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Joyce L. Hornick Dietetic Intern University of Maryland, College Park January 4, 2012 2012 by Joyce L. Hornick, http://joycehornick.com/

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Case Report: General Information MH: 44 yo AA Female Admitted 10/22/11 for slurred speech and difficulty ambulating Height 5 2 (157.48 cm) Weight 149 lbs (67.8 kg) Diagnosed with acute cerebellar ataxia infarction Received treatment for 18 days Discharged to nursing home facility 11/8/11

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Case Report: Social History Living with sister PTA Sister took care of medical and nutritional needs Not employed due to: Limited physical abilities Multiple medical issues Presumed to be on disability-related insurance coverage

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Case Report: Medical/Surgical Data Past Medical History: Type 2 Diabetes Mellitus (DM2) Hypertension (HTN) End Stage Renal Disease (ESRD) with hemodialysis 3 times per week x 2 years Cerebrovascular Accident (CVA) Human Immunodeficiency Virus Disease (HIV) Hepatitis C

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Case Report: Medical/Surgical Data Medications: Heparin (blood clotting) PhosLo (phosphate control) Rena-Vite (renal-specific multivitamin) Sensipar (hyperparathyroidism) Sustiva (HIV) Epivir (HIV) Catapres/clonidine (HTN) No DM medications

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Case Report: Medical/Surgical Data Relevant Information about MH PTA: 10/19/11: Missed hemodialysis appointment. 10/20/11: Family noticed difficulty ambulating. 10/21/11: MH unable to have dialysis. At FSH, fistula blocked and staff attempted to unblock.

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Case Report: Medical/Surgical Data Relevant Information about MH Following Admission: 10/22/11 (Day 1): Admitted for right side weakness, confusion, and cognitive decline. No chest pain, shortness of breath, nausea, vomiting or diarrhea. Examinations scheduled to r/o CVA, Encephalitis, and/or infection. Family reported that MH had been slow to respond and/or talk for the previous three weeks.

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Case Report: Tables Laboratory Results: Appendix A List of Medications: Appendix B Vitamin Supplements: As listed in Appendix B, MH was taking Rena-Vite, as recommended for dialysis patients.

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Case Report: Nutritional History Nutritional history unobtainable due to: non-verbal state cognitive decline Family reported normal appetite/intake until Thursday PTA. MH ate very little by mouth/refused to eat throughout admission. No known food allergies.

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Case Report: Nutritional History Weight parameters: Ideal Body Weight (IBW) = 50 kg Percent of IBW = 136% Body Mass Index (BMI) = 27.34 BMI = overweight

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Case Report: Nutritional History Estimated Nutritional Needs: Source Kcal requirements Protein requirements Fluid requirements Union Memorial Hospital standards Based on 120- 160% IBW = 20-25 kcal/kg = 1356- 1695 Based on a patient on hemodialysis = 1.2-1.4 g/kg = 81-95 Based on 1000 mL + urine output due to patient on hemodialysis NCM Based on a patient < 60 yrs on hemodialysis, 35 kcal/kg = 2373 Stage 5 CKD, on hemodialysis = > 1.2 g/kg= > 81 Stage 5 CKD, on hemodialysis = urine output plus 1,000 mL

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Case Report: Nutritional History Nutrition Care Process, Initial PES: (NI-2.1) Inadequate oral intake related to diet order and current mental status as evidenced by NPO for 3 days (1). Goals: Honor familys wishes concerning patient support options. Nutrition recommendations available if family reconsiders feeding options or if MHs mental status improves.

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Case Report: Nutritional History Nutrition Care Process, Updated PES: (NC-1.1) Swallowing difficulty related to history of CVA and acute cerebellar ataxia infarction as evidenced by PEG tube feeding as primary source of nutrition (1). Family reversed decision. Goals: Meet estimated nutritional needs via PEG at goal rate. Recommendations made to monitor TF tolerance and electrolytes.

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Case Report: Hospital Course of Patient Medical Treatment: 10/22/11 (Day 1): Given Heparin due to suspected CVA Initial lab results: elevated BUN (66 mg/dL) and creatinine (8.19 mg/dL) elevated finger stick blood glucose level (176 mg/dL)

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Case Report: Hospital Course of Patient Medical Treatment: 10/23/11 (Day 2): CT scan performed with no intracranial mass and/or hemorrhage noted. Cultures for bacterial infection negative. Passed SLP bedside swallow test. Diet order: medium carbohydrate diabetic diet, with minimal intake.

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Case Report: Hospital Course of Patient Medical Treatment: 10/25/11 (Day 4): Awake and slight improvement in mental status. Diet order: med. carbohydrate diabetic diet, minimal intake. 10/26/11 (Day 5): Brain MRI indicates acute cerebellar ataxia infarction. Diet order: NPO

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Case Report: Hospital Course of Patient Medical Treatment: 10/28/11 (Day 7): Initial nutrition assessment performed. All oral medications discontinued. Intravenous fluid support of 40 mL/hour for general hydration. Family states DNR/DNI. 10/29/11 (Day 8): Right arm fistula to be used for next hemodialysis treatment.

