Critical Care

and Sepsis Clinical

Case Study
By: Zachary Neveu, KSC Dietetic Intern
Background
The Elliot Hospital
Manchester, NH

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 The Elliot Hospital

The Elliot Hospital The Elliot Health System includes:

The Elliot Health System (EHS) is the largest The Elliot Hospital (main campus)
comprehensive health care provider in Southern New
Elliot at Rivers Edge (outpatient, urgent care, endoscopy)
Hampshire.
The Elliot Hospital was founded in 1890, now it is the Medical Center at Londonderry
center of the EHS. The main campus has 296 acute Medical Center at Hooksett
care beds.
Elliot Senior Health Center
The Elliot Health System is a non-profit
organization the mission is; Elliot Primary Care (multiple locations)
INSPIRE wellness Elliot Pharmacy at Rivers Edge
HEAL our patients
SERVE with compassion in every interaction
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 The Role of Dietitian at the Hospital

Clinical Dietetics
There are 16 dietitians on staff at the main campus both part and full time
(Not including per diems)
These dietitians cover Fuller, CICU, Fitch, GPU/GBU, Pathways consults,
ICU, Pediatrics/Maternity, NICU.
There are nutrition groups in GPU/GBU as well as Pathways.
On certain days dietitians will cover the NICU clinic and Cardiac Rehab.

Outpatient Dietetics
Outpatient RDs see patients for bariatrics, diabetes, weight loss and
other conditions. (Elliot Center for Advanced Nutrition Therapy)
The Elliot licenses dietitians for Hannafords supermarket.
There is also an outpatient oncology dietitian who follows oncology
patients. 4

Sepsis
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 Pathophysiology
Etiology
Sepsis is a typically life threatening condition when the bodies
natural response to infection cause damage to its own tissues
and organs and often hemodynamic instability putting the patient
in critical condition.
Sepsis is caused by an immune response to an infection.
Diagnostic Criteria
Meet the criteria for Systemic Inflammatory Response
Syndrome (SIRS) and have a confirmed or probably infection.
For SIRS typically two of the following criteria;
Body temperature of 101F (38.3C) or above (Febrile) If left untreated severe Sepsis can lead to significant decreased
Heart rate higher than 90 beats per minute
Respiratory rate higher than 20 breaths per minute
Septic shock usually involves the above criteria combined with
Hemodynamic instability.
Treatment
Broad spectrum antibiotics to treat the infection
Fluid resuscitation with IVF to increase arterial pressure
Vasopressors to increase arterial pressure if not responding
adequately to fluid resuscitation
Ventilation in response to respiratory failure
Sedation, especially if significant interventions are required
Supportive services such as nursing and nutrition
Progression
urinary output (hypoperfusion), abrupt changes in mental status,
respiratory failure and abnormal heart function.
Multiple organ dysfunction syndrome
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 Pathophysiology MADE
EASY!
Initial Insult Uncontrolled Inflammatory Response Shock
(accident, surgery, infection, etc.) (Cytokine storm) (Low blood perfusion)

Impaired immune system and

Tissues and cell injury Organ Dysfunction other systems
(Cause they cant get oxygen!) (Because damaged tissues) (Renal insufficiency, respiratory
insufficiency, GI ischemia)

Multi Organ Dysfunction

Syndrome
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 Relevant Lab Values / Monitoring

Temperature
Electrolytes
Sodium, Potassium, Phosphorus, Magnesium, indicator of hydration, kidney function, risk for refeeding
Liver Function Tests (LFTs)
ALT, AST, T. Bili, Elevated LFTs can been seen early in Sepsis, later it could be an indicator of MODS
BUN, Creatinine, Urine Output
Indication of kidney function and level of hypoperfusion, also can indicate hydration status
Low urine output is a very negative sign
Lactic Acid
Indication of significant anaerobic respiration caused by hypoperfusion. Range is 0.5-1 mmol/L
Mean Arterial Pressure
Average arterial pressure in one cardiac cycle. Range 70 - 110 mm Hg 8
 Relevant Medications

Vasopressors
Induce vasoconstriction and elevate blood pressure, increase MAP, Treatment for hypoperfusion

