Aortic Valve Stenosis, Congestive Heart Failure, and

Chronic Obstructive Pulmonary Disease Exacerbation with Development of an Ileus

By Emily PhillipsSt. Helena Hospital, Napa Valley

3/11/2015

Introduction to Mr. H• Personal data: 61 year old male• Social History: 40 – pack per year smoker, Retired• Reason for admission: Non-ST Segment Elevation Myocardial

Infarction (NSTEMI) and Congestive Heart Failure (CHF)• Chief complaint: increasing shortness of breath for 3 days and

“flu-like” symptoms resolved 1 month ago, which have now returned. Symptoms included: fever, chills, cough, and productive sputum

Admitting Diagnoses• NSTEMI – Non-ST Segment Elevation Myocardial Infarction. The

complete occlusion of a minor coronary artery resulting in myocardial infarction, better known as a heart attack.

• CHF – Congestive Heart Failure. Impairment of the ventricles’ capacity to eject blood from the heart or to fill with blood.

• COPD exacerbation – Chronic Obstructive Pulmonary Disease Exacerbation. Persistent progressive airflow obstruction and dyspnea (shortness of breath). This includes chronic bronchitis, emphysema, and asthmatic bronchitis.

Admitting Diagnoses• Right Lower Lobe Pneumonia – Inflammation of the alveoli often

caused by foreign material. These air sacs become filled with fluid or pus, causing cough (with phlegm), fever, chills, and labored breathing.

• Hyponatremia – Low sodium concentration in the blood. Serum sodium below 135 mEq/L.

Medical/Surgical Data• Past Medical History: - Smoker (½ pack per day) for 40 years, currently 5 cigarettes per

day - COPD (not on breathing treatment)- Hypertension - Hyperlipidemia- Obesity - Anxiety disorder - Has not seen a primary care physician for 20 years - No previous pneumonia or sick contact- Alcohol use

Medical/Surgical data• Surgical History: None • Family Medical History: Father had a heart attack at age 60, died

at 82• Medications Prior To Admission:

Medication Purpose Nutrition implications

Tylenol Pain medication, analgesic

Avoid alcohol, caffeine increase s rate of absorption and effect of drug

Multivitamin Provide additional vitamins and minerals

Excess may cause vitamin toxicity

Aleve NSAID, antiarthritic, analgesic

GI pain, constipation, nausea/vomiting, dyspepsia

Admission Physical Data• General: Not lethargic, not dehydrated, looks septic, lying in bed

with mild paroxysmal nocturnal dyspnea (PND/postnasal drip) and mild orthopnea (breathing discomfort aggravated by lying flat). Not in acute pain. Answers questions appropriately

• Heart: Sinus rate and sinus rhythm. Normal S1, S2, no S3. No gallop

• Abdomen: Benign. Bowel sounds present in all 4 quadrants, soft, non-tender. No guarding, no rigidity, no hepatosplenomegaly, no midline, pulsatile mass, or abnormal mass palpable

• Extremities: No pedal edema, peripheral pulses palpable

Overview of Disease States: NSTEMI vs. Aortic Valve

Stenosis• Normal function of the heart

Overview of Disease States: Aortic Valve Stenosis vs. NSTEMI:

Etiologies• Aortic Valve Stenosis- Obstruction at the valvular level- Degenerative calcification (long

standing hemodynamic stress on the valve)

- Rheumatic heart disease - Deformed aortic valve - Increasing age- Chronic Kidney disease

• NSTEMI - Diabetes Mellitus- Physical Inactivity- Lifestyle- Diets deficient in fresh fruits/vegetables

and polyunsaturated fat- Hypertension- Dyslipidemia - Cigarette smoking- Increasing age- Male- Family History- Overweight/Obese- Excess alcohol and carbohydrate

consumption

Symptoms and Clinical Manifestations

• NSTEMI: • Difficulty breathing/Shortness of breath • Cardiogenic Shock • Elevated Troponins • Pain in the sub-sternal area radiating to

the arm and neck• Indigestion• Nausea/vomiting • Sweating • Weakness/fatigue • Rhythmic abnormalities palpitations • Syncope • Dizziness

