Case Presentation P. Martins (PT) · 2015-10-30 · Case Presentation P. Martins (PT) CASE...
Transcript of Case Presentation P. Martins (PT) · 2015-10-30 · Case Presentation P. Martins (PT) CASE...
ESPEN Congress Lisbon 2015
Case PresentationP. Martins (PT)
CASE DISCUSSION - FRAIL ICU PATIENT
Case Discussion - Frail ICU patient
Paulo Martins
75 year, male patientAdmited with severe mid‐epigastric abdominal pain that radiates to the back. The pain worsens with deep inspiration and movement and improves when the patient leans forward.He complains of anorexia and nausea in the last 4 weeks. Complicated with vomiting in the last 3 days
He was diaphoretic, agitated and confused. Febrile (39°C), tachycardic (125/min), tachypnoeic (32 c/min).Hypotension (80/55 mmHg)He had a decreased breath sounds in the base of left lung.Abdominal tendernesss and distension with diminished bowel sounds.
Alchoolic habitsDiabetesHypertension
pH – 7,36
PCO2 – 26,4 mmHg
PaO2 – 88,3 mmHg
HCO3 – 16,2 mmol/L
Sat – 96,9%
Lactates – 5,33 mg/dl
Leucocytes – 13000
Hct – 54,3%
Glicemia – 145 mg/dl
Na – 142 mmol/L
K – 3,1 mmol/L
Ca – 7,1 mg/dl
Total proteins - 6 mg/dl ; Albumine– 2,1 mg/dl
BUN – 30 mg/dl
Creatinine – 1,1 mg/dl
GOT –85 U/L; GPT – 106 U/L; Alkaline phospathase – 80 U/L
γ-glutamyl transpeptidase – 140 U/L
Bilirrubin total – 1,2; Bilirrubin direct – 0,8
Serum lactate dehydrogenase (LDH) – 230 U/L
CRP – 0,5 mg/dl
Transcutaneous abdominal ultrasonography* Gallblader distended with thin walls and biliary sludge. Biliary tree normal diametre
* Pancreatic enlargement with a slightly heterogeneous parenchyma and an overall ↓ of reflectivity
Seric amylase – 6721 U/L and seric lipase – 4870 U/L
Which are your first therapeutic measures ?
NaCl 0,9% - 1000 cc in 30 min
KCl 7,5% - 50 mmol iv
Tramadol - 100 mg iv 8/8 h
Enoxiparin – 40 mg iv
CVP – 8 mmHg
BP – 98/58 mmHg
Diuresis – 20 cc
pH – 7,42
PCO2 – 29,4 mmHg
PaO2 – 70,3 mmHg
HCO3 – 17 mmol/L
Sat – 95%
Lactate – 4,1 mg/dl
In the next hours maintains abdominal pain but improves the nausea with disapearance of
vomiting.
Is febrile (39°C) with hypotension (85/55 mmHg), so we started vasopressors (Nor-
epinephrine 0,5 μgr/Kg/min).
He was oliguric and with abdominal distension.
The value of intra-abdominal pressure was 8 mmHg
After few hours he felt better from the abdominal pain
BP – 120/75 mmHg
Diuresis - 40 cc urine/hour
Severe acute pancreatitisPersistent organ failure (> 48H) or infected pancreatic necrosis
The patient is 1,74 m tall and has 60 Kg in weight
In the last 4 weeks he lost 5,8 Kg
What you need to ask for the nutritional status evaluation of this patient ?
IMC – 19
Unintentional weight loss of almost 10% in the last 4 weeks
How can you measure the nutritional risk of this patient?
NRS 2002 – Score > 3
Nutric SCORE - 7
Proposed Clinical Definition of Phenotype of Frailty
Fried LP et al – J Gerontol A BiolSci Med Sci 2001, 56: M146-56
The patient is 1,74 m tall and has 60 Kg in weight
In the last 4 weeks he lost 5,8 Kg
What you need to ask for the nutritional status evaluation of this patient ?
IMC – 19
Unintentional weight loss of almost 10% in the last 4 weeks
How can you measure the nutritional risk of this patient?
