clinical nutrition intervention for hypoxic hepatitis · ncp: assessment nutrition focused physical...

Clinical Nutrition Intervention

for Respiratory Failure

Induced Hypoxic HepatitisA PRESENTATION BY KARINA FALCONE

DIETETIC INTERN

FLORIDA INTERNATIONAL UNIVERSITY

Objective

To demonstrate how the Nutrition Care Process

was used to provide medical nutrition therapy to

a patient diagnosed with metabolic

encephalopathy and hypoxic hepatitis due to

respiratory failure

Outline

Patient Overview

Etiology and Pathophysiology

Literature Review

Nutrition Care Process

Summary

Patient Overview

JW is a 66-year-old Caucasian, transgender (male to female) female

PMH: arthritis, chronic back pain, COPD, depression, HTN, T2DM, morbid obesity

Admitted to the hospital on April 7, 2019 for pain medication

overdose and difficulty breathing (found unresponsive and foaming

at the mouth)

Patient Overview

Patient denied suicidal ideation or attempt

At home, JW takes conjugated estrogen, as well as daily opiates and NSAIDS for her

chronic back pain

Patient used to drink excessively, however,

states she has been sober for 10 years

Diagnosis and Medical Course

April 7

EMS gave the patient Narcan 4mg and D50

Narcan – naloxone hydrochloride; opioid antagonist; competes for the

same receptors; reverses effects including respiratory depression,

sedation, and hypotension

D50 - hypertonic solution of dextrose in water; can be used to treat

dehydration

Narcan - FDA prescribing information, side effects and uses [Internet]. Drugs.com. 2019 [cited 25 May 2019]. Available from: https://www.drugs.com/pro/narcan.html

Dextrose 50% Injection - FDA prescribing information, side effects and uses [Internet]. Drugs.com. 2019 [cited 25 May 2019]. Available from: https://www.drugs.com/pro/dextrose-50-

injection.html


April 8

At the hospital, patient was diagnosed with AKI, hyperkalemia, dehydration, elevated lactic acid levels, opioid overdose, and

pneumonia

She was placed in BiPap for respiratory support

Once stabilized, patient was removed from BiPap and placed on a clear liquid diet


April 9

Liver enzymes (LFT including ALT and AST) found elevated and continued to rise

Began re-displaying symptoms of respiratory failure (low oxygen saturation, increased lactic acid levels); placed on BiPap again and eventually ventilation

Kidney function continued to decline; dialysis catheter inserted

Patient diagnosed with hypoxic hepatitis (“shock liver”) and metabolic encephalopathy due to respiratory failure


April 10

Patient placed on enteral feeding

Dialysis started

Transferred to Main Baptist Hospital for further evaluation and

possible surgery

Opioid Overdose Induced

Respiratory Failure

Opioids are a CNS suppressant – this is why they cause respiratory

depression

A symptom of overdose is <12 breaths per minute

In a retrospective study, 84.8% of patients who were hospitalized for

opioid overdose were placed on mechanical ventilation due to

respiratory failure

Pfister G, Burkes R, Guinn B, Steele J, Kelley R, Wiemken T, Saad M, Ramirez J, Cavallazzi R. Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes.

Journal of Critical Care. 2016;35:29-32.

Hypoxic Hepatitis (HH)

What is Hypoxic Hepatitis?

Centrilobular necrosis

Hepatic necrosis around the

central veins

Henrion J, Schapira M, Luwaert R, Colin L, Delannoy A, Heller F. Hypoxic Hepatitis: Clinical and Heamodynamic Study in 142 Consecutive Cases. Medicine. 2003;82:392-406. Soleimanpour

H, Safari S, Shahsavari Nia K, Sanaie S, Alavian S. Opioid Drugs in Patients With Liver Disease: A Systematic Review. Hepatitis Monthly. 2016;16.


How is it diagnosed?

A clinical setting of cardiac, circulatory, or respiratory failure

A dramatic, but transient, rise in serum aminotransferase activity

Exclusion of other causes of liver cell necrosis, especially viral or drug

induced hepatitis

**Note that evidence shows most opioids do not lead to liver damage on their

own; heroin abuse or opioids mixed with acetaminophen may lead to liver

damage when abused

Henrion J, Schapira M, Luwaert R, Colin L, Delannoy A, Heller F. Hypoxic Hepatitis: Clinical and Heamodynamic Study in 142 Consecutive Cases. Medicine. 2003;82:392-406. Soleimanpour

H, Safari S, Shahsavari Nia K, Sanaie S, Alavian S. Opioid Drugs in Patients With Liver Disease: A Systematic Review. Hepatitis Monthly. 2016;16.


