delaying surgery until "protein levels are up"

[KBS]

Hello group,

I need a couple of really good articles and/or suggestions how to
approach the following situation. 33M adm w/ Coccidiodes PNA 3 weeks
ago. 5'9", 137lbs. He has no other medical hx except alpha-1
antitrypsin. Pt has been in/out of the hospital for 6 weeks total and
weight is down 25lbs. He does appear to have muscle wasting. Pt was
intubated for two weeks, on oxepa, 35 cal/kg and 2g pro/kg for the 2nd
week of intubation period. Pt has been extubated for a week, on a
regular diet, and taking about small meals w/ supplements. Cal count
shows about 1800 cal/d and 90g protein/d.

The situtation: pt needs a lobectomy due to necrotic lobe with
purulent drainage, but the CT surgeon won't operate until pt's
"nutrition is buffed up." His Alb level is now 2.0 and the surgeon
wants "protein levels up or the surgery will be delayed." Despite me
providing high pro/high cal food lists and supplements, the surgeon
has insisted the pt consume 8 Ensure+/d and meals or he will place a
DHT for EN. The pt was able to consume 6 Ensures yesterday, but I'm
not sure how long he can maintain this regimen. I'm also not sure
what the CT surgeon's goal is for pt's "protein levels." The surgery
is scheduled for tomorrow if CT surgeon feel pt's "protein levels" are
acceptable.

Please provide suggestions and/or literature! Thanks a lot.

Kathleen Standafer, MS, RD, CNSD
Denver, CO

[Cheryl Sabillo]

Have you checked the CRP level? As we all know, albumin is not a marker of nutritional status.

Cheryl

--
You received this message because you are subscribed to the Google Groups "Critical Care Nutrition" group.
To post to this group, send email to criticalca...@googlegroups.com.
To unsubscribe from this group, send email to criticalcarenutr...@googlegroups.com.
For more options, visit this group at http://groups.google.com/group/criticalcarenutrition?hl=en.

[Kathleen Standafer]

Cheryl, 

Thanks for the reply. I realize hepatic protein levels are not indicative of nutrition status. This patient clearly is malnourished based on weight loss alone. I am concerned that surgery would be delayed based on protein levels, so was looking specifically for surgical literature and/or a dialogue that may be more effective than explaining over and over 'hepatic protein levels and nutrition status.' Its common for docs, nurses, etc to use albumin and nutrition or edema and nutrition synonymously! Frustrating!

Kathleen

Sent from my iPhone

<Serum Proteins as Markers of Nutrition- What Are We Treating.pdf>

<Jensen Malnutrition Conundrum.full.pdf>

<Adult starvation and disease-related malnutrition- A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committeeq.pdf>

[JRCF]

Can you hand him the ASPEN SCCM ICU Nutrition Guidelines(that do not support
using these protein levels as nutritional markers) and the Article by Le
Banh
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/dig
estive-health/nutrition-support-team/nutrition-articles/BanhArticle.pdfabout
the futility of measuring Acute phase protein in patient with ongoing
inflammation and how their PAB will likely not be a true increase --- if at
all?

It is hard to turn this ship...(especially with the surgeons)....still
trying myself.

CFRay, RD,CNSD

Hello group,

--

[Cheryl Sabillo]

I totally agree with you. The surgeons and oncologists that I work with also have this idea. They even try to order TPN due to low albumin levels. Some of our surgeons would wait 2 or more weeks, if they can, before they operate on a very malnourished patient, or a patient who is at very high surgical risk, for that matter. I guess the pros and cons have to be weighed.

Cheryl

[KBS]

Thank you everyone for the great information. The ICU attending now
wants to try growth hormone, so I would again like some information/
guidance. The data I've seen is in Cancer/HIV patients, and not shown
to be effective, but potentially harmful. Thoughts? Thanks.

Kathleen Standafer, Denver, CO

[JRCF]

I am even having trouble convincing all but one of the RD’s…… for ____sake! 
Good Luck 

 

CFRay, RD CNSD

[Gabriele]

Hi Kathleen,
I fear that nobody will be able to give you the answer to the qestion
Could I consider my pt ready for surgery on a metabolic point of
view ?. There's no answer mainly because is difficult to find a
biochemical marker.In a ICU patient I would use a combined approach :
- biochemical : check the pre albumin trends (it is not a marker of
nutritional state but of it gives you an idea of liver ability to work
in an anabolic direction), check the need of insulin to keep glucose
level controlled (it tells you the level of catabolic activation and
or hepatic function), check potassium balance (if drived by anabolic
metabolic profile it could be negative), check nitrogenous balance
- clincal : is the patient able to walk for few meters in ICU (if
permitted by clincal condition), what is the opinion of your
physiotherapist, is the patient able to move in the bed or he/she
necessarly need nurse assistance.

According to the patient you described I think you did all your best
to drive the anabolic metabolic profile. I fear you will not find a
definitive answer in litterature, I did not...I can not help for the
growth hormone use but I can tell you that is widely used in burned
patients but despite I work in Burn Unit I have no experience.

Gabriele Bassi M.D.
General, Trauma and Burn Intensive Care
Milano, Italy

> > Denver, CO- Nascondi testo citato
>
> - Mostra testo citato -

[Merin Kinikini]

I think in these situations, having them at least consume a supplement, such as “Impact Recovery” that contains antioxidants and omega 3’s (I believe the dosing is 3 cans/day x 5 days) would make the most sense and has the most literature support for decreasing infections post-op.   Consuming this type of supplement is not the same as consuming Ensure.

 

I think your surgeons have a right to be concerned, as risk of complications and mortality is extremely high in patients with a low albumin.  Do you ever monitor CRP and prealbumin to see if the things you are doing preoperatively are helping?  Getting the CRP and inflammation down is the role of the pharmaconutrition in these supplements.

 

Thanks

 

Merin Kinikini, RD, FNP, CNSC

 

 

 

 

From: criticalca...@googlegroups.com [mailto:criticalca...@googlegroups.com] On Behalf Of Cheryl Sabillo

Sent: Sunday, October 02, 2011 8:34 PM
To: criticalca...@googlegroups.com