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Running head: GRANDROUND CASE STUDY

Grand Round Case Study

Trevor Talbot & Paige ONeil

Marywood University
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GRANDROUND CASE STUDY
PART 1

1. Patient description:

Demographic: Caucasian male

Age: 65 yo

Anthropometrics:

Height: 72

Weight: 71.2 kg/156.6 lbs

BMI: 21.3: healthy weight

IBW: 178 lbs/81 kg

% IBW: 88%

Temp: 100

BP: 140/90

Pulse: 120

Relevant medications/use:

Ascorbic acid (500 mg every 12 hrs.): vitamin C, used to prevent or treat low

levels of the vitamin in people who do not obtain enough through their diet.

Chlorhexidine (.12% oral solution 15 ml every 12 Hrs.): used to clean skin

Famotidine tablet (20 mg every 12 hrs.): treats ulcers and gastroesophageal reflux

Heparin injection (5,000 units every 8 hrs.): used as an anticoagulant

Insulin (regular injection every 6 hrs.): treats diabetes and hyperglycemia

Multivitamin tablet (1 tab daily): dietary supplement containing a variety of

vitamins and minerals

Zinc sulfate (220 mg daily): a supplement used to treat zinc deficiency

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Methadone (5 mg every 8 hrs.): treats moderate to severe pain

Oxandrolone (10mg every 12 hrs.): promotes weight gain after surgery, trauma, or

infection

Senna tablet (8.6 mg daily): used as a laxative and stimulant

Docusate oral liquid (100 mg every 12 hours): stool softener and laxative

Silver sulfadiazine 1% cream (topical application daily): antibiotic used in partial

thickness or full thickness burns

Acetaminophen (650 mg every oral every 4 hrs. as needed): treats minor pain and

reduces fever

Midazolam HCL (100 mg in sodium chloride .9%/100 ml IV infusion, initiate

infusion at 1 mg/hr.): used as anesthesia or a sedative

Hydromorphone (injection .5-1 mg, intravenous every 3 hrs. as needed): a

narcotic used to control pain

Fentanyl (injection 50-100 mcg intravenous every 15 minutes as needed): used to

control pain

Propofol (10mg/ml premix infusion, start at 25mcg/kg/min intravenous

continuous): used as anesthesia or sedative

Thiamin (100 mg x 3 days): a B1 complex vitamin, treats vitamin B1 deficiency-

beriberi

Folate (1 mg x 3 days): vitamin B, treats anemia

Allergies: Tylenol
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Dietary HX: not following any specific diet. Stable weight for past 6 months. Has not

been monitoring blood glucose levels for about a year.

Medical HX: diabetes, HTN, GERD

Surgical HX: cholecystectomy 30 years ago.

Social history: Recently unemployed and coming from Atlanta, GA to move in with his

parents. Previously lived alone. Smokes 1 PPD for >30 yrs., and drinks heavily consuming 2-3

beers daily an up to 1 case of beer on Saturdays and Sundays. English is primary and only

language. 11 years of primary education.

Relevant family medical history:

Father: HTN

Mother: Anxiety disorder, HTN

Hospital diet order: NPO with EN. Impact with glutamine @ 20 ml/hr., advance 20

ml/hr. every 4 hrs. to 60 ml/hr. Final goal rate per RD.

Previous medical nutrition therapy: N/A

Hospital course:

40% TBSA burn: Managed per burn team. Daily dressing changes continued.

Sent to OR for debridement and split thickness skin grafting.

Respiratory failure: Intubated for airway protection. Bronchoscopy performed.

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Pain: Versed gtt (drops), increase methadone to 10mg every 8 hours. Dialudid

and fentanyl prn (when necessary). Wean Propofol to off possibly by the end of the day of

admission: currently at 25ml/hr.

Hyperkalemia: Secondary to metabolic, respiratory acidosis. Improving Last

K+5.9. Continue to resuscitate with LR (lactated Ringers solution).

Protein-calorie malnutrition: Advance TF to goal rate per nutrition.

Acute kidney injury: Continue fluid resuscitation.

