+

NUTN 515 Case Study Cellulitis, Necrotizing Fasciitis

Wound Management

+Hello! Class, meet Mr. H! Client Hx

 55 y/o male with dx of cellulitis, necrotizing fasciitis, skin infection

 PMH: hepatitis C, HTN, liver cirrhosis, smoker, binge ETOH

 Social: Unmarried; girlfriend

+

What he’d been up to PTA

Vacationing in Belize

Sailing up/down Caribbean coast Bitten multiple times on LE from unknown organisms Consumed ~1/5 Rum per day Drank on plane trip home with minimal food intake

Developed fever, chills, and nausea on plane trip home

+Upon Admit

 Presented with…  Fever  Increased delirium/confusion  AKI  RLE erythema x3 weeks  Tachycardia  Severe sepsis  Blackened/purplish spots on plantar sides of

both feet

+How Mr. H lost his tan

 Onset of delirium d/t ETOH and alcohol withdrawal

 Development of necrotizing fasciitis Full thickness skin loss (knee to ankle) s/p debridement of wounds

Wound vac placed

 Intubated and tx to ICU

+

Nutrition Assessment

+Food/Nutrition Related History

 Dietary Hx: per pt partner, was eating fine prior to onset of illness  No food intake on plane trip home

 Typical Drug and alcohol intake  Cigarettes: 2 PPD  Alcohol: intermittent binge drinking, recorded 12

drinks/wk per chart

 Pt preferences: strawberry, banana

Medication Indication Interactions

Ceftazidime antibiotic Follow low Na diet

Clindamycin antibiotic Take with water

Colace bowel med Rec high-fiber diet to prevent constipation

Vibramycin antibiotic Mineral fortified foods

Pepcid acid blocker Take supps 2 hrs before/after drug Mg supps: drug absorption Fe supps: drug Fe absorption

Ativan anti-anxiety Limit caffeine < 400-500 mg/d Caution w/grapefruit, citrus, herbal supps, echinacea Avoid alcohol

Vancomycin antibiotic --

Mg/K+/Phos protocols

electrolyte replacements

K+: not with salt subs Phos: watch for vit D and Ca levels Mg: Pepcid, take fiber, Fol or Fe supp 2 hrs before/after (1)

Food/Nutrition Related History

+Nutrition Focused Physical Findings  Orbital fat pad: WNL

 Triceps skin fold: WNL

 Temporal muscle: mildly depressed

 Interosseous muscle: WNL

 Clavicle: WNL

 Calf muscle: LLE edema, RLE wound

 Other, general:  Overweight/obese  Major high-output wound on RLE (knee ankle), covered

by WV

+Anthropometrics

Measurements

Ht 6’1”

Wt 115.7 kg (254.5 lbs)

Wt Hx (7 months PTA) 115 kg (253 lbs)

BMI 33.6 kg/m2

IBW 84-92 kg (184-202 lbs)

%IBW 126%

+ Anthropometrics

 Final recommendations  Energy: 2300-2900 kcals/d  Protein: 185-230 gm/d

Estimated Energy Needs

Kcals Kcal/kg ABW 20-25

Total Kcals/d 2300-2900

Protein gm/kg IBW 1.5 – 2 – 2.5

Total gm/d 140 – 185 – 230

Fluid mL/d 2953

+Biochemical data, Medical tests, Procedures

 Procedures  I+D, RLE debridement (above knee-ankle)  I+D, Wound Vac (WV) placed  Debridement, WV replaced  RLE debridement, cadaver allograft, WV

replaced  PICC placed  More cadaver allograft on RLE  Dressing change

+Biochemical data, Medical tests, Procedures

Lab Range Measure

Na 136-148 138

K 3.5-5.1 3.6

Cl 97-109 104

CO2 22-32

BUN 9-25 11

Crt 0.6-1.2 1.64

Alb 3.4-5.2 3.3

Ca 8.4-10.2 8.2/8.76 adj

Lactate 0.5-1.9 6.2

= High = Low

+

Diagnosis & Treatment

+Diagnosis

 Increased nutrient needs (protein) r/t presence of major, non-healing, high-output wound up to 2600 mL

 Inadequate protein-energy intake r/t minimal PO intake and increased needs for wound healing, as evidenced by presence of non-healing wound

+

Literature Review

Recommended Treatment

(2)

17

Overview – Metabolic Response to Stress

Ebb Flow

Acute Response Adaptive Response (catabolism) (anabolism)

Length Immediately following injury

Post fluid repletion & restoration of O2 transport

Can last for months

Physiologic Response

Hypovolemic Shock Tissue Hypoxia Insulin levels

 Glucose production  FFA release  Insulin levels  Catecholamines, glucagon, cortisol

Gradual decrease in hormonal response

Metabolic Response

 Cardiac output  O2 consumption  Body temp

Cardiac output O2 consumption Body temp Energy expenditure Total body PRO catabolism

Hyper-metabolic rate Phase of repletion and recovery

+Nutrition Intervention

 Nutrition Support

 High-energy, high-protein nutrition intervention to meet needs  Snacks  Enteral supplements  Nutrient-enriched shakes

18

(3)

+Goal Setting

 Individualized  Pt’s ability to consume adequate/energy protein  Severity of wound  Rate of healing

 Goals should address  Provision of adequate calories/protein  Prevention of weight loss of ≥ 10% admit weight  Supplementation of vitamins & minerals prn

(3)

+Increasing Oral Intake

 Provide smaller, more frequent meals

 Encourage pt to eat on a timely schedule and never skip meals

 Keep snacks readily available

 Work with nurses and therapists to promote feeding

(3)