• Aortic Valve Stenosis: • Chest pain/tightness• Heart failure • Syncope• Systolic Hypertension• Shortness of breath• Fatigue • Heart palpitations• Elevated Troponins• Lower perfusion pressure• Altered heart sounds

Pathophysiology: NSTEMI vs. Aortic Valve Stenosis

• NSTEMI: • Atherosclerotic plaque build up

compromises oxygen flow to heart • Plaque ruptures and develops a

thrombus or a blood clot causing a blockage of blood flow

• Lack of blood flow causes cardiomyocytes to become oxygen starved

• Cardiomyocytes slow contraction, rupture and die, releasing troponins into the artery

• Adrenaline is released, the rest of the heart compensates by beating faster

Aortic Stenosis• When the heart contracts the aortic

valve opens and blood is pumped into the aorta

• When the heart relaxes, the aortic valve closes

• A narrowed aortic valve limits the amount of blood ejected from the ventricle into the aorta

• Increases afterload by increasing pressure

• Increases contractility to overcome the outflow resistance

• This results in ventricular hypertrophy and followed by degeneration and death of the cardiac myocytes

NSTEMI and CHF• After myocardial infarction Loss of heart muscle cells

Ventricular Hypertrophy

Dilated Cardiomyopathy

Aortic Stenosis and CHF

Aortic Stenosis Chronic Pressure Increase in afteroad/contractility

Ventricular Hypertrophy

Dilated Cardiomyopathy

Nutrition Interventions: Aortic Valve Stenosis vs. NSTEMI

• NSTEMI- Low fat- Low cholesterol- Low sodium - High fiber - Manage weight - Omega-3 fatty acids - Emphasis on fruits, vegetables,

and whole grains

• Aortic Valve Stenosis- Main therapy is surgical

replacement - Before surgery NPO (nothing by

mouth)- Fluid may be restricted - Diuretics may be used to

remove fluid around heart and lungs

Overview of Disease States: Congestive Heart Failure

(CHF)

Pathophysiology: CHF

• Chronic inflammation causing the heart to beat inefficiently

• Impairing these functions: 1. Afterload – the pressure the

ventricle opposes against the aorta

2. Contractility – the force the ventricle contracts with

3. Preload – how much blood fills the ventricle before it is ejected

Etiology: CHF• Myocardial Infarction• Aortic Stenosis • Heart valve disorders • Chronic Hypertension • Coronary Artery Disease/Chronic Ischemia • Constrictive Pericarditis • Restrictive cardiomyopathy • Dilated cardiomyopathy

Clinical Manifestations: CHF• Decreased blood flow leads to: - Dyspnea- Fatigue- Weakness- Exercise intolerance- Poor adaptation to cold temperatures- Hyponatremia - Ascites - Edema - Cough with productive sputum- Orthopnea - PND

Nutrition Therapy: CHF• Fluid modified diet: Less than 2 L fluid per day (for sodium levels below

130 mEq/L) • Sodium restriction: less than 2 gm of sodium per day• Thiamine and Potassium supplementation to compensate for losses in

patients on diuretics • Limit or discontinue alcohol use • Small frequent meals for patients experiencing early satiety• Educating patient on how to season food without the use of salt• Nutrition support: • Low volume feedings for enteral feedings • TPN only indicated for patients with limited gut function and may be

maximally concentrated

Overview of Disease States: COPD exacerbation

• Normal Pulmonary Function:- Supply the body with oxygen while

removing carbon dioxide - Air enters the lungs through the

trachea, which divides into the right and left bronchi supplying the lungs

- The bronchi divide again into smaller bronchioles

- The bronchioles end in small air sacs (alveoli), which are responsible for the exchange of oxygen and carbon dioxide

