Nutritional Management of Sepsis By Erika Stahl January

Nutritional Management of Sepsis By Erika Stahl January 2013

Case Presentation -85 year old African-American female -Diagnosis: -sepsis due to pneumonia -metabolic encephalopathy -hypernatremia -pressure ulcers x 4

Past Medical History • Dysphagia • ESRD with dialysis • CAD, CVA, MI, Hypertension, Hyperlipidemia • s/p ischemic bowel colon resection ileostomy • hyperthyroidism

Evidence Based Guidelines - 2 year prospective, randomized, clinical study - NG tube vs. ND in critically ill patients (101 pts) - APACHE score < 20 = critically ill - APACHE score ≥ 20 = severely critically ill - Huang H, et al. Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical Illness. Journal of the Academy of Nutrition and Dietetics. 2012; 112 (8): 1138 - 1145.

Findings: • Patients with a high APACHE score (≥ 20) had better outcomes using ND tube • - Increased energy and protein intake (90. 4% and 93. 2% of estimated energy and protein needs) • -Reduced feeding complications • -Improved nitrogen balance • -Shorter ICU stay • Huang H, et al. Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical Illness. Journal of the Academy of Nutrition and Dietetics. 2012; 112 (8): 1138 - 1145.

Evidence Based Guidelines • Review article on wound healing and nutrition • Dietitian should consider physical assessment of pressure ulcers • Recommendations based off experience with 68 patients at a long-term acute-care hospital • Tempest M, et al. Nutrition, Physical Assessment, and Wound Healing. Support Line. 2010; 32 (3): 22 -28.

Recommendations: • Patients with stage 3 or 4 pressure ulcers: • 500 mg of vitamin C BID for 14 days • 220 mg of zinc sulfate for 14 days • 700 to 3, 000 IU of vitamin A per day if deficiency suspected. • Glutamine and arginine may be useful • Protein- 1. 5 to 2 g/kg & Energy- 35 to 40 kcal/kg • Tempest M, et al. Nutrition, Physical Assessment, and Wound Healing. Support Line. 2010; 32 (3): 22 -28.

Evidence Based Guidelines • Goals of nutrition support with a septic patient: • Prevent starvation • Minimize metabolic complications (ex. hyperglycemia) • Correct nutrient deficiencies • Manage fluid and electrolyte balance • Achieve normal homeostasis • Escott-Stump S, Mahan LK, Raymond JL. Krause’s Food and the Nutrition Care Process. 13 th ed. St. Louis, MO: Elsevier Saunders; 2012.

Food and Nutrition Related History • Follows a pureed diet with nectar thick fluids at nursing home for dysphagia • Recently been in a car accident poor dietary intake MD Rx Megace • *Possible risk for Refeeding Syndrome* • Allergic to ascorbic acid/vitamin c hives

Nutrition Focused Physical Findings • Verbally unresponsive, altered mental status (PD 1. 1. 1) • Extremities contracted into body (PD-1. 1. 4). • Thin cachectic extremities (PD-1. 1. 4) • Pressure ulcers x 4 (PD-1. 1. 8) • One stage 4; One deemed unstagable; two healing

Anthropometric Measurements • Height (AD-1. 1. 1) • 154 cm (60. 6 inches) • Weight (AD-1. 1. 2) • 56. 5 kg (124. 56 lbs) • BMI (AD-1. 1. 5) • 23. 82 • IBW • 118. 6%

Lab Values • Albumin 2. 7 (BD-1. 1) • Creatinine 4. 1 (BD-1. 2. 2) • GFR 8. 47 • Na 159 (BD-1. 2. 5) • Hgb 8. 4 (BD-1. 10. 1) • Hct 27. 0 (BD-1. 10. 2)

Nutrient Needs • Energy= 1680 - 1792 calories (CS-1. 1. 1) • Mifflin x 1. 2 activity x 1. 5 -1. 6 injury factor • Protein= 82. 5 and 88 grams (CS-2. 2. 1) • 1. 5 to 1. 6 g protein/kg of body weight • Fluid= ~1700 ml (CS-3. 1. 1) • 1 ml fluid/kcal method

Classification • ARAMARK: Severely Compromised (level 4) • Follow up every 1 -4 days • DRG: Unspecified Protein-Calorie Malnutrition

Nutrition Diagnosis • Inadequate energy intake (NI-1. 4) related to increased needs due to sepsis, dialysis and multiple pressure ulcers as evidenced by poor dietary intake (<50%) noted in activities of daily living (ADL) flow sheet and statement from nurse that the patient only consumes a few bites of food once per day.

Nutrition Intervention • Enteral Nutrition (ND-2. 1) via PEG • Formula/solution (ND-2. 1. 1): Recommend Nepro at 20 ml/hour for the first 48 hours. As tube feeds well tolerated and electrolytes remain stable, increase rate of tube feeds to 30 ml/hour on day three and to goal of 38 ml/hour by day four. Goal rate of 38 ml/hour will provide a total of 912 ml, 1642 calories, and 74 grams of protein. Water flushes deferred to physician. • Commercial food (ND-3. 1. 2): 1 packet of Pro. Source daily via feeding tube. This will provide an additional 15 grams of protein and 60 calories.

Monitoring and Evaluation • Follow up every 1 -4 days (usually every day) • Complete electrolyte and renal profile (BD-1. 2) • Accuchecks (BD-1. 5. 2) • Monitor for nausea, vomiting, and residuals from tube feedings (PD-1. 1. 5) • Monitor for signs of refeeding syndrome • Enteral nutrition intake (FH-1. 3. 1)

Results • Patient d/c to nursing home • Unknown formula & rate given to patient • Patient returned for hyperkalemia, hyperglycemia, & on-going sepsis

Questions?