Outline the appropriate nutrition support plan for Mr. Maddox. What will be an ideal ...

Answer to #1

When enteral access is available, recommend starting Nepro in order to meet kcalorie and protein needs. In order to avoid electrolyte imbalances, start very slowly at 10 mL/hr and advance by 10 mL q 6 hours/as tolerated to goal rate of 70 mL/hr (based on 22 hours per day to account for interruptions in the ICU). This will provide 1540 ml, 2772 kcal, 125 grams protein, and 1120 mL free water (33 kcal/kg, 1.5 g protein/kg). Provide approximately 1652 mL free water via maintenance IV or divided flushes.

Answer to #2

Energy Requirements:
(9.99 x actual weight ) + (6.25 x height)  (4.92 x age)  161
(9.99 x 72.7) + (6.25 x 167.64)  (4.92 x 57)  161
726.3 + 1047.75  280.44  161
1329 or 1300 kcal
Energy needs = REE x AF x IF = 1300 x 1.4 = 1861-1994
 seated work w/requirement to move but little strenuous leisure activity
 no injury factor

Protein Requirements:
72.7 kg x 0.8-1.0 g/kg = 58-73 g of protein

Answer to #3

Altered nutrition-related laboratory value  potassium and phosphorous related to AKI as evidenced by serum K 5.7 mEq/L and serum PO4 5.3 mg/dL.
Malnutrition related to critical illness/hypercatabolism as evidenced by inadequate energy intake for previous 7 days, preorbital and tricep fat wasting, and temporal muscle wasting.

Answer to #4

Increased risk for diabetes mellitus, cardiovascular disease, and cancer.

Answer to #5

 Wt reduction
 DASH eating plan
 Dietary sodium reduction
 Physical activity
 Moderation of alcohol consumption
 Smoking cessation may reduce risk for further HTN and CVD complications

Answer to #6

 Estimated energy needs: 30-35 kcal/kg IBW/day = 2590-3023 kcal/day or 2600-3000 kcal/day
 Estimated protein needs: 1.8-2.0 g protein/kg IBW/day = 155-173 g protein/day
These estimations were based on ideal body weight because of the fluctuation of weight this patient has experienced since admission. Additionally, would want to avoid the risks of overfeeding the patient (hyperglycemia, increased CO2) while he is in critical condition. These ranges were selected based on the previous estimations for a patient with AKI who is going to be on CRRT.

Answer to #7

 Mediterranean diet:
- high consumption of fruits, vegetables, cereals, legumes, and nuts
- Olive oil main source of dietary fat
- Low consumption of meat and dairy products
 This may be appropriate for Mrs. Moore since there is evidence that the diet reduces risk factors for cardiovascular disease, such as hypertension and dyslipidemia
 This may be culturally inappropriate for Mrs. Moore considering she is American, African-American and her current lifestyles are consistent with her nationality which contradicts the Mediterranean diet (i.e. she has a high consumption of salty processed foods, meat, and saturated fats butter)

Answer to #8

 The temporal wasting is evidence of muscle-wasting
 Losses in the preorbital pads and triceps suggests subcutaneous fat loss.
 These pieces of evidence should indicate acute malnutrition and the RD should adjust his/her energy/protein recommendations:
- Energy: 30-35 kcal/kg
- Protein: 2.0 g/kg
 The etiology of protein-energy malnutrition from AKI is related to the metabolic derangements that occur from it (and from the underlying catabolic illness/precipitating factor) and results in the degradation of proteins and amino acids. Additionally, fuel substrates may not be utilized efficiently due to the presence of cortisol and epinephrine. Together, these will result in an increase in lipolysis, lower the uptake of glucose by peripheral tissues, and result in protein sparing. This overactive use of the Cori cycle is an inefficient utilization of energy substrates.

Answer to #9

Salt sensitivity (defined as  10 increase in mean arterial pressure with salt loading) occurs in  50 of hypertensive patietns. Target organ events are higher in salt sensitive patients. Sodium adversely affects endothelial cells and an increased Na/K ratio is also associated with increased CVD and CVA. Therefore, consumption of <2400 mg>

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