CRITICAL CARE CASE STUDY

Nate Medunick

PATIENT JH 91 YO female Dry weight – 121# (55kg) Height- 66” BMI-19.5Admission diagnosis: POD#3Hiatal hernia

repair, Nissen fundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

ESTIMATED NUTRITIONAL NEEDS Based on actual weight in recent PMH

(54kg) Kcals 1350-1620 (25-30kcals/kg) Protein – 70-81g (1.3-1.5g/kg) Fluid 1620ml (30ml/kg) High Nutritional risk

NISSEN FUNDOPLICATION A surgeon wraps the part of the

stomach known as the gastric fundus around the lower esophagus (including the LES) in a Nissen fundoplication. This helps to strengthen the barrier and prevent the back flow of acids into the esophagus

DIET AFTER NISSEN FUNDOPLICATION SURGERY

Patients must make dietary and lifestyle adjustments for about six weeks following Nissen fundoplication surgery. Three days following surgery, most patients are on a clear liquid diet, which may include:

apple juice beef broth chicken broth cranberry juice decaffeinated tea grape juice Jell-O  After the clear liquid diet, most patients are put on a full liquid diet for an additional

three days. This diet consists of anything on the clear liquid diet plus the following: Carnation instant breakfast (not chocolate) creamed soups (strained, no broccoli or tomato) cream of wheat (or cream of rice) ice cream (vanilla or strawberry) milk (no chocolate milk) sherbet yogurt (plain, blended, or custard with fruit or seeds) Seven days after surgery, most patients are able to tolerate a soft food diet.

However, to heal properly, patients must keep their stomach from stretching. This will require them to eat small, frequent meals six to eight times per day

HIATAL HERNIA  A hiatal hernia is what doctors call it

when a part of the stomach moves up into the chest area. Normally, the stomach sits below the diaphragm, the layer of muscle that separates the organs in the chest from the organs in the belly. The esophagus, the tube that carries food from the mouth to the stomach, passes through a hole in the diaphragm. In people with a hiatal hernia, the stomach pushes up through that hole, too.

SYMPTOMS OF HIATAL HERNIA Burning in the chest, known as

heartburn Burning in the throat or an acid taste in

the throat Stomach or chest pain Trouble swallowing A raspy voice or a sore throat Unexplained cough

PATIENT JH 91 YO female Dry weight – 121# (55kg) Height- 66” BMI-19.5Admission diagnosis: POD#3Hiatal hernia

repair, Nissen fundoplication and wedge resection (SLH), followed by a MI with a stent placed. Barium swallow showed a small perforation at the distal esophagus.

INITIATING CMH RD- K.A. TPN initiated with Day 1 bag- 50g/AA,

100g/dextrose, and no lipids

Recommendations Day 2/goal- 80g/AA, 250g/dextrose, providing 1170 calories

50 g lipids Monday and Thursday ( lipid shortage at the time) with lipids, provides 1670 calories

Recommendations based on 25 kcal to 30 kcal per Kg for CCU Patient, not vented.

NUTRITION CARE – NATE DI

Patient required intubation post op day exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes

Day 1 nutrition intervention followed initiating

RD care plan: 50g AA, 100g dextrose, no lipids Day 2 Nutrition plan based on dry wt-121 Kcals 1200-1375 (22-25kcal/kg--intubated) Protein- 72-83g (1.3-1.5) wound healing Fluid – Per Intensivist Needs remained constant during care

DAY 2

POD #1 S/P exploratory laparotomy, drainage of mediastinal fluid collection, and placement of gastric and jejunal tubes

POD #5 hiatal hernia repair, Nissen fundoplication

patient continued on mechanical ventilation without sedation, but high doses of neosynephrine

lab values include: WBC 17.3 trending up (TU), total bilirubin 1.5 - TU, urine output- approximately 10 – 33 cc/hr

NUTRITIONAL INTERVENTION– DAY 2

(intubated) Custom TPN- 1500ml-80gm/AA, 115gm/dextrose + 90 gm dextrose from D5 containing IVF, no lipids. Total: 1017 calories

