Weight: 94.04 kg, 207 lbs

❏ Body Mass Index: 33.72 kg/m2

Obese Class 1- BMI: 30.0 - 34.9

❏ Usual Body Weight: 95.45 kg, 210 lbs11

Biochemical Data

Abnormal Laboratory Values Upon Admission

Patients Value Normal Value

BUN 22.0 mg/dL 7-18 mg/dL

Creatinine 1.38 mg/dL 0.6-1.3 mg/dL

Calcium 8.0 mg/dL 8.5-10.2 mg/dL

RBC 4.60 x10/mcL 4.7-6.1 x10/ mcL

Hgb 11.8 gm/dL 13.5-17.5 gm/dL

Hct 35.0% 38.8-50%

Chloride 110 mmol/L 96-106 mmol/L

Sodium 146 mmol/L 136-145 mmol/L

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Medical Tests and Procedures

❏ PICC Line ❏ PEG Tube Placement❏ Urine analysis❏ Upper GI Endoscopy❏ Esophagram❏ Barium Swallow Study❏ MRI of the Brain❏ CAT scan of the thorax❏ CT of the soft tissue neck❏ MRA of the head and neck❏ 2-D Echo ❏ MRA of the head and neck

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Nutrient Needs

Nutrient Estimated Needs

Formula Used

Calories 2181 kcal/day Mifflin St Jeor 1677 x (stress factor 1.3)

Protein 109 grams/day 20% of total calorie requirement

Fluid 2363 mL/day 25 mL/kg

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Initial Assessment

❖ Continuous nausea and vomiting❖ Spots of blood in vomit❖ Hoarse from vomiting and has a burning throat❖ Labs, BUN (45 mg/dl) and Creatinine (3.37 mg/dL) were

elevated.

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Initial Assessment

Test Results:

❖ CT of the Thorax showed moderate wall thickening of the entire esophagus

❖ Electrocardiogram identified severe inflammation of the esophagus.

❖ MRI confirmed nonhemorrhagic medulla oblongata infraction.

❖ Per Speech Therapy, patient continues to present with dysphagia and remains unsafe for PO intake.

❖ Esophagram supported tracheal aspiration per SLP.

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Aramark Nutrition Care LevelInitial Assessment (11/3/16)

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Nutrition Care Indicator Category Priority Points

Nutrition/Diet Order or anticipated NPO > 4 days (4 points)

Weight Status BMI. 33.72 (0 points)

Primary Diagnosis/Contributing Condition

Sepsis (4 points)

Energy Intake <=50% of estimated energy requirements for >/ 5 days (points 4)

Interpretation of weight loss 1-2% in 1 week (3 points)

Total points: 15 points High Risk

Follow up #1

❖ Patient unable to swallow 2/2 to stroke. ❖ Modified Barium Swallow: Result: NPO, severe dysphagia

with tracheal aspiration. PEG recommended.❖ Patient refusing PEG

➢ Personally witnessed living life with a PEG tube.➢ Father-in-law did not enjoy his life because of the

adversities he faced ■ Pain and daily flushing and cleaning of tube.

Patient did not want PEG tube to hinder his ability to take part in everyday life.

❖ Clinimix Started

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Aramark Nutrition Care LevelFollow up # 1 (11/7/16)

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Nutrition/Diet Order or anticipated New Parenteral Nutrition (Clinimix 4.25%/10% + IV IntraLipids) (4 points)



Sepsis (4 points)

Energy Intake <=50% of estimated energy requirements for >/ 5 days (points 4)



Follow up #2

❖ Hiccups for 2 days❖ Agreed to PEG- Big thank you to his wife!

❖ TPN Consult Received❖ PICC Line inserted

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Nutrition/Diet Order or anticipated New Parenteral Nutrition (TPN) (4 points)



Sepsis (4 points)

Energy Intake (0 points )



Follow up #3

❖ PEG tube endoscopically: unsuccessful

➢ thick endometrial lining

❖ TPN was started

❖ 2nd Attempt: PEG placement surgically placed:

Successful.

❖ Enteral Feeding Started; TPN Discontinued

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Nutrition/Diet Order or anticipated New Enteral Nutrition (Jevity 1.2 cal @ 75 mL/hr.) (4 points)



Sepsis (4 points)

Energy Intake Meeting greater than 75% of needs (0 points )



Malnutrition IdentificationDegree of Malnutrition:

Non-Severe (moderate) Malnutrition

1. Pt has been NPO for 5 days

2. 1-2% weight loss in 5 days

3. Fat wasting in tricep region and orbital region

4. Muscle wasting in temporal region

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❖ Nutrition Diagnoses

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1) Acute disease or injury related malnutrition related to stroke resulting in dysphagia as evidence by mild muscle and fat wasting, 1% weight loss in the past 5 days, and meeting </=50% of estimated energy for >/= 5 days.