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Case Report: Hospital Course of Patient Medical Treatment: 10/31/11 (Day 10): Case manager to meet with family to review choices and goals of care. 11/1/11 (Day 11): Family changes position and now wants aggressive care. Orders for PT/OT evaluation and PEG placement placed. SLP efforts with nectar and puree were unsuccessful.

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Case Report: Hospital Course of Patient Nutritional Care: 11/2/11 (Day 12): MH remains nonverbal and non-responsive. PEG placed with no complications or post-operative issues. TF recommendations: Nepro at 15 mL/hr, increasing by 10mL every 4 hours to a goal rate of 35 mL/hour (providing 1512 kcals, 68 g protein, and 613 mL water) 225 mL water flushes every 6 hours Add one packet of Juven with one water flush to provide an additional 70 kcals and 7 g protein Additional recommendations include monitoring electrolytes.

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Case Report: Hospital Course of Patient Nutritional Care: 11/3/11 (Day 13): MH receiving Nepro at goal rate of 35 mL/hour, with 1 packet of Juven and 225 mL water flushes every 6 hours. Recommendations include: Continue TF at current rate with flush Replace Juven with 1 oz. ProSource (providing additional 60 kcals and 15 g protein) Continue to monitor electrolytes 11/5/11 (Day 15): Physicians prescribed potassium chloride due to low potassium blood level (3.1 mEq/L).

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Case Report: Hospital Course of Patient Nutritional Care: 11/7/11 (Day 17): MH tolerating TF of Nepro at goal rate of 35 mL/hour, with 1 oz. ProSource and 225 mL water flushes every 6 hours. SLP determines MH at risk for silent aspiration with trials of nectar liquids and puree via spoon. Based on SLP evaluations, diet order changed to allow full liquid, honey thick when MH is sufficiently aware/awake. Goals include: TF tolerance Monitoring SLP efforts to advance oral diet.

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Case Report: Hospital Course of Patient 11/8/11 (Day 18): MH discharged to nearby nursing home. Lab values for BUN and creatinine remained elevated throughout stay. Phosphorus fluctuated, but was typically elevated. Magnesium was elevated, but brought down to normal limits approximately half way through course of treatment. Blood glucose levels were elevated, brought under control, and became elevated again prior to discharge.

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Case Report: Hospital Course of Patient Discharge instructions included: Hemodialysis via the AV port Continued PEG feeding Honey thick liquids when sufficiently oriented to safely drink

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Case Report: Hospital Course of Patient Discharge medications included: Aspirin (blood clotting) Catapres/clonidine (HTN) Pravachol (HLD) PhosLo (phosphate control) Rena-Vite (renal-specific multivitamin) Sensipar (hyperparathyroidism) Sustiva (HIV) Epivir (HIV) Ziagen (HIV) Bactrim (antibiotic) No DM medications

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Case Discussion: Medical Considerations Develop long-term care options and goals. Prognosis of acute cerebellar ataxia infarction. Limit extension of existing stroke. Provide rehabilitation efforts with medication. Prevent future ischemic events using risk-factor reduction treatments. Control HTN and DM2 via oral diet/medication therapy (4). Restrict sodium, fluid, potassium for ESRD/CKD control (5). MHs ESRD/CKD requires continued hemodialysis to control HTN and loss of renal function (5).

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Case Discussion: Nutritional Considerations Metabolic and gastrointestinal complications must be monitored (6). A.N.D. specific guidelines to maintain electrolyte balance for hemodialysis. Comparison of Nutrition prescription, Nutrition Care Manual of A.N.D. (7) with Nepro (8) recommendations.

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Case Discussion: Nutritional Considerations NutrientNCM (7)Nepro (8) Energy (kcals)23731512 Protein (g) > 8183* Sodium1-3 g890 mg Potassium2-3 g890 mg Phosphorus (mg)800-1000603 Calcium< 2 g890 mg Vitamin B6 (mg)27.1 Vitamin B12 (mcg)38.2 Vitamin C (mg)60-10090 Vitamin E (IU)1582 Folate (mg)10.9 Zinc (mg)1523 *Includes Proscource All other water-soluble vitamins follow the DRI. Vitamin D and Iron, individualized for each patient. MH also taking Rena-Vite (contains B vitamins, vitamin C, folic acid, and biotin)

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Case Discussion: Implications of Findings to the Practice of Dietetics Ultimate goals: All nutrition oral Control of HTN, DM2, and HIV Prevention of future CVAs Prognosis of attaining goals unknown Long-term tube feeding vs. palliative care

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Case Discussion: Implications of Findings to the Practice of Dietetics Clinical literature review by Plonk. Evidence-based recommendations for PEG placement in only four medical conditions. Included acute stroke with dysphagia (9). The study did not look at co-morbidities in conjunction with acute stroke with dysphagia. Looked at ethical placement of PEGs avoidance of end-of-life discussions.

