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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • List contraindications to enteral nutrition (EN) therapy.

  • Calculate the protein, calorie, and fluid requirements for a patient who is to receive EN therapy.

  • Recommend an appropriate enteral formula and feeding route.

  • Implement an appropriate monitoring plan to achieve the desired nutritional endpoints and avoid complications.

  • Design an appropriate regimen for administering medications via a feeding tube, including recommending alternate dosage forms for medications that cannot be crushed.

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PATIENT PRESENTATION

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Craig Baker is a 47-year-old man referred to the nutrition support team for evaluation and possible initiation of parenteral nutrition. The history on the referral states: admission to the hospital 3 days ago with c/o nausea, vomiting, and abdominal pain, primarily in the epigastric and LUQ region. Continued c/o nausea and abdominal pain; no vomiting in the last 24 hours. He is currently NPO except for sips of water for comfort.

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QUESTIONS

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Problem Identification

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1.a. What other information is necessary or would be helpful to evaluate the patient and provide recommendations for a nutrition support plan of care?

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1.b. What is the appropriate timing for nutrition intervention?

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1.c. Based on risk-versus-benefit considerations, is the consult for initiation of parenteral nutrition appropriate for this patient?

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CLINICAL COURSE

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After following appropriate procedures, you obtain the following additional information about the patient.

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HPI

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Mr Baker began having symptoms of nausea and epigastric/LUQ pain about a week (per patient) prior to hospital admission. He thought this would “go away on its own; like in the past,” and then he began feeling weak and dizzy. He finally asked a friend to take him to the ED after he had several episodes of vomiting the day before admission. His history indicates five episodes with symptoms of nausea and abdominal pain in the last 8 months. With previous episodes, the pain was reported as less severe and lasted only a couple days; nausea occurred, but there was no vomiting; he was not weak or dizzy. He did not go to the hospital with the past episodes since the pain improved on its own.

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In the ED, Mr Baker received 6 L of 0.9% NaCl for hydration; D5%/0.45% NaCl + 20 mEq KCl/L has been infusing at 150 mL/h since then. A CT scan in the ED indicated edema of the proximal pancreatic duct with possible stricture and a small pancreatic pseudocyst.

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Height: 72 in. Weight: no admission weight available; weight on hospital day 2 was 84 kg. Patient states that he lost a few pounds when he was hospitalized 4 months ago but ...

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