What causes HH?

Majority of cases are caused by these 4 underlying conditions

Decompensated congestive heart failure

Acute cardiac failure

Exacerbated chronic respiratory failure

Circulatory shock


How can HH be treated?

Best way to treat HH is to treat the underlying cause, in this case believed to be respiratory failure

Kidney failure may be exacerbating feature

Waseem N, Chen P. Hypoxic Hepatitis: A Review and Clinical Update. Journal of Clinical and Translational Hepatology. 2016;4:263-268.

Current MNT recommendations for

Respiratory Failure

Both over and underfeeding can be detrimental for patients on

ventilation, however if patient is obese, permissive underfeeding is

suggested

Indirect calorimetry (IC) is preferred method to determine exact

energy requirements, however if this is not feasible then use

predictive equations

1.2-2.0 g/kg protein

Nelms M, Sucher K, Lacey K. Nutrition therapy and pathophysiology. 3rd ed. Boston: Cengage Learning; 2016.

Current MNT recommendations for

Respiratory Failure

Goals of MNT during RF

Meet nutritional needs that will support weaning from ventilation

Preserve and restore lean body mass

Blunt the inflammatory response

Maintain fluid balance

In the first week, try to meet 65% of goal feeding and increase from

there based on labs and progress


Recent Literature in MNT for

Respiratory Failure

Enteral nutrition in the ICU

Supplemental parenteral nutrition (parenteral nutrition used alongside enteral) has a deleterious effect on patient’s in the ICU, however enteral nutrition alone correlates well with positive health outcomes

Low-dose or trophic enteral nutrition has similar benefits with less gastrointestinal complications compared with early full dose caloric feedings

Fremont R, Rice T. How soon should we start interventional feeding in the ICU?. Current Opinion in Gastroenterology. 2014;30:178-181.


Respiratory Failure

Underfeeding vs full feeding for critically ill patients with

acute respiratory failure

Moderate feeding showed lower 60-day mortality rates

Underfeeding showed lower occurrence of GI signs and symptoms

except for aspiration and abdominal distention

Stuani Franzosi O, Delfino von Frankenberg A, Loss S, Silva Leite Nunes D, Rios Vieira S. Underfeeding versus full enteral feeding in critically ill patients with acute respiratory failure: a

systematic review with meta-analysis of randomized controlled trials. Nutrición Hospitalaria. 2017;34:19.


Respiratory Failure

In contrast… other groups looking at underfeeding vs full

feeding in critically ill patients

While those being fed 33-70% of estimated requirements had lower

overall mortality rates than full fed patients

There were no differences in length of ICU stay or other secondary clinical outcomes (duration of mechanical ventilation, onset of

pneumonia, gastrointestinal intolerance)

Choi E, Park D, Park J. Calorie Intake of Enteral Nutrition and Clinical Outcomes in Acutely Critically Ill Patients. Journal of Parenteral and Enteral Nutrition. 2014;39:291-300.

Arabi Y, Aldawood A, Haddad S, Al-Dorzi H, Tamim H, Jones G, Mehta S, McIntyre L, Solaiman O et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. New

England Journal of Medicine. 2015;372:2398-2408.

NCP: Assessment

Food / Nutrition Related History

Medications – conjugated estrogen, opiate pain relievers, NSAIDS

Unable to assess any other nutrition related history as patient has altered

mental status

Anthropometric Measurements

Weight 117kg (257lbs)

Height 170cm (5’7”)

BMI 40.48

NCP: Assessment

Biochemical Data, Medical Tests, Procedures

General condition - moderate distress, pt confused, tachypneic,

hypoxic

Diagnosis - AKI, hyperkalemia, dehydration, elevated lactic acid level,

elevated LFTs, metabolic encephalopathy, opioid overdose,

pneumonia

High RR >30

NCP: Assessment


Most recent labs

Low hemoglobin (11.2 g/dl)

Crit high potassium (7.5 mmol/L)

High creatinine (3.01 mg/dl)

High BUN (40 mg/dl)

Low calcium (8 mg/dl)

Low albumin (2.9 g/dl)

High ALT (SGPT) (4617 U/l)

High AST (SGOT) (9008 U/l)

High ammonia (105 umol/l)

High bilirubin (1 mg/dl)

NCP: Assessment


Urine - opiates screen positive; trace amounts of acetones, blood,

protein, bacteria

Chest x-ray - pneumonia

Placed on BiPap

NCP: Assessment

Nutrition Focused Physical Findings

Patient appearance consistent with obese category BMI (40.48)