+Enteral Nutrition

 Indications  Inability of pt to consume adequate energy/

protein (< 75% in 3 days)  Completion of fluid resuscitation  Hemodynamically stable  Not initiating vasopressors  Free of lactic acidosis and abdominal pressure

 Consider immune-enhancing formula

(3)

(3,4,5)

22

Nutrition Prescription

Burn Patients Septic Patients Critically Ill BMI > 30

Energy 25-30 kcal/kg 20-25 kcal/kg (Flow Phase)

22-25 kcal/kg IBW

Protein 1.5-2 gm/kg 1.5-2 gm/kg 2-2.2 gm/kg with severe wounds

2 gm/kg (proportionally higher than energy needs)

Vitamins & Minerals

- Daily MVI - Vit C: 500 mg/d - Vit A: 10,000 IU/d - Other: arginine, glutamine, fish oil

-Vit C: 3000 mg/d -Vit E: 3000 IU/d -Other: arginine, glutamine, fish oil

Source Nutrition Care Manual KSMC Practice Guidelines KSMC Practice Guidelines

+Nutrient Exceptions to DRIs

 Vitamin & mineral needs are usually increased due to…  Loss from wounds  Healing  Changes in metabolism

 Vitamins & Minerals  1000-2000 mg/d Vitamin C  10,000 IU/d Vitamin A  220 mg/d zinc  MVI qd

(3,7)

+

Intervention

MNT

(6)

Review of Diagnoses

Diagnoses Major Concerns Increased nutrient needs (protein)

Minimal PO intake

Elevated energy/protein needs for wound healing

Large protein leak

Development of “acute disease- or injury related- malnutrition”

Inadequate protein-energy intake

Intervention

Goals of Treatment

Short Term

Initiate nutrition support, enteral feedings via DHT to meet pt’s elevated energy/protein needs to prevent injury-related malnutrition

Long Term

Increase pt energy/protein intake to support adherence of allograft to RLE, and eventually stabilize pt for use of autografts for enhanced wound healing

+Intervention – Course

HD#5-POD 1

 Pt extubated, MD ok to initiate enteral feedings  Placement of DHT  Recommended Peptamen Bariatric @ 85 mL/hr

 6 scoops beneprotein + Nancy’s yogurt qd

 Vitamin & mineral supplementation  MVI (Thera) qd  220 mg zinc qd x 14 days  1000 mg Vit C qd  Vitamin D3 1000 units BID

+Intervention – Course

HD#6

 Failed attempt at DHT placement d/t delirium

 Problems: minimal PO intake, refusing DHT, increased energy/protein needs

 Solution: creation of custom milkshakes for adequate provision of energy/protein

+ Milkshake Recipe

Item Kcals Protein (gm)

1 can Carnation Plus, vanilla 375 13

5 oz Nancy’s yogurt 80 8

4 scoops Beneprotein 100 24

2 pkts Carnation Instant Breakfast powder, strawberry

260 10

1 carton skim milk 90 8

Total provision per shake 905 63

Total provisions (TID) 2715 189

Estimated Energy Requirements 2300 - 2900

185 - 230

+ Intervention – Course

HD#8

 PO intake: improving, posted sign in pt room re: shakes TID

 Plastics consult – pt not stable for autografts MD note: autografts “could tip him over”

HD#10

 OR: first attempted cadaver graft

+Intervention - Course

HD#12

 IM suggests calorie count

 New shake recipe: 1054 kcals/49 gm PRO ea.

 Staff note from plastic surgeon  PAB (5) too low for autografts, pt not stable  Questions for progression to anabolic state

+Plastic Surgeon’s Note

 Need for peripheral hyper-alimentation in addition to PO feeds? Yes, TF not TPN if needed  Need they be BCAA? No

 Concern that liver can’t synthesize sufficient protein to respond to MNT. Correct

 Is pt at risk for encephalopathy r/t increased protein intake? No

 Is PO intake truly adequate? Started calorie count

 Is there a role for anabolic steroids? No, per MD

+ Intervention - Course

HD#13

 GI response to note: Cirrhosis well compensated in past without Alb so predict lab abnormalities d/t acute illness.  CRP: 4.8 (goal <0.8 mg/dL)

 Prescribed low Na diet + Aldactone

 OR: more allograft

HD#15

 Calorie count = 4560 kcals/195 gm PRO

>100% of needs based on 2400 kcals/140 gm PRO

+Intervention - Course HD#18

 Wound healing: good adherence, poor granulation (40%)

 Plan to tx to other facility (burn unit)

 Communication with MDs at tx hospital   Start TF @ 50% needs, nocturnal   Impact Peptide 1.5 @ 60 mL hr x 12 hrs

  1080 kcals, 68 gm protein, 554 mL free H2O, 1080 mg vit C

HD# 6 7 8 9 11 12 15 18

WV Output

1100 1300 1700 2600 500 350 1050 400

+Outcome

 Transfer to other medical center for further, aggressive treatment  HGH  Anabolic steroids

 Excision of allograft, placement of autograft

 Noted hyperglycemia started on insulin, given DM diet ED and glucometer

 D/c home 10 days after admit on 15 units Glargine pm

+References

1.  Pronsky ZM, Crowe JP. Food-Medication Interactions. 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010.

2.  Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MI: Saunders Elsevier; 2008.

3.  Nutrition Care Manual. Nutrition Care: Burns. Available at: http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=5512 Accessibility verified April 5, 2012.

4.  Nutrition Practice Guidelines: Sepsis. KSMC Clinical Practice Guidelines.

5.  Nutrition Practice Guidelines: Estimated Needs. KSMC Clinical Practice Guidelines.

6.  Jensen et al. Starvation and disease related malnutrition. JPEN 2010; 34(2): 156-159.

7.  Stechmiller J. Understanding the Role of Nutrition and Wound Healing. NCP;25(1): 61-68.