2) Altered nutrition-related laboratory values related to GI bleed as evidence by medical dx and decreased hgb/hct.

Initial Nutrition Diagnoses:PES Statements

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❖ Intervention

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1. Advance to GI Soft- low residue diet when medically appropriate per MD and SLP rec’s

2. Recommend Clinimix 4.25%/10% + IV IntraLipids 20% @ 83 mL/hr. This will provide the pt with 1515 calories (69% of needs), 85 grams of protein (78% of needs), and 1992 mL of fluids (84% of needs).

3. If patient agrees to NG/PEG tube feeding use the following recommendations:

Osmolite 1.2 cal @ 20 mL/hr increasing slowly to goal rate of 75 mL/hr. This will provide the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 mL of fluid (62% of needs). 28

Medical Intervention

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❏ Consultations:❏ GI ❏ Neurology ❏ Speech Therapy❏ Physical Therapy❏ Surgery

❏ Rehydration

Goals

Short Term Goals:

❏ Meet at least 75% of nutritional needs through Parenteral Nutrition (Clinimix)

❏ Maintain Weight throughout Hospitalization❏ If patient continues to refuse Enteral Nutrition, advance to

TPN and meet a 100% of nutritional needs.

Long Term Goals:

❏ Meeting a 100% of needs through PEG placement and Enteral Nutrition

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❖ Monitoring and Evaluation

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❏ Tolerance and rate of PPN/EN support were monitored during every follow up.

❏ Laboratory values and electrolyte were closely monitored and addressed if abnormal.

Monitoring & Evaluation

Conclusion

Pt was discharged to home health with a PEG tube on enteral nutrition of Osmolite @ 75 mL/hr. This provided the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 mL of fluid (62% of needs).

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Question 1

What syndrome does this patient have?

FREE RESPONSE

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Question 2

Wallenberg affects ….

a. more than 200,000 people in the worldb. less than 200,00 people in the worldc. None of the above

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Question 3

___________ and ________ needs to be monitored to check TPN tolerance

a. Triglyceridesb. Sodiumc. Phosphorus d. Glucose

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What could have been done differently with this patient’s nutrition intervention?

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Question 4

Did you learn anything new or interesting from this case study?

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Question 5

References1. Oshima F. Dysphagia with lateral medullary infarction (Wallenberg’s syndrome). Rinsho Shinkeigaku.

2011;51(11):1069–1071. doi:10.5692/clinicalneurol.51.1069.

2. Kwon M, Lee JH, Kim JS. Dysphagia in unilateral medullary infarction: Lateral vs medial lesions. Neurology.

2005;65(5):714–718. doi:10.1212/01.wnl.0000174441.39903.d8.

3. Cassata C. Cathy Cassata. http://www.everydayhealth.com/wallenbergs-syndrome/guide. Accessed January 19,

2017.

4. Kinman Medically T. Wallenberg syndrome. http://www.healthline.com/health/wallenberg-syndrome. Accessed January 19, 2017.

5. Wallenberg syndrome . National Institutes of Health. https://rarediseases.info.nih.gov/diseases/9263/wallenberg-syndrome. Published March 12, 2012. Accessed January 14, 2017.

6. PEARCE J. Wallenberg’s syndrome. Journal of Neurology, Neurosurgery, and Psychiatry. 2000;68(5):570. doi:10.1136/jnnp.68.5.570.

7. http://www.csun.edu/~lisagor/Fall%202012/NutritionCareProcess.pdf8. Mahan L, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process. St. Louis, MO: Elsevier

Saunders; 2012.9. Madsen H, Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Practical

Gastroenterology. 2006;30(7): 46-68.10. Definition of Terms List. Academy of Nutrition and Dietetics’ Web site.

http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/definitionoftermsashx. Updated August 2012. Accessed January 13, 2016.

11. Hui K, McCauley S. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. Journal of the Academy of Nutrition and Dietetics. 2013;11 3(6):S17-S28.

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http://www.csun.edu/~lisagor/Fall%202012/NutritionCareProcess.pdf

http://www.csun.edu/~lisagor/Fall%202012/NutritionCareProcess.pdf

http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/definitionoftermsashx

http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/definitionoftermsashx

clinical case report: nutrition management for left aspect ......8. mahan l, escott-stump s, raymond...

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