1. Nutritional and Medical
Implications of Aspiration
Pneumonia Associated with
Septic Shock and Mental Status
Changes

2. Presentation Outline
 Background Information
◦ Aspiration Pneumonia
◦ Septicemia and SIRS (systematic
inflammatory response syndrome)
 Patient Information
 Medical Treatment
 Nutritional Treatment
 Implication to the Field of Dietetics
◦ Aspiration Risk Factors
◦ Aspiration Precautions
 Questions

3. Aspiration Pneumonia
 An infection of the lungs that can occur after
foreign material enters the lungs or the
airways leading to the lungs (2).
 “Silent” asymptomatic aspiration is a
common occurrence in healthy individuals;
however, aspiration pneumonia occurs in a
subset of these individuals and the infection
is caused by non-harmful bacteria, primarily
anaerobes, part of the normal bodily flora
(3).

4. Septicemia & SIRS
 Septicemia exists when infectious
organisms or their toxins accumulate
in the bloodstream in significant
quantities and is often associated with
severe infections (4).
 Additionally, systematic inflammatory
response syndrome (SIRS) and
subsequently Septic Shock can occur
along with serious infections.

5. Infection vs. SIRS
source: http://bit.ly/Yogwpq

6. Case Study –The Patient
LA was admitted in respiratory
distress with mental status changes
following an episode of vomiting and
suspected aspiration whose local
infection progressed to sepsis and
septic shock.
 The case illustrates the challenges in
meeting the nutritional needs of a
critically ill patient with a history of
aspiration pneumonia, dependent on
enteral nutrition.

7. General Information
 Initials: LA
 Age: 86 years old
 Race: white
 Gender: male
 Diagnosis: septic shock, hypotension,
and mental status changes
 Height: 5’11”
 Weight: 160 lbs.
 BMI: 22.36
 Hospital Duration: 11 Days.

8. Social History
 LA resides in a nursing home in
Westminster, MD.
 He is a widower with a son, a
daughter, two granddaughters, and
one great granddaughter
 No history of alcohol or drug abuse
 Full code status
 Medicare Insurance

9. Medical/Surgical History
 Benign brain Disease
tumor s/p  Degenerative
resection arthritis
 Cerebral vascular  Dysphagia s/p
accident PEG placement
 Mitral valve  Aspiration
disease Pneumonia
 Congestive heart  Gastritis
failure  Hiatal Hernia
 Arterial fibrillation  Hypothyroidism
 Cardiomyopathy  Osteoporosis
 COPD
 Depression

10. Medical Treatment
 11/10/12- admitted in respiratory distress noted to be hypotensive, hypoxic, and
tachypneic. Given Lasix BP dropped from 119/74-80/40
◦ Antibiotics started, fluid bolus
◦ INR/PT was set to be monitored daily due to significant past bleeding complications
◦ white blood cell count: 25,000 indicating leukocytosis
11/11/12- Triple lumen catheter for vasopressor & antibiotics, placed on BiPAP and
came off the same day to nasal flow oxygen,
 11/12/12- weaned from oxygen, given pulmonary toilet, cardiologist consult/ following
 11/13/12- GI doctor was consulted because G-tube stopped working in the night (nurses
cleaned chamber)
 11/15/12- LA was moved to IMC but was wheezing and a COT was called was placed
back on BIPAP and remained in the IMC.
 11/19/12- Antibiotic treatment was completed and discontinued, triple lumen catheter
was removed. Thoracentesis was suggested to remove excess fluid from the pleural
space.
 11/20/12- Considered clinically improved, possible thoracentesis procedure was differed
 11/21/12-Pulmonologist indicated Thoracentesis was unnecessary. LA was discharged
back to nursing home

11. Nutritional History
 Unable to obtain nutritional history
from patient as a result of mental
status changes
 Information was obtained from nursing
home and medical records
◦ In Sept. (2012) pt was admitted to CHC w/
dysphagia, r/t to worsening mental status.
During that admission a PEG tube was
placed.
 On bolus feeding regimen at nursing
home (tolerating until vomiting
episode)

12. Past Tube Feeding Regimen
 1 can of bolus formula at: 6am, 9 am,
12 pm, 3 pm, 6pm, and 9pm
 Osmolite 1.2, which provided: 1728
kcal, 80 grams of protein, and 720 ml
of water flushes.
 Tolerating regimen until shortly before
admitted when he vomited, no
information on the cause of emesis

13. Nutritional Treatment
 11/12/12: Nutrition Consult for TF
assessment was placed
◦ Intern recommended pt switch from bolus
to continuous feeds
 “recommend start Isosource 1.2 (equivalent to
Osmolite 1.2) tube feedings at 10ml/hour and
advance every four hours until reaching to goal
rate of 60 ml/hr (1728 kcal, 76 g protein, and
1181 ml of free water daily).

14. Nutritional Treatment
 Tube feeding tolerance, labs, GI
function, I&O’s, weight trends, and
aspiration precautions were monitored
 The RD goal was to meet 100 percent
of LA’s needs via tube feeds within the
first 48 hours.

15. Nutritional Diagnosis
 PES statement: “Inadequate oral
intake (IDNT – NI-2.1) related to
dysphagia and respiratory distress, as
evidenced by, permanent PEG tube
placement and acute exogenous
oxygen dependency”.

