ESPEN Congress Lisbon 2015

Case PresentationP. Martins (PT)

CASE DISCUSSION - FRAIL ICU PATIENT

Case Discussion - Frail ICU patient

Paulo Martins

75 year, male patientAdmited with severe mid‐epigastric abdominal pain that radiates to the back. The pain worsens with deep inspiration and movement and improves when the patient leans forward.He complains of anorexia and nausea in the last 4 weeks. Complicated with vomiting in the last 3 days

He was diaphoretic, agitated and confused. Febrile (39°C), tachycardic (125/min), tachypnoeic (32 c/min).Hypotension (80/55 mmHg)He had a decreased breath sounds in the base of left lung.Abdominal tendernesss and distension with diminished bowel sounds.

Alchoolic habitsDiabetesHypertension

pH – 7,36

PCO2 – 26,4 mmHg

PaO2 – 88,3 mmHg

HCO3 – 16,2 mmol/L

Sat – 96,9%

Lactates – 5,33 mg/dl

Leucocytes – 13000

Hct – 54,3%

Glicemia – 145 mg/dl

Na – 142 mmol/L

K – 3,1 mmol/L

Ca – 7,1 mg/dl

Total proteins - 6 mg/dl ; Albumine– 2,1 mg/dl

BUN – 30 mg/dl

Creatinine – 1,1 mg/dl

GOT –85 U/L; GPT – 106 U/L; Alkaline phospathase – 80 U/L

γ-glutamyl transpeptidase – 140 U/L

Bilirrubin total – 1,2; Bilirrubin direct – 0,8

Serum lactate dehydrogenase (LDH) – 230 U/L

CRP – 0,5 mg/dl

Transcutaneous abdominal ultrasonography* Gallblader distended with thin walls and biliary sludge. Biliary tree normal diametre

* Pancreatic enlargement with a slightly heterogeneous parenchyma and an overall ↓ of reflectivity

Seric amylase – 6721 U/L and seric lipase – 4870 U/L

Which are your first therapeutic measures ?

NaCl 0,9% - 1000 cc in 30 min

KCl 7,5% - 50 mmol iv

Tramadol - 100 mg iv 8/8 h

Enoxiparin – 40 mg iv

CVP – 8 mmHg

BP – 98/58 mmHg

Diuresis – 20 cc

pH – 7,42

PCO2 – 29,4 mmHg

PaO2 – 70,3 mmHg

HCO3 – 17 mmol/L

Sat – 95%

Lactate – 4,1 mg/dl

In the next hours maintains abdominal pain but improves the nausea with disapearance of

vomiting.

Is febrile (39°C) with hypotension (85/55 mmHg), so we started vasopressors (Nor-

epinephrine 0,5 μgr/Kg/min).

He was oliguric and with abdominal distension.

The value of intra-abdominal pressure was 8 mmHg

After few hours he felt better from the abdominal pain

BP – 120/75 mmHg

Diuresis - 40 cc urine/hour

Severe acute pancreatitisPersistent organ failure (> 48H) or infected pancreatic necrosis

The patient is 1,74 m tall and has 60 Kg in weight

In the last 4 weeks he lost 5,8 Kg

What you need to ask for the nutritional status evaluation of this patient ?

IMC – 19

Unintentional weight loss of almost 10% in the last 4 weeks

How can you measure the nutritional risk of this patient?

NRS 2002 – Score > 3

Nutric SCORE - 7

Proposed Clinical Definition of Phenotype of Frailty

Fried LP et al – J Gerontol A BiolSci Med Sci 2001, 56: M146-56

The patient is 1,74 m tall and has 60 Kg in weight

In the last 4 weeks he lost 5,8 Kg

What you need to ask for the nutritional status evaluation of this patient ?

IMC – 19

Unintentional weight loss of almost 10% in the last 4 weeks

How can you measure the nutritional risk of this patient?

NRS 2002 – Score > 3

Nutric SCORE - 7

What is your nutritional strategy ?