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Case Discussion: Implications of Findings to the Practice of Dietetics FOOD trials data (10). Studies of statistical trends and PEG placement and CVA patients (11). Prognosis regression in medical care (12). Syndromes of adverse outcome for geriatric patients (12). Future decisions about MHs care.

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References 1. Academy of Nutrition and DIetetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 3 rd ed., 2011. 2. Acute Cerebellar Ataxia. Medline Medical Encyclopedia. Source: http://www.nlm.nih.gov/medlineplus/ency/article/001397.htm. Posted 2/5/11. Accessed: December 19, 2011.http://www.nlm.nih.gov/medlineplus/ency/article/001397.htm 3. Ovbiagele, B., MD, MSc and Nath, A., MD. Increasing incidence of ischemic stroke in patients with HIV infection. Neurology. http://www.neurology.org/content/76/5/444. Accessed January 2, 2012. http://www.neurology.org/content/76/5/444 4. Winkler, S., Pharm.D., BCPS. Cerebrovascular Disease. University of Illinois at Chicago. 1998. http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/CVD.html. Accessed: December 26, 2011. http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/CVD.html 5. Overview. Chronic Kidney Disease. Academy of Nutrition and DIetetics Nutrition Care Manual. Source: http://nutritioncaremanual.org/content.cfm?ncm_content_id=78549. Accessed: December 26, 2011. http://nutritioncaremanual.org/content.cfm?ncm_content_id=78549 6. Complications of Nutrition Support. Chronic Kidney Disease. Academy of Nutrition and DIetetics Nutrition Care Manual. Source: http://nutritioncaremanual.org/content.cfm?ncm_content_id=78581. Accessed: December 26, 2011. http://nutritioncaremanual.org/content.cfm?ncm_content_id=78581 7. Nutrition Prescription. Chronic Kidney Disease. Academy of Nutrition and DIetetics Nutrition Care Manual. Source: http://nutritioncaremanual.org/content.cfm?ncm_content_id=78568. Accessed: December 26, 2011. http://nutritioncaremanual.org/content.cfm?ncm_content_id=78568 8. Formulary Database. Nepro plus Carb Steady. Academy of Nutrition and DIetetics Nutrition Care Manual. Source:http://www.nutritioncaremanual.org/calculators/_calculators_CalcFRM_solution.cfm?mode=formulary&SolutionID=157. Accessed: December 26, 2011.http://www.nutritioncaremanual.org/calculators/_calculators_CalcFRM_solution.cfm?mode=formulary&SolutionID=157 9. Plonk, W., MD. To PEG or Not to PEG. Practical Gastroenterolgy. July 2005. Pg. 16-31. 10. The FOOD Trial Collaboration (multiple authors from multiple countries). Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD); a multicentre randomised controlled trial. The Lancet. February 26, 2005. Vol. 365. Pg. 764-772. 11. Elia, M., Stratton, R., et. al. Home enteral tube feeding following cerebrovascular accident. Clinical Nutrition. 2001. Vol. 20(1). Pg. 27- 30. 12. Kearney, C., MD. Palliative Care and Nutrition. A PowerPoint presentation dated 3/4/11. 13. End Stage Renal Disease. American Kidney Fund. Source: http://www.kidneyfund.org/kidney-health/kidney-failure/end-stage-renal- disease.html. Posted 2/11/08. Accessed: December 19, 2011.http://www.kidneyfund.org/kidney-health/kidney-failure/end-stage-renal- disease.html 14. Full Code. Patient friendly definitions. California Pacific Medical Center. Source: http://www.cpmc.org/services/ethics/faq.html. Accessed: December 19, 2011.http://www.cpmc.org/services/ethics/faq.html 15. Hemodialysis and Arteriovenous Fistula. Medline Medical Encyclopedia. Source: http://www.nlm.nih.gov/medlineplus/ency/article/007434.htm. Posted 9/21/11. Accessed: December 19, 2011. http://www.nlm.nih.gov/medlineplus/ency/article/007434.htm 16. Refeeding Syndrome. RD411. Source: http://www.rd411.com/index.php?option=com_content&view=article&id=528:refeeding- syndrome&catid=92:enteral-and-parenteral-nutrition&Itemid=386. Posted March 2011. Accessed: December 19, 2011.http://www.rd411.com/index.php?option=com_content&view=article&id=528:refeeding- syndrome&catid=92:enteral-and-parenteral-nutrition&Itemid=386

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Any Questions?