angelawolfenberger.weebly.com€¦ · Web viewUnderstanding the Disease and Pathophysiology. 1. What is inflammatory bowel disease? What does current medical literature . indicate

Case Sudy #1 Inflammatory Bowel Disease: Crohn’s Disease HN632 Angela Wolfenberger, 2/23/15

I. Understanding the Disease and Pathophysiology

1.What is inflammatory bowel disease? What does current medical literature indicate regarding its etiology?

Inflammatory bowel disease (IBD) is a chronic autoimmune inflammatory disorder affecting the gastrointestinal (GI) tract. IBD can present as Crohn’s Disease, which can affect segment all along the GI tract, or as ulcerative colitis, which is a continuous inflammation beginning at the rectum and traveling upward in the colon. IBD is thought to have a strong genetic component (ex. it is more common in those of Jewish heritage), but is influenced by environmental factors such as smoking, NSAID and antibiotic use, infectious agents (bacteria, viruses), intestinal flora, cigarette smoke, and dysregulated mucosal immune response to inflammation. IBD affects approximately 500,000 Americans, and initial onset of symptoms is generally between the ages of 15 and 35. Symptoms include: abdominal pain, fever, anemia, weight loss, diarrhea, malnutrition, growth failure, food intolerances, arthritis, mouth sores and other dermatologic issues (such as erythema nodosum and pyoderma gangrenosum), hepato-biliary complications, (hepatic steatosis, gallstones, etc.), and increased incidence of malignancy (colon cancer).

2. Mr. Sims was initially diagnosed with ulcerative colitis (UC) and then diagnosed with Crohn’s. How could this happen? What are the similarities and differences between Crohn’s and UC?

Ulcerative colitis and Crohn’s Disease generally present with similar symptoms (abdominal pain, diarrhea, fever, etc.), and both are part of the IBD spectrum. As previously mentioned, UC begins in the rectum and continues up the colon as a continuous inflammation. Crohn’s, on the other hand, can affect any part of the GI tract, most often the distal ileum of the small intestine and the colon. Crohn’s also causes inflammation in segments, and can “skip” sections of the intestinal tract to inflame other sections. UC affects only the mucosa, but Crohn’s can damage all layers (transmural), causing fistulas, strictures, and bowel obstruction. Symptoms of Crohn’s such as malabsorption and malnutrition generally do not affect UC sufferers. Crohn’s also has more frequent acute episodes, and may eventually require surgery in up to 2/3 of patients. UC generally does not require surgery. Both conditions predispose the patient to colorectal cancer.

Most Ulcerative Colitis sufferers are diagnosed in their 30’s, while most Crohn’s patients are diagnosed in their teens and early twenties. Mr. Sims was diagnosed at 32 (or 33), which may have been why he was originally diagnosed with UC.

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4. What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn’s? Explain.

1. Previous diagnosis of Crohn’s 2.5 years ago with hospitalization. Last 5-7 cm of jejunum and first 5 cm of ileum affected.

2. Admit with diarrhea, fever, weight loss and abdominal pain-- consistent with Crohn’s disease.

3. Labs indicate low values of Vitamins A (free retinol- 17.2 microg/dL), C (<.1 microg/dL), and D (22.7 ng/dL), which is consistent with nutrient malabsorption due to Crohn’s disease. C-reactive protein levels are also high (2.8mg/dL), which indicates inflammatory response. Additionally, Mr. Sims tests positive for Anti-Saccharomyces cerevisiae antibodies (ASCA), a useful marker for Crohn’s disease (UC generally recognizes perinuclear antineutrophil cytoplasmic antibodies-pANCA).

4. Mr. Sims’ abdomen is distended and tender, which is consistent with Crohn’s symptoms. Minimal bowel sounds may indicate an obstruction, which is a complication often associated with Crohn’s disease progression.

5. Crohn’s patients often have extraintestinal symptoms of the disease. What are some examples of these symptoms? Is there evidence of these in his history and physical?

1. Arthritis (joint inflammation/pain) is the most common extraintestinal complication of IBD

2. Kidney Stones (particularly oxalate stones) are the most commonly encountered IBD kidney complications.

3. Hepatobiliary complications (sclerosing cholangitis, hepatitis, gallstones, pancreatitis, etc.) are seen with Crohn’s disease, with fatigue and low energy and fatigue the most common symptoms.

4. Eye problems (redness, itchiness, pain) occur in about 10% of people with IBD.

5. Mouth lesions are often associated with IBD.6. Skin abnormalities (painful bumps/ulcers/sores/rashes) can occur with

IBD7. Osteoporosis may be a consequence of malnutrition/malabsorption in

Crohn’s.

Mr. Sims has lost about 17% of his usual body weight (UBW) in the last 6 months (from 168# to 140#), which is consistent with the malnutrition caused by Crohn’s. His hemoglobin (HgB 12.9g/dL), hematocrit (Hct %), and Ferritin (16 mg/dL) are low, which indicates anemia (consistent with malabsorption and/or rectal bleeding with Crohn’s). Mr. Sims was hospitalized last September with an abscess (the record does not state what type). Mr. Sims does not appear to have any other extraintestinal complications.

