Natalie Rohr

Andrea Rose
KNH 411
Professor Matuszak
Case Study 29: Open Abdomen
1. The patient has suffered a gunshot wound to the abdomen. This has resulted in an open
abdomen. Define open abdomen. The medical record describes the use of a wound VAC. Describe
this procedure and its connection to the diagnosis for open abdomen.
Juan underweight a laparostomy surgery. This technique is used when the fascia of the abdomen is left
open intentionally (exposed to the environment) to avoid elevation of intra-abdominal pressure, or IAP.
This allows a quick access to Juans abdomen if a follow-up surgery is required. Leaving the abdomen
open also prevents pressure buildup that may lead to further complications. A temporary abdominal
closure, or TAC, is achieved using a dressing or technology intended to protect the exposed viscera. The
wound VAC is an advanced procedure that closes the wound by using a vacuum. The treatment minimizes
hospitalization, increases outpatient comfort, and achieves dramatic results. The VAC procedure applies
localized negative pressure to draw the edges of the wound to the center of the site. The negative pressure
is applied to a special dressing positioned within the wound cavity. By applying the pressure directly to
the wound, fluid is able to be removed (the fluid may cause swelling, stimulate cell growth, increase
blood flow) and therefore the healing response can be increased. Since Juans abdomen was left open just
in case a follow-up surgery was needed, by using the VAC procedure, it can help decrease the chances of
fluid build up within his abdominal cavity.
Vacuum-Assisted Closure (VAC) - Wound Care. (2015, June 18). Retrieved October 26, 2015,
from http://www.wakehealth.edu/Plastic-Surgery/Wound-Care/Vacuum-Assisted-Closure.htm

Friese, R. (2012, June 19). Open Abdomen. Retrieved October 26, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/22714062

2. The patient underwent gastric resection and repair, control of liver hemorrhage, and resection of
proximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on
this patients ability to meet his nutritional needs.
After undergoing multiple surgeries regarding the GI tract, there are several potential effects of the
surgeries on Juans ability to meet his nutritional needs. Gastric resection and repair can often lead to
symptoms of early satiety or sudden fullness. This feeling can lead to inadequate oral intake for the

patient since they feel full faster. Dumping syndrome is another symptom that may develop. Dumping
syndrome is thought to occur because there is a decrease in the amount of space left in the GI tract, so the
ability to hold nutrients before they are released into the intestines is reduced. Treatment for dumping
syndrome includes small frequent meals, limited liquids at meals, avoidance of very sugary foods and
greasy foods.
Juans liver hemorrhage may result in a decreased production of bile which can hinder the digestion and
absorption of dietary fats. The digestion and absorption of dietary fats can be problematic following a
gastric and small bowel resection. Other factors that may affect this include increased rate of nutrients
moving through the GI tract (dumping syndrome) and a decrease in enzyme production.
Since majority of nutrients obtained by the body are absorbed in the jejunal portion of the small intestine,
undergoing a resection of proximal jejunum may decrease Juans ability to absorb nutrients such as B
vitamins, thiamin and folic acid, through his GI tract. Starting Juan on an enteral nutrition or PO early is
thought to help aid in his recovery.
Pataki, L. (n.d.). Nutritional Challenges After Surgery. Retrieved October 26, 2015, from
http://www.gistsupport.org/media/GISTS 2011/Pataki_2011_Nutritional_Challenges_After_GIST_Sur.pdf

