CASE STUDIES 1 : Q 2

• NORASHIKIN MUSTAFA0913252

• MARIAM NABILAH 0917992

• WAN NURUL HAZIRAH 0910592

0913838

0914606

• NUR AFIFAH’ AMALINA

• WAN NOR AMALINA

Question 2AH is a 82 years old man. He had been diagnosed with cancer last year and had finished all the radiation therapy all together 15 treatments. But recently patient had admitted back to hospital due to pyloric cancer and underwent operation of the stomach. Currently he is on TPN, and the physician already done gastrojejunostomy for long term plan.He is on Nutriflex (peripheral) after operation (75 ml/hr). After 2 days, he started with mix feeding TPN and EN, before changing to EN solely on the next day. Discuss the dietary care plan for AH in current condition and after changing to EN solely.Anthropometry Data: Weight = 42 kg; Height = 165cmBiochemical Data:RBG: 6.2 mmol/L Hb: 10.1 g/dLUrea: 5.9 mmol/L Potassium: 4.5 mmol/LSodium:134 mmol/L Creatinine: 94 mmol/L normalTotal Protein: 59 g/L Albumin: 29 g/dL

OVERVIEWName = AHSex = MaleAge = 82 years oldCondition = PYLORIC CANCER +

done GASTROJEJUNOSTOMY + on TPN, Nutriflex (peripheral) after

operation (75ml/hr).After 2 days = TPN + EN before EN solely.

•Discuss the dietary care plan in current condition + after changing to EN solely?Q:

Anthropometry Data

Weight = 42 kgHeight = 165 cmBMI = 15.43 kg/m² (underweight)IBW = 50 kg @ normal BMI 18.5 kg/m²Biochemical Data

:

CHEMICAL VALUE N.VALUE INDICATION

RBG 6.2 mmol/L 7- 11 mmol/L Low

Hb 10.1 g/dL 12.1-15.1 g/dL Low

Urea 5.9 mmol/L 2.0-6.8 mmol/L Normal

K 4.5 mmol/L 3.5-5.5 mmol/L Normal

Na 134 mmol/L 135-145 mmol/L Slightly Low

Creatinine 94 mmol/L 60-110 mmol/L Normal

T.Prot 59 g/L 68-83 g/L Low

Albumin 29 g/dL 35-40 g/dL Low

:

BIOCHEMMICAL ASSESTMENT

CHEMICAL INDICATION ASSESTMENT

RBG LowMalnutrition due to previous

cancer condition

Hb Low Due to cancer condition

T.Prot Low

PEM due to previous cancer condition

Na Slightly Low

Electrolite imbalance due to fasting procedure before the

surgical

Albumin LowPEM due to previous cancer

condition

Clinical Data Diagnosed with cancer and had finished all the 15 radiation

therapies. Recently, admitted back due to pyloric cancer and underwent

operation of the stomach Gastrojejunostomy for long term EN plan.

Dietary Plan

• TPN –Nutriflex (75 ml/hr)

DAY 1 +2

• Mix PN + EN

DAY 3 • Total EN

DAY 4-6

• Total EN (based on IBW)

DAY 7

PES STATEMENT

Malnutrition due to previous cancer condition as evidenced by low albumin level which is 29g/dL in biochemical assessment.

Objectives of MNT

1. To provide nutrition support consistent with patient’s medical condition, nutritional status, and available route of administration.

2. To improve patient’s nutritional status and outcomes after surgery.

3. To avoid complications related to the technique of nutritional delivery.

Implementation

To provide nutrition support consistent with patient’s medical condition, nutritional status, and available route of administration.

1) The process of changing nutrition support from TPN to mix feeding of PN and EN, until total EN is accomplished through gradual stage to avoid refeeding syndrome and to parallel with patient’s condition.

Post surgery, patient is given TPN (Nutriflex) for 2 days considering that patient is underwent surgery for pyloric cancer.

Then, patient is given mix feeding of PN and EN before TEN is given to patient, but the amount of feeding is increase gradually to avoid re-feeding syndrome.

2) The product selected for EN of this patient is Peptamen®. It is an elemental formula which is nutritionally complete and suitable for post operative patients. It is also a partially hydrolyzed protein product that is easily absorbed by the GIT.

Implementation

To improve patient’s nutritional status and outcomes after surgery.

i. The initial estimation of nutrient requirements is based on current body weight (1300-1400 kcal/day) to promote adequate energy intake but preventing the refeeding syndrome.

ii. After 7 days, the ideal body weight is used to estimate the energy requirement to promote weight gain (1500-1600 kcal/day)

iii. Higher protein factor of 1.2-1.5g/kg BW is used to calculate protein requirement for this post surgery patient in order to promote wound healing and tissue repair as well as improving protein stores.

To avoid complications related to the technique of nutritional delivery.

i. The tube is flush with 30ml of water before and after feeding to prevent occlusion.

ii. Elevate the head of the bed 30-45 degrees during feeding and 30-60 minutes after feedings to minimize the risk of aspiration.

iii. Practice hygiene through the whole process of feeding the patient including preparing the enteral formula, feedings, and also post-feeding cleanliness to prevent bacterial contamination.