Part 2

Disease state:

The patient was admitted with level 2 trauma caused by burns covering 40% of body

surface area after being involved in a trailer fire, and the wounds appear to have ruptured blisters

and devitalized skin. Specifically, the burns involve the face, bilateral upper extremity, bilateral

lower extremity circumferentially, scrotum, back, and buttocks. The burns on the patients

abdomen and lower extremity were judged to be of a 1st degree nature and of partial thickness;

the burns sustained on the patients right arm and mid/left back are 2nd degree in nature; and his

burns presented near the inguinal region were noted to present erythema and blistering at the

head of the penis and scrotum. A performed nasopharyngolaryngoscopy revealed laryngeal

edema and soot on the vocal cords bilaterally, and therefore it has been recommended to intubate

the patient for this reason. Occasional wheezing exhibited by the patient may be related to smoke

inhalation as evidenced by observed patchy infiltrates on the performed chest x-ray.

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In despite of his injuries sustained, a Glasgow coma score was rated as 14, signifying that

the patient is fully conscious and lucid. The range of motion ascribed to the patient in the

affected and relevant areas is diminished with reports of pain. The patients medical history

shows that he has diabetes, HTN, and GERD, which will surely complicate any nutritional

intervention. Compacted with this is the patients surgical history revealing a performed

cholecystectomy over 30 years ago. However, lowfat, highprotein, highcarbohydrate, enteral

tube feedings with appropriate caloric content are recommended, and as such the

cholecystectomy may not prove problematic in terms of fat consumption (Nutrition MD, 2017).

Diabetes has multiple effects on molecular biology in non-healing wound patients, including

hyperglycemia, decreased or impaired production of cytokines and their receptors that interfere

with the function of cells such as macrophages, and collagen accumulation, with these factors

possibly making infection more likely in this individual (Qing, 2017). Beside macrophages,

neutrophils also play an important role in the healing process, and Tennenberg et al. found that

neutrophils from patients with diabetes are prone to apoptosis or programmed cell death, which

may be related with hyperglycemia (Qing, 2017). Accordingly, this would cause decreased

functional longevity of neutrophils and increased neutrophil clearance from infectious sites,

possibly contributing to the increased susceptibility and severity of infections in diabetic patients

(Qing, 2017). Additionally, the patients abdomen was observed to be distended. In relation to

this, it has been shown that burns cause plasma, the fluid component of the blood, to leak from

the blood vessels, and it is this loss of circulating fluid that may elicit shock in the individual

(Burn, 2016).

In order to prompt wound healing, protein needs for this patient will be elevated within a

range of 1.5-2g/kg/day in alignment with recommendations for the critically ill including burn
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victims (Charney, 2016). This is even more necessary when considering that burn patients have a

non-functional skin barrier in the affected areas, therefore they experience loss of liquids,

minerals, proteins and electrolytes, which can lead to protein, energy and micronutrient

deficiencies due to intense catabolic processes, infections and increased bodily needs (Muzaffer,

2016). The loss of fluid in the patient in question should already be established as is evidenced

by a nursing assessment observing poor skin turgor in the patient. Moreover, for burn injuries

with >20% of total body surface area, energy needs can be as much as 140% of basal energy

requirements, and protein needs can be as much as 150% of usual protein requirements (Skolnik,

2015). Complimentary to this recommendation, when considering enteral feeding it has been

advised to choose a formula with higher amounts of protein, between 20-25% of kcals

consumed, and to additionally select a formula with supplemental glutamine and omega-3 fatty

acids for increased healing (Nelms, 2016).

PART 3

Lab results Reference Range Actual Significance in Disease State

Potassium 3.5-5.5 5.9 Occurs due to cellular and tissue damage

Chloride 95-105 113 Indicates dehydration
Carbon Dioxide 23-30 20 Due to smoke inhalation
Creatinine Serum 0.6-1.2 1.26 Indicates kidney dysfunction/disease
Glucose 70-110 211 Indicates diabetes
Magnesium 1.8-3 1.5 Loss through wounds
Calcium 9-11 6.9 Loss through wounds
Protein 6-8 4.7 Loss through wounds
Albumin 3.5-5 2.1 Levels seen in inflammation, shock,
malnutrition
Prealbumin 16-35 12 Associated with sepsis and organ
dysfunction
AST 0-35 44 Liver damage, may be due to alcohol use
C-Reactive <1 12 Indicates inflammation or a long-term
Protein disease state
WBC 4.8-11.8 18.1 Related to trauma or inflammation
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Hemoglobin 14-17 18.7 Occurs when the body needs an increased
oxygen capacity
Hematocrit 40-54 54.4 Related to dehydration or decreased
oxygen
PH 7.35-7.45 7.31 Acidic state of the body
HCO3 24-28 19.6 Metabolic acidosis