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7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain these values.

Lab Value Indication Hemoglobin (HgB 12.9g/dL) Hematocrit (Hct %) Ferritin (16 mg/dL)

Transferrin (180 mg/dL)

Total Protein (5.5g/dL), Prealbumin (11mg/dL), and Albumin (3.2g/dL)

Calcium (9.1mg/dL)Magnesium (1.8 mg/dL)

Vitamin A (17.2 microg/dL)Vitamin C (<.1 microg/dL)Vitamin D (22.7 ng/dL)

C-reactive protein (2.8mg/dL)

Sodium (136 mEq/L)Potassium (3.7 mEq/L)

Low-may indicate anemia, consistent with chronic inflammation, malabsorption of B12 or folate or Fe and/or rectal bleeding with Crohn’s

Low- Indicator of illness

Low- indicative of malnutrition and is also corroborated by his recent history of 28# weight loss in six months. Many patients with suboptimally treated Crohn’s experience hypoalbuminuria.

Borderline (Low)-indicates nearly depleted stores, probably from malnutrition associated with Crohn’s.

Low- Consistent with nutrient malabsorption due to active Crohn’s disease.

High- which indicates inflammatory response, correlating with disease activity.

Borderline (Low)- Watch-If low, could indicate dehydration (from diarrhea)

The WBC count is also borderline high (11.1x103/mm3), but should be watched, because leukocytosis with Crohn’s can indicate a serious infection or abscess. Also, Alkaline Phosphatase (120U/L) is borderline High, so should be monitored. If it increases, high ALK PHOS may indicate hepatic stress due to inflammation from Crohn’s flare-up, but since ALT and AST are normal, elevated levels could indicate bone activity (extraintestinal complication). The aberrant test results from Mr. Sims’ labs are all consistent with malnutrition, malabsorption, and inflammation, which signal that he is having an exacerbated episode of Crohn’s.


Additionally, Mr. Sims tested positive for Anti-Saccharomyces cerevisiae antibodies (ASCA), a useful marker for Crohn’s disease. Patients that test positive for ASCA have a higher rate of surgery—and early surgery than other Crohn’s patients.

8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.

Though he may be supplementing his vitamin and mineral intake, Mr. Sims is still at risk for nutritional deficiencies, as evidenced by his low vitamin A, C, and D values, his low Hct and HgB levels, and his borderline low Calcium and Magnesium values. Mr. Sims’ Crohn’s disease may be causing malabsorption from bowel inflammation; so additional supplements may not be having any affect. Mr. Sims is also experiencing severe diarrhea, which further indicates malabsorption of nutrients. The patient may also be experiencing food avoidance, because of his severe abdominal pain and diarrhea, which would also contribute to insufficient vitamin and mineral intake. This is supported by the patient’s 28# weight loss (17%) over the last 6 months. Mr. Sims’ exacerbated Crohn’s causes inflammation, which causes vitamins/minerals (such as A, C, Zn, B vitamins, etc.) to be used at an accelerated rate. He may also be suffering from anemia from blood loss, with concomitant Iron deficiency (or B12/folate). Finally, since his Crohn’s has inflamed the distal ileum in the past, he may be experiencing malabsorption of B12 because exacerbated Crohn’s may compromise the uptake sites for this nutrient. 9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide rationale for your answer.

Short bowel syndrome (SBS) can occur after partial removal of greater than 2/3 of the small intestine (leaving the patient with less than 200cm of functioning small intestine). Surgery to ameliorate Crohn’s disease is a common cause of short bowel syndrome. Short bowel syndrome can cause malabsorption, weight loss, diarrhea, dehydration, loss of electrolytes, and hypokalemia.

Mr. Sims has had 200 cm (1/3 of the total length) removed from his small intestine, so he would probably not be considered for a short bowel syndrome diagnosis at this time. He is also young, which improves his chances for having the remaining portion of small intestine compensate for the lost portion. He does, however, exhibit several of the symptoms (ex. malabsorption, diarrhea), and if the resection occurred at the terminal ileum or if he undergoes further resection of the small intestine, he should be monitored for this condition.

10. What type of adaptation can the small intestine make after resection?


If the Jejunum portion of the small intestine is surgically removed, then the ileum portion is able to increase in size (length and diameter) and absorptive capacity. The height of the villi increases, and crypts become deeper. This phenomenon, called “compensatory hypertrophy of the ileum”, may take 1-2 years, but can help the patient recover near normal quality of life. Early initiation of enteral nutrition after resection improves compensatory function in remaining small intestine.

Unfortunately, many Crohn’s patients require ileocecal resection, involving the terminal 1/3 of the ileum and the ileocecal valve. Loss of the ileocecal valve puts a patient at higher risk for SBS. Further, removal of the terminal ileum results in permanent collapse of B12 absorption, and of bile salt and intrinsic factor reabsorption. Lifelong B12 shots would be required. Long-term enteral or parenteral nutrition may also be indicated.

