paige whitmire dietetic intern 2014-2015. background information “old” practice ideas to reduce...
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Overview Patient information Therapeutic Hypothermia Therapeutic hypothermia’s impact on nutrition My patient vs. current research Nutritional assessment based on findingsTRANSCRIPT
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Paige WhitmireDietetic Intern 2014-2015
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Background Information“Old” practice ideas to reduce ICP
Fluid restrictionUse of Mannitol (diuretic)Hyperventilate (decrease CO2 levels)No feeding due to glucose metabolism risk
“New” practices continue to be developed
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OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia’s impact on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 4: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/4.jpg)
OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia’s impact on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 5: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/5.jpg)
Patient SelectionLearning about a new protocol
“Cutting edge” research
Opportunity to directly measure resting metabolic rate
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Medical DiagnosisPrimary diagnosis: subarachnoid hemorrhagePatient’s prognosis: poor
Hypothermia could improve outcomes?
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Therapeutic HypothermiaCooling: obtained goal temperature in 7
hoursMethod of Cooling:
External Cooling Gaymar Meditherm Cooled to: 32.8◦CDuration: 5 days hypothermicRe-warming: 0.1◦C per hour to 37.1◦C
Obtained in 25 hours
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Medication/ParalyticsParalytic
Vecuronium: 0.8 mg/kg/minSedatives
Midazolam: 0.7 mg/kg/hrFentanyl: 175 mg/hr
3% saline @ 15 mL/hrInsulin drip: 3 units/hrKCl: 20mEq as needed
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OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 11: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/11.jpg)
OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 12: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/12.jpg)
PathophysiologyCauses of neurological damage due to stroke
or brain injuriesMitochondrial damage
Production of free radicals Reperfusion causing further damage
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Why hypothermia may work…Hypothermia counteracts multiple steps of
cellular injury following acute strokeReduces oxygen consumption
Inhibit free radical formation and inflammatory responses
Limit edemaLower the amount of intracellular calcium
Exact mode is still being researched
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Benefits from metabolic effectsNeuroprotective effects by reduction or
delay in metabolic consumption during the stress of a CNS injuryReduces CMRO2 by 5% per degree Celsius
5.9% reduction in energySlows lactic acid production to prevent
acidosisLowers metabolic and energy demandsPromotes tissue preservation
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Methods for Cooling: SurfaceCold air, water and/or ice through a
thermoconductive blanketCooling jacketsIce packingAdvantages
NoninvasiveInexpensiveEasy to implement
DisadvantagesFluctuations in body temperatureProlonged time to achieve the temperature goal
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Methods for Cooling: IntravascularInfusion of ice-cold fluids through intravascular
catheters (with metal or circulating cold water–filled balloon conductors)
AdvantagesShorter time to goal temperatureMore precise hypothermic control Less shivering
DisadvantagesMore invasiveHigher cost
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Potential ComplicationsShiveringPneumoniaDecreased cardiac outputHyperglycemiaThrombocytopeniaHypokalemiaLoss of gut functionFever
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OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 21: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/21.jpg)
OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
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Energy expenditure in ischemic stroke patients treated with moderate hypothermia10 patients treated with moderate hypothermia
(33∘C) following an acute ischemic strokeIndirect calorimetry was performed over the first 6
days after admissionMean daily TEE decreased significantly:
1,549 kcals before initiation of hypothermia1,099 kcals the first day1,129 kcals the second day1,157 kcals the third dayReturned to baseline (and 16% above) after
hypothermia was terminated
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Modification of the Harris-Benedict Equation to Predict the Energy Requirements of Critically Ill Patients during Mild Therapeutic Hypothermia
5 patients suffering from acute cerebral injuries who underwent mild hypothermiaIndirect calorimetry measurements:
Every 3-4 hours during cooling/re-warming Every 12 hours during the steady hypothermic state
Basal metabolic rate decreased by 30.3%Every drop in temperature by one degree led
to a 5.9% reduction in energyMeasured TEE was 16.7% lower than
calculated TEE
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Metabolic Downregulation: A Key to Successful Neuroprotection?Hypothermia slows but does not completely
prevent the eventual depletion of ATPSeveral studies suggest that metabolism is not
significantly remarkable in neuroprotectionExample: rodents subjected to 20 minutes of
forebrain ischemia Brain levels of various metabolites were no different
from rats who were in a normothermic state Thus, the influence of hypothermia on cerebral