Reviewed with Intensivist and asked if IVF would be adjusted

Plan moving forward: increase dextrose in TPN because D5 1/2NS was transitioned to NS

lipids would be added Monday and Thursday due to national shortage

nutritional monitoring and evaluation: tolerance of TPN with goal of 80gm/AA,

200gm/dextrose, transition to jejunal tube feeding when appropriate per surgery recommendations

DAY 2 OF CAREPES P-Inadequate energy intake(improvement shown-

unresolved) E- S/P exploratory laparotomy (2/18) S-TPN prescribedGI assessment abdomen-distended and soft Bowel Sounds-hypoactive Emesis color- tanSkin 2+ General edema wounds-six total wounds including surgical wounds,

Jackson Pratt, and G tubefluid balance-2411.1mlpharmacy-calcium chloride repletion

DAY 3 OF CARE

POD#2 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity 1 cal@ 10ml/hr (254kcal, 11gm/protein) prescribed by Thoracic surgeon (jevity 1 cal was MD preferred)

labs included: phosphorus 3.0 trending down (TD), potassium 4.1 stable, calcium 7.6 stable, magnesium 2.0 (TD), CO2/PCO2 38 (TD)

TPN order and discussed with Intensivist- 1500ml, amino acids-80gm (320kcal), dextrose-140gm (476kcal), lipids-40gm (400kcal)- no MVI, no trace elements, with trophic feeding, total calories/protein: 1450 total kcals, 91 gm protein

Custom electrolytes K acetate 40mEq (potassium stable), Na phosphate 25 mEq ( repletion), Na acetate 22, Ca gluconate 9(stable), Mg sulfate 7(repletion)

LEARNING EXPERIENCE the original electrolyte plan - K acetate

40mEq , Na phosphate 25 mEq , Na acetate 22, Ca gluconate 9, Mg sulfate 7

Plan changed following a discussion with the Intensivist - concern was- Although; CO2 was TD, pH-7.38 Slightly more Acetate would possibly increase pH over 7.38

Acetate is added to correct Acidosis; Intensivist felt that the Patient was not trending toward acidosis at the time

DAY 4 – PATIENT DECLINING

POD#3 S/P exploratory laparotomy. Diet: NPO, TPN, and trophic feeding jevity 1 cal @ 10ml/hr (254kcal, 11gm/protein)

patient continued on mechanical ventilation with propofol sedation and Neo-Synephrine weaned to lower dose

IVF-NS @ 50ml/hr continued Labs include: Ca 8.0, Cl 112, Mg 2.0, Phos 1.8, and

Potassium 3.7 nutritional intervention-TPN – 1500ml: 80gm/amino acids (320kcal), 165 gm /Dextrose (561kcal) 6 ml/hr propofol (158 calories ) trophic TF (254 calories, 11 gm protein) D5 carriers with multiple antibiotics (127 kcal) Total ~1420 calories, 91 gm protein TPN electrolytes 40mEq K acetate, 15 mEq K

phosphate, 25 mEq Na phosphate, 9 mEq Ca gluconate, 7 mEq Mg sulfate. TPN discussed with Intensivist

Promote with fiber was recommended in note—no renal problems at the time; thoracic surgeon paged by RD. MD still preferred Jevity 1 cal

CONCLUSION

JH was in poor condition toward the end of my nutritional care rotation:

Patient was requiring multiple antibiotics, including zyvox

LFTs/renal labs were elevating, multisytem organ failure ensued

I found out that JH soon expired due to poor condition and advanced age

I would not have changed anything with my nutritional plan of care

What I learned What I learned:

TPN and electrolyte needs pH and acid/base balance Intensivists are approachable and a great

information source RD’s recommendations can show direct results

in lab work

SOURCES http://www.healthline.com/health/gerd/

nissen-fundoplication#2 http://www.uptodate.com/contents/

hiatal-hernia-the-basics?source=search_result&search=Hiatal+hernia&selectedTitle=2%7E75