Case Report:Nutrition Support in a

Critically Ill Patient at risk for Essential Fatty Acid Deficiency

Rebecca Scofield, MSARAMARK Dietetic Internship

Underwood-Memorial HospitalFebruary 7, 2012

Disease StateDiverticular Disease

Primary cause of patient’s long hospital stayComplications included inflammation,

abscesses, sepsis and infection, bleeding, and perforation

Usual treatment includes antibiotics, bowel rest

⅓- ¼ of patients require surgeryHartmann’s procedure, splenic flexure

takedown, drainage of abscess, colostomy performed

ComorbiditiesPt became Vent-Dependent Respiratory

Failure (VDRF) following surgeryAcute Respiratory Distress Syndrome

(ARDS), resolvedType 2 Diabetes Mellitus (T2DM)Peanut allergyRisk for Essential Fatty Acid Deficiency

(EFAD)

EFADEssential Fatty Acid Deficiency

Absence of EPA, DHA, ALA (omega-3 fatty acids)

Signs/Symptoms:DermatitisFatty liverHair lossBiochemical indicationsDeath

S/S can occur within 2 weeks

Evidence-Based Nutrition Recommendations

Academy of Nutrition and Dietetics: Evidence Analysis LibraryCritical Illness Guidelines state:Energy requirements most accurate when using

Ireton-Jones 1992 equation and indirect calorimetry not available

Enteral Nutrition (EN) recommended over Parenteral Nutrition (PN) in patients with functioning GI tract

EN associated with reduced cost, septic morbidity, and infections

Delayed PN in pts who are not malnourished

Evidence-Based Nutrition Recommendations

Casaer et al, 2011Randomized, controlled, multi-center trialN = 4,640Intervention: Early vs. late PN in critically ill

adultsEarly initiation on day 3Late initiation on day 8

Primary Outcomes: ICU length of staySecondary Outcomes: Infection rates,

inflammation, length of VDRF, status at discharge

Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.

Evidence-Based Nutrition Recommendations

Caesaer et al, continued:Results

Late PN Initiation group:Shorter ICU stayFewer infectionsReduction in patients who require > 2 days

VDRF$1600 reduction in health care costsNo difference in mortality between groups

Early initiation of PN appears less beneficial than withholding PN until day 8Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y,

Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.

Evidence-Based Nutrition Recommendations

deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218.

De Meijer et al, 2010Non-comparative study (case series)N = 10Intervention: PN fish oil as sole lipid therapy for

infants in ICUPrimary Outcome: Onset of EFAD, defined by

triene:tetraene ratio >0.2Secondary Outcomes: Clinical s/s of EFAD

DermatitisHair lossGrowth impairment

Evidence-Based Nutrition Recommendations

deMeijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218.

De Meijer et al, continued:Results

FA composition changed from composition of soybean oil (higher omega-6) to that of fish oil (higher omega-3)

No dermatitis, hair loss, growth retardation in any patients

Bilirubin levels improved in 90% of patients with cholestasis

Fish oil contains sufficient EFAs to prevent clinical and biochemical s/s of EFAD and sustain growth in infants

Evidence-Based Nutrition Recommendations

Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.

Mateu-de Antonio et al, 2008Retrospective cohort studyN = 42 (final n = 39)Intervention: Soybean- vs. olive oil-based lipid

emulsions in PNPrimary Outcomes: Infection rate and

leukocyte countSecondary Outcomes: Acute phase proteins,

length of ICU stay, mortality rate

Evidence-Based Nutrition Recommendations

Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008 Apr;99(4):846-54.

