NUTN 515Case Study: CABG

Heidi SchultzOregon Health & Science University4/19/2010

Introduction

83 year-old Vietnamese female. Admitted to the hospital on 2/17/10

with chest pain. Pt was inpatient for a total of 22

days. 18 days in CICU.

This case study will cover her 22 day inpatient stay.

History

Pt seen at another hospital 10/2009. Dx with severe 3-vessel coronary artery

disease. Pt seen at this hospital early February for

pneumonia; treated and discharged. On 2/17/10 (Day 1), Pt was admitted to

the ER at another hospital. Complaints of chest pain.

Tx to this hospital for surgery.

Cliff Notes – 22 day stay

ColonoscopyCABGx3Respiratory distress/pneumonia/ventedNutrition consulted beginning Day 9TFMetabolic acidosisStabilizedOral POEducation providedConsult with JCAHO

Assessment: Food/Nutrition-Related History

PT IS A VEGETARIAN Typical intake:

Breakfast: ▪ 2 slices of bread or cereal;

coffee with 4 bags of sugar. Lunch: ▪ Homemade Vietnamese

soup with veggies. Dinner: ▪ Stir-fry vegetables with tofu

and white rice or noodles. Snacks/desserts: ▪ Pt likes chocolate and

cookies.

Assessment: Anthropometrics

Height: 60” (152 cm) Weight: 142 lb (64.5 kg) Weight Change: No significant

change BMI: 27.8 (overweight) IBW: 100 lbs (45.5kg) %IBW: 142%

Assessment: Biochemical Data

Glucose/Endocrine Profile:• Glucose, casual: 133 mg/dL high (Ref 60-99)

Electrolyte and Renal Profile:• Lytes: WDL• Troponin: negative for MI

Nutritional Anemia Profile:▪ HGB: 8.3 g/dL low (Ref 11.7-15.7)▪ Hematocrit: 24% intitially low; 33% after two units low

(Ref 34.9-46.9)▪ Iron 27 ug/dL low (Ref 40-150)▪ Ferritin WDL

Assessment: Nutrition-Focused Physical Findings

Vital Signs: Blood Pressure 125/70; WDL HR 80 and regular; WDL Respiratory rate 18; WDL

Assessment: Patient HistoryPersonal History

Pt is an 83 year-old female.

Vietnamese. Moved to US from

Vietnam in 1982. Non-English

speaking.

Assessment: Patient HistorySocial History

Pt lives at home with her son. Pt is a non-smoker and non-drinker. Pt does not speak English. Pt uses a walker and is not physically

active. Decreased exercise tolerance.

Code Status: Full Code

Assessment: Patient HistoryMedical History Coronary Artery Disease Thalassemia Pneumonia Asthma DM2 Hypercholesterolemia HTN C-section

Assessment: Daily Medications (home)

Purpose Drug Considerations

Antihypertensive Diovan 160 mg

can also ↓ Hgb, Hct

Platelet Aggregation Inhibitor for ↓ risk of MI

Plavix 75 mg

Oral Hypoglycemic/Sulfonylurea

Glipizide LX 10 mg

Anti-hyperlipidemic Simvastatin 40 mg

Anti-hyperglycemic Metformin 1000 mg

Anti-diabetic Actos 45 mg can also ↑ TG, LDL

Asthma Singulair 10 mg

Osteoperosis Actonel 150 mg

Anti-asthma (as needed)

Albuterol Can ↑ glucose; angina

Coronary Artery Disease

Plaque builds up in the arteries that supply blood to the heart.

Reduces blood flow to the heart (angina).

Increases chance of blood clots.

Can cause heart failure.

Thalassemia

An inherited blood disorder: Mediterraneans/Asians/African Americans. Abnormal hemoglobin.

Hemoglobinopathy Thalassemia: ▪ Underproduction of globin protein (either alpha or beta

chain). Sickle-cell anemia: ▪ Abnormality of globin protein (mutant of beta globin

chain).

Thalassemia: Types and Treatment

Thalassemia Minor:• Have small red blood cells but few symptoms.

• Typically no specific treatment needed.

Thalassemia Major:• Babies may be stillborn or develop severe anemia in their first

year of life. • Severe Thalassemia can lead to heart failure and early death.

Regular blood transfusions often required.• Require chelation therapy to remove excess iron from the body.• Too much iron can damage the brain, heart, liver and endocrine

system.• Folate supplements.

Day 1 – Admitted to Hospital Pt admitted to another hospital

with chest pain.

Pt tx to this hospital for CAD surgery.

MD unsure that surgery is indicated. Symptoms may be related to anemia.

GI evaluation requested.

Day 3 - Colonoscopy

Pt underwent colonoscopy.

5 polyps removed. Otherwise normal

colonoscopy. No obvious source

of long-term GI blood loss.

Scheduled CABG.

CABG During CABG, a healthy

artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery.

