Question

On hospital day (HD) 3, you visit Adam and learn that he has been NPO since admission due to his medical GI evaluation. Because Adam is feeling better and his GI symptoms have resolved, the medical team has just advanced Adam to a regular diet. Adam reports an excellent appetite and is looking forward to eating.

Anthropometric Data:
Weight: 73 kg (161 lbs)
Last weight: 75 kg (165 lbs) at admission

Biochemical Data: (HD 3)
Sodium 134 (135-145 mEq/L) Glucose 95 (70-139 mg/dL)
Potassium 3.3 (3.6-5.0 mEq/L) Phosphorus 2.9 (2.7 - 4.5 mg/dL)
Blood Urea Nitrogen 22 (6-24 mg/dL) Magnesium 1.4 (1.3 - 2.1 mEq/L)
Creatinine 0.2 (0.4-1.3 mg/dL)

Clinical Data:
Medications: protonix, lipitor, captopril

Dietary Data:
Diet Prescription: Regular

Questions
1. Is Adam at risk for refeeding syndrome? Explain.
2. What biochemical indices should be monitored with refeeding syndrome?
3. What factors mediate the refeeding process?
4. Do you have any recommendations for interventions for Adam?


On HD 6, Adam undergoes an urgent laparotomy for a severe gastric ulcer with perforation. On postoperative (postop) day 1/HD 7, you visit Adam for reassessment. He is currently in the ICU on mechanical ventilation with increased drainage from a nasogastric tube.

Anthropometric Data:
Weight: 77 kg (169 lbs) on HD 7
Last weight: 73 kg (161 lbs) on HD 3

Biochemical Data: (postop day 1/HD 7):
Sodium 143 (135-145 mEq/L) Creatinine 0.2 (0.4-1.3 mg/dL)
Potassium 3.5 (3.6-5.0 mEq/L) Glucose 139 (70-139 mg/dL)
Chloride 88 (98-110 mEq/L) Calcium 7.7 (8.5-10.5 mEq/L)
Carbon Dioxide 41 (20-30 mEq/L) Phosphorus 3.0 (2.7 - 4.5 mg/dL)
Blood Urea Nitrogen 24 (6-24 mg/dL) Magnesium 1.4 (1.3 - 2.1 mEq/L)
Arterial Blood Gas:
pH 7.48 (7.35-7.45)
PaCO2 48 (35-45 mm Hg)
PaO2 90 (80-100 mm Hg)
HCO3 29 (22-26 mEq/L)

Dietary Data:
Diet Prescription: NPO

Questions
1. Describe Adam’s acid–base status.
2. What specific acid–base disorder does he have?
3. What interventions would you recommend to manage this acid–base imbalance?

It is now postoperative day 6/HD 12 and Adam remains in the ICU. He is currently receiving enteral nutrition support since postop day 3, which provides him with 1,700 calories and 100 g protein.

Anthropometric Data:
Weight: 76 kg (167 lbs)
Last Weight: 77 kg (169 lbs) postop day 1/HD 7
Admit weight 75 kg (165 lbs)

Biochemical Data:
Albumin 2.1 g/dL (3.5 to 5.0 g/dL)
Prealbumin 14 g/dL (17-36 g/dL)
Urine urea nitrogen (UUN) 10 g/24 hours

Questions
1. How do you interpret Adam’s current albumin and prealbumin levels? What information does this provide to your assessment of Adam’s nutritional status?
2. Calculate Adam’s nitrogen balance. Is he in positive or negative nitrogen balance?
3. Based on this information, how would you assess Adam’s current nutrition plan?
4. What biochemical indices can you monitor to further assess nutritional adequacy?

It is now HD 15 and Adam is recovering well. He has been moved out of the ICU to the medical ward and is preparing for discharge home. His appetite and oral intake are improving. Based on his labs and symptom of fatigue, an iron supplement is ordered.

Biochemical Data (HD 15):
Hemoglobin 12.0 (13.5 to 17.5 g/dL)
Hematocrit 34 (42 to 52%)
Mean corpuscular volume 98 (80–99 fL)
Red cell distribution width (RDW-SD) 50 (39-46 fL)

Clinical Data:
Medications: iron, protonix, lipitor, captopril

Dietary Data:
Diet Prescription: Regular
Questions

1. Describe the abnormalities in Adam's biochemical data.
2. What type of anemia or anemias might Adam have? What are his risk factors?
3. What additional biochemical measures would be required to make a more accurate assessment?

Answer 1

1. Yes, he has the risk for refeeding syndrome, as he is appetite, he may suddenly intake excessive diet.

2. In refeeding syndrome we can find hypophosphatemia mainly and other electrolyte imbalances. so we have to monitor serum phosphate level, glucose, pottasium, magnesium & other electrolytes.

3. sudden excessive calorie intake induces insulin secretion to conversion of glycogen it requires the phosphorus, magnesium as a co-factor. Because of previous starvation, its depletion & excessive intracellular intake for glycogen process, decreased serum phosphate level and fatal consequences.

4.Intervention for refeeding syndrome is at beginning low calorie supplement along with electrolytes and vitamin supplementation.

1. Adam has metabolic alkalosis

2. Metabolic alkalosis with compensatory Co2 retention

3. Metabolic alkosis occurs as a result of gastic acid loss, fluid replacement is recommended