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Nutritional Issues in The ICU Case File

A 46-year-old man is hospitalized in the ICU with severe acute pancreatitis. He is now hemodynamically stable Nutritional Issues in the ICU Case File

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128 views2 pages

Nutritional Issues in The ICU Case File

A 46-year-old man is hospitalized in the ICU with severe acute pancreatitis. He is now hemodynamically stable Nutritional Issues in the ICU Case File

Uploaded by

https://medical-phd.blogspot.com
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Nutritional Issues in the ICU Case File

https://medical-phd.blogspot.com/2021/05/nutritional-issues-in-icu-case-file.html

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 42
A 46-year-old man was admitted to the ICU for the management of severe acute pancreatitis. The
patient developed acute respiratory insufficiency requiring intubation and mechanical ventilator
support. His respiratory status remains unimproved on hospital day 4. At this point, his
hemodynamic status has improved, and he no longer requires vasoactive agents for support of his
blood pressure. 

⯈How would you initiate nutritional support for this patient?


⯈What are the potential limitations in your ability to deliver nutritional support?
⯈What are the factors that contribute to the increase in this patient's nutritional requirements?

ANSWER TO CASE 42:


Nutritional Issues in the ICU

Summary: A 46-year-old man is hospitalized in the ICU with severe acute pancreatitis.
He is now hemodynamically stable, but is still requiring ventilatory support
on hospital day 4. 

 Initiating nutritional support: Begin appropriate enteral nutritional support based on his


nutritional status and projected needs. This nutrition plan needs to take into account his
ongoing severe inflammatory response and his associated respiratory dysfunction. 
 Potential limitations to deliver nutritional support: For this patient with severe acute
pancreatitis requiring mechanical ventilator support and large volume fluid resuscitation,
traditional nutritional intake by mouth may not be possible. In addition, the intestinal edema
associated with his resuscitation may contribute to impaired intestinal motility and
absorption. 
 Factors contributing to increased nutritional requirements: Hyper metabolism and
increased catabolism from his pancreatitis will contribute to marked increase in amino acid
requirement and decreased ability to utilize glucose.

ANALYSIS

Objectives

1. To learn the approaches to nutritional assessments and strategies of monitoring responses to


nutritional support.
2. To learn the nutritional management of patients with pancreatitis and renal insufficiency
(with and without concurrent hemodialysis).
3. To learn the principles of nutritional support specifically designed for the modulation of host
inflammatory and immune responses.

Considerations
This is a 46-year-old man who has been in the hospital for 4 days. The severe inflammatory
response in pancreatitis can generate large fluid shifts between the intravascular and extravascular
space leading to hemodynamic instability as well as edema and respiratory failure. Patients with
severe pancreatitis require aggressive fluid resuscitation to maintain adequate intravascular volume
to support end-organ perfusion. This patient's hypotension did not respond initially to fluid
resuscitation alone and required pressor support, but now his BP has improved. Typically, these
patients will have large net positive fluid balance, to which the lungs are most sensitive, especially
in the setting of ARDS. This type of lung injury requires prolonged mechanical respiratory support
beyond the initial resuscitation phase. In addition, his initial hypotension may have decreased his
end-organ perfusion, which can lead to acute kidney injury. This patient's source of acute
pancreatitis is unknown, but based on statistics, alcoholic pancreatitis is highly probable. If his
pancreatitis is due to alcohol, he may also have a poor baseline nutritional status due to chronic
excess alcohol consumption. Additionally, he may have deficiencies that would benefit from
specific vitamin and mineral supplementation in addition to caloric and protein provision. Enteral
nutritional support will target the delivery of 25 to 30 kcal/kg of nonprotein calories and 1.5 to 2.0
g/kg of proteins per day. Close monitoring to avoid hyperglycemia (glucose >140- 160) should be
implemented. Similarly, if nasogastric feeding is initiated, the patient should be closely monitored
for signs of intolerance such as abdominal distension, and/or high gastric residual volumes ( >500
mL).

Approach To:
Nutritional Issues in the ICU
DEFINITIONS

ENTERAL NUTRITION: Nutrition provided through the gastrointestinal tract via a tube,


catheter, or stoma that delivers nutrients distal to the oral cavity.

PARENTERAL NUTRITION: The intravenous administration of nutrition, either via central or


peripheral access.

PROTEIN-CALORIE MALNUTRITION: A recent weight loss of >10% to 15% or actual body


weight <90% of ideal body weight.

TROPHIC FEEDING: Low-volume enteral feeding (usually 10-30 mL/h) mean to prevent


mucosal atrophy but insufficient to provide adequate calorie and protein requirements.

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