Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate

Paige WhitmireDietetic Intern 2014-2015

Background Information“Old” practice ideas to reduce ICP

Fluid restrictionUse of Mannitol (diuretic)Hyperventilate (decrease CO2 levels)No feeding due to glucose metabolism risk

“New” practices continue to be developed

OverviewPatient information

Therapeutic Hypothermia

Therapeutic hypothermia’s impact on nutritionMy patient vs. current research

Nutritional assessment based on findings



Therapeutic hypothermia’s impact on nutritionMy patient vs. current research


Patient SelectionLearning about a new protocol

“Cutting edge” research

Opportunity to directly measure resting metabolic rate

Medical DiagnosisPrimary diagnosis: subarachnoid hemorrhagePatient’s prognosis: poor

Hypothermia could improve outcomes?

Therapeutic HypothermiaCooling: obtained goal temperature in 7

hoursMethod of Cooling:

External Cooling Gaymar Meditherm Cooled to: 32.8◦CDuration: 5 days hypothermicRe-warming: 0.1◦C per hour to 37.1◦C

Obtained in 25 hours

Medication/ParalyticsParalytic

Vecuronium: 0.8 mg/kg/minSedatives

Midazolam: 0.7 mg/kg/hrFentanyl: 175 mg/hr

3% saline @ 15 mL/hrInsulin drip: 3 units/hrKCl: 20mEq as needed



Therapeutic hypothermia impacts on nutritionMy patient vs. current research






PathophysiologyCauses of neurological damage due to stroke

or brain injuriesMitochondrial damage

Production of free radicals Reperfusion causing further damage

Why hypothermia may work…Hypothermia counteracts multiple steps of

cellular injury following acute strokeReduces oxygen consumption

Inhibit free radical formation and inflammatory responses

Limit edemaLower the amount of intracellular calcium

Exact mode is still being researched

Benefits from metabolic effectsNeuroprotective effects by reduction or

delay in metabolic consumption during the stress of a CNS injuryReduces CMRO2 by 5% per degree Celsius

5.9% reduction in energySlows lactic acid production to prevent

acidosisLowers metabolic and energy demandsPromotes tissue preservation

Methods for Cooling: SurfaceCold air, water and/or ice through a

thermoconductive blanketCooling jacketsIce packingAdvantages

NoninvasiveInexpensiveEasy to implement

DisadvantagesFluctuations in body temperatureProlonged time to achieve the temperature goal

Methods for Cooling: IntravascularInfusion of ice-cold fluids through intravascular

catheters (with metal or circulating cold water–filled balloon conductors)

AdvantagesShorter time to goal temperatureMore precise hypothermic control Less shivering

DisadvantagesMore invasiveHigher cost

Potential ComplicationsShiveringPneumoniaDecreased cardiac outputHyperglycemiaThrombocytopeniaHypokalemiaLoss of gut functionFever









Energy expenditure in ischemic stroke patients treated with moderate hypothermia10 patients treated with moderate hypothermia

(33∘C) following an acute ischemic strokeIndirect calorimetry was performed over the first 6

days after admissionMean daily TEE decreased significantly:

1,549 kcals before initiation of hypothermia1,099 kcals the first day1,129 kcals the second day1,157 kcals the third dayReturned to baseline (and 16% above) after

hypothermia was terminated

Modification of the Harris-Benedict Equation to Predict the Energy Requirements of Critically Ill Patients during Mild Therapeutic Hypothermia

5 patients suffering from acute cerebral injuries who underwent mild hypothermiaIndirect calorimetry measurements:

Every 3-4 hours during cooling/re-warming Every 12 hours during the steady hypothermic state