Jeejeebhoy, K. (2002, May 14). Short bowel syndrome: A nutritional and medical approach. Retrieved
October 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
3. The metabolic stress response to trauma has been described as a progression through three
phases: the ebb phase, the flow phase, and finally the recovery or resolution. Define each of these
and determine how they may correspond to this patients hospital course.
The stress response has been described as a progression through three phases: the ebb phase, the flow
phase, and finally the recovery or resolution phase. The ebb phase encompases the immediate period after
surgery (2-48 hours). This period is characterized by shock resulting in hypovolemia and decreased
oxygen availability to tissues. There is a fall in insulin levels and a rise in glucagon.The reduction in
blood volume results in decreased cardiac output and urinary output. The goal of medical care during this
acute period is to restore blood flow to organs, maintain oxygenation of all tissues, and stop all
hemorrhaging. As the patient stabilizes, the flow phase begins. This phase emcompasses the classic signs
and symptoms of metabolic stress: hypermetabolism, catabolism, and altered immune and hormonal
responses. The final adaptation phase or recovery phase indicates a resolution of the stress with a return to
anabolism and normal metabolic rate (Nelms 668). When Juan first was admitted to the hospital, h was

most likely in the ebb phase. He was admitted on 3/22 and lab values were not recorded until 3/29,
therefore it can not be certain how long Juan was in the ebb phase. His flow phase started right after his
ebb phase ended and lasted at least until 3/29. His glucose levels, while still high on 4/1, starting
lowering, which suggest that he was entering the recovery phase.
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In Nutrition
Therapy and Pathophysiology (Third ed). Boston, MA: Cengage Learning.
4. Acute-phase proteins are often used as a marker of the stress response. What is an acute-phase
protein? What is the role of C-reactive protein in the nutritional assessment of critically ill trauma
patients? What other acute-phase proteins may be followed to assess the inflammatory stress
response?
An acute-phase protein is one whose plasma concentration increases (positive acute-phase proteins) or
decreases (negative acute-phase proteins) by at least 25% during inflammatory disorders (Nelms 669). Creactive protein is made by the liver and it is released into the blood within a few hours after tissue injury,
the start of an infection, or other case of inflammation. In other words, the C-reactive protein indicates
inflammation or infection in trauma patients. It can also show when the patient has moved into the
recovery phase. Positive acute phase proteins, such as C-reactive and alpha-1-antitrypsin, tend to increase
when there is inflammation and negative acute phase proteins, such as albumin and prealbumin, decrease
during injury. Other acute-phase proteins that may be followed include fibronectin, ceruloplasmin, and
serum amyloid A.
C-reactive protein: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved October 26, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003356.htm

Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In Nutrition
Therapy and Pathophysiology (Third ed.). Boston, MA: Cengage Learning.
5. Metabolic stress and trauma significantly affect nutritional requirements. Describe the changes
in nutrient metabolism that occur in metabolic stress. Specifically address energy requirements and
changes in carbohydrate, protein, and lipid metabolism.
The level of injury and subsequent risks really affect the nutritional requirements due to metabolic stress
and trauma. There is a delicate balance between prevention of malnutrition and prevention of the possible

complications of nutrition support. During metabolic stress, the body is in a catabolic state and is
therefore breaking down proteins and muscle mass which in turn puts the body in a negative nitrogen
balance. Measured weight may not be reflective of actual weight due to fluid resuscitation, losses from
wounds, and loss of blood, therefore when determining REE, actual body weight, ideal body weight, or
adjusted body weight will be used for obese patients (since Juan is considered obese, this would be how
we would figure out his energy requirements). For normal-weight individuals, actual body weight is used
in calculations for REE. ASPEN guidelines recommend that patients with a BMI greater than 30 should
receive approximately 25-30 kcal/kg of ideal body weight per day. For normal-weight individuals, it is
recommended 25-30 kcal/kg of actual body weight. Protein requirements should be estimated
approximately 1.2-1.5 grams of protein/kg of ideal body weight per day. Glucose recommendations for
trauma patients is 30-70% of total daily caloric intake, or 2-5g/kg/day. Lipid recommendations are 1530% of total daily caloric intake or less than 0.1g/kg/hr.
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In Nutrition
Therapy and Pathophysiology (Third ed.). Boston, MA: Cengage Learning.
Reference Cards. (n.d.). Retrieved October 26, 2015, from http://www.meded.virginia.edu/pda/refcards/criticalcare/Cal.htm
6. Are there specific nutrients that should be considered when designing nutrition support for a
trauma patient? Explain the rationale and current recommendations regarding glutamine,
arginine, and omega-3 fatty acids for this patient population.
For trauma patients, it is very important that they increase their caloric and protein needs. The
recommendations for protein are anywhere from 1.2 - 1.5g/kg a day. The percentage of calories needed
depends on the patient's EER and the severity of the trauma. Typically it is 30-35 kcal/kg Along with
calories and protein, there is also an increased need in vitamin C, vitamin E, zinc, and selenium. It has
been shown through research that early provision of micronutrients, such as zinc and selenium, improves
recovery. There is also an increased need for B vitamins, potassium, magnesium, phosphorous, and zinc
due to cutaneous losses, the catabolic state, and urinary losses. Not too fiber is recommended because gut
motility is already decreased due to the trauma. Arginine and glutamine are both amino acids that are
recommended in the recovery process in order to help rebuild and maintain lean body mass. Arginine is
an amino acid that promotes protein synthesis and wound healing. Glutamine helps decrease gut
inflammation and gut permeability. Both of these amino acids help prevent muscle breakdown and
catabolism. More research on both of these amino acids has to be done so for now there are no definite

recommendations. Omega-3 fatty acids are important for trauma patients because it helps reduce
inflammation and regulates normal blood lipoprotein.
Kim, J. (n.d.). Wound Healing. Retrieved October 26, 2015, from
http://www.med.upenn.edu/gec/user_documents/KimStefankiewiczWoundHealing.pdf

Todd, S. (2006, October 21). Nutrition support in adult trauma patients. Retrieved October 26, 2015,
from http://www.ncbi.nlm.nih.gov/pubmed/16998141

Hayes, G. (n.d.). Nutritional Supplements in Critical Illness. Retrieved October 26, 2015, from
http://www.aacn.org/wd/cetests/media/acc224.pdf
7. Using current evidence-based guidelines, explain the decision-making process that would be
applied in determining the route for nutrition support for the trauma patient.
First we would have to look at the reason for the patients metabolic stress. For Juan, his metabolic stress
and trauma was induced by a gunshot wound followed by multiple surgeries. We would then need to
assess the patient to see if he/she is getting the correct energy intake orally and if they are not, we would
then need to evaluate the patient for either parenteral or enteral nutrition. Juan is not not able to receive
his necessary energy orally so when prescribing what to do next we would need to look at how his gut is
functioning. Since Juans GI tract is not functional, we would write him a diagnosis and intervention for
TPN. If patients show symptoms of diseases of the small intestine, radiation enteritis, moderate to severe
pancreatitis, severe diarrhea, and hyperemesis, then a diagnosis and intervention of TPN would also be
required. If a patient shows signs or symptoms of dysphagia, cancer of head or neck, or esophageal
obstruction, then EN would be diagnosed, however, this is not the case in Juans situation.
Enteral Nutrition and Total Parenteral Nutrition. (n.d.). Retrieved October 26, 2015, from
http://www.rcuonline.net/images/ENandTPN.pdf
8. Calculate and interpret the patients BMI.
BMI wt in kg / (ht in m) squared
BMI 102.7 / (1.78 m) squared = 32.1

