Question

Rhonda is a 67yo retiree recently involved in an MVA. She’s comatose in the neuro ICU and her medical team is concerned about cerebral edema. As a result, they’ve placed her on a severe fluid restriction. Rhonda’s prognosis is sketchy; she’s been in a coma for 2d already, her O2 sats are dipping and your team has decided to intubate and place her on mechanical ventilation. The good news is that she does have bowel sounds and the dietetic intern has been asked to provide tube feed recommendations. At this point, Rhonda’s ICU doc is confident that her condition will require tube feeding for at least 8 weeks. Your intern is formulating a plan, but she needs some of your expertise.  Below are the questions she’s posing to you (6pts each):

a. Since Rhonda may come out of her coma in a couple of days, I was thinking we’d use an NG tube for her feedings. Sound good? If not, what would you do?

b. The medical team has requested a continuous (24h) tube feed. We have a lot of formulas to choose from, but I don’t see one specific for comatose patients. Do you have any suggestions based on Rhonda’s condition and treatment plan?

c. 8 weeks later: Rhonda’s been out of her coma for and off of mechanical ventilation for a week now. Her condition is stable, her fluid restriction has been lifted, and the medical team would like her to start eating a PO diet, at least a little bit. The original tube feed order (from part b) is still in place and Rhonda’s stated that she doesn’t have any appetite. Do you have any suggestions forchanges we can make to Rhonda’s tube feed order to help increase her appetite and encourage PO intake?

d. Another 2 weeks later: Rhonda’s completely off of her tube feed,but her appetite is still somewhat low and her PO intake isn’t meeting her estimated energy and protein needs. She did a great job on the tube feed, so how about we just give her some of the same enteral formula to drink in-between meals? That will help get some extra calories and protein into her system, right?  If not, what might you suggest?

P

Answer 1

a. NG tube feeding in comatase patient is very difficult and may complicate to aspiration pneumonia as stomach contents regurgitate. So gastrostomy is better method. 1st week can be given by enteric route. 2nd week onwards parenteral route can be advised.

b. The patient with cerebral edema will have increased intracranial pressure leading to challenges in enteric feeding for a long time. nutritional requirement is very high as there will be increased metabolism and catabolism. Average of 25 to 30 calorie per kg per day is required. 1.5 to 2 gram of protein per kg per day is required to be included in formula. Less than 35% of calorie to be made up of fats. 325 mg of magnesium is required for proper brain function. Other multivitamins and antioxidants to be included in the formula.

c. Instead of continuous feeding by tube, we can order for intermittent or cyclic feeding. This can encourage PO diet taken orally

d. Its better to avoid tube feeding at this moment. 75% body weight . K calorie to be supplemented with immune enhancers to be given