Nutritional and Medical Implications of Aspiration Pneumonia Associated with Septic Shock and Mental Status Changes

Presentation Outline Background Information

◦Aspiration Pneumonia ◦Septicemia and SIRS (systematic

inflammatory response syndrome) Patient Information Medical TreatmentNutritional Treatment Implication to the Field of Dietetics

◦Aspiration Risk Factors ◦Aspiration Precautions

Questions

Aspiration Pneumonia An infection of the lungs that can occur

after foreign material enters the lungs or the airways leading to the lungs (2).

“Silent” asymptomatic aspiration is a common occurrence in healthy individuals; however, aspiration pneumonia occurs in a subset of these individuals and the infection is caused by non-harmful bacteria, primarily anaerobes, part of the normal bodily flora (3).

Septicemia & SIRSSepticemia exists when

infectious organisms or their toxins accumulate in the bloodstream in significant quantities and is often associated with severe infections (4).

Additionally, systematic inflammatory response syndrome (SIRS) and subsequently Septic Shock can occur along with serious infections.

Infection vs. SIRS

source: http://bit.ly/Yogwpq

Case Study –The PatientLA was admitted in respiratory

distress with mental status changes following an episode of vomiting and suspected aspiration whose local infection progressed to sepsis and septic shock.

The case illustrates the challenges in meeting the nutritional needs of a critically ill patient with a history of aspiration pneumonia, dependent on enteral nutrition.

General InformationInitials: LA Age: 86 years old Race: white Gender: male Diagnosis: septic shock, hypotension,

and mental status changes Height: 5’11”Weight: 160 lbs. BMI: 22.36Hospital Duration: 11 Days.

Social History LA resides in a nursing home in

Westminster, MD.He is a widower with a son, a

daughter, two granddaughters, and one great granddaughter

No history of alcohol or drug abuse

Full code status Medicare Insurance

Medical/Surgical History Benign brain tumor

s/p resectionCerebral vascular

accident Mitral valve disease Congestive heart

failure Arterial fibrillation Cardiomyopathy COPDDepression Alzheimer's Disease

Degenerative arthritis

Dysphagia s/p PEG placement

Aspiration Pneumonia Gastritis Hiatal Hernia Hypothyroidism Osteoporosis

Medical Treatment 11/10/12- admitted in respiratory distress noted to be hypotensive, hypoxic,

and tachypneic. Given Lasix BP dropped from 119/74-80/40

◦ Antibiotics started, fluid bolus

◦ INR/PT was set to be monitored daily due to significant past bleeding complications

◦ white blood cell count: 25,000 indicating leukocytosis

11/11/12- Triple lumen catheter for vasopressor & antibiotics, placed on BiPAP and came off the same day to nasal flow oxygen,

11/12/12- weaned from oxygen, given pulmonary toilet, cardiologist consult/ following

11/13/12- GI doctor was consulted because G-tube stopped working in the night (nurses cleaned chamber)

11/15/12- LA was moved to IMC but was wheezing and a COT was called was placed back on BIPAP and remained in the IMC.

11/19/12- Antibiotic treatment was completed and discontinued, triple lumen catheter was removed. Thoracentesis was suggested to remove excess fluid from the pleural space.

11/20/12- Considered clinically improved, possible thoracentesis procedure was differed

11/21/12-Pulmonologist indicated Thoracentesis was unnecessary. LA was discharged back to nursing home

Nutritional History Unable to obtain nutritional history from

patient as a result of mental status changes

Information was obtained from nursing home and medical records ◦In Sept. (2012) pt was admitted to CHC w/

dysphagia, r/t to worsening mental status. During that admission a PEG tube was placed.

On bolus feeding regimen at nursing home (tolerating until vomiting episode)

Past Tube Feeding Regimen 1 can of bolus formula at: 6am, 9

am, 12 pm, 3 pm, 6pm, and 9pmOsmolite 1.2, which provided:

1728 kcal, 80 grams of protein, and 720 ml of water flushes.

Tolerating regimen until shortly before admitted when he vomited, no information on the cause of emesis

Nutritional Treatment 11/12/12: Nutrition Consult for TF

assessment was placed◦Intern recommended pt switch from

bolus to continuous feeds “recommend start Isosource 1.2

(equivalent to Osmolite 1.2) tube feedings at 10ml/hour and advance every four hours until reaching to goal rate of 60 ml/hr (1728 kcal, 76 g protein, and 1181 ml of free water daily).

Nutritional Treatment Tube feeding tolerance, labs, GI

function, I&O’s, weight trends, and aspiration precautions were monitored

The RD goal was to meet 100 percent of LA’s needs via tube feeds within the first 48 hours.

Nutritional Diagnosis PES statement: “Inadequate oral

intake (IDNT – NI-2.1) related to dysphagia and respiratory distress, as evidenced by, permanent PEG tube placement and acute exogenous oxygen dependency”.

Nutritional Treatment 11/13/12 (Day 2)- Goal not met. LA’s tube

feeds were running at 30 ml/hr, which provided 864 kcal, 38 g protein, and 590 ml free water. (G-tube stopped working) corrected.

11/15/12- Tube feeds still not at goal. They were running at 40ml/hr to provide: 1152 kcal, 51 g protein, and 787 ml of free water (nursing error. RD consulted nursing about Tube feeding.

11/16/12 (Day 4)- Tube feeds were running at goal rate of 60ml/hr with minimal residuals

11/20/12 (Day 8)- LA noted to be tolerating TF at goal w/ minimal residuals, and normal bowel movements.

Estimated NeedsBased on ASPEN Critical Care

Guide Lines ◦Energy: 1448-2172 kcal 20-30g/kg

body weight◦Protein: 73-87 grams 1-1.2 g/kg ◦Fluid: fluids were closely monitored

by medical team. Water flushes every six hours was recommended to keep G-tube working. I&O’s were monitored.

Lab Values WBCs elevated on admit –leukocytosis,

normal 11/15Potassium elevated (on admit)- normal

11/11BUN- slightly elevated Glucose -(129-169) Slightly elevated Hemoglobin /hematocrit –decreased

anemiaCalcium- slightly decreased Sodium and chloride - Slightly decreased

Medications Lasix prn - diuretic Carvedilol- beta blocker, CHF Hydrocortisone- anti-inflammatory steroid Guaifenesin – Thins mucous in lungs Warfarin- Blood thinner Albuterol– Asthma Ativan –Anxiety Zosyn, Azithromycin, & Ceftriaxone - Antibiotics Lansoprazole – Decrease stomach acid Losartan Potassium- High blood pressure Milk of Magnesia- Constipation Multivitamin- Therapeutic Saccharomyces Boulardii – Probiotic

Implication to the Practice of Dietetics While it is difficult to diagnosis

aspiration pneumonia as a direct result of enteral feeding, it is a common complication dietitian’s must be aware of.

Evidence suggests the benefits of early enteral feeding on the prognosis of critically ill patients (11)

Thus it is important to constantly monitor and practice prevention of risk factors in critically ill patients

Risk Factors for Aspiration Pneumonia Supine positioning Impaired level of consciousness GERD Neurological deficits Age >60Enteral intubationMal positioned feeding tubeBolus vs. Continuous feedingMechanical ventilationPoor oral healthInadequate nurse to patient ratio

Strategies and Precautions to Prevent Aspiration Pneumonia Elevate bed between 35-40 degrees Identify and treat GERDContinuous feeding over bolus feeds. Verify tube placement Monitor gastric residuals to ensure

they are < 500ml Monitor patient for complaints of

discomfort, distention Monitor bowel movements

References References: Critical Illness- Complications of Nutrition Support. Academy of Nutrition and Dietetics Nutrition Care Manual. Source:

http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=89675 Assessed December 6th, 2012 Aspiration Pneumonia. Pub Med. Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001179/ Assessed January 1st 2013. Aspiration Pneumonia in adults. Uptodate. Source:

Http://uptodate.com/contents/aspiration-pneumonia-in-adults?topickey=ID%2F72.htm Assessed December 5, 2012 Septicemia. MedlinePlus. Source: http://www.nlm.nih.gov/medlineplus/ency/article/001355.htm Assessed January 1, 2013 Management of severe sepsis and septic shock in adults. Uptodate. Source: http://www.uptodate.com/contents/management-of-severe-sepsis-and-septic-shock-in-adults Assessed December 29th, 2012 Treatment of Staphylococcus aureus bacteremia in adults. Uptodate. Source:

http://www.uptodate.com/contents/treatment-of-staphylococcus-aureus-bacteremia-in-adults. Assessed: December 6th 2012. Septic Shock- Treatment. University of Maryland Medical Center. Source: http://www.umm.edu/ency/article/000668trt.htm Assessed December 15th, 2012 Septic Shock. Medline Medical Encylopedia. Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001689// Assessed: December 5th, 2012. What level of protein intake or what protein delivery is associated with improvements in length of stay in the hospital?

Academy of Nutrition and Dietetics Evidence Analysis Library. Source: http://andevidencelibrary.com/evidence.cfm?evidence_summary_id=250647&highlight=critically%20ill&home=1 Assessed: December 21st, 2012. Enteral Nutrition. Academy of Nutrition and Dietetics Nutrition Care Manual. Source:

http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255292 Assessed: January 1st 2013 Aspiration Risk and Enteral Feeding: A Clinical Approach. Nutrition Series in Gastroenterology. Source:

http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/copy_of_apr03opillaarticle.pdf

Assessed: December 6th, 2012.

Questions