NRS 2002 – Score > 3
Nutric SCORE - 7
What is your nutritional strategy ?
Two days later
He was polipneic and diaphoretic with oxygen peripheric saturation that
doesn’t improve with increased O2 delivered by Venturi mask 40%.
pH – 7,19; PCO2 – 38 mmHg; PaO2 – 58 mmHg; HCO3 – 12,2 mmol/L; Sat – 78 %
PaO2/FiO2 - 125
Lactate –7,3 mg/dl
Tachycardia (130/min) with BP – 78/50 mmHg
Oliguric (< 10 cc/h)
It increases the abdominal distension with IAP 28 mmHg
We start early enteral nutrition with a polymeric solution (1 Kcal/ml)
increasing slowly…… 1200 Kcal/day
Leucocytes – 22200
Hematocrit – 36,3%
Glucose – 186 mg/dl
Na – 144 mmol/L
K – 4,2 mmol/L
Ca – 6,8 mg/dl
Total proteins - 5,1 mg/dl e Albumine– 2,2 mg/dl
BUN – 45 mg/dl
Creatinine – 1,72 mg/dl
SGOT – 98 U/L; SGPT – 120 U/L; Alkaline phosphatase – 96 U/L;
Total bilirubin – 1,8 mg/dl ; Direct bilirubin – 1,2mg/dl
LDH – 320 U/L
CRP – 24,4 mg/dl
What to do?
Entubate and start mechanic ventilation (Tv 430 cc ; RR 18 ; PEEP 10 cm H20; FIO2 80%)
Stabilize the shock (nor‐epinephrine 1 μg/Kg/min; dopamine 10 μg/Kg/min)
Analgesic and sedation (Fentanyl – 0,8 µg/Kg/h ; Propofol 2% ‐ 3 mg/Kg/h)
And what about nutritional support?
The patient has already enteral nutrition , do you modify it?
We maintain polymeric enteral nutrition (1Kcal/ml)……1200 Kcal/day
With metoclopramide 8/8 h
But the patient increased gastric residual volume (> 300 cc)……
We reduce the enteral feeding rate at 50%...........but the patient increase the gastric
residual volume (> 600cc).
The nurse aspirates enteral formula in oral cavity
The abdominal distension increases with IAP of 18 mmHg
The echo‐abdominal examination shows ascites
How can we solve this problem?
We insert nasojejunal tube maintaining enteral nutrition at 500 cc/day
And start parenteral nutrition:
1000 Kcal – Carbohydrates – 2 g/Kg/day (120 g/d)
Lipids ‐ 0,5 g/Kg/day (MCT‐LCT mixture) (30 g/d)
Proteins – 0,8 g/Kg/day with 0,5 g/Kg/day of glutamine (78 gr/d)
Vitamins and oligoelements
Leucocytes – 30000
Hematocrit – 31,2%
Glucose – 71 mg/dl
Na – 154 mmol/L
K – 4,6 mmol/L
Ca – 8,2 mg/dl
Total proteins - 5,4 mg/dl; Albumine– 1,9 mg/dl
BUN – 59 mg/dl
Creatinine – 0,87 mg/dl
SGOT – 120 U/L; SGPT – 180 U/L; Alkaline phosphatase – 174 U/L;
Total bilirubin – 8,9 mg/dl ; Direct bilirubin – 5,5 mg/dl
LDH – 480 U/L
CRP – 12,1 mg/dl
What you do?
In the next days he is febrile 38°C, the IAP increases (28 mmHg) and the dislodgementof nasojejunal tube implies several endoscopic measures to put it back
We drain ascitis…… stop enteral nutrition and increase parenteral caloric support
with glutamine
Parenteral Nutrition
1500 Kcal – Carbohydrates – 3 g/Kg/day (180 g/d)
Lipids ‐ 0,8 g/Kg/day (MCT‐LCT mixture) (48 g/dia)
Proteins – 1 g/Kg/day with 0,5 g/Kg/day of glutamine (90 gr/d)
Vitamins and oligoelements
The IAP diminished (14 mmHg)…..