Depending on the success of compensatory hypertrophy of the ileum, a high calorie diet may be indicated to prevent weight loss. Extensive surgery may also reduce the intestine’s capacity to absorb micronutrients, and patients may require supplementation (ex. Folate). Finally, the remaining intestine may have difficulty absorbing fats (this does not occur with carbohydrate or protein), so a reduction in dietary fat may be indicated, and depletion of fat soluble vitamins and minerals (A, D, E, K, Ca, Mg) may follow.

11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care team monitor?

Short bowel syndrome causes a decrease in transit time, which can result in diarrhea, steatorrhea, dehydration, loss of electrolytes, hypokalemia and weight loss from malabsorption. Mr. Sims may also experience cramping, bloating, heartburn, weakness, and fatigue. Clinical staff should monitor Mr. Sims’ labs for electrolyte levels, dehydration, and vitamin and mineral absorption. They should also check his weight, frequency and severity of diarrhea, lethargy, and abdominal pain and distention.

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II. Understanding Nutrition Therapy

13. What are the potential nutritional consequences of Crohn’s disease?

Patients with Crohn’s disease may suffer from malnutrition, malabsorption of nutrients, growth failure, and weight loss. The inflammation caused by Crohn’s disease can severely restrict the quality of nutrition absorbed from ingested foods. Protein, micronutrient, and caloric requirements may not be met. Also, the pain, bloating, and diarrhea associated with the condition often causes food avoidance. Protein energy malnutrition may ensue. Loss of minerals, including FE, ZN, CA, MG, K, and vitamins such as A, D, E, and K may affect bone, wound healing, and immunity. Negative nitrogen balance may also occur.


Hyperhomocysteinemia frequently occurs with Crohn’s disease, which can increase risk of artery disease.

Additionally medications frequently prescribed may have nutritional impacts as well (such as osteoporosis or hyperglycemia). Finally, food intolerances, (ex. Lactose, gluten) whether permanent or temporary, may result from inflammation or resection of the small intestine.

14. Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with placement of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not have and ileostomy, and his entire colon remains intact. How long is the small intestine, and how significant is the resection?

Mr. Sims was fortunate in that the resection occurred in the jejunum and proximal ileum (where carbohydrates, proteins, fat, and vitamins are absorbed), because compensatory hypertrophy of the ileum may return near normal function to his small intestine and preserve his quality of life. The small intestine, according to cadaver studies can range from 600-800 cm in length. Mr. Sims has retained at least 2/3 of his small intestine, which should be enough for near normal absorption to return. The ileocecal valve was retained, which is important for keeping bacteria from the colon from contaminating the small intestine. The distal ileum also appears to be intact, which is imperative for B12 absorption, as well as reabsorption of bile salts and intrinsic factor. The duodenum, the site of iron absorption, also appears to be intact. Mr. Sims’ stool should be monitored for steatorrhea, and decrease dietary fat decreased as needed, as lipid digestion may be diminished (temporarily or permanently) by the jejunal resection.

15. What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?

Most digestion and absorption of nutrient occurs in the first 100 cm (duodenum and jejunum) of the small intestine. The jejunum is the site for amino acids, small peptides, mono and disaccharides, and most micronutrient absorption (B vitamins-except B12, C, A, D, E, K, Ca, P, Mg, Fe, Zn, Cr, Mn, and Mo), and lipid digestion and absorption. The proximal ileum also absorbs amino acids and peptides and micronutrients (Vitamin C, D, K, Folate, and Mg). Water, sodium, and lipids are absorbed by passive diffusion throughout the small intestine.


III. Nutrition Assessment

16. Evaluate Mr. Sims’ %UBW and BMI.

Ht- 5’9”, 175cm Wt.- 140#, 63.6kg BMI- 20.7 UBW- 168#, 76.4kg

Weight lost in 6 months= 28# %UBW lost in 6 months= 17%

IBW= 106#+6#/in over 60”= 106+(6x9)= 160

(140 lbs.) / (2.2) = 63.6 kg, (69 in) x (0.0254) = 1.75 m

(63.6 kg) / (1.75 m)2 = 20.7 kg/m2= BMI, normal

Mr. Sims is at a normal weight and BMI, but has had a severe weight loss (>10% in 6 months), which puts him at risk of protein energy malnutrition. He is at 87.5% of his IBW, which (80-90%=mild malnutrition). Mr. Sims is also at 83% of his UBW, and 75-84% of UBW indicates moderate malnutrition, so I would classify him as malnourished.


