Inpatient case study formally presented to the nutrition care team at Presence Resurrection Medical Center.

1. Inpatient Case Study
Cheryl Fitzgerald
Dietetic Internship
Summer 2017
Critically ill Patient on Ventilation
with Transaminitis after Nephrectomy

2. ADIME

3. Assessment: 6/29
➢ 72 y.o male s/p nephrectomy, CKD - stage 3
○ Post-op complications: respiratory failure, pulmonary edema,
and V Tach -> intubation
➢ Trach/PEG/NPO on 6/25 at Advocate Condell, transferred to
HFMC on 6/28
○ Osmolite 1.5 @50 ml/hr

4. Assessment: 6/29
➢ PMH: DM, CABG, HLD, HTN, A Fib, MI, gastritis, diverticulosis, and
cocaine use
➢ Meds: Lipitor, Pacerone, Peridex, Pepcid, Lasix, Metformin,
Miralax, Coumadin, Fentanyl drip
➢ Skin Breakdown:
1. Chest puncture
2. R Lower Ab puncture
3. Stage II: ab under G-tube

5. Assessment: Nutrition Needs
➢ Ht: 5’10” Admission Wt: 204# BMI: 29.4 IBW: 166#
➢ Energy: 15-20 kcal/kg = 1392-1856 kcal/day
➢ Protein: 1.0-1.3 g/kg = 93-121 g/24 hours
➢ Osmolite 1.5 @50 ml/hr: 1650 kcals/day
69 g/pro/day
➢ Per RN:
○ No residuals
○ Excessive gas
○ No BMs x5 days

6. Assessment: Lab Values
➢ Prealbumin = 8.0
➢ Glucose = 158
➢ AlkPhos = 219
➢ ALT = 114
➢ AST = 148
➢ Total Bilirubin = 1.2

7. Nutrition Diagnosis
1. Increased nutrient needs(protein) related to increased demand
for nutrient as evidenced by low prealbumin 8.
2. Altered nutrition-related laboratory values related to liver
dysfunction as evidenced by Alkphos 219, AST 148, ALT 114,
and Total Bilirubin 1.2.

8. Nutrition Intervention
➢ Increase protein
➢ Change TF formula to Pivot 1.5 to meet semi-elemental
therapeutic nutrition needs
○ Goal Rate: 55ml/hr
○ 1815 kcals/day and 112 g/pro/day
○ 20 kcal/kg and 1.2 g/pro/kg of current body wt

9. Goals of Nutrition Invention:
➢ Meet >85% needs for nutrition support
➢ Tolerate TF
➢ Normal BMs
➢ Prealbumin >20
➢ LFTs WNL

10. Monitoring & Evaluation
➢ Labs
➢ TF tolerance
➢ BMs
➢ Weight

11. Reassessment: 7/6
➢ Nutrition Consult on 7/5: Pt w/ 350 cc residuals & ab. distention
○ TF changed to Vital 1.5
○ Goal Rate 55 ml/hr:
1815 kcals/day and 82 g/pro/day
20 kcal/kg and 0.9 g/pro/kg
➢ Pt tolerating TF at 50 ml/hr with only 40 cc residuals
➢ Regular BMs, laxatives provided and increased fiber in formula
change (Vital 1.5 = 6g Fiber/1000 ml)
➢ Coumadin discontinued

12. Reassessment: 7/6
➢ Wt. change: -9#
○ -2.1L since admission, diuresing
➢ LFTs improved but still elevated:
○ AST = 70
○ ALT = 63
○ AlkPhos = 177
○ Total Bilirubin = 1.7
➢ Continue to monitor and evaluate:
○ TF tolerance, labs, weight

13. Reassessment: 7/13
➢ Transferred out of ICU
➢ Continued to wean off ventilation
➢ Pt tolerating TF at 55 ml/hr, 40 ml/hr flushes, no residuals
➢ On Flexi-Seal FMS, no BMs noted per RN
➢ Wt. change: -21.3#
○ -4.7L since admission, diuresing
➢ No updated LFTs since 7/6
➢ Coumadin reordered

14. Reassessment: 7/13
➢ Intervention per continued dx:
○ Order PAB and LFP
○ Continue TF as tolerated
➢ Monitor and evaluate:
○ TF tolerance, labs, weight

15. Reassessment: 7/20
➢ Pt still on ventilation
➢ Buried Bumper Syndrome (BBS), unable to insert Dubhoff
○ Pt off TF x4 days unknown to Nutrition Services Dept.
■ At risk for refeeding syndrome
○ Receiving: Clinimix-E and 250 ml 20% Lipids daily
■ 1010 kcals/day
➢ Elevated INR
○ Vit K injections
○ Coumadin discontinued
➢ TPN order requested
○ PEG to be replaced 7/21 if INR <21. Cyrany J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy.
World Journal of Gastroenterology. 2016;22(2):618. doi:10.3748/wjg.v22.i2.618.