Mateu-de Antonio et al, continued:Results

No difference in infection rate or appearance, acute phase proteins, or major outcomes between groups

Olive oil group: increase in leukocyte count Soybean oil group: decrease in leukocyte count

Soybean oil emulsions Cause increase in omega-6 FA May interfere with immune function, be precursors to

inflammatory markers, and inhibit macrophage functionOlive oil-based lipid emulsions

May serve as a safe alternative to soy-based PN infusions

Case PresentationPatient: SF58 Year old Caucasian femaleDx: Pneumonia, s/p GI surgery, VDRF, ARDS,

sepsis, DMGI surgery prevents from enteral accessPeanut allergy prevents from receiving lipid

emulsion (per pharmacy protocol)Without lipids for 14 days

NCP: AssessmentClient History

Hypothyroidism, diverticulosis, temporal arteritis, HTN, GERD, steroid-induced hyperglycemia, T2DM

Allergies: Cipro, Augmentin, MacrobidEx-smoker

NCP: AssessmentFood/Nutrition-Related History

Unable to obtain from pt due to sedation/VDRFFamily friend stated pt tolerated soy-

containing foodsGood intake at homeCooked for herselfSocial drinkerMedications at home

NCP: Assessment

NCP: AssessmentNutrition-Focused Physical Findings

OverweightSedatedEdemaCushingoid/puffy face+OstomyNG tube

NCP: AssessmentAnthropometric Measurements

Height: 5’8”Admission wt: 81.6 kg (180 lbs)BMI: 27.35IBW: 140 lbs

Pt experienced 40 lb gain during hospital admission due to fluid overload

NCP: AssessmentBiochemical Data, Medical Tests, and Procedures

Intubation/mechanical ventilationNG tube placementTLC placementTracheostomyBronchoscopyFrequent lab drawsPEG placement

NCP: Assessment

NCP: AssessmentNutrient NeedsEstimated energy needs (1.1):

Using Ireton-Jones 1992 1836 kcal/day

Estimated protein needs (2.2): 1.3-1.5 g/kg (Using high-end IBW) 91-105 g/day

Estimated fluid needs (3.1): 25 ml/kg (Using high-end IBW) 1750 ml/day

NCP: AssessmentNutrition Status Classification

NCP: Nutrition Diagnoses#1. Altered GI function (NC-1.4) related to diverticulitis

and perforation as evidenced by decreased bowel sounds, little ostomy output, and bowel resection.

#2. Inadequate parenteral nutrition infusion (NI-2.6) related to potential allergy to lipid emulsion as evidenced by lipid emulsion not being administered and no fatty acids delivered to patient.

#3. Predicted food-medication interaction (NC-2.4) related to combined ingestion of levothyroxine and enteral formula via NG tube causing decreased bioavailability of medication as evidenced by 24-hour continuous feeding and p.o. levothyroxine prescribed via NG tube.

NCP: InterventionsInitiate PN (ND-2.2)

ND-2.2.1 Formula/solution: Parenteral nutrition was started 4 days s/p surgery Recommendation: 490 ml 50% dextrose (to start

with 30% dextrose first day), 1000 ml 10% amino acids, and 200 ml 20% lipid to provide 1633 kcal, 100 gm protein, and 1690 ml total volume.

To meet approximately 100% of kcal and protein needs and 97% fluid needs.

Lipids not administered for 10 days due to pharmacy protocol and risk for crossover allergic reaction to soy.

NCP: InterventionsCoordination of Nutrition Care (RC-1)

RC-1.3 Collaboration/referral to other providers:Communication between

NursingPhysiciansPharmacyNutrition

Required to determine a course of action for testing lipids with the patient before being introduced to PN solution.

NCP: Interventions Initiate EN (ND-2.1)

ND-2.1.1 Formula/solution: Goal enteral formula once patient able to begin feedings: Glucerna 1.2 via NG tube at 55 ml/hr continuous over 24

hours. Provided 1584 kcal and 79 grams protein meeting 98% of kcal

needs and 94% of protein needs at that point in time.Adjusted due to Synthroid:

Glucerna 1.2 at 60 ml/hr continuous over 21 hours with one packet liquid Prosource daily.

Provided 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs.

NCP: InterventionsND-2.1.4 Feeding tube flush:

Glucerna 1.2 at 60 ml/hr over 21 hours with one packet of liquid Prosource daily met 58% of the patient’s fluid needs, requiring additional water.