17. Calculate Mr. Sims’ energy requirements, using kcal/kg of body weight.

Mr. Sims requires a high calorie diet due to inflammation and malnutrition. Normal diet for acute Crohn’s “flare ups” is 30-35 kcal/kg. We chose to use 30 kcal/kg. Though he has had a significant weight loss, he is still at a normal BMI, and his GI tract may better tolerate the lower kcal/kg

30 kcal/kg x 63.6 kg = 1909 kcal/day

18. What would you estimate Mr. Sims’ protein requirements to be?

Acute Crohn’s patients require a high protein diet (1.0-1.5g/kg of body weight). We chose to use 1.5 g/kg because of Mr. Sims’ malnourished state, and because he healing required a higher protein component.

1.5 g x 63.6 kg = 95.4 g of protein 95.4g x 4 kcal/g = 381.6 kcal/day of protein

19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs.

Test Reference Range Patient’s Value Reason/Cause

Chemistry

Protein, total (g/ dL) 6-8 5.5 (low) Low- indicative of malnutrition (protein status) Many patients with suboptimally treated Crohn’s experience hypoalbuminuria.

Albumin (g/dL) 3.5-5 3.2 (low)

Prealbumin (g/dL) 16-35 11 (low)

C-reactive protein (mg/dL)

<1 2.8 (high) High- Indicates inflammatory response, correlating with disease activity.

HDL-C (mg/dL) >45 38 (low) Low- Indicates active Crohn’s (a feature of critical illness)

ASCA Neg + Marker for Crohn’s disease. Patients that test positive for ASCA have a higher rate of surgery—and early surgery than other Crohn’s patients.

Hematology

PT (sec) 12.4-14.4 15 (high) Long-Indicates vitamin K deficiency (from Crohn’s/


malabsorption)

Test Reference Range Patient’s Value Reason/Cause

Hemoglobin (Hgb, g/dL)

14-17 12.9 (low) Low-May indicate iron deficiency, nutritional deficit, malabsorption

Hematocrit (Hct, %) 40-54 38 (low) Low- Consistent with chronic inflammation, nutritional deficit, and/or rectal bleeding with Crohn’s

Ferritin (mg/mL) 20-300 M 16 (low) Chronic inflammatory diseases may lower stores, positive acute phase reactant

Transferrin (mg/dL) 215-365 M 180 (low) Low- Indicator of acute inflammatory reactions, drops when Fe stores are depleted

ZPP (µmol/mol) 30-80 85 (high) High- Increases in ZPP is usually caused by iron deficiency and inflammatory conditions

Vitamin D 25 hydroxy (ng/mL) (low)

30-100 22.7 (low) Low- Consistent with nutrient malabsorption and inadequate dietary intake due to active Crohn’s disease.

Free retinol (vitamin A; µg/dL)

20-80 17.2 (low)

Ascorbic acid (mg/dL) .2-2.0 < .1 (low)

IV. Nutrition Diagnosis

20. Select two nutrition problems and complete the PES statement for each.

A. Involuntary weight loss (NC-3.2) related to poor appetite and symptoms of Crohn’s disease exacerbation diagnosis (bloating, abdominal pain, diarrhea, malabsorption of nutrients) as evidenced by unintentional weight loss of 17% of UBW over a six-month period and abnormal lab results (low HgB, Hct, Proteins, Vitamin A, D, C, etc.)

B. Inadequate Protein Intake (NI-5.7.1) related to diagnosed exacerbation of Crohn’s disease with increased nutrient needs and decreased ability to consume/digest/absorb sufficient protein as evidenced by low biochemical protein, albumin, and prealbumin levels, client’s history of Crohn’s disease, loss of appetite with severe diarrhea and abdominal pain, and small intestine resection.


V. Nutrition Intervention

21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least 7-10 days. What information would the nutrition support team evaluate in deciding the route for nutrition support?

The nutrition support team needs to know the details of the small intestine resection including what section(s) and how much small intestine remains. They would also need to know if there is GI function/motility (stool output), hydration (urine output) and nutrition status (labs), nutrient requirements (calculated), medications prescribed (for interaction or side effects), and if nausea/diarrhea/vomiting/appetite is present (visual assessment/chart).

Mr. Sims’ resection left ample small intestine (2/3) to eventually return to normal diet and oral intake. PN is generally reserved for severely malnourished patients with limited remaining small intestine, without preservation of ileocecal valve, or with colon removal, none of which applies to Mr. Sims. Research shows that early administration of enteral nutrition is well tolerated and prevents postoperative complications such as infection. Early EN has also been shown to improve the compensatory hypertrophy of the ileum.

A high calorie, high protein formula will be considered because of the elevated protein requirements for healing after surgery, with lower levels of lipids if they are not well tolerated after the small intestine resection. Multiple small feedings per day may best help him tolerate the formula. After surgery, it is important to supply Mr. Sims with fluids and electrolytes to keep him hydrated and to maintain metabolic control. Enteral nutrition should follow (after the first 24-48 hours) because the patient will probably briefly require bowel rest for the resected small intestine. Mr. Sims’ jejunostomy will help him tolerate early initiation of enteral feeding and help his GI function return to normal. The team will need to monitor his hydration and electrolyte status, as well as him GI motility and weight. The team can decrease PN amount when the Mr. Sims is able to tolerate some oral feeding without excessive ostomy output (along with weight maintenance or gain). The patient should be encouraged to try to resume oral intake (along with enteral nutrition to maintain caloric intake) as soon as he is able. Clear liquids, given a few hours after surgery, have been found to prevent morbidity. The team must also monitor his labs for nutrition status (protein, vitamin/mineral status, etc.), as Mr. Sims was malnourished upon admission, which contributes to post-operative complications and mortality. The patient should be given a lactose free, low fiber diet until the resected intestine heals, because he will probably be (temporarily) lactose intolerant.


