Major Case Study: Critical Illness & Nutrition Support

You are the RD in the burn unit of your hospital. You have been consulted for a
nutrition assessment of Mr. G, and you will be responsible for follow-up assessments,
planning, and monitoring throughout his hospitalization.

Initial admission information available from the medical chart:

Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms,
and back in an accident at the chemical plant where he works. After emergency first aid
at the plant, he was transported by ambulance to the university hospital burn center.
Mr. G was in shock when he was admitted.

Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned

skin is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-
injury wt: 165#

Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem
20 screening panel, ABGs, and UA.

Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck,
upper back, arms, hands, and upper thighs.

Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted.
Urinary output, P, and BP monitored hourly. NPO x 12 hrs or until hemodynamic
stability achieved. NG tube placed for stomach decompression. Maalox q 2 hrs through
NG tube and IV Famotidine.

Initial hospital course:

As soon as the shock was under control, Mr. Gs wounds were washed, debrided,
and dressed with silver sufadiazine using fine-mesh gauze. He was given a
tetanus shot and 600,000 units of procaine penicillin were administered q 12 hrs.
After 18 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned;
patient is responsive to pain, but limited alertness; breathing & respiration
normal
By 24 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On morning of second day (~ 30 hours), a Nutrition Consult was ordered for
feeding recommendation.

Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the
initial consult, on day 2 of admission.
 Kirsten Olson

1. Which of the following statements best describes your nutrition screening of Mr. Gs
risk level? (1 pt)

_____ Minimal risk (patient is at or above IBW, no weight loss prior to admission);
no specialized nutrition therapy over the first week of hospitalization is required.

_____ Moderate risk (patient is at or above IBW, no weight loss prior to admission);
limited alertness duration likely > 72 hours; trophic feeds recommended to be
started within 48 hours of admission and continued through first week of
hospitalization.

__x__ High risk (patient is at or above IBW, no weight loss prior to admission) with
high injury severity; enteral feeds recommended to be started within 48 hours of
admission; enteral nutrition support recommended to provide >80% of goal energy
& protein needs.

_____ High risk (patient is at or above IBW, no weight loss prior to admission) with
high injury severity; trophic feeds recommended to be started within 48 hours of
admission; parenteral nutrition support recommended to provide >80% of goal
energy & protein needs.

2. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the

following methods. Show your work.

a. Quick shortcut per the ASPEN Critical Care Guidelines [25-35 kcal/kg BW] (2 pts)

kg 25 35 kcal
165 lbs = 1875 2625 kcal
2.2 lbs kg

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

kg 2.54 cm
(10 165 lbs ) + (6.25 70 in ) (5 32) + 5 = 1706.25 kcal
2.2 lbs in

1706.25 1.1 (confined to bed ) 1.5 1.85 (TBSA 20 40%) = 2815 3472 kcal

c. Comment on whether these two estimates differ or are similar, and what you
would use as your actual energy recommendation for this patient. Provide
justification for why you selected this energy recommendation. (2 pts)

The ASPEN estimate is much lower. ASPEN guidelines are specifically intended for the
critical care patient, whereas the Mifflin St. Jeor equation is not. However, he has been
NPO for about 30 hours already, it will take time to advance to goal, he is not on
ventilation, and due to the location of some of his burns, he will probably not want to
 Kirsten Olson

eat very much for a while. Also, the Curreri equation, which the Pocket Guide
recommends for burn patients, results in a recommendation of 3075 kcal per day:

kcal
25 75 kg + 40 30 = 3075 kcal
kg

Overall, it appears that there is somewhat more risk of underfeeding than overfeeding
this particular patient. I would start him out with an amount between the ASPEN range
and the MSJ range that allowed for 20% - 25% protein, assess tolerance and adequacy
as well as possible, and then make adjustments as necessary. The suitable available
formula choices only offer 25%, or less than 20% protein. So, after calculating protein
needs, I would recommend an amount of kcal that would provide the appropriate
amount of protein within this range of kcal, using a 25% protein formula. This results in
a recommendation of 2400 kcal per day.

(1875 + 2625) kcal (2815 + 3472) kcal

= 2250 kcal = 3143.5 kcal
2 2

Range: 2250 to 3143.5 kcal per day; protein calculation in question 3 below.

kcal kcal
112.5 g PRO 4 4 = 1800 kcal 150 g PRO 4 4 = 2400 kcal
g PRO g PRO

1800 kcal is too low; 2400 kcal is within the estimated energy need range. (If a suitable
20 24% protein formula was available, I might use that to give more calories.)