Flush the NG tube with 125 ml water every 4 hoursNursing to use enteral protocol to flush during

medication administration.

NCP: Monitoring and Evaluation

Ongoing monitoring of:Weight

AD-1.1 Body composition/growth/weight EN/PN regimen intake

FH-1.3.2 Parenteral Nutrition Intake FH-1.3.1 Enteral Nutrition IntakeFH-3.1 Medication and herbal supplements

LabsBD-1.2 Electrolyte and renal profileBD-1.6 Inflammatory Profile

Medications

ConclusionComplicated cases may not be able to follow

evidence-based guidelines at all timesAllergies pose problem to some patients who

need enteral or parenteral supportNutritional management of SF involved EN, PN,

multidisciplinary cooperation for optimal outcome

EFAD avoided in this patient after trial dose of soybean lipid emulsion

ConclusionSF’s nutrition interventions involved initiation of

PN, modification of the PN prescription, and finally introduction of EN

EN formula and rate changes made to avoid nutrient-medication interactions

Patient unable to be weaned from ventilator before discharge, but stable

ConclusionPatient had PEG tube placed for continued EN supportTolerating tube feeding at goal at discharge:

Glucerna 1.2 @ 60 ml/hr x 21 hours with 1 packet liquid Prosource Daily

Providing total of 1572 kcals, 91 grams of protein, and 1014 ml of free water, meeting 98% of kcal needs and 100% protein needs.

Water flushes: 125 ml q 4 hours and with medicationsTrach-to-vent upon dischargeDischarged to long-term acute care facility due to

extensive medical needs

References1. Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. W.B. Saunders; 2007.

Pp. 155, 696-97, 741, 769-71, 916-17.2. Diverticulitis. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION=treatments-and-drugs. Accessed 16 Jan 2012.3. Acute Respiratory Distress Syndrome. PubMed Health website. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001164/4. Peanut Allergy. The Mayo Clinic: Health Information. http://www.mayoclinic.com/health/peanut-allergy/DS00710/DSECTION=risk-factors. Accessed 16 Jan 2012.5. De Meijer VE, Le HD, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Prevents Essential Fatty Acid Deficiency in Parenteral Nutrition-dependent Patients. JPGN 2010;50: 212–218.6. Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition Practice Guidelines. A.N.D. Evidence Analysis Library website. http://www.adaevidencelibrary.com/topic.cfm?cat=3016. Accessed 20 Jan 2012.7. Martindale RG, McClave SA, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med 2009;37:1757-61.8. Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr 2009; 28:387-400.

References9. Casaer MP, Mesotten D, Hermas G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Vanden Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med 2011;365: 506-17.10. De Meijer VE, Gura KM, Le HD, et al. Fish oil-based lipid emulsions prevent and reverse parenteral nutrition-associated liver disease: the Boston experience. JPEN 2009;33:541–7.11. Cunnane SC. Problems with essential fatty acids: time for a new paradigm? Prog Lipid Res 2003;42:544–68.12. Waizberg DL, Torrinhas RS & Jacintho TM. New parenteral lipid emulsions for clinical use. JPEN 2006;30:351–67.13. Mateu-de Antonio J, Grau S, Luque S, Marin-Casino M, Albert I, Ribes E. Comparative effects of olive oil-based and soyabean oil-based emulsions on infection rate and leucocyte count in critically ill patients receiving parenteral nutrition. Br J Nutr 2008;99: 846–854.14. American Dietetic Association. International Dietetics and NutritionTerminology (IDNT) Reference Manual. 3rd ed. Chicago, Il: American Dietetic Association; 2011. 15. Ireton-Jones CS, Turner WW Jr, Leipa GU, Baxter CR. Equations for estimation of energy expenditures in patients with burns with special reference to ventilatory status. J Burn Care Rehabil. 1992;13:330-333.16. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2010.17. Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010.

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