Guesstimates and TF recs

My patients are getting really complicated. The first lady I saw this week had nonalcoholic steatohepatitis, hypertension and serious fluid excess (the first hospital she had been to had pulled 7 liters out of her via paracentesis!), diabetes, and failing kidneys, but she was actually admitted for a pulmonary infection. When my RD asked me about my plan for assessing her, I think I looked at her blankly. We ended up asking her about recent weight change (she reported about a 47% weight loss over the last 6 months), any diet that she follows at home, and her current appetite. We switched her to 6 small meals each day to try and increase her intake, and we are following up with her on Friday to see how her labs have changed.

The renal service has been a little slow this week, so we’ve spent a bit of time working on TF recommendations for neuro trauma patients. Many of them come in from the ER and we often don’t have good heights for the patients, so we estimate based on how much of the bed they are taking up. It makes me a little nervous to be using such a crude metric…however, we usually we all come up with the same guess. A couple of lessons from this experience:

-Propofol is an IV sedative that many trauma patients receive. Each mL of propofol provides 1.1 kcal from fat, which needs to be calculated into a TF regimen. My patient this afternoon was receiving 36 mL/hr, for a total of 950 kcal from the medication alone (about 42% of his overall calorie requirements!) We ended up switching him from the CHO control formula he was on to a high protein formula in order to meet his protein needs without exceeding his energy needs. Since his glucose had been high (probably due to the prednisone he was receiving), we had to justify the change in the note. I am looking forward to following up and seeing if they take our recommendation.

-My RD tells me that the literature has shown that it is ok to underfeed head trauma patients, as long as their protein needs are being met. Outcomes are not worse in patients who receive only 70% of their estimated nutrition needs (except protein).

I’m bracing to watch a PEG placement tomorrow – my RD is going to sit this one out because she said she nearly fainted the last time she watched one. Oy.