Review 1 nutrition_case

1. Nutrition therapy in
Critically-ill adult patient :
Case study
F 곽형규 F 이민성

2. 75Y / M 정OO 36976485
1. SCLC c myopathy
- s/p EC #6 (2018/7/30 - 2018/11/12)
- RT (60Gy/30F, 2018/12/12 - 2019/1/24)
- r/o myopathy associated with SCLC
- last CTx 4/29
5/12 응급실 방문함.
상기 병력 있는 분으로 전일 오전 1회 설사가 있었으며, 금일 2시간 전부터 배꼽 주변부 복통을 호소했으며 물설사를 8회
정도 함. 식사 한 후 1회 구토도 하였음. 발열, 오한이 지속되어 응급실에 내원함.
매스꺼운 증상은 없으나 근육통이 심하다고 함. 혀가 말리면서 입이 바짝 마른다고 함. 항암 시작하기 전 항암 부작용으로
설사, 근육통이 생길 수 있다고 들었다고 함.
기침 호흡곤란은 없으나 가래는 암이 재발한 후로부터 증가했다고 함.
소변볼 때 dysuria는 없으나 straining, hesitance는 있다고 함. 알고 있는 전립선 비대증은 없다고 함.

3. GW/EF(+/-) F/C(+/+) HA/Dizz(-/-)
C/S/R(-/+/-) sore throat(-)
chest pain(-) dyspnea(-)
Abdominal pain(+, 배꼽 주변 불편한 정도) A/N/V/D/C(-/-/+/+/-)
Urinary Sx.(-)
anemic, Anicteric
dehydrated tongue
Symmetric expansion without retraction
Regular heart beat without murmur
CBS without Crackle, Wheezing
Soft and flat, not distended
Normoactive BS
T/RT(-/-)
L/E edema (-/-)
skin turgor decreased

4. ED evaluation and management
Current problem>
1. Septic shock c neutropenia
- Pneumonia c pleural effusion
- Colitis
apnea, CO2 retention 되면서 의식 저하 있어
intubation 후 septic shock manage 위해 EICU adm.

5. Chest CT & Abdomen CT
Nonspecific colitis in A-T-D colons.
Overall decreased size of multiple liver metastasis.
A 5.5cm sized intrarenal AAA with ulcerated mural thrombus.
Diffuse atherosclerosis in the aorta and branches.
Interval development of fibrosis and GGO at RUL and LLL base
--> r/o RT change
r/o combined pneumonia for RUL GGO
REC) clinical correlation
Increased amount of right pleural effusion.
Overall decreased size and enhancement of the infiltrative mediastinal mass.

6. Basic information
Height 163cm
Previous body weight : 54 – 56
Bwt @ admission : 56.4
Ideal BWT : 60
Adjusted BWT : unmeasurable
Indirect calorimetry : Unavailable
VCO2 calculation : Unavailable
20-25kcal/kg/day : 1100-1375Kcal/kg/day
Penn state Equation (Tmax 38.1/Ve 9.2) 1620.3 kcal
NRS 2002 : 4 (>=3)
NUTRIC : 6 (>5)

7. EICU course of nutrition support
5/12-13(admission) : NPO
5/14-15 : free water 100cc tid + d10 40cc/hr (400kcal, Glucose 90g)
5/15 ~ : TPN(npo)
Vol 1408 ml, Cal 1342.8 kcal
Protein 77.5 g (1.4g/kg)
Lipid 40 g (0.71g/kg) GIR 2 sound ok, diarrhea 2-3회 지속
mg/kg/min
5/16-21 : TPN 42cc/hr, protamine and lipid 10cc, 10cc/hr
5/22 : TPN stop / Tube feeding 500kcal/day 시작 (distended abdomen, Bowel sound + but weak)
5/23 : 500kcal 유지, Bowel
5/13-18 : 설사 소량 1회 혹은 없음
5/19-20 : 설사 5회 1500cc (이후로 2-3회 per day)

8. Other clinical situation
5/13
Antibiotics : meropenem
NE 12-16mcg/min, PCV 12/8/24/40%, 설사 2회, leg mottling appearance ++
5/14
NE 10-9mcg/min, PSV 7/7/35%, 설사 1회, mottling ++
5/15
NE 12-4mcg/min, PSV 7/8/35-50%, 설사 0회, feet only mottling+
5/16
NE Off, PCV ~ PSV 14~8/6/35-50%

9. Laboratory findings to consider

12. Discussion
1. Parenteral nutrition timing, amount
2. Enteral nutrition timing, amount
3. Further suggestion