Aortic Valve Stenosis Congestive Heart Failure and Chronic

Aortic Valve Stenosis, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease Exacerbation with Development of an Ileus By Emily Phillips St. Helena Hospital, Napa Valley 3/11/2015

Introduction to Mr. H • • • Personal data: data 61 year old male Social History: History 40 – pack per year smoker, Retired Reason for admission: admission Non-ST Segment Elevation Myocardial Infarction (NSTEMI) and Congestive Heart Failure (CHF) • Chief complaint: complaint increasing shortness of breath for 3 days and “flu-like” symptoms resolved 1 month ago, which have now returned. Symptoms included: included fever, chills, cough, and productive sputum

Admitting Diagnoses • NSTEMI – Non-ST Segment Elevation Myocardial Infarction. The complete occlusion of a minor coronary artery resulting in myocardial infarction, better known as a heart attack. • CHF – Congestive Heart Failure. Impairment of the ventricles’ capacity to eject blood from the heart or to fill with blood. • COPD exacerbation – Chronic Obstructive Pulmonary Disease Exacerbation. Persistent progressive airflow obstruction and dyspnea (shortness of breath). This includes chronic bronchitis, emphysema, and asthmatic bronchitis.

Admitting Diagnoses • Right Lower Lobe Pneumonia – Inflammation of the alveoli often caused by foreign material. These air sacs become filled with fluid or pus, causing cough (with phlegm), fever, chills, and labored breathing. • Hyponatremia – Low sodium concentration in the blood. Serum sodium below 135 m. Eq/L.

Medical/Surgical Data • - Past Medical History: History Smoker (½ pack per day) for 40 years, currently 5 cigarettes per day COPD (not on breathing treatment) Hypertension Hyperlipidemia Obesity Anxiety disorder Has not seen a primary care physician for 20 years No previous pneumonia or sick contact Alcohol use

Medical/Surgical data • • • Surgical History: History None Family Medical History: History Father had a heart attack at age 60, died at 82 Medications Prior To Admission: Admission Medication Purpose Nutrition implications Tylenol Pain medication, analgesic Avoid alcohol, caffeine increase s rate of absorption and effect of drug Multivitamin Provide additional vitamins and minerals Excess may cause vitamin toxicity Aleve NSAID, antiarthritic, analgesic GI pain, constipation, nausea/vomiting, dyspepsia

Admission Physical Data • General: General Not lethargic, not dehydrated, looks septic, lying in bed with mild paroxysmal nocturnal dyspnea (PND/postnasal drip) and mild orthopnea (breathing discomfort aggravated by lying flat). Not in acute pain. Answers questions appropriately • Heart: Heart Sinus rate and sinus rhythm. Normal S 1, S 2, no S 3. No gallop • Abdomen: Benign. Bowel sounds present in all 4 quadrants, soft, non-tender. No guarding, no rigidity, no hepatosplenomegaly, no midline, pulsatile mass, or abnormal mass palpable • Extremities: Extremities No pedal edema, peripheral pulses palpable

Overview of Disease States: NSTEMI vs. Aortic Valve Stenosis • Normal function of the heart

Overview of Disease States: Aortic Valve Stenosis vs. NSTEMI: Etiologies • Aortic Valve Stenosis - Obstruction at the valvular level - Degenerative calcification (long standing hemodynamic stress on the valve) - Rheumatic heart disease - Deformed aortic valve - Increasing age - Chronic Kidney disease • - NSTEMI Diabetes Mellitus Physical Inactivity Lifestyle Diets deficient in fresh fruits/vegetables and polyunsaturated fat Hypertension Dyslipidemia Cigarette smoking Increasing age Male Family History Overweight/Obese Excess alcohol and carbohydrate consumption

Symptoms and Clinical Manifestations • • • Aortic Valve Stenosis: Chest pain/tightness Heart failure Syncope Systolic Hypertension Shortness of breath Fatigue Heart palpitations Elevated Troponins Lower perfusion pressure Altered heart sounds • • • NSTEMI: Difficulty breathing/Shortness of breath Cardiogenic Shock Elevated Troponins Pain in the sub-sternal area radiating to the arm and neck Indigestion Nausea/vomiting Sweating Weakness/fatigue Rhythmic abnormalities palpitations Syncope Dizziness