This creates a new passage, and oxygen-rich blood is routed around the blockage to the heart muscle.

http://www.youtube.com/watch?v=HYLNDuGsTEw

Day 6 – CABGx3

Pt underwent a Triple Coronary Artery Bypass Graft. Pt tolerated surgery well.

Day 8 – S/P CABG: Pt Intubated Pt experienced

respiratory distress and was intubated.

Sedated with Propofol. Fat emulsion. 1.1 kcal/cc.

Rate of Propofol was 4 cc/hour. Adds about 11 grams of

fat every 24 hours. TGs were checked: 103

mg/dL (Ref <149).

Day 8 – Critical Issues Respiratory Distress w/Hypoxemia Renal Insufficiency ▪ Creatinine 2 mg/dL high (Ref .5 to 1.1)▪ GFR 34 mL/min/1.73m2 low (Ref 75)

Metabolic Acidosis ▪ pH ABG 7.30 low (Ref 7.35-7.45)

Hypotension ▪ BP 98/43 low

Possible Health Care Associated Pneumonia (HCAP)▪ Procalcitonin 1.17 ng/mL high (Rev .05 - .50)

Day 8 – Thalassemia Treatment

Received 2 units PRBCs in past 24 hours

Pre-Transfusion

Post-Transfusion

Reference Range

RBC 3.08 10^ 12/L

WDL 3.8 to 5.20

Hgb 8.6 g/dL 11.1 g/dL 11.7 to 15.7

Hct 25.3% 32.4% 24.9% to 46.9%

Day 9 – First RD Visit; Day 1 TFNutrition received a Consult for TF: NG Tube Energy needs - Penn State equation used

1500 kcal/day Protein 1.2 g/kg (78 grams/day) Fluid: 1500 ml

Formula: Jevity 1.2 (house) high fiber Goal rate of 55 ml/hr Provide 1584 kcal 1069 ml free water from TF; 300 ml from flushes (total

1369 ml) Will get additional free water from IVF

Day 9 - Nutrition SummaryNutrition Summary: Day 9 pt experienced respiratory distress

resulting in re-intubation; NG placed today to meet nutritional needs. Pt was ordering and eating adequate amount of kcal here prior to intubation as per records.

PES: Oral intake inadequate related to intubation as

evidenced by NPO. Plan is short-term enteral feeding with goal of

attaining adequate kcal and protein.

Inpatient MedsPurpose Drug Administrati

onWound healing Vitamin C 1,000 mg PO BID

Electrolytes Klor-Con M20 PO BIDAntihypertensive Captopril 6.25mg PO q8HPlatelet agg inhibitor

Plavix 75 mg PO daily

Antihypertensive Lopressor 25 mg PO BIDAntibiotic Bactroban Nasal Topical BIDAntibiotic Cipro 400 mg 200 ml IV dailyAntibiotic Azactam .5 gm 25 ml IV q 6 HAntisecretory Protonix 40 mg 10 ml IV dailyHyperglycemia Reg Insulin 150

units1.5 mL IV qBag

Sedation Propofol 1,000 mg 100 ml IV demand

Sympathomimetic

Dobutamine 500 mg

40 ml IV qBag

Day 10 – Day 2 of Tube Feeding Pt still vented. Pt still hypotensive (109/55) with

chronic metabolic acidosis. Pt taken off Propofol and put on Versed.

HCAP with fever (101.3 F) persisting. Acute renal insufficiency improved. Respiratory – stable vent settings. Started TF yesterday.

Day 10 – Day 2 of Tube FeedingLabs noted – Complete Metabolic

Panel: BUN 40 mg/dL high Creatinine 1.35 mg/dL high Protein, Total 5.7 g/dL low Pre-albumin 11 low Albumin 2.6 g/dL low Lytes WDL

Day 13 – Second RD Visit; Day 5 TF Pt hemodynamically stable and off

pressors. MD changed TF to 2-Cal

Concentrated.Pt needs

2 Cal HN

Prosource

Combined

Calories 1500 1200 60 1320Rate Na 25 ml/hr Na 25 ml/hrProtein 78 g 50 g 15 g 80 gFree Water

1500 ml 427 ml free; 300 ml flushes.

na 427 ml free; 300 ml flushes.

Day 13 – Nutrition SummaryNutrition Summary: Day 13; pt has been on TF for 4 days while

intubated in CCU; did not reach goal volume (55 ml/hr) on Jevity 1.2; yesterday MD changed to two-cal for minimal fluid; RD added 2 packets of Prosource protein per day to increase protein intake. This enables the current TF order to meet 88% of est Cal needs; 102% est protein needs.

Nut problem: Ongoing

Day 14 – Day 5 of Tube Feeding Pt tolerating concentrated formula

well and is at goal rate.

