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A 77-year-old man is admitted to the hospital after a cardiac arrest. He suffered a massive anterior wall myocardial infarction. The patient underwent an intra-aortic balloon pump and is now in an intensive care unit requiring mechanical ventilation. He has a history of well-controlled hypertension and hyperlipidemia. There is no history of diabetes mellitus, kidney disease, or stroke. He was a former smoker (1 PPD × 15 years, quit about 35 years ago), does not consume alcohol, and has no allergies. He takes metoprolol 50 mg po twice daily, simvastatin 20 mg po daily, aspirin 81 mg po daily, and lisinopril 10 mg po daily. Prior to this admission, he had lived independently with his wife and was able to perform his daily activities without difficulty. He managed his own finances and was driving.

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Physical examination reveals a 5-ft, 48-kg (body mass index [BMI] 21 kg/m2) elderly male on mechanical ventilation on a propofol drip. Per the patient's wife, his weight is about 12% less than what he had weighed about a year ago. Pulse is 120/min regular, BP 100/60 mm Hg, respiration is 24/min, and temperature is 38.9°C. His skin is warm and dry with good capillary refill. Chest is clear to auscultation bilaterally with poor inspiratory support. Cardiac examination reveals tachycardia with occasional skipped beats. S1 and S2 are noted without murmurs. Abdomen has normal bowel sounds. Extremities show good pulses with 1+ pedal edema. The patient is restless and anxious. He is not aggressive but has vigorous movements.

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Lab work reveals albumin 2.8 g/dL, BUN 28 mg/dL, creatinine 0.7 mg/dL, hemoglobin 9.6 g/dL, and serum cholesterol 115 mg/dL. Additional lab tests are unremarkable. Nursing reports that the patient had a large bowel movement a day ago.

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On day 4, the patient continues to be in the intensive care unit with response to painful stimulus. He opens his eyes to verbal commands and nods appropriately to yes/no questions. It has been difficult to wean him off ventilator support and he continues to remain on mechanical ventilation. The patient's family is concerned about the patient's nutritional status and wants to start nutrition on him; they confirm that the patient continues to be a full code.

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1. How would you approach the nutritional assessment in this patient?

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2. What are the possible routes for nutritional support in this patient?

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3. What are the potential complications associated with the above approach?

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Answers

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  1. In acute care settings, anorexia, various disease processes, test procedures, and medications can compromise dietary intake. Under such circumstances, the goal is to identify and avoid inadequate intake and assure appropriate alimentation. The objective is to gather enough information to establish the likelihood of malnutrition due to poor dietary intake or other causes to assess whether nutritional ...

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