16. Reassessment: 7/20
➢ Wt. change: -28#
○ -12.4L since admission, diuresing
○ CBW: 176#
➢ LFTs WNL except for: AST and Total Bilirubin
➢ PAB = 16
➢ Nutrition Needs based on CBW:
○ 20-25 kcals/kg = 1600-2000 kcal/day
○ 1.0-1.2 g/pro/kg = 80-96 g/pro/day

17. Nutrition Diagnosis: 7/20
1. Increased nutrient needs(protein) related to increased demand
for nutrient as evidenced by low prealbumin 16.
2. Discontinued: Altered nutrition-related laboratory values
related to liver dysfunction as evidenced by Alkphos 177, AST 70,
ALT 63, and Total Bilirubin 1.7 on 7/13.
➢ No Further Nutr. Intervention recommended at this time
3. Inadequate parenteral nutrition related to infusion volume not
reached due to prolonged NPO status as evidenced by inadequate
PN volume compared to estimated requirements.

18. Nutrition Intervention: 7/20
➢ Clinimix-E and 20% Lipids for 24-48 hours
➢ Begin Cyclic TPN formula based on CBW:
○ 350 g/Dex = 1190 kcals/day
○ 90 g/AAs = 360 kcals/day
○ 250 mL 20% Lipids MWF = 214 kcals/day
■ TGs = 176
➢ If PEG replaced resume TF at goal rate:
Vital 1.5 @ 55ml/hr

19. Goals of Nutrition Invention: 7/20
➢ Meet >85% needs for nutrition support
➢ Tolerate TPN
➢ Prealbumin >20
Monitoring and Evaluation:
➢ TPN tolerance, labs, weight

20. Update 7/24-7/27
➢ MTE -5 left out 2/2 high bilirubin
➢ D50 + KCL 20 @ 83 ml/hr for 24 hrs in addition to TPN
➢ Resolved Dx - Inadequate Parenteral Nutrition Infusion Dx
○ Increased Nutrition Needs (protein) remains until PAB >20
➢ PEG replaced - INR WNL
➢ TF at Goal Rate Vital 1.5 @ 55 ml/hr with 60 ml flushes Q hr
➢ T piece during day/ventilation at night
➢ Wounds improved
○ Only chest puncture from surgery noted for wound care

21. Research

22. 2. Yap S, Park S, Egan B, Lee H. Cytokine elevation and transaminitis after laparoscopic donor
nephrectomy. AJP: Renal Physiology. 2012;302(9):F1104-F1111. doi:10.1152/ajprenal.00543.2011.
Transaminitis after Nephrectomy
➢ 32 pts undergoing donor nephrectomy vs 17 pts receiving
other laparoscopic surgery
➢ Nephrectomy may have direct effects on distal organs such as
the liver
➢ Elevated AST and ALT levels only seen in nephrectomy pts
➢ Both pts: Significant increase in extracellular fluid volume and
postoperative diuresis

23. 3. Pomierny-Chamioło L, Moniczewski A, Wydra K. Oxidative Stress Biomarkers in Some Rat Brain
Structures and Peripheral Organs Underwent Cocaine. Neurotoxicity Research. 2012;23(1):92-102.
Cocaine Use & Peripheral Organs
➢ 48 rats administered b/t 15-18 mg/kg/day cocaine infusion, 14 days
➢ MDA (malondialdehyde) and SOD (superoxide dismutase) =
Oxidative stress biomarkers
➢ SOD levels increased in liver, no sig. effects on heart or kidneys
➢ MDA levels sig. increased in liver, heart, and kidneys
○ Liver affected the most, MDA levels up 50%
➢ Other clinical findings referenced.:
○ acute or chronic cocaine use resulted in renal toxicity
○ Risk factor for MI, arrhythmia and ischemia

25. Summary
➢ Transaminitis may occur after Nephrectomy
➢ Cocaine use may cause increased oxidative stress levels
➢ Semi-elemental formulas beneficial for pt’s tolerance, digestion,
absorption, immune function, and reducing inflammation
➢ PN should be used when EN is not possible due to technical
problems such as BBS
○ Begin EN once issues resolve, GI clears pt

26. References
1. Cyrany J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy.
World Journal of Gastroenterology. 2016;22(2):618. doi:10.3748/wjg.v22.i2.618.
1. Yap S, Park S, Egan B, Lee H. Cytokine elevation and transaminitis after laparoscopic donor
nephrectomy. AJP: Renal Physiology. 2012;302(9):F1104-F1111.
doi:10.1152/ajprenal.00543.2011.
1. Pomierny-Chamioło L, Moniczewski A, Wydra K. Oxidative Stress Biomarkers in Some Rat
Brain Structures and Peripheral Organs Underwent Cocaine. Neurotoxicity Research.
2012;23(1):92-102. doi:10.1007/s12640-012-9335-6.
2. Vital® 1.5 Cal | calorically dense, peptide-based formula. Abbottnutrition.com. 2017. Available
at: https://abbottnutrition.com/vital-1_5-cal. Accessed July 29, 2017.
3. Brown B, Roehl K, Betz M. Enteral Nutrition Formula Selection. Nutrition in Clinical Practice.
2014;30(1):72-85. doi:10.1177/0884533614561791.