When interpreting a BMI of 32.1, it can be said that the patient is obese because a BMI greater than 30 is
considered obese.
9. What factors make assessing his actual weight difficult on a daily basis?
Factors that make assessing his actual weight difficult on a daily basis include edema or fluid losses while
the patient was in the ebb phase of metabolic stress. During this phase, the patient lost a lot of fluid,
resulting in lowering his body weight. Then in the flow phase, it is possible that swelling can occur due to
fluids recovering from the ebb phase, resulting in a weight gain for the patient. During these phases it is
possible to see the weight shifting up and down multiple times so it would be hard to get an accurate read.
10. Calculate energy and protein requirements for Mr. Perez. Use at least two methods (including
the Penn State) to estimate his energy needs. Explain your rationale for using each one. For the
Penn State calculation, the minute ventilation is 3.5 L/minute and the max temperature is 39.2.
Harris Benedict 66.5 + (13.75 x 102.7kg) + (5 x 177.8cm) - (6.78 x 29) = 2171 x
1.4 (injury factor) = 3039 kcal (2500 - 3500 kcal/day)
Penn State (0.85 x 2171) + (175 x 39.2) + (33 x 3.5) - 6,443 = 2378 kcal (20003000 kcal/day)
I used the Penn State energy requirement method because the Penn State equation has the highest
accuracy when compared to measured energy expenditure. It is also imperative to include consideration
of any paralytic drugs and mechanical ventilation that are used to treat the critically ill patient, as these
interventions affect energy requirements (Nelms 671-672). I then used the Harris Benedict method
because it wa required that that method was used and then the calories determined from that equation, put
into the Penn State equation.
Protein requirements major surgery 102.7 kg x 1.5 g of protein = 154 g protein/day
The patients protein needs were calculated based on the requirement of 1.5 because he has undergone
major surgery and protein will help him heal at a faster and more appropriate rate.
11. What does indirect calorimetry measure?
The most commonly used approach for measuring energy requirements in critically ill patients and in
human metabolic research is indirect calorimetry. It is based on the fact that energy expenditure is
proportional to the bodys oxygen consumption and carbon dioxide production. Expired air contains less
oxygen and more carbon dioxide than inspired air. When the differences in oxygen and carbon dioxide in

inspired and expired air are known and the volume of air moving through a subjects lungs is measured,
the bodys energy expenditure can be calculated (Nelms 254).
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In Nutrition
Therapy and Pathophysiology (Third ed). Boston, MA: Cengage Learning.
12. Compare the estimated energy needs calculated using the predictive equations with each other
and with those obtained by indirect calorimetry measurements.
Based on the Harris Benedict equation he needs 3039 kcals. According to the Penn State equation he
needs 2378 kcals. The indirect calorimetry shows his current energy expenditure to be 3657 kcals. His
actual energy expenditure is much higher than calculated from the predictive equations. This is due to the
fact that the trauma will cause a higher need of energy to help with the healing.
13. Interpret the RQ value. What does this indicate?
The RQ value is 0.76 on 3/29. It is the ratio of carbon dioxide released to the oxygen consumed. This
helps to indicate the metabolism of the patient because the value will change depending on what type of
source is being broken down for energy. The RQ value for glucose is 1 while the RQ value for saturated
fat is .667. His RQ value of 0.76 shows that he is breaking down more fat than carbohydrates.
Metabolism for Energy and the Respiratory Quotient. (n.d.). Retrieved October 26, 2015, from
http://www.tiem.utk.edu/~gross/bioed/webmodules/respiratoryquotient.html
14. What factors contribute to the elevated energy expenditure of the patient?
Factors that contribute to Juans elevated energy expenditure include his surgeries (gastric repair, control
of liver hemorrhage, and the resection of proximal jejunum), his gunshot wound injury and the healing
process that comes along with that, his high BMI, as well as his fever and respiratory rate could all
influence his high energy needs.
15. Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and grams of
protein are provided with his prescription. Read the nutrition consult follow-up and the I/O record.
What was the total volume of PN provided that day?
With Mr. Perez is currently receiving 2964 kcal and 194 g of protein with his prescription of 135 mL/hr.
The total volume provided that day from his prescription would be 3240 mL. According to the I/O record,
Mr. Perez is receiving 3312 mL from his TPN, therefore it can be said that he is receiving less mL of TPN

than he is supposed to be receiving (3888 mL, even though it says he needs 3657). Also based on the I/O
record it can be said that he is retaining some fluid with his daily intake being 5472 mL and his daily
output being 4584 mL for a positive net I/O of 888mL.
16. Compare this nutrition support to his measured energy requirements obtained by the metabolic
cart on day 7. Based on the metabolic cart results, what changes would you recommend be made to
TPN regimen, if any? What are the limitations that prevent the health care team from making
significant changes to the nutrition support regimen?
Based on the current metabolic cart measurement, it does not indicate overfeeding so we will
recommended to continue the current TPN regimen. We also recommended to initiate trickle feeds of
Pivot at 5 mL/hr (an additional 120 mL and 180 kcal and 11.2 g of protein a day). A limitation that would
prevent the healthcare team from making significant changes to the nutrition support regimen would be
how he progresses in healing from his surgeries and whether or not he has to go back into the ER for
another surgical procedure.
17. The patient was also receiving propofol. What is this, and why should it be included in an
assessment of his nutritional intake? How much energy did it provide?
Propofol is a drug that slows nervous system activity. It helps with sedation. It is available as an emulsion
similar to a 10% parenteral lipid emulsion and provides 1.1 kcals/mL as fat. This means that there are
extra lipid calories that are obtained from the propofol. These need to be included in the assessment so
that there will not be problems with overfeeding due to not including these calories. In his case, his
propofol is adding an additional 924 kcal.
DeChicco, R. (n.d.). Contribution of Calories from Propofol to Total Energy Intake. Retrieved October
26, 2015, from http://www.andjrnl.org/article/S0002-8223(95)00438-6/abstract
18. The RD recommended that trickle feeds be initiated. What is this and what is the rationale? The
RD recommended the formula Pivot 1.5 for these trickle feeds. What type of formula is this, and
what would be the rationale for choosing this formula?
It said it was recommended to initiate trickle feeds of Pivot at 5 mL/hr. It provides 1.5 kcal/mL and 22.2 g
of protein per 237 mL serving size. Based on that, he would be getting 120 mL which provides 180 kcal
and 11.2 g of protein that day from the Pivot trickle feeds. Trickle feeding is when the feedings are given
at a very reduced rate from actual metabolic needs in order to supplement parenteral feedings. The Pivot
1.5 formula has concentrated calories to help with fluid-restrictions. It also has high protein content which

can help with his healing. It is a hydrolyzed, peptide-based protein system to help promote absorption. It
also has arginine, glutamine, and omega-3 fatty acids which will help with immune function. In his case,
this formula is helpful because he needs to be able to easily absorb the protein so that it is there to help
him with the healing of his wound and trauma. The immune support also is beneficial in that is will help
him to lessen the opportunity for infection because his immune cells will be able to fight it.
Pivot 1.5 Cal. (n.d.). Retrieved October 26, 2015, from
http://abbottnutrition.com/brands/products/pivot-1_5-cal
19. List abnormal biochemical values for 3/29, describe why they might be abnormal, and explain
any nutrition-related implications.
On 3/29 his sodium, BUN, creatinine serum, glucose, osmolality, alkaline phosphatase, ALT, AST, CPK,
lactate dehydrogenase, C-reactive protein, VLDL, LDL, triglycerides, and HbA1c were all high.
His inorganic phosphate, total protein, albumin, prealbumin, and HDL-C were all low.
Parameter