22. The members of the nutrition support team note his serum phosphorus and serum magnesium are at the low end of the normal range. Why might that be of concern?

Phosphorous and magnesium stores may be low due to malnutrition and malabsorption resulting from Crohn’s disease, especially the inflammation caused by the current exacerbation of the disease. Mr. Sims has had poor appetite and diminished nutrient intake, and has experienced severe diarrhea. Hypophosphatemia may also be caused by the patient’s low vitamin D, which is necessary for the absorption of phosphate (magnesium is also necessary for phosphate absorption). Low phosphate can cause respiratory problems, confusion, loss of appetite, and changes in bone and mineral metabolism.

Magnesium is important for nerve and muscle function. Hypomagnesaemia is generally caused by malnutrition, extensive diarrhea, or malabsorption, all of which Mr. Sims is currently experiencing. Hypomagnesaemia can cause nausea/vomiting, loss of appetite, fatigue, muscle spasm/tremors/weakness, and personality changes.

The support team must also monitor Mr. Sims’ phosphate and magnesium levels (as well as potassium) to watch for any sudden drops, which can indicate refeeding syndrome, causing respiratory symptoms, cardiac arrhythmias and death (heart failure). If Mr. Sims is placed on PN, the resulting increased carbohydrate metabolism will cause insulin release and his cells to take up increased levels of phosphate and magnesium. Additionally, absorption of these nutrients may be affected by the small intestine resection (vitamins and minerals are mostly absorbed in the jejunum), which could also cause body stores to drop dangerously low.

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented?

Refeeding syndrome is defined as severe fluid electrolyte alterations that can occur in severely malnourished patients. It is seen in starved patients (such those with marasmus from anorexia nervosa), or malnourished patients after surgery. Refeeding syndrome is caused by metabolic abnormalities during oral, enteral, or parenteral nutrition repletion. Metabolism shifts from catabolism to anabolism. The body begins to make large quantities of glucose, so insulin is released when carbohydrates are introduced, which triggers cellular uptake of potassium, phosphate, and magnesium. If serum concentrations of these electrolytes plummet, cardiac arrhythmias and arrest as well as respiratory failure may occur.

Mr. Sims may be at risk for this syndrome. He was malnourished when he was admitted to the hospital, according to his significant weight loss over the last 6 months (17%) and his low nutritional status (low protein, vitamins, and minerals) according to his labs. An additional contributing factor would be if he was he was NPO for 5 days (because of his malnourished state) after his surgery.


Refeeding syndrome can be prevented be introducing calorie repletion slowly. Patients at risk for refeeding syndrome generally receive nutritional support at about 10 kcal/kg/day, raising it gradually to goal amounts within a week. Electrolytes must be monitored, watching for falling potassium, phosphorous, and magnesium levels, as well as hyperglycemia. Vitamin, mineral, and electrolyte are important as well.

24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively, and a nutrition support consult was ordered. Initially, he was prescribed to receive 200 g dextrose/L, 42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition was initiated at 50 ml/hr. with a goal rate of 85 ml/hr. Do you agree with the team’s decision to initiate parenteral nutrition? Will this meet his estimated nutritional needs? Explain. Calculate: pro (g); CHO (g); lipid (g); and total kcal from his PN.

I do not agree with the decision to initiate parenteral nutrition. Current research indicates that early enteral nutrition introduction; with oral intake of clear fluids as soon as possible is the preferred method to prevent postsurgical complications and infection. Also, because Mr. Sims may be at risk of refeeding syndrome, caloric repletion must begin at lower levels than indicated b the team, and raised slowly over a week to the goal rate (while monitoring electrolyte levels).

o Protein needs: 95.4 g/dayo Caloric needs= 1908 kcal/dayo Fluid requirements: 1 ml/kcal a day =1908 ml= 1.9 L/day

Parenteral Nutrition: Initial = 50ml/hr. x 24hr = 1200ml/day = 1.2 L/day

PRO = 1.2L x 42.5g amino acids/L = 51g amino acids/day51g amino acids/day x 4kcal/g = 204 kcal amino acids

CHO = 1.2L x 200g dextrose/L = 240g dextrose/day240g dextrose/day x 3.4kcal/g = 816 kcal dextrose

Lipid = 1.2L x 30g lipids/L = 36g lipids/day36g lipids/day x 10kcal/g = 360 kcal lipids

