Nutrition Support Case Study

57 year old male with pancreatitis (ETOH-related). Intermittent symptoms for the past 6 months, but has not sought
care until now. Transferred from outside hospital where he was managed conservatively, remaining NPO for nine
days without tube feeding or TPN. He was then allowed to try clear liquids but he did not tolerate. On hospital day 9
he was found to have pseudocysts and transferred to Hershey Medical Center for further management.

Screening data:

Ht = 180 cm
Wt = 100 kg
Wt change in the six months prior to admission: yes
Amount of weight lost: 25 kg
Decreased intake prior to admission: >3 days

Tmax 36.5 degrees centigrade

Heart rate 88 beats/minute
Currently receiving D5½ NSS + 30 mEq KCl/L @ 125 mL/hr
Intake/Output = 4000/3800

LABS: ​134 | 100 | 20 ​ Glc = 115 C = 8.0 Mag = 1.3 Phos = 2.0 Alb = 3.6
3.3 | 26 | 0.8

1. What is the patient’s nutritional status? Is there additional information you’d like to have before making the
assessment?

ASPEN criteria meets severe protein/energy malnutrition related to 10% weight loss in 6 months and NPO for 
9 days. Has a 1980 kcal deficit. Check for physical signs of wasting and hand grip strength.  

2. What is the patient’s metabolic state (metabolic rate, catabolic rate)?

Patient is mildly catabolic because not getting enough calories. SIRS criteria are heart rate above 90, 
respiratory above 20, temperature above 38, and WBC 11-12.  

3. What other metabolic abnormalities can you identify and why might they exist?

With increased insulin then their is increased glucose uptake and low phos, K and Mg.  
Low Mg reduces parathyroid hormone (PTH) and decreases calcium. However, serum calcium may not be a 
good reflection of calcium and may want to request ionized calcium.  
His IV dextrose could be increasing his insulin.  
4. Should TPN be started?

Yes, unable to tolerate clears and NPO for 9 days.  

5. Write a nutrition diagnosis statement (PES) for this patient.

Malnutrition related to inadequate intake from pancreatitis as evidenced by 20% weight loss in 6 months and 
NPO for 9 days.  

6. Is he at risk for refeeding syndrome?

Yes! His Mg and phos are already low, which may be related to his dextrose IV.  

7. What should be done?

Limit dextrose in IV to 3g/kg in the TPN. Goal would be to fix the labs before starting nutrition. 

8. Calculate needs

Mifflin = 1845 kcals  

PSU (1.1) factor = 2120 kcals 
Adjusted body weight 83 kg  
protein 1.75 g/kg = 145 g 

9. What is the composition of the IVF?

D5 125ml/hr 50g/L= 3L x50 g = 150 g/day  

½ NS= 77 mEq = 3 Lx 77 = 231 mEq/day  
30 mEq KCl/L = 3 x 30 = 90 KCl mEq/day  
Cl = 321 mEq/day  
 
*remember 1.5 L of free water is 1.5 L of isotonic volume  

10. Write a TPN order.

AA = 175 g (10%) 
Fat = 0.5g/kg, 42 g/day, 420 kcals  
Dextrose = 1020 kcals/2 = 510 kcals initially, start at 2g/kg and stop dextrose in IV.  
Volume = 105 ml/hr with 10% or 1900 ml/day if use 15%  
⅔ NSS 
Ace 50 mEq 
K 125 mEq 
Phos 25 mol 
Ca 20-25 (recheck serum ca)  
Mg 24 
 
Re-check of lab data after the first day of TPN reveals:

​129 | 96 | 29 ​ Glc = 140 Ca = 8.9 Mag = 1.9 Phos = 2.2

3.5 | 21 | 0.9

11. What changes if any should be made to the TPN?

AA 200 /day (15%) 

NSS ¾  
Ace 75 mEq 

On HMC day 4 (day 13 of total hospitalization), the patient’s body temperature spikes to 39.0 degrees centigrade and
his pseudocysts are found to be infected. He goes to the operating room for drainage and I&D. He is admitted to the
intensive care unit sedated and mechanically ventilated.

Tmax 39.3 degrees centigrade

Minute ventilation = 18.0 L/min
TPN continues
IVF: D5 LR @ 50 mL/hr
Intake/output = 8000/3000

LABS: ​136 | 100 | 33 ​ Glc = 190 C = 8.3 Mag= 1.6 Phos = 2.9 Alb = 2.3
3.8 | 29 | 1.0
7.31/50/115/30

12. What is his metabolic state?

Septic 
Elevated BG, febrile  
hypermetabolic state related to infection.  

13. What is his acid-base status?

Elevated CO2, acidosis. Respiratory acidosis not compensated because if elevated bicarb.  

14. What is the composition of his IVF?

Lactate ringer is 30 mEq and mimics the blood bicarb,.  

 
15. What other metabolic problems exist?

hyperglycemia, hypornatremia.  
 
 
16. Why is his Intake/output so high?

Patient was just in the OR, where they pump fluids. 

17. Why is his albumin falling?

Inflammatory state and hemodilution.  

18. Re-calculate his nutrient needs.

2760 kcal  
2g/kg protein = 170 g/day 

19. Is the patient’s blood glucose control adequate? Why or why not?

No, the patient has a BG of 190, which is above 180. Drip regular insulin, not long acting. Additionally put 
patient on a sliding scale for insulin. 

20. Re-formulate his TPN.

2760 kcals
AA 200g/day  
Could take lipid out for ICU patient 
Volume at 15% 2520 ml/day because renal function could be impaired  
NSS ¾ normal saline  
Ace 75 
K 100 mEq  
Phos 25 mEq 
Ca 30 mol 
Mg 24 mEq

21. Any other recommendations?

Start on a sliding scale for insulin  

If on propofol, take lipid out as recommended  
 
On HMC day 6, the patient returned to the operating room for further debridement. During the surgery, a jejunostomy
tube was placed. He now has ARDS. Nephrology service is following but he is not on dialysis.

LABS: ​138 | 110 | 70 ​ Glc = 160 C = 8.2 Mag = 2.4 Phos = 5.5
5.0 | 20 | 1.8
7.32/40/80/19 (FIO​2​ is 0.8)

22. Would indirect calorimetry be of any help?

No, FIO2 is too high (0.8) and 60% is the limit. 

23. Any TPN changes?

Could D/C the potassium  

lower phos to 10 mmol or D/C 
Acetate to 125 mEq for metabolic acidosis 

24. Should he start tube feeding? If so, what formula?

Oxepa 
The additional antioxidants and omega 3 may reduce his inflammatory response. It is also 1.5kcal/ml, which 
limits some fluid. 

25. Can patient be bolus fed? Why or why not?

No, bolus feeds cannot go into the jejunum because this could mimic dumping syndrome.  

26. Are gastric residual volumes of concern and how would you monitor tolerance to the tube feeding?

Cannot monitor gastric residues because bypassing the stomach with the tube.  
Best marker is abdominal distension. 
 
27. Explain how to transition from TPN to tube feeding.

Decrease TPN as tube feedings increase. Could just lower the rate of TPN initially to account for the calories 
being provided in the TPN. Monitor for tolerance. 

28. Explain why enteral feeding is preferable to parenteral feeding.

Enteral uses the gut and there is less risk for infection.