Pathophysiology: COPD exacerbation

• Progressive obstruction and inflammation of the airways • Irritants cause neutrophils, T-lymphocytes, and other inflammatory

cells to accumulate in the airways • Inflammatory mediators attempt to destroy and remove inhaled

foreign debris• In chronic scenarios, the response is ongoing, which inevitably

causes structural and physiological lung changes • The airways become narrowed and swollen • Excess mucus production and poorly functioning cilia makes airway

clearance especially difficult • Build up of mucus creates an environment where bacteria can thrive

Etiology: COPD• Chronic bronchitis • Productive cough and shortness of breath that lasts 3+ months for

at least 2+ years in a row• Cigarette smoking • Repeated exposure to secondhand smoke, air pollution, and

occupational exposure• Inflammation of the airways and lung tissue • Deficiency of the protein alpha 1-antitrypsin (ATT)

Signs and Symptoms: COPD• Dyspnea with possible wheezing• Persistent cough with sputum production • Increased breathing rate • Lung hyperinflation• Diminished breath sounds (crackles and wheezes) • Cyanosis in hypoxemic patients – this could lead to heart failure

due to the heart’s increased work to pump blood through the lungs • Digital clubbing

COPD exacerbation• Defined as “worsening of COPD symptoms, or a change in the

patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variations

• Causes: bacteria/viral lung infections and air pollution • Additional causes include: smoking, lack of pulmonary

rehabilitation, poor adherence to drug therapy

Nutrition Interventions: COPD• Goals: Prevent weight loss, maintain and restore lean body mass• Small, frequent meals to accommodate shortness of breath • Food choices easy to chew, swallow, and digest• Nutrient-dense nourishment and/or supplements • Vitamin/mineral supplement • Avoid overfeeding and excessive carbohydrate intake

Chronology of Medical and Nutritional Interventions: Newly Developed

Conditions• Newly developed conditions: • Cardiogenic shock following aortic valve replacement (2/6/15)• Patent Ductus Arteriosus (2/8/15)• Fluid overload (2/9/15)• Alcohol withdrawal (2/10/15)• Respiratory Failure (2/12/15)• Leukocytosis and Ileus (2/14/15)• Intra-abdominal free air of unknown origin (2/15/15)• Perforated cecum and septic shock – (2/16/15) • Heparin-Induced Thrombocytopenia – (2/20 – 2/26) • Vancomycin-Resistant Enterococci (VRE) (3/9)

Definitions of Newly Developed Conditions:

• Cardiogenic Shock: inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively. There is insufficient perfusion to the tissues

• Patent Ductus Arteriosus (PDA): a congenital disorder in the heart wherein a neonate’s ductus arteriosus fails to close, with age PDA may lead to congestive heart failure

• Fluid overload: too much fluid in the blood. Can be caused by excess sodium content in the body and subsequently increase in extracellular volume

• Alcohol withdrawal: cessation of alcohol use after prolonged usage. The response is a hyper-excitable response of the central nervous system to lack of alcohol.

• Leukocytosis: elevated white blood cell count • Septic shock: A systemic inflammatory response and immunosuppressive process that prevents an

adequate response to infection or trauma. This may result in organ dysfunction or hypoperfusion abnormalities. It can cause multiple organ dysfunction and death.

• Respiratory Failure: occurs when the respiratory system is no longer able to perform its normal functions. It can result from long standing chronic lung disease like COPD or cystic fibrosis, or as a result of an acute insult to the lung as seen with acute lung injury or acute respiratory distress syndrome

• Heparin-Induced Thrombocytopenia: deficiency of platelets in the blood caused by the anticoagulant Heparin

• Vancomycin Resistant Enterococci: type of bacteria called enterococci that developed a resistance to an antibiotic called vancomycin

Chronology of Medical and Nutrition Treatments

Date Procedure Nutrition Intervention

2/5/15 Aortic Valve Replacement and Ascending Aortic Aneurism Graft

NPO

2/9/15 Thoracentesis NPO

2/10/15 Cardioversion and Aortic Aneurism Replacement

NPO

2/15/15 Exploratory laparotomy with subtotal colectomy and end-ileostomy

NPO

2/16/15 Patient on mechanical ventilation NPO, TPN @ 63 mL/hr (1590 kcals, 100 gm protein)