Pathophysiology: NSTEMI vs. Aortic Valve Stenosis • NSTEMI: • Atherosclerotic plaque build up compromises oxygen flow to heart • Plaque ruptures and develops a thrombus or a blood clot causing a blockage of blood flow • Lack of blood flow causes cardiomyocytes to become oxygen starved • Cardiomyocytes slow contraction, rupture and die, releasing troponins into the artery • Adrenaline is released, the rest of the heart compensates by beating faster

Aortic Stenosis • When the heart contracts the aortic valve opens and blood is pumped into the aorta • When the heart relaxes, the aortic valve closes • A narrowed aortic valve limits the amount of blood ejected from the ventricle into the aorta • Increases afterload by increasing pressure • Increases contractility to overcome the outflow resistance • This results in ventricular hypertrophy and followed by degeneration and death of the cardiac myocytes

NSTEMI and CHF • After myocardial infarction Loss of heart muscle cells Ventricular Hypertrophy Dilated Cardiomyopathy

Aortic Stenosis and CHF Aortic Stenosis Chronic Pressure Increase in afteroad/contractility Ventricular Hypertrophy Dilated Cardiomyopathy

Nutrition Interventions: Aortic Valve Stenosis vs. NSTEMI • Aortic Valve Stenosis - Main therapy is surgical replacement - Before surgery NPO (nothing by mouth) - Fluid may be restricted - Diuretics may be used to remove fluid around heart and lungs • - NSTEMI Low fat Low cholesterol Low sodium High fiber Manage weight Omega-3 fatty acids Emphasis on fruits, vegetables, and whole grains

Overview of Disease States: Congestive Heart Failure (CHF)

Pathophysiology: CHF • Chronic inflammation causing the heart to beat inefficiently • Impairing these functions: 1. Afterload – the pressure the ventricle opposes against the aorta 2. Contractility – the force the ventricle contracts with 3. Preload – how much blood fills the ventricle before it is ejected

Etiology: CHF • • Myocardial Infarction Aortic Stenosis Heart valve disorders Chronic Hypertension Coronary Artery Disease/Chronic Ischemia Constrictive Pericarditis Restrictive cardiomyopathy Dilated cardiomyopathy

• - Clinical Manifestations: CHF Decreased blood flow leads to: Dyspnea Fatigue Weakness Exercise intolerance Poor adaptation to cold temperatures Hyponatremia Ascites Edema Cough with productive sputum Orthopnea PND

Nutrition Therapy: CHF • Fluid modified diet: Less than 2 L fluid per day (for sodium levels below 130 m. Eq/L) • Sodium restriction: less than 2 gm of sodium per day • Thiamine and Potassium supplementation to compensate for losses in patients on diuretics • Limit or discontinue alcohol use • Small frequent meals for patients experiencing early satiety • Educating patient on how to season food without the use of salt • Nutrition support: • Low volume feedings for enteral feedings • TPN only indicated for patients with limited gut function and may be maximally concentrated

Overview of Disease States: COPD exacerbation • Normal Pulmonary Function: - Supply the body with oxygen while removing carbon dioxide - Air enters the lungs through the trachea, which divides into the right and left bronchi supplying the lungs - The bronchi divide again into smaller bronchioles - The bronchioles end in small air sacs (alveoli), which are responsible for the exchange of oxygen and carbon dioxide

Pathophysiology: COPD exacerbation • Progressive obstruction and inflammation of the airways • Irritants cause neutrophils, T-lymphocytes, and other inflammatory cells to accumulate in the airways • Inflammatory mediators attempt to destroy and remove inhaled foreign debris • In chronic scenarios, the response is ongoing, which inevitably causes structural and physiological lung changes • The airways become narrowed and swollen • Excess mucus production and poorly functioning cilia makes airway clearance especially difficult • Build up of mucus creates an environment where bacteria can thrive

Etiology: COPD • Chronic bronchitis • Productive cough and shortness of breath that lasts 3+ months for at least 2+ years in a row • Cigarette smoking • Repeated exposure to secondhand smoke, air pollution, and occupational exposure • Inflammation of the airways and lung tissue • Deficiency of the protein alpha 1 -antitrypsin (ATT)

