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Critical Care-Sepsis Case Study
Critical Care-Sepsis Case Study
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The Elliot Hospital
Clinical Dietetics
There are 16 dietitians on staff at the main campus both part and full time
(Not including per diems)
These dietitians cover Fuller, CICU, Fitch, GPU/GBU, Pathways consults,
ICU, Pediatrics/Maternity, NICU.
There are nutrition groups in GPU/GBU as well as Pathways.
On certain days dietitians will cover the NICU clinic and Cardiac Rehab.
Outpatient Dietetics
Outpatient RDs see patients for bariatrics, diabetes, weight loss and
other conditions. (Elliot Center for Advanced Nutrition Therapy)
The Elliot licenses dietitians for Hannafords supermarket.
There is also an outpatient oncology dietitian who follows oncology
patients. 4
Sepsis
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Pathophysiology
Etiology Treatment
Sepsis is a typically life threatening condition when the bodies Broad spectrum antibiotics to treat the infection
natural response to infection cause damage to its own tissues Fluid resuscitation with IVF to increase arterial pressure
and organs and often hemodynamic instability putting the patient
in critical condition. Vasopressors to increase arterial pressure if not responding
adequately to fluid resuscitation
Sepsis is caused by an immune response to an infection.
Ventilation in response to respiratory failure
Diagnostic Criteria Sedation, especially if significant interventions are required
Meet the criteria for Systemic Inflammatory Response Supportive services such as nursing and nutrition
Syndrome (SIRS) and have a confirmed or probably infection.
For SIRS typically two of the following criteria; Progression
Body temperature of 101F (38.3C) or above (Febrile) If left untreated severe Sepsis can lead to significant decreased
Heart rate higher than 90 beats per minute urinary output (hypoperfusion), abrupt changes in mental status,
Respiratory rate higher than 20 breaths per minute respiratory failure and abnormal heart function.
Septic shock usually involves the above criteria combined with Multiple organ dysfunction syndrome
Hemodynamic instability. 6
Pathophysiology MADE
EASY!
Initial Insult Uncontrolled Inflammatory Response Shock
(accident, surgery, infection, etc.) (Cytokine storm) (Low blood perfusion)
Temperature
Electrolytes
Sodium, Potassium, Phosphorus, Magnesium, indicator of hydration, kidney function, risk for refeeding
Liver Function Tests (LFTs)
ALT, AST, T. Bili, Elevated LFTs can been seen early in Sepsis, later it could be an indicator of MODS
BUN, Creatinine, Urine Output
Indication of kidney function and level of hypoperfusion, also can indicate hydration status
Low urine output is a very negative sign
Lactic Acid
Indication of significant anaerobic respiration caused by hypoperfusion. Range is 0.5-1 mmol/L
Mean Arterial Pressure
Average arterial pressure in one cardiac cycle. Range 70 - 110 mm Hg 8
Relevant Medications
Vasopressors
Induce vasoconstriction and elevate blood pressure, increase MAP, Treatment for hypoperfusion
Sedation
Used highly in the ICU, especially when the patient is intubated and has significant interventions or surgery, reduces
incidence of PTSD from the ICU
Antibiotics (ABX)
Used for treatment of the cause of sepsis. Due to the systemic infection at least 2 broad spectrum ABX are used but positive
blood cultures for specific bacteria can indicate the use of more specific ABX to treat the initial infection
IVF
For fluid resuscitation and electrolyte repletion, can also provide small amount of dextrose
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HELP I FORGOT
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The Case
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Presentation, History, Anthropometrics, Dietary
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Day 1 - 7/25 (Late PM) through 7/26 - Wednesday
Patient became confused with slurred speech in the ED. Labs: Na 142, K 4.2, BUN 23, Cr 1.06, Lactic Acid 3.1, ALT 32,
AST 49, T. Bili 0.4
Patient was shown to be tachycardic and hypotensive, she was
intubated with an O2 sat of 87%. Temp: 101 F (38.3 C)
She was given a CT scan which showed free air and fluid in her Metabolic Stressors: Septic shock, peritonitis, acute respiratory
peritoneal cavity, she was given an NGT to low continuous failure (Intubated FIO2% of 60)
sunction (LCS) Calculated energy requirement protein requirements.