2/19/15 Thoracentesis NPO, TPN @ 85 mL/hr (1790 kcals, 150 gm protein)

2/22/15 Thoracentesis NPO, TPN @ 44 (895 kcals, 75 gm protein)

2/26/15 Tracheostomy NPO, PN @ 50 mL/hr (1195 kcals, 75 gm protein). Tube feed stopped

3/4/15 PEG placed Enteral feeding stopped from 3/3 at midnight, restarted through PEG on 3/5

Normal Intestinal Function• Small intestine: - Primary site of digestion and

absorption • Large intestine: - Bacterial fermentation of

remaining carbohydrates and amino acids

- Synthesis of small amounts of vitamins, storage, and excretion of fecal residues

- Absorb water

Ileus• Definition: decreased or absent motility of the bowel and forward movement of bowel

contents • Causes: - Appendicitis- Botulism- Medications (opiates/sedatives)- Diabetic ketoacidosis- Electrolyte imbalance- Gastroenteritis - Obstruction of the mesenteric artery - Pancreatitis - Hypomotility - Crohn’s disease - Surgical complications

Pathophysiology: Ileus• Exact pathogenesis remains unclear • Surgical stress response leads to systemic generation of endocrine

and inflammatory responses • Increased number of macrophages, monocytes, dendritic cells, T

cells, natural killer cells, and mast cells

Clinical Manifestations: Ileus• Abdominal pain/cramping • Nausea • Vomiting • Diarrhea • Constipation • Abdominal distention • Hypoactive bowel sounds

Ileus Nutrition Therapy• Delay oral feeding until ileus resolves clinically • Parenteral/Enteral feedings indicated• Having patients chew gum may simulate gastrointestinal feedings

Perforated Cecum and Pneumoperitoneum

• Perforated Cecum – a hole or piercing through the wall of the cecum

• Pneumoperitoneum – presence of air or gas in the peritoneal cavity

Ileostomy and Subtotal Colectomy

• Opening of the ileum at the abdominal wall

• Removal of part of the large intestine

• Opening into the abdominal wall

• The end of the ileum is brought through the stoma, typically on the lower right side of the of the abdomen

Nutritional Management of Ileostomies

• Begin with clear liquids • Small frequent meals, low fiber • Limiting fluids with meals • Encourage higher sodium intake (unless otherwise indicated) • Rehydration beverages if excessive fluid is lost

Admission Nutrition Assessment

• Diet history: “eating well prior to admission”. Mr. H. is unsure of exact weight change before admit, but believes overall weight has increased over the past few months.

• Allergies: no known food allergies • Admitting nutrition order: Cardiac (2 gram sodium, low

cholesterol, low fat)• Admitting intake: approximately 88% of meals, ~930 kcals

averaged over 3 days.

Admission Nutrition Assessment

• Anthropometrics: - Height: 180 cm - Weight: 90.9 Kg (standing scale) - Body Mass Index (BMI): 28- Ideal Body Weight (IBW): 78.1 Kg- Percent IBW: 116% - Estimation of macronutrient needs: - Carbohydrate: 176 – 276 gm/day (35-55% estimated calorie needs for COPD) - Fat: 67 – 100 gm/day (30-45% estimated calorie needs for COPD)- Protein: 109 – 136 gm/day (1.2 – 1.5 g/kg for pulmonary disease) - Calories: 2008 – 2454 kcals (Ireton Jones) - Evaluation of current intake: intake is low (~46% of estimated needs), however

patient appeared well nourished. No interventions were recommended upon initial assessment.