TOTAL kcal = 1380 kcal/day (initial)

Goal = 85ml/hr. x 24hr = 2040ml/day = 2.04 L/day


Pro = 20.4L x 42.5g amino acids/L = 86.7 g amino acid/day86.7g amino acids/day x 4kcal/g = 346 kcal amino acids

CHO = 2.04L x 200g dextrose/L = 408g dextrose/day408g dextrose/day x 3.4kcal/g = 1632 kcal dextrose

Lipid = 2.04L x 30g lipids/L = 61.2g lipids/day61.2g lipids/day x 10kcal/g = 612 kcal lipids/day

TOTAL kcal = 2590 kcal (Goal)

The initial rate of PN (50ml/hr.) will not meet his caloric needs (nor is it expected to meet them). The goal rate (85ml/hr.) will exceed his caloric needs. If he can tolerate the goal rate, his weight may begin to normalize. Neither rate of PN meets his protein needs (95.4g/day). A higher concentration of amino acids may be required. The initial PN rate (50ml/hr.) will not meet Mr. Sims fluid requirement, but the goal rate of 85ml/hr. will meet the fluid requirement.

25. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).

1. Involuntary weight loss- (NC 3.2)GOAL- Restore appetite by timely healing of small bowel resection,

reduction of abdominal distention, pain and remediation of diarrhea. Maintain/normalize weight through high calorie, high protein enteral feedings and transition to oral feeding as soon as is practical. Supplemental EN may be required to prevent weight loss until body nutrient stores normalize (protein, vitamins/minerals) and blood count normalizes. Patient will regain weight slowly until IBW (160#) is achieved.

Nutrition Intervention: Parenteral Nutrition Composition (ND 2.2.1) High protein formula with added glutamine for healing. Transition to Enteral Nutrition Composition (ND 2.1.1) Early administration of EN using high calorie, high protein formula. Vitamin and Mineral Supplements (ND 3.2.1) multivitamin/mineral supplement with added vitamin C (ND 3.2.3 10525), D (ND 3.2.3 10526), A (ND 3.2.3 10524), Thiamin (ND 3.2.3 10529), Phosphorous (ND 3.2.4 10544), Potassium (ND 3.2.4 10543), Iron (ND 3.2.4 10541), Magnesium (ND 3.2.4 10542), Zn (ND 3.2.4 10546), as required to normalize nutrient status, as determined by lab results. Add Modified food supplements (ND 3.1) with high calorie and high protein to aid healing of small bowel resection and encourage weight regain.

2. Inadequate protein-energy intake (NI-5.3)GOAL: Normalize total protein, albumin, prealbumin, ferritin, and

transferrin levels through PN /EN formula. Patient will require a high protein PN formula, then transition to a high calorie, high protein EN formula, combined with oral intake as tolerated.

Nutrition Intervention: Parenteral Nutrition Composition (ND 2.2.1) High protein formula with added glutamine for healing. Transition to Enteral Nutrition Composition (ND 2.1.1) Early administration of EN using high calorie, high protein formula. Medical food supplements (ND 3.1.3) Modified beverage


High protein oral formula to meet protein requirements for increased requirements caused by exacerbation of Crohn’s disease with subsequent small intestine resection-as tolerated.

VI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:

Measure Mr. Sims’ dataOxygen consumption (mL/min) 295CO2 production (mL/min) 261RQ 0.88RMR 2022What does this information tell you about Mr. Sims?

Indirect calorimetry is based on the supposition that volumes of gases exchanged by the lungs reflect cellular metabolic levels.

Oxygen consumption (VO2) is a measure of the oxygen absorbed and utilized by the body each minute. VO2 is used to determine how much energy a patient expends. Normal Value for critically ill patient=250ml/min

CO2 production (VCO2) measures the volume of CO2 produced and how much oxygen has been used. Normal value for critically ill patient=200ml/min

Respiration Quotient (RQ) indicates the fuel mixture being used by the body (>1= fat synthesis with excess CHO, 1=CHO, .85=mixed, .82=Pro, .7=Fat, <.65= ketone production. RQ is a marker for tolerance of nutrition support. It does not correlate with over/underfeeding. Normal value for critically ill patient= .65-1

RMR (Resting Metabolic Rate) is a measure of the calories expended per day on bed rest. Normal value for a critically ill patient = 1800-2200kcal.

RQ = volume of CO2 expired/volume of O2 consumed

Mr. Sims’ RQ value of .88 indicates that he is metabolizing a mixed diet, so he is tolerating the PN well. The estimated RMR, VO2, and VCO2 indicate, however, that Mr. Sims’ is using more calories than the estimated 1908 (30 g/kg).

27. Would you make any changes to his prescribed nutrition support? What should be monitored to ensure accuracy of his nutrition support? Explain.