Signs and Symptoms: COPD • • • Dyspnea with possible wheezing Persistent cough with sputum production Increased breathing rate Lung hyperinflation Diminished breath sounds (crackles and wheezes) Cyanosis in hypoxemic patients – this could lead to heart failure due to the heart’s increased work to pump blood through the lungs • Digital clubbing

COPD exacerbation • Defined as “worsening of COPD symptoms, or a change in the patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variations • Causes: bacteria/viral lung infections and air pollution • Additional causes include: smoking, lack of pulmonary rehabilitation, poor adherence to drug therapy

Nutrition Interventions: COPD • • • Goals: Goals Prevent weight loss, maintain and restore lean body mass Small, frequent meals to accommodate shortness of breath Food choices easy to chew, swallow, and digest Nutrient-dense nourishment and/or supplements Vitamin/mineral supplement Avoid overfeeding and excessive carbohydrate intake

Chronology of Medical and Nutritional Interventions: Newly Developed Conditions • • • Newly developed conditions: Cardiogenic shock following aortic valve replacement (2/6/15) Patent Ductus Arteriosus (2/8/15) Fluid overload (2/9/15) Alcohol withdrawal (2/10/15) Respiratory Failure (2/12/15) Leukocytosis and Ileus (2/14/15) Intra-abdominal free air of unknown origin (2/15/15) Perforated cecum and septic shock – (2/16/15) Heparin-Induced Thrombocytopenia – (2/20 – 2/26) Vancomycin-Resistant Enterococci (VRE) (3/9)

• • • Definitions of Newly Developed Conditions: Cardiogenic Shock: Shock inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively. There is insufficient perfusion to the tissues Patent Ductus Arteriosus (PDA): a congenital disorder in the heart wherein a neonate’s ductus arteriosus fails to close, with age PDA may lead to congestive heart failure Fluid overload: overload too much fluid in the blood. Can be caused by excess sodium content in the body and subsequently increase in extracellular volume Alcohol withdrawal: withdrawal cessation of alcohol use after prolonged usage. The response is a hyper-excitable response of the central nervous system to lack of alcohol. Leukocytosis: Leukocytosis elevated white blood cell count Septic shock: shock A systemic inflammatory response and immunosuppressive process that prevents an adequate response to infection or trauma. This may result in organ dysfunction or hypoperfusion abnormalities. It can cause multiple organ dysfunction and death. Respiratory Failure: Failure occurs when the respiratory system is no longer able to perform its normal functions. It can result from long standing chronic lung disease like COPD or cystic fibrosis, or as a result of an acute insult to the lung as seen with acute lung injury or acute respiratory distress syndrome Heparin-Induced Thrombocytopenia: Thrombocytopenia deficiency of platelets in the blood caused by the anticoagulant Heparin Vancomycin Resistant Enterococci: Enterococci type of bacteria called enterococci that developed a resistance to an antibiotic called vancomycin

Chronology of Medical and Nutrition Treatments Date Procedure Nutrition Intervention 2/5/15 Aortic Valve Replacement and Ascending Aortic Aneurism Graft NPO 2/9/15 Thoracentesis NPO 2/10/15 Cardioversion and Aortic Aneurism Replacement NPO 2/15/15 Exploratory laparotomy with subtotal colectomy and end-ileostomy NPO 2/16/15 Patient on mechanical ventilation NPO, TPN @ 63 m. L/hr (1590 kcals, 100 gm protein) 2/19/15 Thoracentesis NPO, TPN @ 85 m. L/hr (1790 kcals, 150 gm protein) 2/22/15 Thoracentesis NPO, TPN @ 44 (895 kcals, 75 gm protein) 2/26/15 Tracheostomy NPO, PN @ 50 m. L/hr (1195 kcals, 75 gm protein). Tube feed stopped 3/4/15 PEG placed Enteral feeding stopped from 3/3 at midnight, restarted through PEG on 3/5

Normal Intestinal Function • Small intestine: intestine - Primary site of digestion and absorption • Large intestine: intestine - Bacterial fermentation of remaining carbohydrates and amino acids - Synthesis of small amounts of vitamins, storage, and excretion of fecal residues - Absorb water