Chronology of weights Date Weight in Kg

2/1/15 90.9

2/4/15 90.7

2/8/15 96.9

2/10/15 95.6

2/11/15 96

2/14/15 97.6

2/15/15 95.2

2/17/15 101.6

2/19/15 102.8

2/21/15 103.2

2/23/15 98.4

2/26/15 93.4

3/2 /15 91.8

3/4/15 88.5

3/9/15 87.4

Chronology of Weights

2/1/

2015

2/2/

2015

2/3/

2015

2/4/

2015

2/5/

2015

2/6/

2015

2/7/

2015

2/8/

2015

2/9/

2015

2/10

/201

5

2/11

/201

5

2/12

/201

5

2/13

/201

5

2/14

/201

5

2/15

/201

5

2/16

/201

5

2/17

/201

5

2/18

/201

5

2/19

/201

5

2/20

/201

5

2/21

/201

5

2/22

/201

5

2/23

/201

5

2/24

/201

5

2/25

/201

5

2/26

/201

5

2/27

/201

5

2/28

/201

5

3/1/

2015

3/2/

2015

3/3/

2015

3/4/

2015

3/5/

2015

3/6/

2015

3/7/

2015

3/8/

2015

3/9/

2015

Weight Trend

Nutrition related laboratory values

Date 2/2/15

2/4

2/8

2/10

2/11

2/14

2/16

2/17

2/19

2/21

2/23

2/26

3/2 3/4

WBC 23.6

18.6

21.4 45.1 23.1 18.7 11.7 14.5

Hgb 8.8 8.5 8.7 10.2 7.5 9.9 9.1 11.2 8.7 10.4 10.2

Na 126

122

124 126 123 146

K 2.8 2.8 3.2 3.4 3.1 3.0

Glucose 177

132 132 136 164 133 144 134

BUN 23 27 33 41 38 29 31 27 30 28 17

Mg 2.4 2.3 2.6 3.1 2.6 2.4

Pre albumin

8.1 4.0 5.1 10.7 16.3

Albumin 3.2 2.6 1.8 1.7 1.7 1.9

Chronology of Labs

2-Feb

3-Feb

4-Feb

5-Feb

6-Feb

7-Feb

8-Feb

9-Feb

10-F

eb

11-F

eb

12-F

eb

13-F

eb

14-F

eb

15-F

eb

16-F

eb

17-F

eb

18-F

eb

19-F

eb

20-F

eb

21-F

eb

22-F

eb

23-F

eb

24-F

eb

25-F

eb

26-F

eb

27-F

eb

28-F

eb

1-M

ar

2-M

ar

3-M

ar

4-M

ar

5-M

ar

WBC Albumin Prealbumin

Nutrition related medicationsVitamin/ Minerals

Antibiotics/ antifungals

Gastrointestinal medications

Fluid medications

Sedatives Other

Multivitamin Vancomycin Miralax Potassium Chloride

Propofol Sliding Scale Insulin

Thiamine Levofloxacin Colace Sodium Chloride @75 mL/hr

Ativan Drip Methyl-prednisone

Folic acid Caspofungin Docusate Senna

Lasix Lipitor

Zosyn Protonix Metolazone Warfarin

Flagyl Reglan Vasopressin

Lactobacillus

Nutrition Diagnoses • Inadequate oral food/beverage intake R/T decreased appetite, shortness of

breath, and status/post surgery AEB Estimated energy needs, consuming 26-75% - 2/8

• Inadequate oral food/beverage intake R/T compromised function of the Gastrointestinal (GI) tract AEB Need for NPO status – 2/17

• Inadequate intake from enteral/Parenteral nutrition (PN) R/T compromised function of GI tract and high enteral nutrition residuals and fluid overload requiring decreased PN rate AEB patient meeting 45% of estimated caloric needs – 2/23

• Inadequate intake from enteral/parenteral nutrition R/T compromised function of the GI tract and restricted fluids AEB tube feed/TPN less than estimated needs and PN currently provides ~65% of estimated needs – 2/26

• Inadequate intake from enteral/parenteral nutrition R/T procedure schedules AEB tube feeding stopped for over 24 hours