Basal metabolic rate decreased by 30.3%Every drop in temperature by one degree led

to a 5.9% reduction in energyMeasured TEE was 16.7% lower than

calculated TEE

Metabolic Downregulation: A Key to Successful Neuroprotection?Hypothermia slows but does not completely

prevent the eventual depletion of ATPSeveral studies suggest that metabolism is not

significantly remarkable in neuroprotectionExample: rodents subjected to 20 minutes of

forebrain ischemia Brain levels of various metabolites were no different

from rats who were in a normothermic state Thus, the influence of hypothermia on cerebral

metabolism probably does not fully explain its protective effect

My patient vs. Current ResearchHypothermic

4/7/15

Re-warming Day 1

4/8/15

Re-warming Day 2

4/9/15

Temperature 32.8◦C 35.4◦C 37.1◦C

Heart Rate 53 69 74

Minute Ventilation 6.2 7.1 6.3

ICP 19 21 23

DeltaTrac 1,950 kcals 2,440 kcals 2,755 kcals

Equation vs. CalorimeterHypothermic State (32.8◦C)

58% above the PSU equation calculationDay 1 Re-warming (35.4◦C)

51% above the PSU equation calculationDay 2 Rewarming (37.1◦C)

47% above the PSU equation calculation

4800

4400

4000

3600

3200

2800

2400

2000

1600

1200800

400

4800440040003600320028002400200016001200800400

Penn State Equation (kcal/day)Mea

sure

d Re

stin

g M

etab

olic

Rate

(kca

l/day

)

Subject

Regression

Line of Identity

4140393837363534333231

4500

4000

3500

3000

2500

2000

1500

1000

Maximum body temperature (centigrade)

Rest

ing

Met

abol

ic Ra

te (k

cal/d

ay)









NCP: AssessmentCalories

Prior to hypothermia protocol: 2,475 kcals/day (PSU equation x 1.1)

During hypothermia protocol and medical paralysis: 1,375 kcals/day (PSU equation)

After completion of hypothermia protocol: 2,440 kcals/day (indirect calorimetry measurement)

Protein: 130 g/day (1.75 g/kg of adjusted body weight)

Alterations during admissionPrior to hypothermia protocol

Nutren 1.5 @ 80 mL/hr (x 21 hours)Beneprotein: 3 scoops/L of feedingNutrisource Fiber: 2 scoops in 50 mL of water 4x/day

During hypothermia protocol and medical paralysisReplete @ 70 mL/hr (x 19.5 hours)Beneprotein: 5 scoops/L of feedingNutrisource Fiber: 3 scoops in 75 mL of water 4x/day

After completion of hypothermia protocolNutren 1.5 @ 85 mL/hr (x 19.5 hours)Beneprotein: 3 scoops/L of feedingNutrisource Fiber: 3 scoops in 75 mL of water 4x/day

NCP: DiagnosisIncreased nutrient needs (energy) (NI- 5.1)

related to therapeutic hypothermia protocol as evidenced by resting metabolic rate calorimetry measurement of 1,950 calories while in a hypothermic state.

NCP: InterventionFood and or/nutrient delivery (ND) Enteral and Parenteral Nutrition (ND-2) –

Enteral Nutrition (ND-2.1) – Composition: Provided nutrition through the GI tract via

keofeed tube based on patient’s calculated protein and measured energy needs.

NCP: Monitoring and Evaluation

Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution

Criteria: Patient will receive Nutren 1.5 @ 80 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 2 scoops in 50 mL of water 4x/day in order to meet her calculated protein and energy requirements.


Criteria: Patient will receive Replete @ 70 mL/hr, Beneprotein 5 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water 4x/day in order to meet her energy requirements during the hypothermia protocol.


Criteria: Patient will receive Nutren 1.5 @ 85 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water four times per day in order to meet her energy requirements after the hypothermia protocol is complete.

ConclusionLimited researchMeasurement of my patient prior to

hypothermia protocol may have given a different result

Case-to-case basisEstablish measurement in protocol

Therapeutic hypothermia may have benefits, but not necessarily nutritionally

Badjatia, Neeraj, and Evangelia Strongilis. "Metabolic Impact of Shivering During Therapeutic Temperature Modulation." Stroke. American Stroke Association, 16 Oct. 2008. Web. 30 Apr. 2015.