Due to the fact that he was quickly admitted for burn injury, rather than for another

disease state, this was the only laboratory data that was obtained. All of this data indicates that he

was severely burned, has chronic alcohol abuse, hypertension, and has unmaintained diabetes.

Specifically, the patients C-reactive protein (CRP) levels were severely elevated in alignment

with his state of trauma and thus inflammation. In relation to this trend of observed elevated CRP

was the presence of hypoalbumenia, as decreased levels of albumin have been shown to be

correlated negatively with CRP levels, suggesting that serum albumin levels are more closely

associated with inflammation than nutrition status (Ishida et al., 2014). Moreover,

hypoalbumenia is common in critically ill patients including burn patients, and Ramos et al. has

found that hypoalbumenia is associated with greater affected body surface area (BSA) in relation

to burns, greater burn severity and higher mortality rate (Ishida et al., 2014). Hypoalbumenia in

burn patients results from fluid resuscitation and higher vascular permeability in burn wounds

that allows higher exudation and a subsequent protein loss through the wound, which is

something that should certainly be taken in to consideration in the process of healing along with

protein needs (Ishida et al, 2014).

Beyond the trend of these two lab results, BUN and osmolality were shown to be within

acceptable limits, seemingly suggesting that the patient is not severely dehydrated, at least for the

time being. However, the presence of hypoalbumenia may skew the results associated with

osmolality. Additionally, and as would be expected, WBC was elevated beyond normal limits in
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association with the patients injured state. Glucose levels were severely elevated in accordance

with the patients diabetes. However, it has been noted that nearly all burn patients experience

insulin resistance as part of their hypermetabolic response compounded with the effect from any

concurrent diabetes, and will need to be placed on an insulin drip to maintain tight control of

their blood glucose levels (Nutrition MD, 2017). This was noted as being done in the medication

notes. Finally, the result of lowered bicarbonate concentrations corresponds with his lowered

serum Ph and noted metabolic acidosis.

PART 4

A complete 24 hour dietary recall could not be obtained from this patient, however, it

was recorded that he consumes two to three beers daily and a case on Saturday and Sunday. This

is an extreme amount of alcohol consumption and exceeds the upper recommendation of alcohol

for males, which is up to two beers every day. It was also obvious from his lab report that his

blood glucose was twice the normal limit, which is an indicator for the patients diagnosis of

diabetes. Since he knew of this prior diagnosis, it can be concluded that he either has not had

diabetes education to help control his glucose levels, or simply does not want to change his

eating habits which would improve his condition. Therefore, it would be beneficial for this

patient to be referred to a dietitian after discharge from the hospital. Upon admission, he needed

to be intubated for airway protection due to edema and soot on the vocal cords. Due to this, he

was put on a Parkland formula using lactated Ringers (LR) at 610 mL/hr. Later, he was put on

an NPO (nothing by mouth) diet with EN (enteral nutrition). The formula used was Impact with

Glutamine at 20 mL/hr, advance 20 mL/hr every four hours to 60 mL/hr.

The administering of an enteral formula with glutamine seems like the best course of

action being as a number of historic small single-center randomized controlled trials (RCTs)
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have demonstrated positive treatment effects on clinical outcomes with glutamine

supplementation, and meta-analyses based on these trials demonstrated a significant reduction in

hospital mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS with

intravenous (IV) glutamine supplementation (Mundi et al., 2016). Additionally, the importance

of initiating enteral feeding with glutamine as early as possible in the critically ill can be attested

to by the fact that in this population glutamine stores can become depleted in 25%35% of cases

at the time of admission to the ICU (Mundi et al., 2016). While it is not stated if the enteral route

of administration was placed as a duodenostomy or rather a gastrostomy, the latter is preferable

as the duodenal route is better tolerated than gastric feeding due to an 18% failure rate in the

latter from regurgitation (Nutrition MD, 2017).