Two days later

He was polipneic and diaphoretic with oxygen peripheric saturation that

doesn’t improve with increased O2 delivered by Venturi mask 40%.

pH – 7,19; PCO2 – 38 mmHg; PaO2 – 58 mmHg; HCO3 – 12,2 mmol/L; Sat – 78 %

PaO2/FiO2 - 125

Lactate –7,3 mg/dl

Tachycardia (130/min) with BP – 78/50 mmHg

Oliguric (< 10 cc/h)

It increases the abdominal distension with IAP 28 mmHg

We start early enteral nutrition with a polymeric solution (1 Kcal/ml)

increasing slowly…… 1200 Kcal/day

Leucocytes – 22200

Hematocrit – 36,3%

Glucose – 186 mg/dl

Na – 144 mmol/L

K – 4,2 mmol/L

Ca – 6,8 mg/dl

Total proteins - 5,1 mg/dl e Albumine– 2,2 mg/dl

BUN – 45 mg/dl

Creatinine – 1,72 mg/dl

SGOT – 98 U/L; SGPT – 120 U/L; Alkaline phosphatase – 96 U/L;

Total bilirubin – 1,8 mg/dl ; Direct bilirubin – 1,2mg/dl

LDH – 320 U/L

CRP – 24,4 mg/dl

What to do?

Entubate and start mechanic ventilation (Tv 430 cc ; RR 18 ; PEEP 10 cm H20; FIO2 80%)

Stabilize the shock (nor‐epinephrine 1 μg/Kg/min; dopamine 10 μg/Kg/min) 

Analgesic and sedation (Fentanyl – 0,8 µg/Kg/h ; Propofol 2%  ‐ 3 mg/Kg/h)

And what about nutritional support?

The patient has already enteral nutrition , do you modify it?

We maintain polymeric enteral nutrition (1Kcal/ml)……1200 Kcal/day

With metoclopramide 8/8 h

But the patient increased gastric residual volume (> 300 cc)……

We reduce the enteral feeding rate at 50%...........but the patient increase the gastric

residual volume (> 600cc).

The nurse aspirates enteral formula in oral cavity

The abdominal distension increases with IAP of 18 mmHg

The echo‐abdominal examination shows ascites

How can we solve this problem?

We insert nasojejunal tube maintaining enteral nutrition at 500 cc/day

And start parenteral nutrition:

1000 Kcal – Carbohydrates – 2 g/Kg/day (120 g/d)

Lipids ‐ 0,5 g/Kg/day (MCT‐LCT mixture) (30 g/d)

Proteins – 0,8 g/Kg/day with 0,5 g/Kg/day of glutamine (78 gr/d)

Vitamins and oligoelements

Leucocytes – 30000

Hematocrit – 31,2%

Glucose – 71 mg/dl

Na – 154 mmol/L

K – 4,6 mmol/L

Ca – 8,2 mg/dl

Total proteins - 5,4 mg/dl; Albumine– 1,9 mg/dl

BUN – 59 mg/dl

Creatinine – 0,87 mg/dl

SGOT – 120 U/L; SGPT – 180 U/L; Alkaline phosphatase – 174 U/L;

Total bilirubin – 8,9 mg/dl ; Direct bilirubin – 5,5 mg/dl

LDH – 480 U/L

CRP – 12,1 mg/dl

What you do?

In the next days he is febrile 38°C,  the IAP increases (28 mmHg) and the dislodgementof nasojejunal tube implies several endoscopic measures to put it back

We drain ascitis…… stop enteral nutrition and increase parenteral caloric support

with glutamine

Parenteral Nutrition

1500 Kcal – Carbohydrates – 3 g/Kg/day (180 g/d)

Lipids ‐ 0,8 g/Kg/day (MCT‐LCT mixture) (48 g/dia)

Proteins – 1 g/Kg/day with 0,5 g/Kg/day of glutamine (90 gr/d)

Vitamins and oligoelements

The IAP diminished (14 mmHg)…..