Bardutzky, Juergen, Dimitrios Georgiadis, Rainer Kollmar, and Stefan Schwab. "Energy Expenditure in Ischemic Stroke Patients Treated with Moderate Hypothermia." Intensive Care Medicine 30.1 (2004): 151-54. Web. 21 Apr. 2015.

C., Tommasino. "Fluids and the Neurosurgical Patient." Anesthesiology Clinics of North America (2002): n. pag. WBS. Standford University, 2002. Web. 22 Apr. 2015.

"Diabetes, Endocrine | Insulin Drips." Uwhealth.org. UW Health, 2013. Web. 23 Apr. 2015. "Fentanyl: Indications, Side Effects, Warnings - Drugs.com." Vecuronium: Indications, Side Effects, Warnings - Drugs.com.

Drugs.com. Know More. Be Sure., 2012. Web. 30 Apr. 2015. Groysman, Leonid. "Therapeutic Hypothermia in Acute Ischemic Stroke." Medscape. Neurosurg Focus, 2011. Web. 20 Apr.

2015. Hartl, Roger. "Effect of Early Nutrition on Deaths Due to Severe Traumatic Brain Injury." Journal of Neurosurg (2008): n.

pag. J Neurosurg. Web. 28 Apr. 2015. Hemmen, Thomas M., and Patrick D. Lyden. "New Approaches to Clinical Trials in Neuroprotection:

Introductino." Stroke. American Stroke Association, 2007. Web. 30 Apr. 2015. Liu, Liping, and Midori A. Yenari. "Clinical Application of Therapeutic Hypothermia in Stroke." Neurological Research.

U.S. National Library of Medicine, May 2009. Web. 29 Apr. 2015. "Midazolam: Indications, Side Effects, Warnings - Drugs.com." Vecuronium: Indications, Side Effects, Warnings -

Drugs.com. Drugs.com. Know More. Be Sure., 2014. Web. 30 Apr. 2015. "Neuroscience Therapeutic Temperature Modulation Guideline (TTM)." Penn State Hershey Medical Center. Portoroz, Slovenia. "Update on Therapeutic Temperature Management."Critical Care 6.2 (2012): 1-42. Meeting Abstracts.

2012 June 7. Web. 22 Apr. 2015. Saur, Joachim, Hans Leweling, and Frederik Trinkmann. "Modification of the Harris-Benedict Equation to Predict the

Energy Requirements of Critically Ill Patients during Mild Therapeutic Hypothermia." In Vivo 22 (2008): 143-46. First Department of Medicine, 2008. Web. 20 Apr. 2015.

Vecuronium: Indications, Side Effects, Warnings - Drugs.com." Vecuronium: Indications, Side Effects, Warnings - Drugs.com. Drugs.com. Know More. Be Sure., 2014. Web. 30 Apr. 2015.

Worp, H. Bart Van Der, Malcolm R. Macleod, and Rainer Kollmar. "Therapeutic Hypothermia for Acute Ischemic Stroke: Ready to Start Large Randomized Trials?" Journal of Cerebral Blood Flow and Metabolism: Official Journal of the International Society of Cerebral Blood Flow and Metabolism. Nature Publishing Group, 2008. Web. 28 Apr. 2015.

Yenari, Midori A., and Thomas M. Hemmen. "Neuroprotection." Stroke. American Stroke Association, 2010. Web. 20 Apr. 2015.

Yenari, Midori, and Kazuo Kitagawa. "Metabolic Downregulation." Stroke. American Stroke Association, 2008. Web. 29 Apr. 2015.

Ziai, Wendy C., and Marek A. Mirski. "Use of Hypertonic Saline in Ischemic Stroke." Stroke. American Stroke Association, 2002. Web. 23 Apr. 2015.

Documents

Paige Whitmire Dietetic Intern 2014-2015. Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate