NUTRITION CARE CONFERENCE SPRING 2015 Mackenzie Cannon Manchester Memorial Hospital PATIENT DATA DEMOGRAPHICS Patient: EF Age: 69 Gender: Female Ethnicity: Caucasian Admission date: 4/1/15 Previous admission: Feb 2015 Date Seen: 4/9/15 PSYCHOSOCIAL Retired nurse Lives with daughters family ANTHROPOMETRICS Height: 54 Weight: 135 lbs / kg Previous weight at Feb admission 179 lbs BLE Edema BMI: 23.1 IBW: lbs112% of IBW UBW: 160 I/O: 840/324 = 514 NUTRITION FOCUSED PHYSICAL FINDINGS Overall Appearance No visible muscle wasting Jaundiced skin tone No edema/ascites GI Poor appetite PTA Tolerating Ensure supplement shake Neurological Altered mental status Assistance required at meals PRIMARY MEDICAL DIAGNOSIS Hepatic Encephalopathy Admitting Diagnosis: Altered mental status Patient Medical History History of alcoholism Alcoholic liver cirrhosis w/portal HTN Previous admission of hepatic encephalopathy HTN Hypothyroidism Family Hx premature CAD HEPATIC ENCEPHALOPATHY Complication of cirrhosis of the liver resulting in: Impaired mentation Neuromuscular dysfunction Altered consciousness Etiology: Three current theories NH 3 accumulation GABA receptor complex Altered neurotransmitter theory 9 LAB WORK Lab TestNormal Range Patients Value DateInterpretation Alk Phos 224 HIGH 243 HIGH 4/2 4/1 Elevated in cirrhosis, indicate bile duct obstruction in liver NH HIGH 73 HIGH 4/9 4/7 Elevated in cirrhosis, liver unable to convert NH3 into urea Glucose HIGH 173 HIGH 4/7 4/1 Glucose intolerance occurs in 2/3 of patients with cirrhosis, d/t insulin resistance in peripheral tissues. Albumin g/dL1.8 LOW 1.9 LOW 4/2 4/1 Liver makes this protein, Low d/t impaired liver function ALT7-56 u/l504/7Elevated with impaired liver function, patient at high end of normal. Liver releases this enzyme when damaged. AST15-37 u/l61 HIGH 77 HIGH 4/2 4/1 Elevated with impaired liver function, liver releases this enzyme when damaged. T. Billi HIGH 2.3 HIGH 4/2 4/1 Elevated with Impaired liver function, Liver can no longer effectively package bilirubin and it accumulates in the serum resulting in jaundiced skin tone Blood Alcohol60664/7WNL indicating adequate renal function Creatinine mg/dL.94/7 WNL, made by liver can be lower with liver damage and starvation Important Hematology HGB G/DL 10.1 LOW 4/7Low d/t macrocytic anemia r/t alcoholic cirrhosis HCT36-46%31.4 LOW4/7Low d/t macrocytic anemia r/t alcoholic cirrhosis MCV80-96 fl103 HIGH4/7 Slightly elevated indicating risk for Macrocytic anemia, r/t alcoholic cirrhosis RDW HIGH4/7 Slightly elevated indicating risk for Macrocytic anemia, r/t alcoholic cirrhosis Serum Folate ng/mL18.2 HIGH4/6High d/t treatment for macrocytic anemia r/t alcoholic cirrhosis Serum B pg/mL1856 HIGH4/6High d/t treatment for macrocytic anemia r/t alcoholic cirrhosis PERTINENT MEDICATIONS Drug/Generic NamePurposeNutritional Concerns Folic AcidB Vitamin, Anti anemic ThiamineB Vitamin, Commonly deficient in Liver disease Nutr.: Increae Thi requirement c increased CHO intake or gastric bypass Oral/GI: IV- Nausea s/Cond: Alcoholism increases risk of def & optic neuropathy Mg OxideMineral supplementMg deficiency is common in Cirrhosis and Hepatic encephalopathy Diet: take fiber, Fol or Fe suppl separately by at least 2 hrs. Do not take c high fiber, high oxalate or high phytate foods RifaximinAntibioticDecreases colonic bacteria production of NH 3 Lactulose