Sedation
Used highly in the ICU, especially when the patient is intubated and has significant interventions or surgery, reduces
incidence of PTSD from the ICU

Antibiotics (ABX)
Used for treatment of the cause of sepsis. Due to the systemic infection at least 2 broad spectrum ABX are used but positive
blood cultures for specific bacteria can indicate the use of more specific ABX to treat the initial infection

IVF
For fluid resuscitation and electrolyte repletion, can also provide small amount of dextrose

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 HELP I FORGOT

Medical Nutrition Therapy / Nutrition Support THAT STUFF

FROM UNDERGRAD

Indications for Nutrition Support

Nutrition support can increase the expected outcomes in critically
ill patients, even in the non-malnourished population.
Early enteral nutrition has shown improve immune response,
prevent protein calorie malnutrition, delay increased gut
permeability.
Parenteral nutrition has a much narrower window and should not
be started in the first week of admission unless the patient was
malnourished prior to admission.
Depends on the rate, access, timing, content and mobility of the
patient.
As dietitians a large part of working with the critically ill is to
determine when to feed and formulating TPN or calculating TFs.

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The Case
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 Presentation, History, Anthropometrics, Dietary
Patient
L.R. 35 y/o female who presented to ED for UTI like symptoms.
Condition deteriorated rapidly and was admitted to Trauma and
Acute Care Surgery (TRACS) emergently and transferred to the
Intensive Care Unit (ICU).
Past Medical History
PMHx includes: ADHD, bipolar disorder, depression, anxiety,
meningioma.
Staff was unable to obtain a detailed history due to not having an
extensive electronic record with us and the rapid deterioration of
the patients condition.
24 hours prior to arrival
The family reports she ate the whole day prior to arrival, what she
ate was not reported.
She came to the ED for UTI like symptoms and was not feeling
well.
She has had no recent prior hospitalizations.
Anthropometrics
Height: 5 7 (170.2 cm) Weight: 236.7 lbs (107.3 kg)
Diet history was unable to be obtained.
The patients medication history was insignificant.
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 Day 1 - 7/25 (Late PM) through 7/26 - Wednesday
Hospital Course
Admitted to the ED for UTI like symptoms.
Alert on arrival.
Patient became confused with slurred speech in the ED.
Patient was shown to be tachycardic and hypotensive, she was
intubated with an O2 sat of 87%.
She was given a CT scan which showed free air and fluid in her
peritoneal cavity, she was given an NGT to low continuous
sunction (LCS)
Started on Vancomycin (GI) and Zosyn (Broad)
Admitted to TRACS for Exploratory laparotomy, surgery included
washout of peritoneum and limited sigmoid colon resection with
a temporary closure. Her bowel was left discontinuous.
Urine Output: 1070 ml
RD Note
Meds: levophed, vasopressin, adrenalin (pressors), fentanyl,
diprivan, precedex (sedatives), insulin drip
Labs: Na 142, K 4.2, BUN 23, Cr 1.06, Lactic Acid 3.1, ALT 32,
AST 49, T. Bili 0.4
Temp: 101 F (38.3 C)
Metabolic Stressors: Septic shock, peritonitis, acute respiratory
failure (Intubated FIO2% of 60)
Calculated energy requirement protein requirements.
Dx statement: Inadequate oral intake r/t acute illness, altered GI
function, GI surgery and vent status AEB NPO order.
Is this patient appropriate to feed?
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Peritoneal Cavity

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 Day 2 - 7/27 - Thursday

Hospital Course
Meds: levophed, vasopressin, adrenalin, fentanyl, diprivan, precedex, insulin drip
discontinued, started low dose sliding scale insulin every 6 hours
1 blood culture positive, awaiting results, continuing Vancomycin and Zosyn

Still NPO with OGT to LCS

IVF: Normal saline at 100 ml/hr

Current plan is for surgery tomorrow for possible colostomy.