3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your

work and provide a goal range. (2 pts)

1.5 2 g PRO per day

75 kg = 112.5 150 g PRO per day
kg

4. Based on the patients needs, consider the enteral formula to recommend

a. Describe two desirable features or characteristics of the type of formula you

would select and recommend. (refer to the UCD TF lecture) (2 pt)

It needs to provide about 20-25% protein, and be free of insoluble fiber due to higher
risk of GI dysfunction in trauma patients.

b. Give one example of an appropriate enteral formula meeting these

characteristics, using the UCDMC formulary provided on the course web
site.(2pt)
Promote
 Kirsten Olson

Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetodine liquid to
be put down the feeding tube? (Use the FMI text for this question) (2 pts)

This is a histamine H2 receptor antagonist, here used to prevent development of a

Curlings (stress) ulcer. Enteral Cimetidine would interact with the tube feeding and
create a precipitate.

6. Describe 3 ways you could determine the adequacy of your recommendations for
energy and protein intake for this burn patient. (In other words, what will you monitor
to decide if your recommendations are adequate, and why?) (3 points)

Weight Some initial catabolism is unavoidable. The goal is to prevent patient

from losing more than 10% of normal body weight. If the patient is rapidly losing
weight, then kcal is inadequate. If the patient loses some weight but the trend is
such that he is not expected to lose more than 10%, and/or the patient begins
gaining initial lost weight back, then kcal is adequate.
Wound healing If the patient is receiving adequate protein and kcal, wound
healing will progress as expected.
Nitrogen balance If protein recommendation is appropriate, negative N balance
will improve; neutral or positive N balance will occur as patient returns to an
anabolic state. [Nutrition in Critical Care slides, NUT 116B]

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.2 @ 60
ml/hr, plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking
100 kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full
TF volume is being delivered each day.
The patient tells you it is difficult for him to eat by mouth due to pain, and that
he doesnt have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current
information available.

a. Energy: (2 pt)

25 35 kcal (1750 + 2450) kcal

ASPEN: 70kg = 1750 2450 kcal, avg: = 2100 kcal
kg 2
 Kirsten Olson

2.54 cm
MSJ: (10 70 kg) + (6.25 70 in ) (5 32) + 5 = 1656.25 kcal
in

1656.25 1.1 (confined to bed ) 1 1.5 (TBSA 0 20%) = 1822 2733kcal

With 15% TBSAB, a figure at the higher end of this MSJ range is more appropriate:

0.75(2733 1822) + 1822 kcal = 2505.25 kcal

Estimated energy need is 2100 2505 kcal/day. With a 25% protein formula, his
maximum estimated protein need can be provided with kcal within this range:

kcal
140 g PRO 4 4 = 2240 kcal
g PRO

Since he is only eating about 100 kcal per day PO, I would recommend 2240 kcal per
day TF for now, plus PO as desired. He is highly unlikely to get too much additional
protein or energy from PO intake at this time.

b. Protein: (2 pt)

1.5 2g PRO per day

70kg = 105 140g PRO per day
kg

c. Fluid: (2 pt)
ml
30 35 70kg = 2100 2450 ml per day
kg

8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show
your work.

ml
60 24hr = 1440ml/day
hr

a. Energy: (2 pt)
1.2kcal
1440ml = 1728kcal
ml
b. Protein: (2 pt)
L 55.5g PRO
1440ml = 80g PRO
1000ml L

c. Fluid: (2 pt) 1440ml 0.807 = 1162ml

 Kirsten Olson

9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.

N balance = g protein (UUN + 4) = 92 g pro (23 g + 4) = - 12.3 g N/d

6.25 6.25

Interpret the results of the nitrogen balance study above. Is the current TF order
adequate to meet estimated protein needs? (2 points)

Mr. G has a negative N balance. The current TF order is not enough to meet estimated
protein needs. He needs 25 60 grams of protein more than the current TF order
gives, and his 100kcal PO intake is only going to contribute a trivial additional amount.

10. Write an ADIME note for your day 10 follow-up assessment of Mr. G. (22 points)
Hints: Follow the ADIME note guidelines provided on the course web site. Use
subheadings. Be sure to evaluate his current anthropometrics (and any trends seen),
current kcal/pro needs, adequacy of the current diet order (including both the TF and
PO intake), and current labs. What do the anthropometric and biochemical data reveal?
Is the current diet order adequate and realistic for the patient? Write a PES statement
that reflects your assessment and include it in your note. In the Plan section, make very
specific nutrition support and monitoring recommendations for this patient at this point
in time.

