Wendy Barth

MNT II
March 1, 2018

Nutrition Support in Sepsis and Morbid Obesity

Case Study #30
Questions 1-14, 16-18

1. Sepsis: is the presence of harmful bacteria and their toxins, in tissues, and typically through
infection of a wound.
Systemic inflammatory response syndrome (SIRS): an inflammatory state affecting the whole
body with organ dysfunction and organ failure.
2. With sepsis a pt can exhibit a body temp. above 101 or below 96.8; heart rate higher than 90
beats/min; respiratory rate higher than 20 breaths a min. In server sepsis organ failure can occur.
Signs include: significantly decreased urine output, abrupt change in mental status, decrease in
platelet count, difficulty breathing, abnormal heart pumping function, and abdominal pain. In
septic shock you would also show extremely low blood pressure. Signs and symptoms are fever,
increased breathing and heart rate, confusion, pneumonia, painful urination with a kidney
infection. The pt has a high lactate, has type 2 DM, a body temp. of 102, elevated heart rate,
difficulty breathing, low blood pressure, and has a positive net Intake of fluids.
3. A Roux-en-Y gastric bypass is a procedure where the surgeon divides the stomach into a large
and small portion. Then the small part is sewn or stapled together to make a pouch, that can hold
up to a cup of food. This makes the patient feel fuller faster and causes them to eat less. The most
probable nutrition concerns for him would be him needing to use vitamin /mineral
supplementation due to malabsorption from diarrhea and nausea.
4. He should receive nutrition support because he’s NPO, currently sedated and on ventilation.
The pros would be that he would be getting adequate energy and nutrients to help support his
recovery and the cons would be that he may be a victim to overfeeding or aspiration. Enteral
would be his best option because he has bowl sounds suggesting his GI tract is working and
when its working its best to be used. The con may be that he’s obese and a feeding tube may be
hard to get down his throat, so he possibly would need to have the feeding administered through
a place other than his mouth and enteral feeding leaves room for bacteria to be introduced into
the system which is why PN has a pro for him in this state.
5. Mr. McKinley’s bariatric surgery can affect my recommendations for nutrition support
because he has a very small stomach that will not hold very much right now suggesting small
feeding throughout the day. I would also have to watch the macro nutrient content given in each
feeding along with the fluid volume while still making sure he gets adequate fluids.
6. The current recommendations for supplementation of omega-3 fatty acids, glutamine, arginine
and antioxidants in nutrition support during sepsis are that arginine helps with the protein
anabolism because in sepsis protein breakdown in increased. The omega 3’s help balance the
pro- and anti- inflammatory mediators in sepsis. Glutamine is needed by the cells in an
inflammatory response and the bowl displays a decrease in glutamine utilization during sepsis.
Plasma concentrations of antioxidants micronutrients are depressed during critical illness and
taking supplements will help with metabolism.
7. Refeeding syndrome is a metabolic disturbance that occurs as a result of reinstitution of
nutrition to patients who are starved, severely malnourished or metabolically stressed due to
severe illness. His recent weight loss will affect my nutrition support recommendations regarding
risk of refeeding syndrome because his body may not know what to do with the nutrients from
the tube feeding or it may be administered in too high amount since his stomach can only hold
about a cup or two. Calorie repletion should be given slowly and increased with tolerance to
avoid refeeding. Electrolyte disturbances can take place within the first few days of refeeding,
cardiac complications within the first week, and neurologic features after.
8. Mr. McKinley’s height is 5’10” and his current weight 325 lbs making his current BMI 46.6
classifying him as obese.
9. Signs and symptoms that are most likely a consequence of Mr. McKinley’s admitting critical
illness are his SOB with flu like symptoms; elevated temperature and heart hate, with a low
blood pressure.
10. His labs show he has high: K, CO2, glucose, bilirubin, ALT, AST, CPK, lactate
dehydrogenase, C-reactive protein, Fibrinogen, lactate, cholesterol, VLDL, LDL, LDL/HDL
ratio, TG, HbA1c, PT, INR, PTT, WBC, transferrin, protein, glucose, ketones, and mucus. He
has low: inorganic phosphate, total protein, albumin, prealbumin, HDL-C, Hgb, Hct, and ferritin.
Elevated potassium is a sign of septic shock, CO2 is high due to his respiratory issues and SOB,
glucose can come from the T2DM and metabolic stress, bilirubin can be from sepsis and since he
has high ALT, and AST possible liver failure from malnutrition. Albumin being low comes from
his sepsis/inflammation and malnutrition since his protein concentration is also low which can be
due to malabsorption from his resent gastric bypass surgery. ALT and AST as I said, show liver
disease as a result of malnutrition. CPK is from the inflammation of the muscles because if
sepsis. High concentrations of lactate show infection and are a marker for doctors when
diagnosing sepsis. C-reactive protein and fibrinogen show bacterial infection and inflammation
from the sepsis. His lipid panel is a result of the diabetes, hypertension, and being overweight.
His blood work shows an infection and inflammation causing the sepsis and metabolic stress.
11. The laboratory measurements that are consistent with sepsis and metabolic stress are: the
high K, high CO2, low phosphate, high bilirubin, low protein, low albumin and pre-albumin,
high lactate and c-reactive protein, high fibrinogen, high WBC count with low Hct and Hgb, high
transferrin, low ferritin, positive urine glucose and positive urine bacteria.
12. Mr. McKinley’s current hydration status based off of his first 24 hour of I/O and the nursing
assessment indicates that the color of his urine is clear/yellow which is a good sign and is shown
using a catheter. He was put on IV fluids and showed a total net I/O of +1430 mL, which could
mean he was dehydrated before the IV due to the sepsis, from his edema, and from his elevated
temperature.
13. Recommended kcal needs: 2100-2700 kcals
Recommended Protein needs: 148-220 g protein per day
14. He is getting inadequate protein because of his sepsis, isn’t getting enough calories because
of his gastric bypass and having lost 100# in 4 months. I would say he has sepsis related
malnutrition due to his altered GI tract which is causing him to not be able to consume adequate
calories.
16. Start EN Vital AF 1.2 at a rate of 45 ml/he, increase by 10-20 ml every 4 hrs until goal of 85
ml/hr for 24 hr continuous feed, providing 2450 kcal, 153 grams protein. Protein powder may be
added to increase protein intake. I chose Vital AF 1.2 because it is a hydrolyzed protein, fish oil
based structured lipids to help manage inflammation and improve GI tolerance.
17. Steps that can be taken to monitor Mr. McKinley’s nutritional status in the ICU are that first
he is tolerating the enteral feedings. Making sure that he is getting the proper macro and micro
nutrients to adequately nourish him is also very important. The RD and doctors can determine
this by checking his current labs to see if he is improving which would also help show if the
sepsis is lessoning and that he is healing.
18. Factors that may affect his tolerance to enteral feeding will deal greatly with his gastric
bypass surgery. His stomach was made a lot smaller making it not hold as large of volume
suggesting smaller volume feedings will work best for his case where a bolus feed could cause
dumping syndrome. Aspiration is also something that may affect his tolerance because he is
unconscious and is using mechanical ventilation
 ADIME Chart Note