In the next days he maintains fever (39°C)
We isolate in tracheo‐bronquial suptum a MR Klebsiella
We have a new condensation image in Torax x‐ray
Leucocytes – 24000
Hematocrit – 34,3%
Glucose – 163 mg/dl
Na – 148 mmol/L
K – 4 mmol/L
Ca – 6,8 mg/dl
Total proteins - 5,6 mg/dl e Albumine–3,1mg/dl
BUN – 41 mg/dl
Creatinine – 1,20 mg/dl
SGOT – 834 U/L; SGPT – 410 U/L; Alkaline phosphatase – 220 U/L; G
Total bilirubin – 10,7 mg/dl ; Direct bilirubin – 7,7 mg/dl
LDH – 1210 U/L
CRP – 10,4 mg/dl
What would you do?
The gastric residual volume was less than 200 cc
We reasume enteral nutrition by naso‐gastric route
We replace the caloric parenteral apport by enteral nutrition
We begin antibiotics to treat the MR Klebsiella
In the next days the fever desapeared
He was hemodinamic stable
The IAP reduced
Enteral Nutrition (1, 5 Kcal/ml 1000 cc)
Carbohydrates – 2,8 g/Kg/day (170 g/d)
Lipids ‐ 0,8 g/Kg/day (MCT‐LCT mixture) (48 g/dia)
Proteins – 1,25 g/Kg/day (75gr/d)
Vitamins and oligoelements
Leucocytes – 8000
Hematocrit –38%
Glucose – 138 mg/dl
Na – 140 mmol/L
K – 4,2 mmol/L
Ca – 8,1 mg/dl
Total proteins - 6,1 mg/dl e Albumine– 3,1 mg/dl
BUN – 35 mg/dl
Creatinine – 1,01 mg/dl
SGOT – 280 U/L; SGPT – 110 U/L; Alkaline phosphatase – 138 U/L;
Total bilirubin – 6,1 mg/dl ; Direct bilirubin – 4,8 mg/dl
LDH – 400 U/L
CRP – 10,5 mg/dl
Procalcitonin – 6
We was now hemodinamic and respiratory stable
He start weaning at 26th day with pressure support ventilation
He was independent from ventilator at 30th day
He was discharged from ICU at 32th day, to a surgical ward
At discharge from ICU is weight was 45 Kg
He was discharge from the Hospital at 58th day. A physical therapy plan has been
prescribed for functional recovery. It is fed orally without protein supplementation.
At Hospital discharge is weight was 42 Kg
He lost weight during hospital stay
Midarm circunference was < 5th centile
Three weeks later he returns to Hospital with fever (39° C), multiple respiratory
purulent secretions and polypneia.
He has a pneumonia in Torax x-ray
pH – 7,42
PCO2 – 28,8 mmHg
PaO2 – 65,1 mmHg
HCO3 – 21,1 mmol/L
Sat – 87%
Lactates – 3,1 mg/dl
He improves PaO2 with Venturi mask at 40%
He was admited to a medical ward….
Start to treat his pneumonia …..
Leucocytes – 12000
Hematocrit –38%
Glucose – 178 mg/dl
Na – 135 mmol/L
K – 3,5 mmol/L
Ca – 8,1 mg/dl
Total proteins - 4,1 mg/dl e Albumine– 2 mg/dl
BUN – 58 mg/dl
Creatinine – 1,14 mg/dl
SGOT – 85 U/L; SGPT – 65 U/L; Alkaline phosphatase – 100 U/L;
Total bilirubin – 1,8 mg/dl ; Direct bilirubin – 1,1 mg/dl
LDH – 400 U/L
CRP – 28 mg/dl
At the entry he has 40 Kg
IMC – 13
He has walking limitations with several muscular atrophies
Which are the main causes of muscular atrophy in this patient ?
What I can do to minimize it?
How can I treat it?
This is an eldery patient with several weeks of hospitalization with an acute
infectious complication
In the next days aggravated the general state…..
Multiorgan failure, unresponsive to therapeutic measures
He died in cachexia and infection at the 12th day after admission
Start Enteral Nutrition (1 Kcal/ml)
How can we diagnose it ?
The Frail Patient at ICU…..
How can we measure it ?
How can we improve the results ?
Message for the future…………