Normal Value

Patients Value

Reason for
Abnormality

Nutrition
Implication

BUN

10.0-20.0

23

Open abdomen
wound healing,
trauma, surgery

Break down of
LBM,
malnourished

Glucose

70-110 mg/dL

164 mg/dL

Liver hemorrhage

Monitored to
prevent
hyperglycemic

Osmolality

285-295

309.3

Inadequate fluid
intake

Dehydration

Alkaline
phosphatase

30-120 U/L

540 U/L

High glucose
levels and
intestinal injury

Patient needs
consistent CHO same mL every
hour

ALT

4-36 U/L

435 U/L

Muscle and
intestinal injuries

Consistent CHO same mL every

hour

AST

0-35 U/L

190 U/L

Shock and severe

injury

Consistent CHO same mL every

hour

CPK

55-170 M U/L

182 M U/L

Shows muscle
damage

Increase protein
intake

Lactate
dehydrogenase

208-378 U/L

750 U/L

Shows possible
tissue damage

Monitor patient consistent CHO

levels

C-reactive protein

<1.0 mg/dL

245 mg/dL

Increased
inflammatory
response

Body no longer in
catabolic stage

VLDL

7-32 mg/dL

110 mg/dL

High levels of
plaque deposits in
artery walls

Reduce
cholesterol

LDL

<130 mg/dL

140 mg/dL

High cholesterol

Reduce
cholesterol

TG

40-160 M mg/dL

274 M mg/dL

Respiratory
difficulties

Monitor - patient
not overfed

Total protein

6-8 g/dL

5.2 g/dL

Open abdomen
healing, trauma,
surgery, protein
catabolism

Break down of
LBM

Albumin

3.5-5 g/dL

1.4 g/dL

Protein loss

Not receiving
enough protein

Prealbumin

16-35 mg/dL

3.0 mg/dL

Marker of
infection,
inflammation,
malnutrition, and
surgery

Low protein
intake,
malnutrition

HDL-C

>45 M mg/dL

40 mg/dL

High cholesterol

Reduce
cholesterol

20. Current guidelines recommend using a nitrogen balance study to assess the adequacy of
nutrition support.
According to Powell (2012) article, what adjustments should be made to assess for nitrogen
losses through fistulas, drains, or wound output?
An increase in protein intake should be made to assess for nitrogen losses through fistulas, drains, and
wound outputs. If there is a negative nitrogen balance, that means that the patient is using more protein to
heal than they are being fed, therefore they are receiving inadequate protein. If the patient underwent a lot
of trauma or metabolic stress, the grams of protein they are receiving still may not be enough due to
wounds, fistulas, or drainage that is causing them to use more protein to heal than what they are receiving.

A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42g. Calculate
his nitrogen balance.
N2 balance = (dietary protein intake / 6.25) - urine urea nitrogen (UUN) - 4
N2 balance = (194 g protein / 6.25) - 42g - 4
N2 balance = -14.96
Since Juans nitrogen balance is negative, this means that the intake of nitrogen into the body is greater
than loss of nitrogen from the body. This means that Juan is not receiving adequate amounts of protein
through his PN.
21. Identify the nutrition diagnosis you would use in your follow-up note. Complete the PES
statement.
Inadequate protein intake (NI-5.6.1) related to metabolic stress and trauma due to a gunshot wound to the
abdomen as evidenced by a negative nitrogen balance.
22. For the PES statement that you have written, establish an ideal goal and an appropriate
intervention.
Goal: Provide enough protein in Juans TPN to ensure that his nitrogen balance is positive in order to heal
promptly as well as ingesting enough protein for the body to function properly.
Intervention: Monitor the amount of protein Juan is receiving to ensure that he is getting adequate
amounts in order to help heal his abdominal wounds and supply the body.
23. What are the standard recommendations for monitoring the nutritional status of a patient
receiving nutrition support?
Nitrogen balance is the biggest way of monitoring a trauma patients nutritional prescription. Determining
serum levels of acute phase reactants such as C-reactive protein, fibrinogen, and alpha-1-glycoprotein and
constituent proteins such as prealbumin, retinol binding protein, and transferrin can also help in
monitoring the nutrition status.
Trauma, J. (2004, September 1). Nutritional Support: Monitoring (Which Tests and How Often?).
Retrieved October 26, 2015, from https://www.east.org/education/practice-managementguidelines/nutritional-support--monitoring-(which-tests-and-how-often-)

