Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017

Case Report Imprimir 

Páginas 217 a 224


Clinical and nutritional evolution of an adolescent accompanied in an Intensive Care Unit of a teaching hospital: case report

Evolución clínica y nutricional de un adolescente acompañado en un Centro de Terapia Intensiva de un hospital de enseñanza: relato de caso

Evolução clínica e nutricional de um adolescente acompanhado em um Centro de Terapia Intensiva de um hospital de ensino: relato de caso

Autores: Alex Richard Costa Silva1; Daniele de Paula Orlandi2; Valdete Regina Guandalini3

1. Stepping in Nutrition and Health by the Graduate Program in Nutrition and Health. Graduation in Nutrition by the Federal University of Espírito Santo (UFES). Vitoria, ES, Brazil
2. Master in Public Management from the Federal University of Espírito Santo (UFES). Vitoria, ES, Brazil. Nutritionist of the Intensive Care Center of the Hospital Universitario Cassiano Antonio Moraes (HUCAM). Vitoria, ES, Brazil
3. Doctor in Food and Nutrition from Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP). São Paulo, SP, Brazil. Adjunct Professor, Health Sciences Center, Department of Integrated Health Education, Federal University of Espírito Santo (UFES). Vitoria, ES, Brazil

Correspondencia
Valdete Regina Guandalini
Universidade Federal do Espírito Santo
Av. Marechal Campos, 1468, Maruipe
Vitória, ES, Brasil. CEP: 29040-090
valdete.guandalini@ufes.br

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How to cite this article

Keywords: Adolescent, Protein-Energy Malnutrition, critical care, nutritional status.
Palabra Clave: Adolescente, desnutrición proteico-calórica, cuidados críticos, estado nutricional.
Descritores: Adolescente, desnutrição proteico-calórica, cuidados críticos, estado nutricional.

Abstract:
OBJECTIVE: Describe the clinical and nutritional evolution of an adolescent admitted to the Intensive Care Unit of a teaching hospital.
CASE DESCRIPTION: 18 years old adolescent, male, underwent hepatic transplantation in childhood due to chronic cholestasis of genetic etiology. He was hospitalized in the ward with convulsive seizures, upper airway inflammation, acute kidney injury (stage 3), with hypothetical diagnostic of H1N1 infection, nephrotoxicity by Tracolimus and glomerulopathy. He presented important tachydyspnea, evolving into acute respiratory failure, which is why he was brought to the Intensive Care Unit and submitted to orotracheal intubation.
COMMENTS: Chronic cholestasis and late hepatic post-transplant with the use of immunosuppressive drugs are related to the presence of protein-caloric malnutrition, low weight and height for the age in patients who do not undergo appropriate nutritional monitoring in long term and also to renal alteration, situations presented in this case. Enteral nutritional therapy was initially adopted for the patient while in the Intensive Care Unit. After extubation, he was weaned off it by introducing oral diet gradually.
CONCLUSION: Despite the limitations in nutritional evaluation, due to the patient's clinical history, the planned nutritional therapy turned out satisfactorily and positively, with rapid adaptation to nutritional needs, which contributed to the improvement of biochemical parameters, decrease of the effects of protein-calorie malnutrition and clinical condition.

Resumen:
OBJETIVO: Describir la evolución clínica y nutricional de un adolescente admitido en el Centro de Terapia Intensiva de un hospital de enseñanza.
DESCRIPCIÓN DEL CASO: Adolescente de 18 años, masculino, pasó por trasplante hepático en la infancia debido a colestasis crónica de etiología genética. Fue internado en la enfermaría con crises convulsivas, inflamación de vías aéreas superiores, lesión renal aguda AKIN III, con hipótesis diagnósticas de infección por H1N1, nefrotoxicidad por Tracolimus y glomerulopatía. Presentó taquidispnea importante, evolucionando para insuficiencia respiratoria aguda, motivo por el cual fue encaminado al Centro de Terapia Intensiva y sometido a entubación orotraqueal.
COMENTARIOS: La colestasis crónica y el post- trasplante hepático tardío con uso de inmunosupresores están relacionados a la presencia de desnutrición proteico-calórica, bajo peso y estatura para edad en pacientes que no realizan el acompañamiento nutricional adecuado a largo plazo y todavía a la alteración renal, situaciones presentadas en este caso. La terapia nutricional enteral fue inicialmente adoptada para el paciente en el Centro de Terapia Intensiva. Luego de la extubación, se adoptó el desmame de la terapia nutricional enteral, iniciándose gradualmente la inserción de la dieta por vía oral.
CONCLUSIÓN: A pesar de las limitaciones en la evaluación nutricional, debido al cuadro clínico del paciente, la terapia nutricional planeada evolucionó de manera satisfactoria y positiva, con rápida adecuación a las necesidades nutricionales, lo que contribuyó para la mejoría de los parámetros bioquímicos, atenuación de los efectos de la desnutrición proteico-calórica y de la condición clínica.

