Staff Relief Case Study

Elena Gonzalez, Dietetic Intern

UH Cleveland Medical Center
Staff Relief Floor & Case Study Patient
Lerner Tower 7 (Telemetry Med Surg)
• Procedures: PEG/J-Tube placements, s/p cardiac caths, wound debridements, overflow from
LT9 (Bariatric: Roux-n-Y/Lap Band)
• Medical conditions: anemia, ETOH/substance abuse, cardiac, diabetes, geriatric, renal, wounds
• Diets: regular, cardiac (low Na, low sat fat, low cholesterol), diabetic, renal, dysphagia
• Tube Feed Formulas: Isosource 1.5, Vital 1.5
Staff Relief Preceptor: Caitlin McCullough RDN, LD
• LT7, Mac 4, and LKSD 40
Patient Case Study: MJ, 36 years old
• Interest in micronutrient deficiencies
• Rare patient case
 Nutritional Deficiencies 2/2 Bariatric Surgery
• Bariatric Surgery
• Mean mortality rate: 0.3%1
• Nutritional deficiencies related to bariatric surgery could lead to anemia,
osteoporosis, and protein malnutrition2
• Possible etiologies of nutritional deficiencies in Bariatric patients:
• Reduced intake and/or malabsorption of nutrients
• Pre-operative deficiencies
• Post-surgery food intolerance
• Changes in taste and eating patterns
• Non-adherence to dietary and supplement recommendations.

1. Flum, DR, Belle SH, King WC, et al. N Engl J Med, 2009.
2. Lupoli R, Lembo E, Saldalamacchia G et al. World J Diabetes, 2017 .
Nutritional Deficiencies 2/2 Bariatric Surgery
• Prognosis
• Could result in life threatening complications if not treated.
• Treatment
• Nutrition: repletion of nutritional deficiencies through supplementation
• Bariatric Vitamins for Life:
• Daily chewable MVI + minerals
• Calcium citrate/carbonate 500-600mg BID (morning & evening)
• Vitamin D3 1000 IUs daily
• Vitamin B12 1000mcg sublingual daily or monthly injection
Nutritional Deficiencies 2/2 Bariatric Surgery
Treatment (Cont.)
Nutrient Clinical Signs & Symptoms Monitoring Repletion Dose
Vitamin K Easy bruising, bleeding, petechia INR 90-150 mcg/day
Folate Macrocytic anemia, weakness, fatigue, sore tongue serum folate at least 400mcg/d
Thiamine Encephalopathy, gait disturbances, dry and wet berberi not recommended 1.1-1.2 mg/d
Vitamin B12 Macrocytic anemia, peripheral neuropathy, sensory deficits, serum B12 and at least 500mcg/d
dry and darkened nails methylmalonic acid
Vitamin C Gingival bleeding, petechiae, hyperkeratosis, not recommended 75-120mg/d
“corkscrew” hair, joint pain, and swelling
Iron Microcytic anemia, pica, fatigue, weakness, hair loss serum ferritin 40-65mg/d
pale skin, koilonychia, brittle nails, glossitis, papillary atrophy
Zinc Abnormal taste, dry brittle nails, poor wound healing, impotence not recommended at least 8 mg/d
Copper Microcytic anemia, fragile hair, muscle weakness, neuropathy serum copper 2 mg/d