24. Hyperglycemia was noted in the laboratory results. Why is hyperglycemia of concern in the
critically ill patient? How was this handled for the patient?
Hyperglycemia often occurs in ICU patients. It can lead to hospital complications and the risk is often
higher in patients that do not have a history of diabetes. Stress hyperglycemia will often decrease as the
surgical stress decreases. There is a strong correlation with hyperglycemia and mortality, morbidity,
length of stay, infections, and overall complications. To control this, the patient was given sliding scale
insulin. From 3/29 to 4/1 his glucose decreased from 164 mg/dL to 140 mg/dL. This is still outside of the
reference range, but it has gotten closer to where it should be.
Farrokhi, F., Smiley, D., & Umpierrez, G. (n.d.). Glycemic control in non-diabetic critically ill patients.
Retrieved October 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718463/
25. What would be the standard guidelines and subsequent recommendations to begin weaning
TPN and increasing enteral feeds?
TPN should be discontinued with transition to PO or enteral nutrition as soon as possible. Once enteral
feedings of PO intake has advanced to greater than 50% of estimated kcals, and the patient is tolerating
this well, the PN formula can be weaned or discontinued. PN can be restarted in 2-3 days if the patient
does not continue to tolerate enteral or PO nutrition of if the intake is less than 50% of estimated
requirements.
Madsen, H. (n.d.). The Hitchhiker's Guide to Parenteral Nutrition Management. Retrieved October 26,
2015, from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestivehealth/nutrition-support-team/nutrition-articles/MadsenArticle.pdf

References:
C-reactive protein: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved October 26, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003356.htm
DeChicco, R. (n.d.). Contribution of Calories from Propofol to Total Energy Intake. Retrieved October
26, 2015, from http://www.andjrnl.org/article/S0002-8223(95)00438-6/abstract
Enteral Nutrition and Total Parenteral Nutrition. (n.d.). Retrieved October 26, 2015, from
http://www.rcuonline.net/images/ENandTPN.pdf
Farrokhi, F., Smiley, D., & Umpierrez, G. (n.d.). Glycemic control in non-diabetic critically ill patients.
Retrieved October 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718463/
Friese, R. (2012, June 19). Open Abdomen. Retrieved October 26, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/22714062
Hayes, G. (n.d.). Nutritional Supplements in Critical Illness. Retrieved October 26, 2015, from
http://www.aacn.org/wd/cetests/media/acc224.pdf
Jeejeebhoy, K. (2002, May 14). Short bowel syndrome: A nutritional and medical approach. Retrieved
October 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
Kim, J. (n.d.). Wound Healing. Retrieved October 26, 2015, from
http://www.med.upenn.edu/gec/user_documents/KimStefankiewiczWoundHealing.pdf

Madsen, H. (n.d.). The Hitchhiker's Guide to Parenteral Nutrition Management. Retrieved October 26,
2015, from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestivehealth/nutrition-support-team/nutrition-articles/MadsenArticle.pdf
Metabolism for Energy and the Respiratory Quotient. (n.d.). Retrieved October 26, 2015, from
http://www.tiem.utk.edu/~gross/bioed/webmodules/respiratoryquotient.html
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In Nutrition
Therapy
and Pathophysiology (Third ed). Boston, MA: Cengage Learning.
Pataki, L. (n.d.). Nutritional Challenges After Surgery. Retrieved October 26, 2015, from
http://www.gistsupport.org/media/GISTS
2011/Pataki_2011_Nutritional_Challenges_After_GIST_Sur.pdf
Pivot 1.5 Cal. (n.d.). Retrieved October 26, 2015, from
http://abbottnutrition.com/brands/products/pivot-1_5-cal
Reference Cards. (n.d.). Retrieved October 26, 2015, from http://www.meded.virginia.edu/pda/refcards/criticalcare/Cal.htm
Todd, S. (2006, October 21). Nutrition support in adult trauma patients. Retrieved October 26, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/16998141
Trauma, J. (2004, September 1). Nutritional Support: Monitoring (Which Tests and How Often?).
Retrieved October 26, 2015, from https://www.east.org/education/practice-managementguidelines/nutritional-support--monitoring-(which-tests-and-how-often-)
Vacuum-Assisted Closure (VAC) - Wound Care. (2015, June 18). Retrieved October 26, 2015, from
http://www.wakehealth.edu/Plastic-Surgery/Wound-Care/Vacuum-Assisted-Closure.htm