No physical signs of malnutrition

Unable to assess appetite and usual consumption as patient has altered

mental status

Patient to remain NPO as per MD

NCP: Assessment

Nutrition Focused Physical Findings

Estimated energy needs

1380-1640 kcal/day (11-13 kcal/kg)

**Permissive underfeeding

Fluid needs 1:1 or as per MD

50-76 g pro/day (0.4-0.6 g/kg due to encephalopathy)

**This was assigned by RD on staff. Based on my research (after the fact) protein needs for respiratory failure are to begin at 20-25g/day to avoid overfeeding, and then increased to 1.2-1.5 g/kg/d

Width M, Reinhard T. The essential pocket guide for clinical nutrition. 2nd ed. Philadelphia: Walters Kluwer; 2018.

NCP: Assessment

Client History

Transgender top reassignment surgery (unknown date)

History of arthritis, chronic back pain, COPD, depression, HTN, morbid

obesity

Patient is a former smoker (unknown dates) and used to drink alcohol

(unknown dates, quit 10 years ago)

NCP: Diagnosis

(P) Inadequate energy intake

RT

(E) Decreased ability to consume sufficient energy from

physiological causes

AEB

(S) confused state, altered mental status, mechanical ventilation

NCP: Intervention

Enteral nutrition support

Recommendations - when NGT placement confirmed, initiate Osmolite 1.5 at 20 ml/hr and increase by 20 ml q 4 hrs to 40 ml/hr;

fluid flushes 30ml q 4 hrs for tube patency or as per MD

Osmolite 1.5 at goal of 40 ml/hr with fluid flushes will provide a total

of 1380 kcals, 58g pro and 881ml of free H2O per 23 hr feeding

(100% of estimated kcal and protein needs)**

**permissive underfeeding due to obesity

NCP: Monitoring and Evaluation

The next morning, nurse stated patient was tolerating tube feeding

well

Running at goal rate

No residuals

By that evening, patient was transferred to main Baptist

Unable to continue following

Conclusions

JW admitted for opioid overdose and difficulty breathing;

diagnosed with AKI, hyperkalemia, dehydration, elevated lactic

acid levels, opioid overdose, and pneumonia

Once stabilized in the ICU, began displaying symptoms of hypoxic

hepatitis due to respiratory failure

Due to encephalopathy, patient could not eat; had to be placed

on enteral support

References

Narcan - FDA prescribing information, side effects and uses [Internet]. Drugs.com. 2019 [cited 25 May 2019]. Available from: https://www.drugs.com/pro/narcan.html

Dextrose 50% Injection - FDA prescribing information, side effects and uses [Internet]. Drugs.com. 2019 [cited 25 May 2019]. Available from: https://www.drugs.com/pro/dextrose-50-injection.html

Pfister G, Burkes R, Guinn B, Steele J, Kelley R, Wiemken T, Saad M, Ramirez J, Cavallazzi R. Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes. Journal of Critical Care. 2016;35:29-32.

Henrion J, Schapira M, Luwaert R, Colin L, Delannoy A, Heller F. Hypoxic Hepatitis: Clinical and Heamodynamic Study in 142 Consecutive Cases. Medicine. 2003;82:392-406.

Soleimanpour H, Safari S, Shahsavari Nia K, Sanaie S, Alavian S. Opioid Drugs in Patients With Liver Disease: A Systematic Review. Hepatitis Monthly. 2016;16.

Waseem N, Chen P. Hypoxic Hepatitis: A Review and Clinical Update. Journal of Clinical and Translational Hepatology. 2016;4:263-268.


Fremont R, Rice T. How soon should we start interventional feeding in the ICU?. Current Opinion in Gastroenterology. 2014;30:178-181.

Stuani Franzosi O, Delfino von Frankenberg A, Loss S, Silva Leite Nunes D, Rios Vieira S. Underfeeding versus full enteral feeding in critically ill patients with acute respiratory failure: a systematic review with meta-analysis of randomized controlled trials. Nutrición Hospitalaria. 2017;34:19.

Choi E, Park D, Park J. Calorie Intake of Enteral Nutrition and Clinical Outcomes in Acutely Critically Ill Patients. Journal ofParenteral and Enteral Nutrition. 2014;39:291-300.

Arabi Y, Aldawood A, Haddad S, Al-Dorzi H, Tamim H, Jones G, Mehta S, McIntyre L, Solaiman O et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. New England Journal of Medicine. 2015;372:2398-2408.

Width M, Reinhard T. The essential pocket guide for clinical nutrition. 2nd ed. Philadelphia: Walters Kluwer; 2018.

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