Case Answers:
Answer 1
B) In this patient, markers of his poor nutritional status include his history (poor eating habits, alcohol abuse, social stressors) and physical exam (BMI, 24lb weight loss in six months, thin appearance, temporal wasting). There are also several labs that are useful in assessing nutrition. Best acute indicators of nutritional status are the retinol binding protein, prealbumin, and transferrin. Albumin is not a good measure of acute nutrition status but a better marker of overall nutrition status.
Answer 2
B) In a patient who is conscious and has a fully functioning GI tract, the best option for feeding is by mouth, and he requires a high caloric intake due his poor nutritional status at baseline.
Answer 3
C) The team should suspect that the patient has a pneumothorax from dobhoff placement in lung. Chest X-ray will confirm occurrence of a pneumothorax (and should be done any time someone becomes acutely short of breath and hypoxic) and the non-rebreather mask hastens absorption of the pneumothorax. The dobhoff should be pulled and serial CXRs followed. If no improvement, chest tube will need to be placed.
Nasogastric tubes (“salems sump”) and dobhoff tubes can both be used for feeding. Nasogastric tubes, although relatively easy to place are commonly dislodged, and prolonged placement can result in nasal and esophageal erosion and sinusitis. Always confirm placement with X-ray to rule out placement in the airway. NGT can be used to feed as well as placed on suction in the setting of a small bowel obstruction or severe ileus. Dobhoff tubes however are dedicated feeding tubes. These are typically weighted at the end and therefore are somewhat easier to pass post-pyloric. These also can very easily end up in the lungs causing a pneumothorax
Answer 4
B) A KUB should be checked to assess for obstruction or ileus. TPN should NOT be started at this time. If enteral feeds are at all possible, they are preferred. Patients who are fed enterally have improved immunologic function and overall better outcomes than patients who are NPO and on TPN. The intestines are a major immune organ, and disuse results in atrophy with increased infectious risk. Low dose tube feeds (10cc/hr) have shown to improve overall function and morbidity and mortality compared to patients on TPN. Risks of enteral feeding include pneumothorax (from dophoff in the lung) or aspiration so head of bed must be elevated at 30 degrees at all times.
Answer 5
C) If an ileus is present, promotility agents such as erythromycin and reglan can be used.
Answer 6
D) All of the above. He now has developed an aspiration pneumonia from worsening ileus or obstruction. Tube feeds should be turned off, NGT placed to suction and he should be started on TPN. He should also receive antibiotics to treat his aspiration pneumonia
Answer 7
D) CBC, LFTs, BMP, cholesterol panel with triglycerides, lipid panel with triglycerides. A central venous catheter or PICC line should be placed and nutrition consult can be ordered to provide an ideal TPN formula. An CXR should be ordered after the CVC/PICC line is placed to confirm placement and ensure there is no pneumothorax.
Answer 8
C) TPN is metabolized in the liver, and can increase the bilirubin and AST/ALT. TPN often causes profound hyperglycemia so insulin is often added to the TPN formula. Enteral feeds, by contrast, are metabolized first in the GI lining, and in doing so may cause diarrhea and decreased GI motility.
Answer 9
C) A malnourished alcoholic is likely to develop refeeding syndrome due to poor nutrition prior to admission. These patients should have slow nutrition initiation over several days before reaching goal nutrition targets. In addition, careful attention should be paid to K+, Phos, Mg with aggressive IV repletion if needed. In this patient, you may consult the TPN pharmacist and RD to decrease provision of kcals by ~ 50% until electrolytes are corrected. Electrolytes should be checked every 12 hours while refeeding. It is also advisable to start thiamine and a multivitamin - this may be beneficial in the malnourished patient prior to nutrition initiation as well to help reduce incidence/severity of refeeding in the first place. Once clinically stable and electrolytes are within normal limits for 24 hours, nutrition should be increased by 10-20% caloric increments until final requirements are met. Consult the Registered Dietitian in your unit to help with management.
Answer 10
B) The patient is fluid overloaded and you’d like to restrict the amount of free water provided in the nutrition regimen. Note that the names of the enteral nutrition formulas give insight to how concentrated the tube feed product is: 2calHN is 2 kcals/mL of tube feed, 1.5 cal is 1.5kcal/mL of TF and finally 1 cal is 1 kcal/mL of tube feed. The denser the formula, the less volume you need per day to meet estimated nutrition targets.
*Tip, make sure to start the enteral nutrition while the TPN is allowed to expire to avoid hypoglycemia. TPN should expire as the tube feed rate is increasing to goal rate to meet targets.
Answer 11
A) Overfeeding beyond estimated caloric requirements or at the high end of estimated caloric requirements can sometimes contribute to or exacerbate hypercapnia in specific patients. While carbohydrates do produce more CO2 per kcal than do fats or proteins, total calories have a greater effect on increased CO2 retention. It is acceptable to permissibly underfeed these patients for a short period of time to improve respiratory status.
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