3. Patel JJ, Mundi MS, Hurt RT, et al. Nutrition in Clinical Practice (NCP), 2017.
 Significant History
• Past Medical History: recent admission for
skin rash (skin biopsy done 04/07/2022),
plemorophic vtach
• Past Surgical History: lap chole and Roux-en-Y
bypass in 2014
• Social Conditions Affecting Health
• Psychological: opioid abuse (on buprenorphine),
depression, and anxiety disorder
Report on Admission
• Date of Admission: 6/19/2022-7/02/22
• Present Illness: presented to the ED 6/19 due to worsening rash now involving
most of the skin on her body and generalized fatigue
• Diagnosis: unknown upon admission; evaluation for etiology of her rash, concern
for nutritional deficiency related to her bariatric surgery
• Dermatology rec’d checking zinc, niacin, copper, vitamin C, and B12 levels; Patient received IV
folate and thiamine upon admission
• General condition upon admission: GI sx (diarrhea, persistent nausea and
vomiting), rash, and generalized fatigue
• General orders:
• Diet: CLD, NPO, regular, supplemental enteral feeds
• Medications: Thiamine, Imodium, MVI + minerals, Folic acid
Nutrition Care Process
Nutrition Assessment – Nutritionally Pertinent Lab Values
Micronutrients Trace Minerals
Vitamin E : alpha tocopherol – 10.1 [5.9-19.4 mg/L]
Zinc, serum: 46 [55-115 µg/dL]
gamma tocopherol – 1.2 [0.7-4.9mg/L]
Selenium, serum: 60.1 [23-190 µg/L]
Vitamin C: 0.2 [0.4-2.0 mg/dL] Copper, serum: 37 [80-158 µg/dL]
Vitamin B6: 10.3 [20-125 nmol/L]
Vitamin B2: 313 [137-370 µg/L]
Anthropometrics
Thiamine (B1): 259 [70-180 nmol/L]
Height (cm): 177.8
Weight (kg): 59
B12, serum: 1676 [211-911 pg/mL] BMI: 18.6
Niacin (B3): 2.43 [0.50-8.45 µg/mL]
Vitamin A: 7.5 [11.9-57.3 µg/dL] 4/05/22: 77.2 kg  23.5% wt loss x 2.5 months
Vitamin D (25-Hydroxy): 23 4/07/22: 75.6 kg
DEFICIENCY: < 20 NG/ML 6/07/22: 70.0 kg
INSUFFICIENCY: 20-29 NG/ML 6/19/22: 59.0 kg – weight on admission
SUFFICIENCY: 30-100 NG/ML
Nutrition Care Process Medications
Nutrition Assessment Prednisone: 20mg, 5mg oral daily
Clinical Signs and Symptoms Pantoprazole: 20mg oral daily
• Worsening body rash Daily MVI + minerals: 1 tablet oral daily
• GI symptoms (n/v/d) Vitamin A IM: 100,000 units daily
• Poor PO intake (stop after 3 days)
50,000 units daily
• Hair loss
(stop after 14 days)
• Significant weight loss
Thiamine: 100mg IV once, 100mg daily
• Multiple micronutrient deficiencies
Ascorbic acid: 100mg IV 2x daily for 7 days
• Encephalopathic d/t high ammonia levels
500mg oral daily
Zinc sulfate: 220mg oral daily
Folic acid: 1mg oral once
Nutrition Care Process
Nutrition Assessment
Dietary History and/or Recall
Assessment (6/21) Follow Up (6/30)
• Eats 2 meals a day at home • S/p EGD and colonoscopy 6/29; EGD showed
possible candida (biopsy was taken)
• “Breakfast is nothing big” • Per rounds, pt exhibiting manipulative behavior –
• Unable to provide examples of her second meal pt was walking on her knees and refusing to
stand up; kept saying that she was not receiving
• When asked if she noticed a change in appetite, she her meals trays
responded “I don’t know. I guess so”. • Per MD, pt has cognitive dysfunction 2/2
• Stated she drinks water. malnutrition and delirium d/t hyperammonemic
encephalopathy
• Recommended Ensure and patient did say that she • Calorie started (6/30); however, were later
drinks a serving of a high protein drink at home but was consulted for enteral recs as MD wanted to place
unable to remember the product name. DHT despite calorie count results
 Nutrition Care Process
Nutrition Assessment
Estimated Energy Needs Nutrition Diagnosis
Severe malnutrition related to acute disease or injury
Kcal/day: 1700-1900 related to rash 2/2 nutritional deficiency as evidenced
(30 kcal/kg of actual wt) by moderate-to-severe muscle wasting and fat loss
per Nutrition Focused Physical Exam and 23.5% wt
Protein (gms): 70+ loss x 2.5 months.
(1.2 gm/kg of actual wt)

Fluid: 1ml/kcal or per team

Nutrition Care Process
Nutrition Assessment Nutrition Goals
• Oral intake >50%
Nutrition Intervention • Consume prescribed supplement
• ONS: Ensure Plus BID, Magic Cup TID, Ensure • Lab values WNL
Pudding TID • Maintain stable weight
• Enteral Recs: Start Isosource 1.5 @10ml -- • Promote healing
increase by 10ml q10-12 hours until goal rate
of 50ml/hr is reached. Nutrition Monitoring and Evaluation with
• FWFs per team's discretion (TF provides
917ml free H2O).
Goals
• TF at goal rate provides: 1800 kcal, 82 gm
• PO intake and tolerance
protein, and 917ml free H2O. • Vitamin and mineral intake
• Closely monitor and replete low lytes PRN • Weight trend
• Stool Output
• Skin healing/integrity
Update:
7/01: Code White Response, transfer from LKSD 40 to MICU
• was in critical condition, intubated and sedated for acute hypoxic respiratory
failure (respiratory fatigue, b/l pleural effusion, atelectasis) on 4-pressors. Was
being treated for septic shock with vanc/mero/mica with ongoing infectious
work-up pending.

7/02: Pronounced dead d/t multi-system organ failure.

Acknowledgements

Special thanks to Caitlin McCullough RDN, LD for being an extremely

helpful and wonderful preceptor!
References
1. Flum, DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N
Engl J Med. 2009; 361:445-454. doi: 10.1056/NEJMoa0901836
2. Lupoli R, Lembo E, Saldalamacchia G et al. Bariatric surgery and long-term nutritional issues. World J
Diabetes. 2017, 8(11): 464-474.  doi: 10.4239/wjd.v8.i11.464
3. Patel JJ, Mundi MS, Hurt RT, et al. Micronutrient deficiencies after bariatric surgery: an emphasis on vitamin
and trace minerals. Nutrition in Clinical Practice (NCP). 2017; 32(4): 471-480. Doi:
https://doi.org/10.1177/0884533617712226