Resumo:
OBJETIVO: Descrever a evolução clínica e nutricional de um adolescente admitido no Centro de Terapia Intensiva de um hospital de ensino.
DESCRIÇÃO DO CASO: Adolescente de 18 anos, masculino, passou por transplante hepático na infância idade devido à colestase crônica de etiologia genética. Foi internado na enfermaria com crises convulsivas, inflamação de vias aéreas superiores, lesão renal aguda AKIN III, com hipóteses diagnósticas de infecção por H1N1, nefrotoxicidade por Tracolimus e glomerulopatia. Apresentou taquidispnéia importante, evoluindo para insuficiência respiratória aguda, motivo pelo qual foi encaminhado para o Centro de Terapia Intensiva e submetido à entubação orotraqueal.
COMENTÁRIOS: A colestase crônica e o pós- transplante hepático tardio com uso de imunossupressores estão relacionados à presença de desnutrição proteico-calórica, baixo peso e estatura para idade em pacientes que não fazem o acompanhamento nutricional adequado a longo prazo e ainda à alteração renal, situações apresentadas neste caso. A terapia nutricional enteral foi inicialmente adotada para o paciente no Centro de Terapia Intensiva. Após a extubação, adotou-se o desmame da terapia nutricional enteral, iniciando-se gradualmente a inserção da dieta por via oral.
CONCLUSÃO: Apesar das limitações na avaliação nutricional, devido ao quadro clínico do paciente, a terapia nutricional planejada evoluiu de maneira satisfatória e positiva, com rápida adequação às necessidades nutricionais, o que contribuiu para melhora dos parâmetros bioquímicos, atenuação dos efeitos da desnutrição proteico-calórica e da condição clínica.

INTRODUCTION

The alteration of the body composition occurs in great part of the pulmonary pathologies. Individuals may present progressive weight loss due to increased energy needs, which is related to both respiratory insufficiency and mechanical ventilation¹. However, excessive energy supply should be avoided by elevating the risk of hyperalimentation, a condition that is harmful to the individual, as a result of metabolic and respiratory changes, such as increased mechanical ventilation time, hyperglycemia, feedback syndrome, among other alterations¹.

In post-transplant of late liver, the renal alteration is a known cause. This alteration may be related to a number of reasons, including the use of immunosuppressants that worsen renal function if the individual has previously had a degree of nephropathy or is undergoing renal replacement therapy2,3 .

In the present article, we report the case of an 18 year old adolescent with respiratory and renal changes admitted to a teaching hospital located in the metropolitan region of Espírito Santo. With the worsening of the respiratory function, it was referred to the Intensive Care Center (ICU). We describe the clinical and nutritional evolution of the patient during the ICU stay until the Nephrology ward.


CASE REPORT

GJSFS is 18 years old, male, only child, single, brown, natural and resident of a municipality in the southern region of Espírito Santo. The younger brother died in childhood due also to the complications of a chronic cholestasis. Parents reported no morbidity. At two years and six months of age he underwent liver transplantation and the donor father was alive. In 2007, he was diagnosed with portal vein stenosis when a stent was placed. The patient also presents severe scoliosis, abdominal distension, intestinal constipation and moderate ascites.

In May 2016, this was treated in a teaching hospital with upper airway inflammation and acute kidney injury AKIN III, and suspected diagnosis of H1N1 infection, nephrotoxicity® tacrolimus and / or glomerulonephritis. At the ward, he presented important tachydyspnea and evolved to acute respiratory failure, which was why he was referred to the ICU, requiring orotracheal intubation.

Suspected H1N1 was ruled out following specific tests. The medical diagnosis was of acute respiratory failure and AKIN III acute renal injury of unknown cause, with indication for renal replacement therapy. Upon admission to the ICU, the patient was followed up by a multidisciplinary team composed of intensive care physicians, nurses, nutritionists, physiotherapists and speech therapists. The length of stay in this unit was 24 days.

With emphasis on the attributions of the nutritionist in the ICU, nutritional, biochemical and dietary prescriptions were performed. To evaluate the nutritional status, we used the referred weight, recumbent height and arm circumference (CB).The nutritional diagnosis was obtained by the curves of height for age and body mass index (BMI) by age proposed by the World Health Organization 4 . The classification of CB was given from the one recommended by Frisancho5.