16. Nutritional Treatment
 11/13/12 (Day 2)- Goal not met. LA’s tube
feeds were running at 30 ml/hr, which
provided 864 kcal, 38 g protein, and 590 ml
free water. (G-tube stopped working)
corrected.
 11/15/12- Tube feeds still not at goal. They
were running at 40ml/hr to provide: 1152 kcal,
51 g protein, and 787 ml of free water
(nursing error. RD consulted nursing about
Tube feeding.
 11/16/12 (Day 4)- Tube feeds were running at
goal rate of 60ml/hr with minimal residuals
 11/20/12 (Day 8)- LA noted to be tolerating
TF at goal w/ minimal residuals, and normal
bowel movements.

17. Estimated Needs
 Based on ASPEN Critical Care Guide
Lines
◦ Energy: 1448-2172 kcal 20-30g/kg body
weight
◦ Protein: 73-87 grams 1-1.2 g/kg
◦ Fluid: fluids were closely monitored by
medical team. Water flushes every six
hours was recommended to keep G-tube
working. I&O’s were monitored.

18. Lab Values
 WBCs elevated on admit –leukocytosis,
normal 11/15
 Potassium elevated (on admit)- normal
11/11
 BUN- slightly elevated
 Glucose -(129-169) Slightly elevated
 Hemoglobin /hematocrit –decreased
anemia
 Calcium- slightly decreased
 Sodium and chloride - Slightly decreased

19. Medications
 Lasix prn - diuretic
 Carvedilol- beta blocker, CHF
 Hydrocortisone- anti-inflammatory steroid
 Guaifenesin – Thins mucous in lungs
 Warfarin- Blood thinner
 Albuterol– Asthma
 Ativan –Anxiety
 Zosyn, Azithromycin, & Ceftriaxone - Antibiotics
 Lansoprazole – Decrease stomach acid
 Losartan Potassium- High blood pressure
 Milk of Magnesia- Constipation
 Multivitamin- Therapeutic
 Saccharomyces Boulardii – Probiotic

20. Implication to the Practice of
Dietetics
 While it is difficult to diagnosis
aspiration pneumonia as a direct
result of enteral feeding, it is a
common complication dietitian’s must
be aware of.
 Evidence suggests the benefits of
early enteral feeding on the prognosis
of critically ill patients (11)
 Thus it is important to constantly
monitor and practice prevention of risk
factors in critically ill patients

21. Risk Factors for Aspiration
Pneumonia
 Supine positioning
 Impaired level of consciousness
 GERD
 Neurological deficits
 Age >60
 Enteral intubation
 Mal positioned feeding tube
 Bolus vs. Continuous feeding
 Mechanical ventilation
 Poor oral health
 Inadequate nurse to patient ratio

22. Strategies and Precautions to
Prevent Aspiration Pneumonia
 Elevate bed between 35-40 degrees
 Identify and treat GERD
 Continuous feeding over bolus feeds.
 Verify tube placement
 Monitor gastric residuals to ensure
they are < 500ml
 Monitor patient for complaints of
discomfort, distention
 Monitor bowel movements

23. References
 References:
 Critical Illness- Complications of Nutrition Support. Academy of Nutrition and Dietetics Nutrition Care Manual. Source:
http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=89675
 Assessed December 6th, 2012
 Aspiration Pneumonia. Pub Med. Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001179/
 Assessed January 1st 2013.
 Aspiration Pneumonia in adults. Uptodate. Source: Http://uptodate.com/contents/aspiration-pneumonia-in-adults?topickey=ID%2F72.htm
 Assessed December 5, 2012
 Septicemia. MedlinePlus. Source: http://www.nlm.nih.gov/medlineplus/ency/article/001355.htm
 Assessed January 1, 2013
 Management of severe sepsis and septic shock in adults. Uptodate. Source:
 http://www.uptodate.com/contents/management-of-severe-sepsis-and-septic-shock-in-adults
 Assessed December 29th, 2012
 Treatment of Staphylococcus aureus bacteremia in adults. Uptodate. Source: http://www.uptodate.com/contents/treatment-of-staphylococcus-aureus-
bacteremia-in-adults.
 Assessed: December 6th 2012.
 Septic Shock- Treatment. University of Maryland Medical Center. Source: http://www.umm.edu/ency/article/000668trt.htm
 Assessed December 15th, 2012
 Septic Shock. Medline Medical Encylopedia. Source:
 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001689//
 Assessed: December 5th, 2012.
 What level of protein intake or what protein delivery is associated with improvements in length of stay in the hospital? Academy of Nutrition and Dietetics
Evidence Analysis Library. Source:
 http://andevidencelibrary.com/evidence.cfm?evidence_summary_id=250647&highlight=critically%20ill&home=1
 Assessed: December 21st, 2012.
 Enteral Nutrition. Academy of Nutrition and Dietetics Nutrition Care Manual. Source: http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255292
 Assessed: January 1st 2013
 Aspiration Risk and Enteral Feeding: A Clinical Approach. Nutrition Series in Gastroenterology. Source:
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-
articles/copy_of_apr03opillaarticle.pdf
 Assessed: December 6th, 2012.

24. Questions