Implementation

ENERGY & PROTEIN REQUIREMENTFAO/WHO/UNU FormulaBEE = 13.5( 42) + 487 = 1054kcalTEE = 1054 X AF (1.0) X IF (1.3) =1370 kcal/day

Schofield EquationBEE = 11.7 (42) + 585 = 1076.4kcalTEE = 1076.4 + SF (0.2 X 1076.4) + AF ( 0.1 X 1076.4)

= 1399.32 kcal/day

BEE > 60 (male) = 13.5(W)+ 487

BEE > 60 (male)= 11.7(W)+585

Stress factor (extensive surgery)

= 10-30%

Adjusted for 24 hr energy expenditure

(bed bound and awake)= +10%

Average E= (1370 + 1399.32)/2 = 1384.66 ≈ 1300 - 1400kcal/day

Protein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day

ENERGY & PROTEIN REQUIREMENT

DAY 1 & 2 (TPN)Nutriflex (75ml/hr) = 1875 ml/1435 kcal/ 60g a.a

ml/cc in 1 day = 75 ml/hr x 24 hr = 1800 ml

Cal in 1 day = (1435 kcal/1875 ml) x 1800 ml = 1377.6 kcal / day

Protein. in 1 day = (60 g/1875 ml) x 1800 ml = 57.6 g protein/day = 1.37 g/kg BW

Glucose in 1 day = (120g/1875ml) x 1800ml(CHO) = 115.2g CHO/dayLipids in 1 day = (75g/1875ml) x 1800ml(Fat) = 72g Fat/day

NuTRIflex Lipid Peri

(peripheral)

DAY 3 ( PN + EN)

PNNutriflex = 1250 ml/ 955kcal/ 40g a.a

EN Cal for EN = 1377.6 kcal – 955 kcal

= 422.6 kcal/day (400-500kcal/day) Min Protein from EN =57.6 g – 40 g = 17.6 g

Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop

Bolus feeding (6 times /day)1.Flush with 30 ml water

2.Give clear fluid like water 40ml.

3.1 ½ scoop + (70 ml water) = 1 ½ scoop x 42 kcal = 63 kcal/feeding timeTotal Calories = 63 kcal x 6 feeding = 378 kcal/dayTotal Protein = 1.7 g x 1 ½ scoop x 6 feeding= 15.3 g/day Total CHO = 5.1g x 1 ½ scoop x 6 feeding = 45.9g/day

Total fat =1.6g x 1 ½ scoop x 6 feeding = 14.4g/day

3.Flush with 30 ml water

Average energy requirement ≈ 1300 - 1400kcal/dayProtein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day

Total calorie (PN+EN) = 955kcal + 378kcal = 1333 kcal

Total protein (PN+EN)= 40g +15.3 g = 55.3g

DAY 3 ( PN + EN)

DAY 4-6 ( TEN ) Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop

STEP 1

1. Flush with 30 ml water

2.(4 scoop + 140 ml water) x 6 feeding Total Calories = 4 (42kcal) x 6= 1008 kcal/dayTotal Protein = 4(1.7g) x 6 = 40.8 g/dayTotal CHO = 4(5.1g) = 20.4g/dayTotal Fat =4(1.6g) = 6.4g/day

3. Flush with 30 ml water

DAY 4-6 ( TEN )

Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoopSTEP 21. Flush with 30 ml water

2.(5 scoop + 175 ml water) x 6 feeding

Add 1 scoop (6.3g) myotein in 2 times feeding per dayCalories = 5(42kcal) x 6 + 2(30.1) = 1320.2 kcal/dayProtein = 5(1.7g) x 6 + 2(5g) = 61 g/day Total CHO = 5(5.1g) x 6 = 153g/dayTotal fat = 5(1.6g) x 6 = 48g/ day

3. Flush with 30 ml water

DAY ≥ 7 (TEN based IBW)

FAO/WHO/UNU FormulaBEE = 13.5( 50) + 487 = 1162 kcalTEE = 1054 X AF (1.0) X IF (1.3) =1510.6 kcal/day

Schofield EquationBEE =11.7 (50) + 585 (for >60 y.o) = 1170kcalTEE = 1170 + SF (0.2 X 1170) + AF ( 0.1 X 1170)

= 1521 kcal/day

Average = (1510.6+ 1521)/2=1515.8 kcal (1500- 1600 kcal)

Protein = 1.2 – 1.5 g/kg BW= 60 – 75g/day

DAY ≥ 7 (TEN based IBW) STEP 3

1. Flush with 30ml of water2. (6 scoop + 210 ml water) x 6 feeding

Calories =6 (42kcal) x 6= 1512 kcal/dayTotal Protein =6(1.7g) x 6 = 61.2 g/dayTotal CHO =6 (5.1g) x 6 = 183.6g/dayTotal fat = 6(1.6g) x 6 = 57.6g/day

3. Flush with 30 ml water

~The End~~Thank

You~