From data of height (1.49 m) and weight (28.0 kg) indicated by the mother of GJSFS the BMI was calculated, obtaining 12.61 kg/m². The classification for height and BMI for age was below the 3rd percentile. CB presented 57.23% of adequacy, classifying it as severe malnutrition.

Clinical signs of severe malnutrition were observed, with presence of lower limb edema, temporal-orbital and deltoid-clavicular-sternal changes in all evaluations. The loss of muscle mass in the temporal-orbital muscles is related to decreased mastication and protein-calorie deficiency. Significant changes in the deltoid-clavicular-sternal parameter are also related to the process of loss of muscle mass in patients with malnutrition6,7. The presence of edemas in the lower limbs may be related to malnutrition, a consequence of the decrease in serum proteins 8 and also the absence of patient mobility during hospitalization time.

Serum proteins were below the reference values (RV) for most of the hospitalization time, confirming the process of malnutrition. Total proteins ranged from 3.91 to 6.65 g / dL, pre-albumin 19 to 27.1 mg / dL and albumin from 1.78 to 2.83 g / dL (Table 1). The total lymphocyte count (CTL)9 was analyzed, since malnourished patients present with compromised production of defense cells, which was found in this case. The percentage of lymphocytes and total leukocytes of the 6th, 13th and 23rd days of follow-up were considered, of which they indicated mild depletion (Table 1).




The Nutritional Risk Index (IRN) was also calculated 6 . The calculations were performed with the albumin values of the 6th day of hospitalization corresponding to the first result of this parameter and with 23rd day. The IRN results were 64.78% and 81.47%, respectively, both classified as severe malnutrition (Table 1).

Bromoprida®, Domperidone®, Lactulona® and Dimeticona®, which are gastrointestinal stimulants (GIT), may cause diarrhea as a side effect of increasing peristalsis10. Tracolimus® is an immunosuppressant and may cause nephrotoxicity, changes in potassium levels, hyperglycemia, constipation, ascites, uremia11,12, some of these conditions were observed in this case.

According to the anthropometric parameters, physical, clinical and biochemical signs approached, the nutritional diagnosis was severe malnutrition. The proposed nutritional care had the objective of reaching basic nutritional needs, recovering and preserving lean mass and nutritional status, in order to facilitate the weaning of mechanical ventilation. The route of administration, when on mechanical ventilation, was the enteral route through a nasoenteric tube. After 24 hours of extubation, the weaning of the enteral diet with oral feeding, after the speech therapy evaluation, was performed.

The calculation of energy requirements was based on the ideal weight of 38.8 kg, according to the BMI / age curve 4 using the Pocket Rule13. The initial target was 1164 kcal, (30 kcal / kg). For proteins, 1.5 g / kg / day was considered according to the recommendations for severe and dialytic patient 13 totaling 42 g / day. The selected micronutrients were those of importance in cholestasis and post-transplant liver late, being vitamins A, D and E, zinc, calcium, magnesium, potassium, phosphorus and iron according to the recommendations of daily intake (IDR) for age14-16.

Calories, protein and micronutrients were reached along dietary evolution (Table 2). As for micronutrients, only potassium, magnesium and vitamin D did not reach the daily recommendations, with 65.60%, 99.03% and 92.6% respectively. However, under these conditions, magnesium and potassium replacement is performed in the ICU routine as needed. While vitamin D supplementation was necessary. The other nutrients exceeded the daily recommendations of ingestion; however, they did not reach the maximum limits of ingestion (UL).




Table 3 shows the evolution of dietary management during the period of ICU stay. After hemodynamic stability, normocaloric oligomeric diet (16% protein and 1.0 kcal / mL) was prescribed. Following the suspension of the TGI-stimulating drugs, there was evolution to a normocaloric hyperproteic diet (21% protein and 1.2 kcal / mL).




After extubation, there was gradual weaning of the enteral diet with oral feeding, consistency evolution and number of meals according to the patient's acceptance and approval of the speech-language pathology team.

On the 24th day, the patient presented improvement of the clinical condition and was discharged from the ICU, continuing the follow-up and the hemodialysis sessions in the nephrology ward.


DISCUSSION

Malnutrition and depletion of lean mass are commonly found in ICU patients, increasing the risks of morbidity and mortality, especially in those who require a long hospital stay. Thus, the development of a hypermetabolic state associated with malnutrition is common17. The nutritional therapy adopted in this case proved to be efficient for improving biochemical parameters, reducing physiological stress, better prognosis and mechanical ventilation.

The inadequacy of the caloric supply in some moments is observed in studies18,19 of the same nature, especially in those patients on mechanical ventilation. The protein adequacy, reached on the 13th day of hospitalization, is consistent with findings in the literature. Fürst and Stehle20 suggest that increased protein supply may influence, in addition to protein synthesis, the supply of amino acids to act as substrates for structural, immunological and metabolic components.