Nutrition Interventions

Date Nutrition intervention Purpose

2/1/15 Cardiac (2 gm sodium, low cholesterol, low fat) Admitting diagnosis, NSTEMI and CHF

2/8/15 Regular Diet liberalized due to poor oral intake

2/9/15 EnsurePlus BID (twice a day) Poor oral intake

2/16/15 PN @ 63 mL/hr (1590 kcals, 100 gm protein) Ileus, perforated cecum, unable to take needs orally

2/19/15 PN @ 85 mL/hr (1790 kcals, 150 gm protein) TPN running at goal, meeting estimated needs

2/20/15 PN @ 85 (1790 kcals, 150 gm protein) + Jevity 1.2 @ 10 mL/hr (288 kcals, 13 gm protein)

Enteral nutrition added to prevent gut atrophy

2/22/15 PN @ 44 mL/hr (895 kcals, 75 gm protein) + Jevity 1.2 @ 10 mL/hr (288 kcals, 13 gm protein)

PN decreased due to patient volume overloaded

2/24/15 Increase Jevity 1.2 by 10 mL/hr Q6 hours to goal rate of 55 mL/hr (2448 kcals, 113 gm protein)

Ileus appears resolved, enteral feedings increased to replace parenteral nutrition

2/25/15 Pivot 1.5 @ 20 mL/hr, increase by 10 mL/hr every 6 hours to goal rate of 55 mL/hr (1980 kcals, 124 gm protein) + PN @ 50 mL/hr (1195 kcals, 75 gm protein)

Formula changed to more concentrated formula to minimize fluid and easier to digest.

2/28/15 TPN stopped Enteral feedings provided needs

3/5/15 NPO, Pivot 1.5 @ 10 mL/hr, goal rate 55 mL/hr via PEG

New PEG placement

Nutrition Monitoring and Evaluation

• Monitor and Evaluate: - Tolerating parenteral nutrition- Fluids/Intake/Output- Bowel function - Weight- Enteral residual volume/tube feeding tolerance - Gut function - Lab values - Swallowing ability - Fat malabsorption- Lactose intolerance

Discharge Plan• Issues with insurance • Medical improvements

Summary• Mr. H’s hospital course was complex and lengthy • Medical nutrition therapy improved his overall outcome despite

challenges faced with surgeries, procedures, and new disease states

References: • http://nstemi.org/ • http://www.cvphysiology.com/Heart%20Disease/HD009b.htm• http://emedicine.medscape.com/article/163062-overview#aw2aab6b2b3 • http://www.cardiothoracicsurgery.org/content/7/1/108 • http://

www.intechopen.com/books/principles-and-practice-of-cardiothoracic-surgery/gastrointestinal-complications-in-cardiothoracic-surgery-a-synopsis

• http://emedicine.medscape.com/article/2242141-clinical#showall• http://ajpgi.physiology.org/content/287/3/G685 • http://emedicine.medscape.com/article/150638-overview#aw2aab6b2b4aa • http://www.mayoclinic.org/diseases-conditions/aortic-stenosis/basics/risk-factors/con-20026329 • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913510/ • https://

www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5803&lv2=8585&ncm_toc_id=8585&ncm_heading=Nutrition%20Care

References• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913510/#B3 • http://copd.about.com/od/copdbasics/a/copdpathophysiology.htm • http://copd.about.com/od/copd/a/copdexac.htm • http://www.healthgrades.com/right-care/digestive-health/paralytic-ileus--causes • http://

www.healthcare-bulletin.com/uploads/media/Gastrointestinal_Complications_Following_Heart_Surgery_01.pdf

• http://emedicine.medscape.com/article/2242141-overview • http://en.wikipedia.org/wiki/Cardiogenic_shock • http://www.bing.com/search?q=septic%20shock%20defi&qs=n&form=QBRE&pq

=septic%20shock%20defi&sc=2-17&sp=-1&sk=&cvid=02eb7217d1b24d2c9a89488dba9148ff

• Nutrition Therapy and Pathophysiology • Krause’s Food and the Nutrition Care Process.