If the Impact formula being administered contains 2 kcals/ml at the high end for this

formula, then once the goal rate of 60 ml/hr is achieved, the patient will be ingesting 2,280

kcal/day which, while certainly a large caloric intake, is insufficient energy consumption for this

individual based on calculated needs at 3,380 kcals as figured below. With this being the case, it

would be recommended to increase the prescribed goal rate to 71 ml/hr with Impact 2 with

glutamine for a daily caloric intake of 3,408 kcals, which would be just greater than what was

calculated. Another consideration is seen in regards to the aforementioned diagnosis of diabetes

identified in the patient. With this in mind, one may consider using a specialized diabetes enteral

formula, as these formulas have a different macronutrient breakdown compared with standard

formulas, intended to aid in improved glycemic control: approximately 40% kcal from

carbohydrate, 20% from protein, and 40% from fat (Brown et al., 2015).

However, the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL)

explored whether the nutrient composition of EN affects the cost of medical care, mortality,
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hospital length of stay, and infectious complications of critically ill patients with DM, and due to

the scarcity of research in this area at this time, it does not appear that the routine use of DM-

specific EN formulas is indicated (Brown et al, 2015). Therefore, the Impact 2 with glutamine

will be maintained as the chosen EN formula. Monitoring urine output has been shown to be the

most reliable method of monitoring fluid resuscitation, namely 0.5 ml/kg/hour (an average of 30-

50 ml /hour) for an adult, and with his urine output recorded at 1295 ml (18ml/kg) over a 24 hr

period, this amounts to roughly 54 ml/hr, indicating that hydration status is acceptable (Grobler

et al., 2012). However, this may also allude to excessive fluid loss. Additionally, water loss in

burn victims can be as much as 4 liters/m2/day, and a range of 30 to 50 ml/hr is given depending

on urine output. Originally, he was administered 610ml/hr, which amounts 14,640ml/day. Yet,

when using the Parkland formula, which was claimed to be used for the former figure, 11,392

ml/day is calculated, and therefore this will be used for the rest of the patients treatment.

RMR (MSJ): 71.2kg (10) + 183cm (6.25) - 65 (5) = 1536kcals

1536kcals (140%) = 2150kcals (inadequate)

New formula: 25kcals/kg + 40kcals/1%TBSA (Nutrition MD, 2017)

25kcals * 71.2kg + 40 * 40%TBSA = 3380kcals

Protein needs: 2g (71.2kg) = 142g

142g (150%) = 213g

213g (4kcals/g) = 852kcals

852kcals/3380kcals = ~25%

Fluid needs:
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Originally given 610ml/hr = 14, 640ml

Parkland formula (IV used for burn patients) 4ml x TBSA (total burned surface area) (%) x body

weight (kg)

4ml * 40 (%TBSA) * 71.2kg = 11,392ml or 474ml/hr

PART 5

New EN prescription: NPO with EN Impact 2 with glutamine @ 20 ml/hr, advance 20 ml/hr

every 4 hours to goal rate of 71 ml/hr.

PES 1: Inadequate energy intake, related to total burn surface area of 40%, as evidenced by

calculated energy needs at 3,380 kcals.

Intervention: Change enteral prescription to provide enough kilocalories for proper healing.

Goal: Maintaining health of the patient and improving the state of his burns.

PES 2: Inadequate protein intake, related to total burn surface area of 40%, as evidenced by

calculated protein needs at 213g.

Intervention: Change enteral prescription to provide enough protein for proper healing.

Goal: Maintaining health of the patient and improving the state of his burns.

PES 3: Inconsistent carbohydrate intake, related to diagnosis of diabetes, as evidenced by

plasma glucose at 211 mg/dL.

Intervention: Nutrition education about diagnosis and the importance of carbohydrate counting.

Goal: Normalize blood sugar levels.

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