Started on Vancomycin (GI) and Zosyn (Broad) Dx statement: Inadequate oral intake r/t acute illness, altered GI
Admitted to TRACS for Exploratory laparotomy, surgery included function, GI surgery and vent status AEB NPO order.
washout of peritoneum and limited sigmoid colon resection with
a temporary closure. Her bowel was left discontinuous. Is this patient appropriate to feed?
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Urine Output: 1070 ml
Peritoneal Cavity
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Day 2 - 7/27 - Thursday
Hospital Course
Meds: levophed, vasopressin, adrenalin, fentanyl, diprivan, precedex, insulin drip
discontinued, started low dose sliding scale insulin every 6 hours
1 blood culture positive, awaiting results, continuing Vancomycin and Zosyn
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Day 3 - 7/28 - Friday
Hospital Course
Trophic TF of 10 replete per hour started at 8:30 am
Formula provides: 240 kcal, 15 grams of protein and 202 ml of
water
Meds: fentanyl, precedex, zyprexa, lassix, propofol
Received propofol overnight
Cutting down on fentanyl and adding oxycodone for pain relief
Labs: Na 150, K 3.7, BUN 19, Cr 0.51, Mag 2.1, Phos 1.8
Hypoactive bowel sounds, no ostomy output yet
Draining serous liquid for JP drain
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Day 8 - 8/2 - Wednesday
Ostomy output: 700, 150, 300 ml (all brown) Sending Boost Orange and Berry with trays (clear) to assist with
nutritional intake
Ostomy output: 250, 150, 100 ml (all brown)
Still following for educational needs when ready.
Still following for educational needs when ready.
Possible transfer to Fuller unit today, MD has reservations.
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Day 13 - 8/7 (Monday) and Day 14 - 8/8 (Tuesday)
Ostomy output: 200, 300, 250 mls Weaning off prednisone, finished all antibiotics, needs to
ambulate more and work with PT/OT
Bowel sounds are active, patient is eating approximately 50% of
meals. Educated patient on new ostomy diet. Discussed foods to avoid
or slowly add back to the diet and foods to eat. Discussed smaller
Attempted to meet with patient for diet education, the patient did more frequently and ensuring good chewing and digestion
not seem ready for diet education and seemed like she wasnt practice.
very responsive or clear so education was deferred to the next
day. The patient demonstrated very good understanding of the diet
and showed good motivation. We talked about her regular diet
Dx statement: Inadequate oral intake r/t altered GI function, GI and it involved a lot of fruits and vegetables and whole grains.
surgery AEB low reported intake (50% x 2 meals)
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Day 17 - 8/11 - Thursday
Hospital Course
I met with the patient for a follow up to see if she had any
additional questions.
She was satisfied with her diet teaching.
Medical and surgical had signed off on the patient.
She was waiting for PT/OT to sign off to be Discharged.
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Thanks!
Questions?
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References
SlidesCarnival for presentation theme and template Miller, K. R., Kiraly, L. N., Lowen, C. C., Martindale, R. G., & Mcclave, S.
A. (2011). CAN WE FEED? A Mnemonic to Merge Nutrition and
Various websites for images (Cited in notes)
Intensive Care Assessment of the Critically Ill Patient. Journal of
Resources from The Elliot Hospital Parenteral and Enteral Nutrition,35(5), 643-659.
Resources from AND Nutrition Care Manuals doi:10.1177/0148607111414136
Mcclave, Stephen A., et al. (2014) Feeding the Critically Ill Patient. Mullins, Ashley. (2016) Refeeding Syndrome: Clinical Guidelines for
Critical Care Medicine, vol. 42, no. 12, pp. 26002610., Safe Prevention and Treatment. Support Line.
doi:10.1097/ccm.0000000000000654. McCray, Stacey, Walker, Sherries, Parrish, Carol R. (2005) Much Ado
Mcclave, Stephen A., et al. (2016) Guidelines for the Provision and About Refeeding Nutrition Issues in Gastroenterology. Series #23. pp
Assessment of Nutrition Support Therapy in the Adult Critically Ill 26-44
Patient. Journal of Parenteral and Enteral Nutrition, vol. 40, no. 2, pp.
159211., doi:10.1177/0148607115621863.
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