As stated above, the estimated RMR, VO2, and VCO2 indicate, that Mr. Sims’ metabolic activity is higher than normal (probably due to post-operative hypermetabolic state), so he is using more calories than the estimated 1908 (30 g/kg). The nutrition team should monitor his weight closely (at least 3x/week) to see if it may be appropriate to increase the calorie/protein content of his PN. His lab values (protein, nutrient status, electrolytes, etc.) must be monitored for


abnormal values. Also, the adequacy of his parenteral intake must be measured at least twice/week.

I would consider increasing the protein percentage of Mr. Sims’ PN. The PN originally ordered did not meet his protein requirements to begin with, so an increase in protein, is warranted, but would require a change in the mixture of macronutrients he is receiving. The RMR of 2022kcal measured through indirect calorimetry is below the 2590kcal that he is receiving through PN, so if the concentration of formula were simply elevated, he would be overfed calorically.

28. What should the nutrition support team monitor daily? What should be monitored weekly? Explain.

Daily: Mr. Sims’ catheter site must be monitored for signs of infection and his temperature taken daily (the primary complication of PN). His weight must be monitored at least 3 times per week (daily at first) to ensure the adequacy of his PN. He was already malnourished and had lost 17% of his UBW in the past 6 months, so he needs to begin to regain weight. He can’t afford to keep losing ground (further weight loss would slow his recovery and put him at risk of complications). Mr. Sims’ serum electrolytes should initially be measured daily to make sure he does not experience refeeding syndrome and to ensure acid/base balance. Later electrolytes can be measured 1-2 times/week. Blood glucose should be checked daily at first, then 3 times per week to avoid hyperglycemia. Fluid intake and output should be measured daily to prevent dehydration and associated immunosuppression.

Weekly: Liver enzyme levels should be taken weekly to monitor lipid tolerance, and to avoid fatty liver and cholestasis. Hematocrit and hemoglobin should be weekly as well. Many of the nutrient status labs that are originally monitored daily can be changed to weekly monitoring once the patient is stable and improving. Triglycerides are monitored weekly to avoid hypertriglyceridemia. Severe hypertriglyceridemia can induce pancreatitis.

29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now abnormal? What should be done about it?

Hyperglycemia (serum glucose >126mg/dl) is a common complication of PN (up to 50%) that can cause immunosuppression and increases morbidity/mortality in surgical patients. “Tight blood glucose control” (glucose 80–110 mg/dL) improves the outcome of surgical patients and PN recipients alike. A higher infection rate at the catheter site is also correlated with hyperglycemia.

The first step to lower blood glucose would be to add regular insulin to his PN regimen. This would immediately lower blood glucose levels. PN formula calculations can then be reviewed to see if lowering the dextrose percentage of the PN formula is indicated.

30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4 gram. By using the daily input/output record for 12/20 that records the amount of PN received, calculate Mr. Sims’ nitrogen balance on


postoperative day 4. How would you interpret this information? Should you be concerned? Are there problems with the accuracy of nitrogen balance studies? Explain.

N2 balance= (dietary protein intake/ 6.25)- urine urea nitrogen-4N2 balance= (86.7g/6.25)- 18.4g-4= -8.5g

Mr. Sims’ appears to be in negative nitrogen balance (N2 balance=18.5g), indicating that he is excreting more nitrogen than he is ingesting. This is commonly found with post-operative patients or those experiencing trauma or illness. Healing is slowed significantly when the patient is in negative nitrogen balance. Negative nitrogen balance also indicates that Mr. Sims’ PN is not effective and should be reevaluated.I would be concerned because Mr. Sims’ PN formula did not include sufficient protein, according to calculations, and recovery from his small bowel resection requires that he receive significant protein for healing. Mr. Sims’ protein status and weight were also low upon admission, so he is not receiving adequate protein to prevent muscle wasting, decreased total body mass (75% of mass lost is fat).

There are several problems associated with Nitrogen balance studies, including:

Inherent error of 24-hour urine collection (overestimate intake and underestimate output)

Inability to measure nitrogen losses from diarrhea/vomiting/flatus/wound weeping

Failure to account for renal impairment (changes in renal function are common in patients with inflammation)

Intake of Nitrogen is difficult to account for if patient receives any oral nutrition

Limits of test-Not a measure of protein anabolism/catabolismTherefore, the nitrogen balance study alone should not be used to

determine PN effectiveness. Along with the other indicators seen in earlier questions, however, re-evaluation of Mr. Sims’ PN formula for a different dextrose to amino acid (higher amino acid/lower dextrose) ratio should be considered.

31. On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous 48 hours and had his first bowel movement. The nutrition support team recommends consideration of an oral diet. What should Mr. Sims be allowed to try first? What would you monitor for tolerance? If successful, when can the parenteral nutrition be weaned?