Urine Output: 1062 ml

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 Day 3 - 7/28 - Friday

Hospital Course RD Note

Surgery scheduled for today
Exploratory laparotomy, with peritoneal washout, diverting
colostomy and appendectomy (because they were in the
neighborhood)
Ostomy stoma looks dusky, possible revision on Monday
Urine Output: 1779 ml
Meds: levophed, adrenalin (pressors), fentanyl, diprivan,
precedex, nimbex
Labs: Na 139, K 3.8, BUN 29, Cr 0.83, Lactic Acid 2.9
Temp: 102.5 F (38.9 C)
Metabolic Stressors: Septic shock, peritonitis, acute respiratory
failure (Intubated FIO2% of 40)
Same statement, same energy requirements
+16288 liters positive since admission for fluid balance

Is this patient appropriate to feed?

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 Day 4 - 7/29 (Saturday) & Day 5 - 7/30 (Sunday)
Hospital Course - Day 4
Meds: levophed, adrenalin, fentanyl, diprivan, precedex, nimbex
discontinued, lassix started
Sepsis is resolving d/t abx treatment
Started lassix due to 16 liters positive fluid balance
Labs: Na 139, K 4.3, BUN 25, Cr 0.54, Lactic Acid 2.1
Still NPO with OGT to LCS
Wake up assessment performed, patient unable to follow
commands but reaching for endotracheal tube, restraints applied.
Sedatives started at half rate.
Urine Output: 4838
Hospital Course - Day 5
Meds: levophed, adrenalin, precedex, fentanyl, zyprexa, lassix
Attempting to wean off pressors
Removing other sedative d/t likelihood of saturation
Started diflucan (abx) due to blood cultures
Labs: Na 145, K 3.4, BUN 24, Cr 0.75, Lactic Acid 1.6, Phos 1.5
Still NPO with OGT to LCS
Draining brown serous liquid for JP drain
Wake up assessment performed, signs of delirium, started
Zyprexa (antipsychotic)
Urine Output: 5231 ml 17
 Day 6 - 7/31 - Monday
Hospital Course
Per surgery able to start trickle or trophic tube feed today
Per MD at rounds he would like to wait until a CT scan can be
done tonight to determine the status of the peritoneal fluid, hold
TF until CT results.
Patient is off pressors, wake up assessment today with attempt
to extubate. Patient still unresponsive
Purulent drains from JP drain, lower abdomen incision opened up
to drain into dressing
Colostomy stoma looks better per MD, no revision
RD Note
Meds: precedex, fentanyl, zyprexa, lassix
Labs: Na 147, K 2.7, BUN 23, Cr 0.49, Lactic Acid 1.1, Mag
1.8, Phos 2.2
Temp: 101 F (38.3 C)
Metabolic Stressors: Intubated at FIO2% of 35
Same statement, same energy requirements
+8700 liters positive since admission for fluid balance
Per TRACS recommended Replete at 10 ml/hr when patient is
ready. Isotonic, low calorie and high protein formula.
Is this patient appropriate to feed?
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 Day 7 - 8/1 - Tuesday

Hospital Course
Trophic TF of 10 replete per hour started at 8:30 am
Formula provides: 240 kcal, 15 grams of protein and 202 ml of
water
Meds: fentanyl, precedex, zyprexa, lassix, propofol
Received propofol overnight
Cutting down on fentanyl and adding oxycodone for pain relief
Labs: Na 150, K 3.7, BUN 19, Cr 0.51, Mag 2.1, Phos 1.8
Hypoactive bowel sounds, no ostomy output yet
Draining serous liquid for JP drain