Ileus • Definition: Definition decreased or absent motility of the bowel and forward movement of bowel contents • Causes: Causes - Appendicitis - Botulism - Medications (opiates/sedatives) - Diabetic ketoacidosis - Electrolyte imbalance - Gastroenteritis - Obstruction of the mesenteric artery - Pancreatitis - Hypomotility - Crohn’s disease - Surgical complications

Pathophysiology: Ileus • Exact pathogenesis remains unclear • Surgical stress response leads to systemic generation of endocrine and inflammatory responses • Increased number of macrophages, monocytes, dendritic cells, T cells, natural killer cells, and mast cells

Clinical Manifestations: Ileus • • Abdominal pain/cramping Nausea Vomiting Diarrhea Constipation Abdominal distention Hypoactive bowel sounds

Ileus Nutrition Therapy • Delay oral feeding until ileus resolves clinically • Parenteral/Enteral feedings indicated • Having patients chew gum may simulate gastrointestinal feedings

Perforated Cecum and Pneumoperitoneum • Perforated Cecum – a hole or piercing through the wall of the cecum • Pneumoperitoneum – presence of air or gas in the peritoneal cavity

Ileostomy and Subtotal Colectomy • Opening of the ileum at the abdominal wall • Removal of part of the large intestine • Opening into the abdominal wall • The end of the ileum is brought through the stoma, typically on the lower right side of the abdomen

Nutritional Management of Ileostomies • • • Begin with clear liquids Small frequent meals, low fiber Limiting fluids with meals Encourage higher sodium intake (unless otherwise indicated) Rehydration beverages if excessive fluid is lost

Admission Nutrition Assessment • Diet history: history “eating well prior to admission”. Mr. H. is unsure of exact weight change before admit, but believes overall weight has increased over the past few months. • Allergies: Allergies no known food allergies • Admitting nutrition order: order Cardiac (2 gram sodium, low cholesterol, low fat) • Admitting intake: intake approximately 88% of meals, ~930 kcals averaged over 3 days.

• - Admission Nutrition Assessment Anthropometrics: Height: 180 cm Weight: 90. 9 Kg (standing scale) Body Mass Index (BMI): 28 Ideal Body Weight (IBW): 78. 1 Kg Percent IBW: 116% Estimation of macronutrient needs: Carbohydrate: 176 – 276 gm/day (35 -55% estimated calorie needs for COPD) Fat: 67 – 100 gm/day (30 -45% estimated calorie needs for COPD) Protein: 109 – 136 gm/day (1. 2 – 1. 5 g/kg for pulmonary disease) Calories: 2008 – 2454 kcals (Ireton Jones) Evaluation of current intake: intake is low (~46% of estimated needs), however patient appeared well nourished. No interventions were recommended upon initial assessment.

Date Chronology of weights Weight in Kg 2/1/15 90. 9 2/4/15 90. 7 2/8/15 96. 9 2/10/15 95. 6 2/11/15 96 2/14/15 97. 6 2/15/15 95. 2 2/17/15 101. 6 2/19/15 102. 8 2/21/15 103. 2 2/23/15 98. 4 2/26/15 93. 4 3/2 /15 91. 8 3/4/15 88. 5 3/9/15 87. 4

3/9/2015 3/8/2015 3/7/2015 3/6/2015 3/5/2015 3/4/2015 3/3/2015 3/2/2015 3/1/2015 2/28/2015 2/27/2015 2/26/2015 2/25/2015 2/24/2015 2/23/2015 2/22/2015 2/21/2015 2/20/2015 2/19/2015 2/18/2015 2/17/2015 2/16/2015 2/15/2015 2/14/2015 2/13/2015 2/12/2015 2/11/2015 2/10/2015 2/9/2015 2/8/2015 2/7/2015 2/6/2015 2/5/2015 2/4/2015 2/3/2015 2/2/2015 2/1/2015 Chronology of Weights Weight Trend