Oral intake is generally initiated with a clear liquids diet that, if tolerated, should be quickly followed by a low fiber, low fat and lactose free diet of easily digested foods. Small, frequent high calorie and high protein meals should be offered, accounting for variations in the patient’s appetite and acceptance of oral nutrition. As oral intake increases (and increased fiber, fat, lactose, etc. have


been added), PN should be lowered concurrently. Mr. Sims should receive approximately 75% of his nutrition orally before PN is discontinued. Oral intake and symptoms such as nausea, vomiting, abdominal bloating, and diarrhea should be continuously monitored so that nutrition support can be reintroduced if necessary. Fats should be limited and/or replaced with MCT oil if steatorrhea is present. The patient should avoid gas-producing foods and foods that are spicy or high in sugar (can cause diarrhea). Individuals vary in the length of times these measures are necessary. Previously, it was thought that patients should be slowly weaned from PN to prevent rebound hypoglycemia, but current guidelines refute this idea, stating that normal glucose balance is restore within 60 minutes after discontinuing PN.

32. OMIT

ADIMEAssessment

Hx: 35-year-old Caucasian Male admitted with chronic diarrhea, fever, and severe abdominal pain. Ht: 175cm Wt.: 63.6kg UBW:168# IBW: 160# BMI: 20.4

Dx: Crohn’s Disease 2 years ago. Pt. has lost 28 lbs. in last 6 months (17% of UBW).


Labs: alb- 3.2 L, prealb- 11 L, Total protein- 5.5 L, Transferrin- 180 L, Ferritin 16 L, ZPP 85 H, CRP- 2.8 H, HBG- 12.9 L, HCT- 38 L, HDL-C 38 L, Vitamin D 22.7 L, Free Retinol 17.2 L, Ascorbic Acid <.1 L Current Diet Order: Parenteral nutrition EER: 1908kcal/day Estimated Protein Needs: 63.6-95.4g/day Meds (at home): 6-mercaptopurine

Diagnosis: Involuntary weight loss (NC-3.2) related to poor appetite and symptoms of Crohn’s disease exacerbation diagnosis (bloating, abdominal pain, diarrhea, malnutrition, malabsorption of nutrients) as evidenced by unintentional weight loss of 17% of UBW over a six-month period and abnormal lab results (low HgB, Hct, total Protein, albumin, prealbumin, transferrin, ferritin, Vitamin A, D, C, etc.)

Intervention: Parenteral Nutrition Composition (ND 2.2.1) High protein formula with added

glutamine for healing after small bowel resection. 160 g dextrose/L (400ml of D40), 51 g amino acids/L (600ml of 8.5%aa), and 30 g lipid/L. Initiate at 20 ml/hr.; increase 10ml/hr. every 8 hours to 83ml/hr., as tolerated. Flush with 60ml warm water every 4 hours and before/after meds. If not tolerated, return to previously tolerated rate.

o 2.0L of formula over 24hours provides 2096kcal, 102g of protein, 60g lipids

Vitamin and Mineral Supplements (ND 3.2.1) multivitamin/mineral supplement with added vitamin C (ND 3.2.3 10525), D (ND 3.2.3 10526), A (ND 3.2.3 10524), Thiamin (ND 3.2.3 10529), Phosphorous (ND 3.2.4 10544), Potassium (ND 3.2.4 10543), Iron (ND 3.2.4 10541), Magnesium (ND 3.2.4 10542), Zn (ND 3.2.4 10546), as required to normalize nutrient status, as determined by lab results.

Modified food supplements (ND 3.1) Transition to oral feeding starting with clear liquids, then adding low residue diet as soon as practicable, adding high protein supplements with added vitamins and minerals as required (evidenced by labs/nutrient status)

Monitor/Evaluate: Parenteral Intake (FH 1.3.2) To ensure adequate intake, prevent

dehydration/edema Body weight (AD 1.1) Discern whether Pt. is losing/regaining/maintaining weight Electrolytes (BD 1.2) Monitor for signs of refeeding syndrome Glucose (BD 1.5) Monitor for signs of hyperglycemia to prevent dehydration and

associated immunosuppression. Lipid profile (BD 1.7) Monitor for hypertriglyceridemiaInitially, it is important to monitor Mr. Sims clinical (physical) state as well as labs to avoid refeeding syndrome and hyperglycemia. As Mr. Sims transitions to enteral and then to oral feedings, M/E needs will be reassessed.Resources by Question:

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Hartl, W. H., Jauch, K. W., Parhofer, K., Rittler, P., & Working Group for Developing the Guidelines for Parenteral Nutrition of the German Association for Nutritional Medicine. (2009). Complications and monitoring–guidelines on parenteral nutrition, Chapter 11. GMS German Medical Science, 7.30. Kopple, J. D. (1987). Uses and limitations of the balance technique. Journal of Parenteral and Enteral Nutrition, 11(5 suppl), 79S-85S31. Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L.Krause, Marie V. (Eds.) (2012) Krause's food & the nutrition care process /St. Louis, Mo. : Elsevier/Saunders, p 321. Braga, M., Ljungqvist, O., Soeters, P., Fearon, K., Weimann, A., & Bozzetti, F. (2009). ESPEN guidelines on parenteral nutrition: surgery. Clinical nutrition,28(4), 378-386.

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