Case #1:

J.A. is a 30 YO WM with h/o EtOH abuse, who was transported to LUMC via Lifestar following high speed motor vehicle accident (MVA), which involved a rollover by the vehicle and the patient was ejected through the front windshield. Upon arrival Glasgow Coma Scale (GCS) was 3. He was intubated and sedated with a closed head injury with ICP monitor in place and multiple fractures, including facial and long bones. His vital signs were stable with pressor agents support (norepinephrine infusion at 5 mcg/min and dopamine infusion at 10 mcg/min), adequate urine output was maintained; his blood was well oxygenated.

On hospital stay #3, enteral nutrition support was initiated with Osmolite HN @ 30 cc/hr with an order to increase 20 cc/hr every 4 hours if residuals are <200 cc, up to a goal of 115 cc/hr via nasogastric feeding tube. Hospital stay #5, metabolic cart was performed with results significant for an REE 2040 kcal, RQ of 1.00 with a standard deviation of 6%. Patient is currently intubated and sedated and presents with elevated intercranial pressure and generalized edema. We are on hospital stay #8 and the tube feedings are on hold secondary to residuals of 250cc.

Per patient's wife, nutrition history was significant for a ten-pound weight gain over the past six months secondary to increase in po intake and decrease in physical activity. Denies taking vitamin/mineral supplements PTA. Utilizing Subjective Global Assessment, this patient presents with a normal nutritional status; however, is at nutritional risk secondary to history of alcohol abuse.

NUTRITIONAL PHYSICAL EXAM

Macronutrient Assessment:
Patient with intact somatic protein and increase subcutaneous fat stores.
No temporal wasting noted.

Micronutrient Assessment:
No obvious physical signs of micronutrient deficiencies.

Review of systems:
CV: On norepinephrine and dopamine
Resp: Intubated and sedated
Abd: +BS, soft, no distention. BM with Fleet enemas
FEN: Tube feedings on hold
Renal: Maintain adequate UO
Ortho: Arm and leg fractures stabilized
Neuro: Closed head injury, sedated, ICP monitor

Medications include: Propofol infusing at 20 cc per hour

BP: 100/80 RR: 20 Temp: 37 Fi02: 50% BM x 1
24 hr input: 2500cc 24 hr urine output: 2978cc Residuals 250cc

Anthropometrics: Ht: 183 cm Admit Wt: 85 kg Current Wt: 87 kg
Usual Body Weight (UBW): 81 kg

Estimated Nutrient Requirements:

BEE= 66.5 + [13.8 x wt (kg)] + [5 x ht. (cm)] - [6.8 - age] x stress factor

Stress factors:

1.1 = afebrile, paralyzed, sedated
1.2 = afebrile, mild to moderately stressed individuals, minor surgery
1.3 = frequent fevers, fulminent sepsis, major surgery
1.4 = frequent fevers with constant motion, agitation, surgical complications
1.5 = repletion, closed head injury, trauma.

BEE: 1951 kcal x 1.5 = 2926 kcal

Protein:

0.6 -0.8g renal failure and not on dialysis
0.8g healthy individual
1.0-1.2g fever, infection
1.3-1.5g wound healing, trauma, surgery, repletion

85 kg x 1.5 = 128 g

Laboratory data:

Sample lipemic

Na: 150 WBC: 15
K: 4.7 HgB: 9
Cl: 110 HCT: 50%
CO2: 27 PLT: 250
BUN: 14 Cr: 1.0
Glucose: 145 Phos: 3.8
Ca: 8.0 Mg: 2.0

Hospital stay #4: ABG=s 7.30 / 55/ 90/ 16
Patient receiving Osmolite HN at 115 cc per hour

Hospital stay #6: ABG=s 7.37 / 42/ 92/ 22
Patient receiving Replete at 60 cc per hour with 2 scoops promod TID