Nutrition related laboratory values Date 2/2/ 2/4 15 2/10 2/11 2/14 WBC 23. 6 18. 6 21. 4 Hgb 8. 8 8. 5 126 122 124 K 2. 8 Glucose 177 132 136 164 BUN 23 27 33 41 38 Mg 2. 4 2. 3 2. 6 3. 1 2. 6 Na Pre albumin Albumin 3. 2 2/8 2/16 2/17 2/19 2/21 2/23 2/26 3/2 3/4 45. 1 23. 1 18. 7 11. 7 14. 5 8. 7 10. 2 7. 5 9. 9 9. 1 11. 2 8. 7 10. 4 10. 2 126 123 3. 2 3. 4 3. 1 3. 0 133 144 134 29 31 27 30 28 146 2. 4 8. 1 4. 0 5. 1 2. 6 1. 8 1. 7 10. 7 1. 9 16. 3 17

Chronology of Labs

Nutrition related medications Vitamin/ Minerals Antibiotics/ antifungals Gastrointestinal Fluid medications Sedatives Other Multivitamin Vancomycin Miralax Potassium Chloride Propofol Sliding Scale Insulin Thiamine Levofloxacin Colace Sodium Chloride @75 m. L/hr Ativan Drip Methylprednisone Folic acid Caspofungin Docusate Senna Lasix Lipitor Zosyn Protonix Metolazone Warfarin Flagyl Reglan Vasopressin Lactobacillus

Nutrition Diagnoses • Inadequate oral food/beverage intake R/T decreased appetite, shortness of breath, and status/post surgery AEB Estimated energy needs, consuming 26 -75% - 2/8 • Inadequate oral food/beverage intake R/T compromised function of the Gastrointestinal (GI) tract AEB Need for NPO status – 2/17 • Inadequate intake from enteral/Parenteral nutrition (PN) R/T compromised function of GI tract and high enteral nutrition residuals and fluid overload requiring decreased PN rate AEB patient meeting 45% of estimated caloric needs – 2/23 • Inadequate intake from enteral/parenteral nutrition R/T compromised function of the GI tract and restricted fluids AEB tube feed/TPN less than estimated needs and PN currently provides ~65% of estimated needs – 2/26 • Inadequate intake from enteral/parenteral nutrition R/T procedure schedules AEB tube feeding stopped for over 24 hours

Date Nutrition intervention Purpose 2/1/15 Cardiac (2 gm sodium, low cholesterol, low fat) Admitting diagnosis, NSTEMI and CHF 2/8/15 Regular 2/9/15 Ensure. Plus BID (twice a day) Poor oral intake 2/16/15 PN @ 63 m. L/hr (1590 kcals, 100 gm protein) Ileus, perforated cecum, unable to take needs orally 2/19/15 PN @ 85 m. L/hr (1790 kcals, 150 gm protein) TPN running at goal, meeting estimated needs 2/20/15 PN @ 85 (1790 kcals, 150 gm protein) + Jevity 1. 2 @ 10 m. L/hr (288 kcals, 13 gm protein) Enteral nutrition added to prevent gut atrophy 2/22/15 PN @ 44 m. L/hr (895 kcals, 75 gm protein) + Jevity 1. 2 @ 10 m. L/hr (288 kcals, 13 gm protein) PN decreased due to patient volume overloaded 2/24/15 Increase Jevity 1. 2 by 10 m. L/hr Q 6 hours to goal rate of 55 m. L/hr (2448 kcals, 113 gm protein) Ileus appears resolved, enteral feedings increased to replace parenteral nutrition 2/25/15 Pivot 1. 5 @ 20 m. L/hr, increase by 10 m. L/hr every 6 hours to goal rate of 55 m. L/hr (1980 kcals, 124 gm protein) + PN @ 50 m. L/hr (1195 kcals, 75 gm protein) Formula changed to more concentrated formula to minimize fluid and easier to digest. 2/28/15 TPN stopped Enteral feedings provided needs 3/5/15 NPO, Pivot 1. 5 @ 10 m. L/hr, goal rate 55 m. L/hr via PEG New PEG placement Diet liberalized due to poor oral intake Nutrition Interventions

Nutrition Monitoring and Evaluation • - Monitor and Evaluate: Evaluate Tolerating parenteral nutrition Fluids/Intake/Output Bowel function Weight Enteral residual volume/tube feeding tolerance Gut function Lab values Swallowing ability Fat malabsorption Lactose intolerance

Discharge Plan • Issues with insurance • Medical improvements

Summary • Mr. H’s hospital course was complex and lengthy • Medical nutrition therapy improved his overall outcome despite challenges faced with surgeries, procedures, and new disease states

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