When started early, nutritional therapy becomes fundamental in the care of the intensive patient, contributing to a decrease in length of stay and maintenance of mechanical ventilation, which is directly associated with recovery. It is essential that nutritional assessment be carried out in detail in order to identify nutritional changes early. The nutritional professional becomes essential in the intensive care routine, since the professional is specifically trained to conduct the patient's dietary behavior through nutritional, physical and clinical evaluation, and to determine the energy intake that will be offered to the patient in a way in order to avoid the feedback syndrome.


CONCLUSION

The planned nutritional therapy, with gradual evolution of the route of administration, consistency, quantity of calories, proteins and specific nutrients, provided adequate nutritional needs for patients with improved biochemical parameters, contributing to the attenuation of the effects of protein- and its clinical condition.


REFERENCES

1. Mueller DH. Dieta para diálise pulmonar. In: Mahan LK, Escott-Stump S, Raymond JL. Krause: Alimentos, nutrição e dietoterapia. Rio de Janeiro: Elsevier; 2012. p.794-95.

2. Charlton MR, Wall WJ, Ojo AO, Ginès P, Textor S, Shihab FS, et al. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl 2009;15(11):1-34.

3. Kong Y, Wang D, Shang Y, Liang W, Ling X, Guo Z, He X. Calcineurin-inhibitor minimization in liver transplant patients with calcineurin-inhibitor-related renal dysfunction: a meta-analysis. PLoS One 2011;6(9): e24387.

4. World Health Organization. Growth reference data for 5-19 years. 2007. Disponível em: http://www.who.int/growthref/en/.

5. Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor: University of Michigan Press; 1990. 189p.

6. Calixto-Lima L, Reis NT. Interpretação de exames laboratoriais aplicados à nutrição clínica. Rio de Janeiro: Editora Rúbio; 2012. 490p.

7. White JV, Guenter P, Jensen G, Malone A, Schofield M, Academy of Nutrition and Dietetics Malnutrition Work Group, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet 2012;112(5):730-38.

8. Fontoura CSM, Cruz DO, Londero LG, Vieira RM. Avaliação nutricional de paciente crítico. Rev Bras Ter Intensiva 2006;18(3):298-306.

9. Kamimura MA, Baxmann A, Sampaio LR, Cuppari L. Avaliação Nutricional. In: Cuppari L. Nutrição Clínica no Adulto. 2. ed. São Paulo: Editora Manole; 2005. p. 96.

10. Oliveira EAS. Fármacos que atuam sobre o aparelho digestivo. 2009. Disponível em: http://www.easo.com.br/Downloads/Farmacos%20que%20atuam%20sobre%20o%20Ap%20Digestivo.pdf.

11. Agência Nacional de Vigilância Sanitária (BR). Tracolimus EMS S.A. Brasília: Ministério da Saúde, 2013.

12. Nacif LS, David AI, Diniz MA, Crescenzi A, Andraus W, Pinheiro RS, et al. A insuficiência renal aguda e tracolimus após transplante hepático. J Bras Transpl 2013; 16(1):1715-41.

13. Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr. 2016;40(2):159-211.

14. Institute of Medicine, Food and Nutrition Board. Dietary reference intakes. Washington (DC): National Academy Press; 2011.

15. Parolin MB, Zaina FE, Lopes RW. Terapia nutricional no transplante hepático. Arq Gastroenterol 2002;39(2):114-22.

16. Barbosa PSH, Pereira LJM, Silva FV, Queiroz TCN, Fagundes EDT, Ferreira AR. Avaliação e suporte nutricional na criança com colestase. Rev Med Minas Gerais 2013;23(2):34-40.

17. Sant'Ana IES, Mendonça SS, Marshall NG. Adequação energético-proteica e fatores determinantes na oferta adequada de nutrição enteral em pacientes críticos. Com Ciências Saúde 2013; 22(4):47-56.

18. O'Leary-Kelley CM, Puntillo KA, Barr J, Stotts N, Douglas MK. Nutritional adequacy in patients receiving mechanical ventilation who are fed enterally. Am J Crit Care 2005;14(3):222-31.

19. Japur CC, Monteiro JP, Marchini JS, Garcia RW, Basile-Filho A. Can an adequate energy intake be able to reverse the negative nitrogen balance in mechanically ventilated critically ill patients?. J Crit Care 2010;25(3):445-50.

20. Fürst P, Stehle P. What are the essential elements needed for the determination of amino acid requirements in humans?. J Nutr 2004;134(6):1558-65.
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