Assessment- Pt, 37 y.o., obese white male, admitted to the MICU from the ER with severe
sepsis, pneumonia. Mr. McKinley had undergone Roux-en-Y gastric bypass surgery 4 months
prior and has a weight loss of approximately 100# to date. He has suffered from T2DM, Htn,
hyperlipidemia, and osteoarthritis the past 10 years. Medications noted and has been off diabetes
meds for 2 months. Has family history of DM, CAD, Htn, COPD, and osteoporosis. Pt is on
mechanical ventilation. He has dry mucus membranes w/o lesions, 2+ pitting edema, and rash
present under skin folds; has an elevated heart rate and temperature, with diminished pulses
bilaterally. He is currently mechanically ventilated, sedated and NPO. Fluid I/O is being
monitored with pt having a fluid requirement of 1800-2000 ml. All labs reviewed and noted.
Nutrition consult requested for initiation of enteral feeding.
Ht: 5’10”, Current wt: 325#, BMI: 46, UBW: 425 (4 months prior), Adj. BW: 285#, Wt loss:
100# in last 4 months Diet order: NPO
Recommended kcal needs: 2100-2700 kcals (14-18 kcals/kg bw)
Recommended protein needs: 148-220 g protein (2.0-2.5 g/day IBW)
Fluid requirement: 1800-2000cc (Per MD order)
Diagnosis: Increased nutrient needs of energy and protein r/t sepsis and metabolic stress AEB
pneumonia, mechanical ventilation, elevated body temperate, and resent wt loss of 100# from
Roux-en-Y gastric bypass 4 months prior.
Inadequate energy intake r/t to sepsis, altered GI function, inability to eat AEB and order for
NPO, mechanical ventilation status, and lab values.
Intervention: Nutrition prescription: Start EN Vital AF 1.2 at a rate of 45 ml/he, increase by 10-
20 ml every 4 hrs until goal of 85 ml/hr for 24 hr continuous feed, providing 2450 kcal, 153
grams protein. Protein powder may be added to increase protein intake. No education or
counseling provided at current time due to patient being sedated.
Monitor & Evaluation: RD will follow-up with patient daily, while admitted, to monitor
tolerance to TF, I/O hydration status, and pertinent lab values. Will make EN feeding
adjustments as needed.