Practical NutritionCases

T R WilsonM Peck

CASE 1• Mr A. 42 years.• Underwent gastric bypass 14 months previously

for BMI 43 (Weight 124Kg).• BMI currently 24 (Weight 69Kg).• Intermittent abdominal pain after eating for last

6 months.• Admitted with bilious vomiting and central

abdominal pain for last 4 days.• Na 141, K 4.1, Urea 11, Creat 147, WCC 20,

Albumin 21

Case 1 - Issues

• MUST 0+2+2 = 4• Refeed: • IV fluid resusciation• Mg / PO4 check and replace• Pabrinex• PICC line• Volume 1.5L• Na 70• K 70-100

Case 2• Mrs B, aged 60 Years.• Recent subtotal colectomy with ileostomy for

obstructing sigmoid cancer.• Preoperative weight 38Kg / BMI = 16.• Admitted with diarrhoea after 3 cycles of adjuvant

chemotherapy.• Current weight 30Kg.• Stoma output 2-2.5L/24 hours.• Started on NG feeding (30mls/hr)• Na 131, K 4.5, Urea 10, Creat 87, Alb 34, Hb 178

Case 2 - Issues

• MUST 2+2+2 = 6• Refeed: Very severe• IV fluid resusciation• Mg / PO4 check and replace• Pabrinex• PICC line• Volume 500 + 1500 ml• Na 30 + 150• K 30 + 60• PO4 Max

CASE 3

• Mr C, aged 84 years 8 days following right hemicolectomy. NG output 500mls/24 hours – presumed ileus. Weight 82Kg. Height 1.7m. Peripheral oedema. Na 129, K 2.9, Urea 5.0, creat 110, WCC 14, Albumin 16.

Case 3 - Issues

• MUST • Refeed: Yes• IV fluid resusciation if needed (overloaded)• Mg / PO4 check and replace• Pabrinex• PICC line• Volume 1.5L +0.5L• Na 70 + 50• K 70 + 40

CASE 4• Mrs D, aged 71 years.• 3 month history of vomiting secondary to

gastric outlet obstruction.• 7Kg weight loss over this time• Current weight 49kg, Height 1.6M.• Expedited gastrojejunostomy yesterday.• Started on off shelf PN feed (1600 Kcal, 12gN)• Bloods next day: Na 137, K 2.7, Urea 3, Creat

43, PO4 0.6, Mg 0.7

Case 4 - Issues

• Stop current feed• Refeed: • Resusciation: Mg / PO4• Pabrinex• (PICC line)• Volume 1 + 0L• Na 50• K 40 + 50 +40• Max PO4 and Mg

Case 4 - Issues

• Significant weight loss - Nutritional depletion• Metabolic alkalosis possible• Possible micro-nutrient problems (low ferritin)• Started on nut support, but a too high Kcal.• Likely refeeding syndrome with low K, PO4,

Mg

CASE 5

• Miss E, aged 18.• Known anorexia nervosa.• BMI 11.• Assaulted with head injury 48 hours earlier.• Neuro-observation for basal skull fracture.• Persistent nausea and increasing drowsiness.• Temperature 35◦C• Blood glucose 1.4. Na 151, K 3.8, Urea 9, Creat 81,

WCC 4, CRP 21.

Case 5 - Issues

• Anorexia – likely poor nutritional state.• Not able to eat properly.• Gut functioning, but is it accessible.• ? Safe for NG tube with basal skull fracture.• Low temp and glucose suggests sepsis despite

normal bloods