Labs noted – Nutrition Panel: Glucose 140 high BUN 46 high Phosphorus 1.7 low Albumin 3.1 low Lytes WDL

Day 16 – Third RD Visit (Heidi)Nutrition Summary: Pt intubated and receiving adequate nutrition

and protein with TF and 2 Prosource per day. Pt tolerating TF at goal rate. Pt continues with anemia most likely due to Thalassemia.

Nut Problem: Ongoing. NPO x7 days.

Days 17 and 18 – Fourth RD Visit (Heidi); Day 9 of TF

Diet order changed to mechanical soft with cyclic TF at night.

Energy needs calculated with Mifflin: REE = 1019 x 1.2 Activity Factor x 1.2 Stress Factor =

1467 Compared to 25 kcal/kg = 1612 kcal Anticipating PO intake to be inconsistent at first, use

higher range of: ▪ 1600 kcal for energy needs ▪ Protein 1 g/kg = 65 grams per day▪ Fluids per MD

Cyclic TF Order Goal 1600 kcal/day (1000 kcal from TF; 600 kcal from

oral PO) Formula: 2 cal HN concentrated; 40 ml/hour for 12 hours

at night Provides: 480 ml (960 kcal); 40 g protein; 336 ml water;

4 free water flushes of 160 ml each (976 ml total water). Pt still on fluid restriction.

Days 17 and 18: Nutrition Summary

Nutrition Summary: As per nurse, pt is to continue with TF

during evening only and consume mechanical soft during the day. Recommend continue with 2-Cal Concentrated at rate of 40 ml/hr for 12 hours. Will order calorie count as well.

Nutrition Problem: Ongoing; pt extubated on Day 17 of stay;

Day 9 of TF. Oral intake continues to be inadequate.

Day 20 – Fifth RD Visit

TF discontinued (11 days TF). NG removed.

Pt ambulating. Diet order changed to general diet

w/2000 ml fluid restriction. Consult received for nutrition education

for low-fat/low-sodium, heart-healthy diet. RD on duty did not perform nut ed due to

confusion about diet order.

Day 21 – Sixth RD Visit (Heidi)Pt transferred to the floor.Nut Summary: Pt discontinued TF 3/8; appetite for oral PO is

improving. Pt is ambulating and hemodynamically stable. Pt consumed 900 kcal and 108 carb for lunch yesterday. Will perform low-fat, low-cholesterol nut ed today.

Nut Problem: Improved. Pt consuming adequate PO with

>1200 kcal intake yesterday and continued adequate intake today.

Nutrition Education Provided Heart-Healthy Eating handouts in

both English and Vietnamese. Took typical dietary intake. Discussed TLC diet:

Limit sat and trans fats. Limit cholesterol. Increase omega-3s. Increase fiber. Continue eating plant based/soy foods.

Referred pt to outpatient RD visit for diabetes education.

Assessment: Food/Nutrition-Related History

PT IS A VEGETARIAN Typical intake:

Breakfast: ▪ 2 slices of bread or cereal;

coffee with 4 bags of sugar. Lunch: ▪ Homemade Vietnamese

soup with veggies. Dinner: ▪ Stir-fry vegetables with tofu

and white rice or noodles. Snacks/desserts: ▪ Pt likes chocolate and

cookies.

Day 21 – JCAHO

Why was TF changed?

How have we accommodated the patient’s language barrier and cultural preferences?

How do we decide which patients to assess?

Day 22 – Patient Discharged Pt was discharged from the

hospital on 3/11/10. Oral diet. Nutrition problem improved. No Albumin/Pre-Albumin.

Pt transferred home. PT and OT through Home Health.

In the past month, the pt has been readmitted twice due to non-nutritional complications/complaints.

Questions?

References National Heart Lung and Blood Institute:

http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html; Accessed 4/8/10 American Dietetic Association: www.eatright.org; Accessed 4/8/10 National Institute of Health: Medline Plus

http://www.nlm.nih.gov/medlineplus/ency/article/000587.htm; Accessed 4/8/10 Charles JC, Heilman RL. Metabolic Acidosis. Hospital Physician, March 2005: 37-42. Van Den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill

patients. N Engl J Med. 2001: 345:1359-1367. Miller J, Kee. Keeping your patient hemodynamically stable. Nursing. May 2007: 37(5)

36-41. Niedert KC. Position of the ADA: Liberalization of the Diet Perscription Improves Quality

of Life for Older Adults in Long-term Care. Journal of the American Dietetic Association (Position Paper). 2005: 1955-1965.

Kollef MH, Bedient TJ, Isakow W, Witt CA. The Washington Manual of Critical Care. Published by Lippincott Williams & Wilkins 2008.

Pronsky ZM. Food Medication Interactions; 15th Edition. Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference; 9th Edition.

Published by Elsevier Inc. 2009. Hemila H, Louhiala P. Vitamin C for preventing and treating pneumonia. Cochrane

Database of Systematic Reviews 2007, Issue 1. Art No.CD005532.DOI:10.1002/14651858. CD005532.pub2.