(ADIME starts pg 8)

11. It is now 3 weeks since admission and Mr. G is now in a transitional care unit. Mr.
Gs wounds are closed and healing well. He is finally interested in trying to eat more
foods orally and his appetite is returning. How could his current continuous TF regimen
(the one recommended in your note above) be modified to provide a total of
approximately 1000 kcal/day and not interfere with his intake at meal times? Make
recommendations for an appropriate transitional TF plan/order and how to monitor.
Make a specific recommendation for both the TF plan and monitoring. (6 points total)

(4 pts) Recommended transitional feeding plan

1. TF Rx: Promote @ 100 ml/hour x 10 hours at night, from 20:00 to 06:00.

Provides 62.5g protein, 1000 kcal, and 839 ml water.
At 20:00, at 24:00, and at end of cycle: In feeding tube, give 3 g soluble fiber mixed
with 60 ml water, then flush with another 60 ml water, to provide a total of 9 g soluble
fiber and an additional 360 ml water, for a total of 1199 ml water per day.

2. One Ensure Enlive Advanced Therapeutic Nutrition shake PO in afternoon until pt is

able to eat at least 800 kcal of food per day (may continue longer if necessary).
Provides 20 g protein, 350 kcal.
 Kirsten Olson

3. Pt has no food restrictions. Recommend soft/easy to chew foods at first.

(2 pts) Monitoring plan

1. I/Os will show full TF order given.

2. Monitor kcal counts to assess pt progress towards sufficient PO intake.

3. Pt weight will remain stable (not go down more than 1 kg over next 2 weeks), as
evidenced by daily weights.

4. Reassess in 2 days.
 Kirsten Olson

ADIME Critical Care

2/15/17 9 am

Assessment
Patient states that it is too painful to eat, and hes not hungry. Pt has been eating and
drinking very little. Nursing staff says entire TF order has been given daily and tolerated
well the past several days, but the order has also been changed.

Patient History:
32 yo male admitted 2/6/17 with 30% TBSA burns to upper body including face. Initial
diet order was TF Promote @ 100ml/hr plus bland, soft PO if desired and as tolerated.
2/15/17: TBSAB now 15%, with additional skin graft surgery to follow next week. Diet
order was changed by MD about 5 days ago. Pt PO intake still minimal.

MD Diet Order/Rx: Jevity 1.2 @ 60 ml/hr, plus PO intake as tolerated.

Anthropometrics:
Ht: 177.8 cm UBW/Wt at admission: 75 kg CBW: 70 kg BMI: 22.1 (normal)
% change BW: - 6.7% (severe weight loss) IBW: 75.5 kg % IBW: 92.8%

Weight Hx:
Wt at admission: 75 kg CBW: 70 kg % change BW: - 6.7% Severe Weight Loss
Pt had normal BMI of 23.7 at admission, but has lost 6.7% BW in 10 days. If he
continues to lose at this rate, he will be at 90% of starting weight in 5 more days.

Nutrition focused physical finding:

Overall appearance: A bit thinner than at intake, wan, weak.
GI: Pt states digestion fine, little appetite. Is tolerating TF well. Denies N&V, diarrhea,
constipation, or abdominal pain.
Cognition: Alert and oriented.
Skin: Pale, but unburned skin has improved color. Edema minimal. Per nursing, wounds
are healing well but slowly: TBSAB now at 15%. Patients facial and hand injuries are
significant and still appear likely to discourage PO intake.

Biomedical data/labs:
albumin 2.7 g/dL (low) prealbumin 8 mg/dL (very low) UUN 23 g/24 hr:
92 g PRO
(23 g + 4) = 12.3 g N/d Negative N balance: 12.3 g N/day (very low)
6.25

Medications:
IV Famotidine and Maalox q 2 hrs through NG tube.
 Kirsten Olson

Estimated Nutrient Needs (based on 70 kg wt):

Energy: BEE x AF/IF (as necessary)
ASPEN: 1750 2450, avg: 2100 kcal (based on 30 kcal/CW)
MSJ: 1822 2733, approx: 2505 kcal (based on AF 1.1 and IF 1.375 for 15% TBSAB)
Range: 2100 2505 kcal/day To provide max. protein at 25% of kcal: 2240 kcal/day

Protein: 105 140 g PRO per day (based on 1.5 2 g per kg CBW/day)

Fluid: 2100 2450 ml per day (based on 30 35 ml/kg CBW/day)

Food and Nutrition Hx:

Patient indicates that oral intake is too painful, and he has little appetite. He really
doesnt want to eat or drink by mouth at this time, at least for the most part. He drinks
about 1 glass of water a day. Three days of kcal counts show PO intake of only 100 kcal
per day. I/Os state that pt is getting the entire TF order each day. Diet order has been
changed to Jevity 1.2 @ 60 ml/hr, plus PO as tolerated. TF provides 1728 kcal, 80 g
PRO, and 1162 ml water. With 100 kcal PO intake and about 1 glass of water per day
PO, pt is only getting approximately 1828 kcal, 83 g PRO, and 1402 ml water per day.