metabolism probably does not fully explain its protective effect
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My patient vs. Current ResearchHypothermic
4/7/15
Re-warming Day 1
4/8/15
Re-warming Day 2
4/9/15
Temperature 32.8◦C 35.4◦C 37.1◦C
Heart Rate 53 69 74
Minute Ventilation 6.2 7.1 6.3
ICP 19 21 23
DeltaTrac 1,950 kcals 2,440 kcals 2,755 kcals
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Equation vs. CalorimeterHypothermic State (32.8◦C)
58% above the PSU equation calculationDay 1 Re-warming (35.4◦C)
51% above the PSU equation calculationDay 2 Rewarming (37.1◦C)
47% above the PSU equation calculation
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4800
4400
4000
3600
3200
2800
2400
2000
1600
1200800
400
4800440040003600320028002400200016001200800400
Penn State Equation (kcal/day)Mea
sure
d Re
stin
g M
etab
olic
Rate
(kca
l/day
)
Subject
Regression
Line of Identity
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4140393837363534333231
4500
4000
3500
3000
2500
2000
1500
1000
Maximum body temperature (centigrade)
Rest
ing
Met
abol
ic Ra
te (k
cal/d
ay)
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OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 31: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/31.jpg)
OverviewPatient information
Therapeutic Hypothermia
Therapeutic hypothermia impacts on nutritionMy patient vs. current research
Nutritional assessment based on findings
![Page 32: Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate](https://reader035.vdocument.in/reader035/viewer/2022062401/5a4d1b687f8b9ab0599b176d/html5/thumbnails/32.jpg)
NCP: AssessmentCalories
Prior to hypothermia protocol: 2,475 kcals/day (PSU equation x 1.1)
During hypothermia protocol and medical paralysis: 1,375 kcals/day (PSU equation)
After completion of hypothermia protocol: 2,440 kcals/day (indirect calorimetry measurement)
Protein: 130 g/day (1.75 g/kg of adjusted body weight)
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Alterations during admissionPrior to hypothermia protocol
Nutren 1.5 @ 80 mL/hr (x 21 hours)Beneprotein: 3 scoops/L of feedingNutrisource Fiber: 2 scoops in 50 mL of water 4x/day
During hypothermia protocol and medical paralysisReplete @ 70 mL/hr (x 19.5 hours)Beneprotein: 5 scoops/L of feedingNutrisource Fiber: 3 scoops in 75 mL of water 4x/day
After completion of hypothermia protocolNutren 1.5 @ 85 mL/hr (x 19.5 hours)Beneprotein: 3 scoops/L of feedingNutrisource Fiber: 3 scoops in 75 mL of water 4x/day
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NCP: DiagnosisIncreased nutrient needs (energy) (NI- 5.1)
related to therapeutic hypothermia protocol as evidenced by resting metabolic rate calorimetry measurement of 1,950 calories while in a hypothermic state.
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NCP: InterventionFood and or/nutrient delivery (ND) Enteral and Parenteral Nutrition (ND-2) –
Enteral Nutrition (ND-2.1) – Composition: Provided nutrition through the GI tract via
keofeed tube based on patient’s calculated protein and measured energy needs.
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NCP: Monitoring and Evaluation
Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution
Criteria: Patient will receive Nutren 1.5 @ 80 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 2 scoops in 50 mL of water 4x/day in order to meet her calculated protein and energy requirements.
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Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution
Criteria: Patient will receive Replete @ 70 mL/hr, Beneprotein 5 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water 4x/day in order to meet her energy requirements during the hypothermia protocol.
Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution
Criteria: Patient will receive Nutren 1.5 @ 85 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water four times per day in order to meet her energy requirements after the hypothermia protocol is complete.
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ConclusionLimited researchMeasurement of my patient prior to
hypothermia protocol may have given a different result
Case-to-case basisEstablish measurement in protocol
Therapeutic hypothermia may have benefits, but not necessarily nutritionally
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Badjatia, Neeraj, and Evangelia Strongilis. "Metabolic Impact of Shivering During Therapeutic Temperature Modulation." Stroke. American Stroke Association, 16 Oct. 2008. Web. 30 Apr. 2015.
Bardutzky, Juergen, Dimitrios Georgiadis, Rainer Kollmar, and Stefan Schwab. "Energy Expenditure in Ischemic Stroke Patients Treated with Moderate Hypothermia." Intensive Care Medicine 30.1 (2004): 151-54. Web. 21 Apr. 2015.
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Drugs.com. Know More. Be Sure., 2012. Web. 30 Apr. 2015. Groysman, Leonid. "Therapeutic Hypothermia in Acute Ischemic Stroke." Medscape. Neurosurg Focus, 2011. Web. 20 Apr.
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Worp, H. Bart Van Der, Malcolm R. Macleod, and Rainer Kollmar. "Therapeutic Hypothermia for Acute Ischemic Stroke: Ready to Start Large Randomized Trials?" Journal of Cerebral Blood Flow and Metabolism: Official Journal of the International Society of Cerebral Blood Flow and Metabolism. Nature Publishing Group, 2008. Web. 28 Apr. 2015.
Yenari, Midori A., and Thomas M. Hemmen. "Neuroprotection." Stroke. American Stroke Association, 2010. Web. 20 Apr. 2015.
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Ziai, Wendy C., and Marek A. Mirski. "Use of Hypertonic Saline in Ischemic Stroke." Stroke. American Stroke Association, 2002. Web. 23 Apr. 2015.