SyrupLaxative, Controls NH 3 levels Diet: High Fiber c ml fluid/day to prevent constipation. Not c lactose or galactose restricted diet. Do not take concomitantly c antacids, Ca or Mg suppl. Nutr. Drug increases abs of Ca & Mg Oral/GI: N/V, Belching, cramps, borborygmi, diarrhea, flatulence MEDICATIONS CONTINUED Drug/Generic NamePurposeNutritional Concerns HeparinAnticoagulantOral/GI: N/V, abdominal pain, GI bleeding, constipation, black tarry stools MetoprololAnti Hypertensive Beta blockerDiet: Decrease Na, Decrease Ca may be recommended. Avoid natural licorice Oral/GI: Dry mouth, N/V, dyspepsia, flatulence, diarrhea, constipation Omeprazole/PrilosecProton Pump Inhibitors- AntiGERD/AntiUlcer- decreasing the amount of acid made in the stomach May decrease the absorption of Fe, Vit B12, Ca. Avoid gingko and St. Johns Wort Oral/GI: Increases Gastric pH, nausea, abdominal pain, diarrhea MNT: HEPATIC ENCEPHALOPATHY kcal/kg dry body weight 50% 60% of calories as CHO 20%-30% of calories as protein ( g/kg body weight) Consider increasing vegetable protein and dairy protein for BCAA 10%-20% of calories as fat Avoid unnecessary diet restrictions Provide 4-6 small meals, one being a late evening CHO rich snack Supplement Thiamine, Folate, B 12, Zn, Ca, Vitamins A,D,E,K as needed Probiotics No alcohol NUTRITIONAL DIAGNOSIS PES: Unintended weight loss related to impaired ability to self feed, loss of appetite, and chronic disease, as evidenced by a 16% weight loss in 2 months. INTERVENTION Current Diet Order: 2 g sodium Diet Continue - Appropriate for HTN and cirrhosis Goal of kcal/kg = kcal 8 oz Chocolate Glucerna BID w/straw if calories cannot be met with food Protein: 1.2 1.5g/kg = 74 92g/day Plant and dairy before animal MVI supplementation Probiotics Consistent Carbohydrate Intake, small frequent meals INTERVENTION Coordination of Care Speak with family Diet changes Compliance with multivitamins and medications Assistance with meals Goal of 75% of meals to be consumed MONITORING & EVALUATION Anthropometrics Monitor weight Patient will maintain body weight in hospital and at home Monitor somatic muscle stores Patient will not present with muscle wasting Monitor fluid retention Patient will not present with edema or ascites Biochemical labs to be monitored NH 3 Hematology, serum B 12 & Folate: Anemia of chronic disease, macrocytic anemia Serum Mg: lactulose therapy increases uptake of Mg Coordination of Care Monitor compliance/tolerance of increased plant protein & fiber Monitor compliance with multivitamin intake Monitor meal intakes MONITORING & EVALUATION OBSTACLES Refeeding syndrome Patient was not eating PTA Start at 20 kcal/kg (1200 kcal) and increase as tolerated Increased Fiber Patient will need to work up to higher intakes of fiber MENU Small frequent meals Breakfast: Oatmeal with almond slivers and diced apple, 1 cup water Snack: Stoneyfield yogurt (active cultures) w/ blueberries, 1 plum, 1 cup skim milk Lunch: Lentil Soup (low sodium), multigrain toast w/ olive oil, baby carrots, 1 cup water Snack: Hummus w/ veggie sticks, Wheat Thin crackers, 1 cup water Dinner: Whole wheat pasta w/ diced tomato, white beans, baby spinach, feta cheese & olive oil Late night Snack: Animal Crackers, 1 cup skim milk Total calories: 1850 CHO: 245g (53%) PRO: 90g (20%) FAT: 57g (28%) Na: 1800mg Fiber: 32g REFERENCES 1. 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