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 Day 8 - 8/2 - Wednesday
Hospital Course
Prepared TF recommendation prior to rounds
Replete at 10 ml/hr increaser by 10 ml/hr Q8 to 40 ml/hr
Formula provides: 960 kcal, 61 grams of protein and 806 ml of
water, 107 g/CHO/day
Patient had wake up assessment in the morning and was
successfully extubated! Patient is off sedatives.
During rounds MD discussed clear liquid diet with ice chips
Patient able to speak and is oriented states I feel awesome
Bowel sounds improving in LUQ and LLQ
Trophic feeds through NGT
RD Note
Meds: zyprexa, lassix
Discontinued precedex for wake up, discontinued Zosyn
Labs: Na 148, K 3.7, BUN 16, Cr 0.49, Phos 2.0
Temp: 99.6 F (37.6 C)
Same statement, same energy requirements
+10138 liters positive since admission for fluid balance
Patient is able to eat and is waiting for a diet order to be
approved by MD and surgery
Recommended following for diet education related to new
ostomy diet teaching.
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 Day 9 - 8/3 (Thursday) and Day 10 - 8/4 (Friday)
Hospital Course - Day 9
Now on home meds for anxiety/bipolar disorder
Labs: Na 146, K 2.8, BUN 11, Cr 0.40, Phos 2.5
Removed NGT and stopped trophic feeds
Diet was upgraded to a Regular diet, asked MD during rounds to
make diet a Soft/Low Residue per hospital protocol.
Bowel sounds are active
Ostomy output: 700, 150, 300 ml (all brown)
Still following for educational needs when ready.
Possible transfer to Fuller unit today, MD has reservations.
Hospital Course - Day 10
Labs: Na 142, K 3.1, BUN 7, Cr 0.47
Transferred to Fuller late last night
Changed diet to Soft/Low Residue per my recommendation and
then make to Clear liquid
Still with altered mental status and intermittently delirious but
resolving
Sending Boost Orange and Berry with trays (clear) to assist with
nutritional intake
Ostomy output: 250, 150, 100 ml (all brown)
Still following for educational needs when ready.
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 Day 13 - 8/7 (Monday) and Day 14 - 8/8 (Tuesday)
Hospital Course - Day 13
No new labs
Temp: 98 F
Ostomy output: 200, 300, 250 mls
Bowel sounds are active, patient is eating approximately 50% of
meals.
Attempted to meet with patient for diet education, the patient did
not seem ready for diet education and seemed like she wasnt
very responsive or clear so education was deferred to the next
day.
Dx statement: Inadequate oral intake r/t altered GI function, GI
surgery AEB low reported intake (50% x 2 meals)
Hospital Course - Day 14
Still with heightened oxygen needs but likely at baseline due to
physical deconditioning/fatigue
Weaning off prednisone, finished all antibiotics, needs to
ambulate more and work with PT/OT
Educated patient on new ostomy diet. Discussed foods to avoid
or slowly add back to the diet and foods to eat. Discussed smaller
more frequently and ensuring good chewing and digestion
practice.
The patient demonstrated very good understanding of the diet
and showed good motivation. We talked about her regular diet
and it involved a lot of fruits and vegetables and whole grains.
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 Day 17 - 8/11 - Thursday

Hospital Course
I met with the patient for a follow up to see if she had any
additional questions.
She was satisfied with her diet teaching.
Medical and surgical had signed off on the patient.
She was waiting for PT/OT to sign off to be Discharged.

Anticipated discharge is to a rehab facility

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Thanks!
Questions?
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 References
SlidesCarnival for presentation theme and template
Various websites for images (Cited in notes)
Resources from The Elliot Hospital
Resources from AND Nutrition Care Manuals
Mcclave, Stephen A., et al. (2014) Feeding the Critically Ill Patient.
Critical Care Medicine, vol. 42, no. 12, pp. 26002610.,
doi:10.1097/ccm.0000000000000654.
Mcclave, Stephen A., et al. (2016) Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Adult Critically Ill
Patient. Journal of Parenteral and Enteral Nutrition, vol. 40, no. 2, pp.
159211., doi:10.1177/0148607115621863.
Miller, K. R., Kiraly, L. N., Lowen, C. C., Martindale, R. G., & Mcclave, S.
A. (2011). CAN WE FEED? A Mnemonic to Merge Nutrition and
Intensive Care Assessment of the Critically Ill Patient. Journal of
Parenteral and Enteral Nutrition,35(5), 643-659.
doi:10.1177/0148607111414136
Mullins, Ashley. (2016) Refeeding Syndrome: Clinical Guidelines for
Safe Prevention and Treatment. Support Line.
McCray, Stacey, Walker, Sherries, Parrish, Carol R. (2005) Much Ado
About Refeeding Nutrition Issues in Gastroenterology. Series #23. pp
26-44
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