In the next days he maintains fever (39°C)

We isolate in tracheo‐bronquial suptum a MR Klebsiella

We have a new condensation image in Torax x‐ray

Leucocytes – 24000

Hematocrit – 34,3%

Glucose – 163 mg/dl

Na – 148 mmol/L

K – 4 mmol/L

Ca – 6,8 mg/dl

Total proteins - 5,6 mg/dl e Albumine–3,1mg/dl

BUN – 41 mg/dl

Creatinine – 1,20 mg/dl

SGOT – 834 U/L; SGPT – 410 U/L; Alkaline phosphatase – 220 U/L; G

Total bilirubin – 10,7 mg/dl ; Direct bilirubin – 7,7 mg/dl

LDH – 1210 U/L

CRP – 10,4 mg/dl

What would you do?

The gastric residual volume was less than 200 cc

We reasume enteral nutrition by naso‐gastric route

We replace the caloric parenteral apport by enteral nutrition

We begin antibiotics to treat the MR Klebsiella

In the next days the fever desapeared

He was hemodinamic stable

The IAP reduced

Enteral Nutrition (1, 5 Kcal/ml  1000 cc)

Carbohydrates – 2,8 g/Kg/day (170 g/d)

Lipids ‐ 0,8 g/Kg/day (MCT‐LCT mixture) (48 g/dia)

Proteins – 1,25 g/Kg/day (75gr/d)

Vitamins and oligoelements

Leucocytes – 8000

Hematocrit –38%

Glucose – 138 mg/dl

Na – 140 mmol/L

K – 4,2 mmol/L

Ca – 8,1 mg/dl

Total proteins - 6,1 mg/dl e Albumine– 3,1 mg/dl

BUN – 35 mg/dl

Creatinine – 1,01 mg/dl

SGOT – 280 U/L; SGPT – 110 U/L; Alkaline phosphatase – 138 U/L;

Total bilirubin – 6,1 mg/dl ; Direct bilirubin – 4,8 mg/dl

LDH – 400 U/L

CRP – 10,5 mg/dl

Procalcitonin – 6

We was now hemodinamic and respiratory stable

He start weaning at 26th day with pressure support ventilation

He was independent from ventilator at 30th day

He was discharged from ICU at 32th day, to a surgical ward

At discharge from ICU is weight was 45 Kg

He was discharge from the Hospital at 58th day. A physical therapy plan has been

prescribed for functional recovery. It is fed orally without protein supplementation.

At Hospital discharge is weight was 42 Kg

He lost weight during hospital stay

Midarm circunference was < 5th centile

Three weeks later he returns to Hospital with fever (39° C), multiple respiratory

purulent secretions and polypneia.

He has a pneumonia in Torax x-ray

pH – 7,42

PCO2 – 28,8 mmHg

PaO2 – 65,1 mmHg

HCO3 – 21,1 mmol/L

Sat – 87%

Lactates – 3,1 mg/dl

He improves PaO2 with Venturi mask at 40%

He was admited to a medical ward….

Start to treat his pneumonia …..

Leucocytes – 12000

Hematocrit –38%

Glucose – 178 mg/dl

Na – 135 mmol/L

K – 3,5 mmol/L

Ca – 8,1 mg/dl

Total proteins - 4,1 mg/dl e Albumine– 2 mg/dl

BUN – 58 mg/dl

Creatinine – 1,14 mg/dl

SGOT – 85 U/L; SGPT – 65 U/L; Alkaline phosphatase – 100 U/L;

Total bilirubin – 1,8 mg/dl ; Direct bilirubin – 1,1 mg/dl

LDH – 400 U/L

CRP – 28 mg/dl

At the entry he has 40 Kg

IMC – 13

He has walking limitations with several muscular atrophies

Which are the main causes of muscular atrophy in this patient ?

What I can do to minimize it?

How can I treat it?

This is an eldery patient with several weeks of hospitalization with an acute

infectious complication

In the next days aggravated the general state…..

Multiorgan failure, unresponsive to therapeutic measures

He died in cachexia and infection at the 12th day after admission

Start Enteral Nutrition (1 Kcal/ml)

How can we diagnose it ?

The Frail Patient at ICU…..

How can we measure it ?

How can we improve the results ?

Message for the future…………