Diagnosis:
Inadequate protein-energy intake NI-5.3 r/t inadequate enteral nutrition infusion AEB
negative N balance of -12.3g N/day, combined oral and enteral intake <60% of
estimated protein needs and <82% of estimated kcal needs, and loss of 6.7% of body
mass in 10 days since admission (75 kg at intake, 70 kg at day 10).

Intervention:
1. Prevent additional weight loss and support wound healing.
2. Consult with MD to change diet order. Recommend 25% protein TF to provide 100%
estimated protein and energy needs, until pt is able to tolerate significant oral intake.
3. Diet Rx: Promote @ 94 ml/hr, plus bland, soft PO if desired and as tolerated.
TF provides: 2256 kcal, 141 g PRO, and 1893 ml water. In feeding tube, give 4 g
soluble fiber mixed with 60 ml water q 8 hours, then flush with 60 ml water, to provide
12 g soluble fiber and additional 360 ml water, for a total of 2253 ml water per day.
4. Encourage pt to continue to drink water, but do not push food. If pt wants to eat,
offer small amounts of soft or liquid, cool or room temperature foods.

Monitoring/Evaluation:
1. I/O will show entire new diet order TF is being delivered, and that pt drinks water.
2. Pt weight will be monitored daily to assure that he stops losing weight.
3. Pt N balance will be monitored every other day to assure that it is improving. It will
become less negative immediately and continue to improve until it is positive.
4. Pt wounds will continue to heal as expected.
5. Reassess patient in 2 days.
(signature)
 Kirsten Olson

Calculations
Anthropometrics:
70
Ht: 177.8 cm UBW/Wt at admission: 75 kg CBW: 70 kg BMI: 1.7782 = 22.1
70
% change BW: 100 75 100% = 6.7 %
kg 70
: 106 + 6 10 = 166 lbs; 166 lbs 2.2 lbs = 75.5 kg % IBW: 100% =
75.5

92.8 %

Weight Hx:
75
BMI at admission: = 23.7
1.7782
5kg kg 1 day
rate of wt loss: = 0.5 day 75 kg 10% = 7.5 kg 7.5 kg = 15 days
10 days 0.5 kg

Estimated Nutrient Needs (based on 70 kg wt):

Energy: BEE x AF/IF (as necessary)
25 35 kcal (1750 + 2450) kcal
ASPEN: 70kg = 1750 2450 kcal, avg: = 2100 kcal
kg 2
MSJ: (10 70 kg) + (6.25 177.8 cm) (5 32) + 5 = 1656.25 kcal
1656.25 1.1 (confined to bed ) 1 1.5 (TBSA 0 20%) = 1822 2733kcal
Higher part of range because 15% TBSA: 0.75(2733 1822) + 1822 kcal = 2505.25 kcal

Estimated energy needs: 2100 2505 kcal/day

kcal
To provide maximum protein at 25% of kcal: 140 g PRO 4 g PRO 4 = 2240 kcal

Protein:
1.5 2g PRO per day
70kg = 105 140g PRO per day
kg
Fluid:
ml
30 35 70kg = 2100 2450 ml per day
kg
 Kirsten Olson

Food and Nutrition Hx:

ml
MD diet order: 60 hr 24hr = 1440ml/day

Energy:
1.2kcal
1440ml = 1728kcal
ml

Protein:
L 55.5g PRO
1440ml = 80g PRO
1000ml L

Fluid: 1440ml 0.807 = 1162ml

With 100 kcal PO intake and about 1 glass of water per day PO, pt is only getting
approximately 1828 kcal, 83 g PRO, and 1402 ml water per day:
kcal PRO
1728 + 100 = 1828 kcal 100 kcal 12% protein = 3 g PRO
4 g PRO

1162 ml + 240 ml (8 oz glass) = 1402 ml

Diagnosis:
Combined oral and enteral intake:
83 g PRO 1828 kcal
100% = 59% 100% = 81.6%
140 g PRO 2240 kcal

Intervention:
ml 1 kcal
Diet Rx: Promote @ 94 ml/hr provides: 94 hr 24 hr = 2256 kcal
ml
62.5 g PRO
2.256 L = 141 g PRO 2256 ml 83.9% water = 1893 ml water
L

(60 + 60) ml 3 = 360 ml 1893 + 360 = 2253 ml