Study Case 4

GROUP MEMBERS :

Nur Faten bt Abu Samah 0919308Nurul Alia Aqilah bt Samiun 0910124Norhafatini bt Aziz 0917272Nur Syafiqa bt Mohd Zulkefli 0915972Nur Athirah bt Amran 0918654

A 16 years old, Indian boy alleged with MVA. He was admitted to hospital with acute subdural hematoma. Decompressive craniectomy has been done and patient was referred to dietitian for enteral Ryle’s tube feeding regime.

MVA (Motor vehicle accident )

Major cause of internal and external injury

Motor vehicle accident injuries are as a direct result of the force of the impact and the biomechanics of injury. 

Most motor vehicle accidents are the typical hyperextension flexion injuries, or more commonly known as "whiplash" injuries.

Acute subdural hematomas

the result of a serious head injury tiny veins between the surface of the

brain and its outer covering (the dura) stretch and tear, allowing blood to collect.

The bleeding fills the brain area very rapidly, compressing brain tissue.

This often results in brain injury and may lead to death.

Decompressive Craniectomy

the removal of a large area of skull to increase the potential volume of the cranial cavity

aiming at reduction of raised intracranial pressure.

At the beginning of the last century, Kocher asserted that "if there is no CSF pressure, but brain pressure exists, then pressure relief must be achieved by opening the skull."

Ryle’s tube feedingo nasogastric enteral feeding (adult

feeding or stomach tube)

ANTHROPOMETRY DATA Height: 1.63m

Weight : 51kg

BMI-for-age percentiles (Boys, 2 to 20 years)

= 25th percentiles ( normal)

OBJECTIVE To provide suitable enteral feeding

product To preserve lean body mass To increase protein synthesis To improve immune and muscle function To promote rapid recovery To shorten hospital stay To reduce the risk of morbidity

PRINCIPLES By providing suitable enteral product to

achieve adequate calories and energy intake

By giving high protein intake up to 1.5g/kg body weight to promote wound healing

By educate patient and caregiver about hygiene and sanitation of enteral feeding

IMPLEMENTATION Elevate the head of the bed 30 to 45

degree during feeding and 30 to 60 minutes after bolus feeding.

Tube feeding should be routinely flush with 20 to 30 ml of water to prevent of occlution.

BIOCHEMICAL DATA   Value Indication Normal value

Sodium 137 mmol/L Normal 135-150 mmol/L

Potassium 3.9 mmol/ L Normal 3.5-5.1 mmol / L

Urea 5.0 mmol/L Normal 2.9-7.9 mmol/L

Creatinine 44 µmol/L Normal 35-132

µmol/L

Albumin 39 g/L Normal 35-50 g/L

Total

protein

70 g/L Normal 60-80 g/L

NUTRITIONAL DIAGNOSIS (PES)

High protein requirement as related to acute subdural hematoma as

evidence by post operative surgery

 OBJECTIVE & PRINCIPLE

Objective Principle

1. To provide Consume high biological value protein food per day such as animal derived food : meat, chicken, fish

2. To minimize weight loss • Consume adequate calorie and nutritionally balance food per day• Avoid skipping meal

3. To prevent infection Consume adequate intake of micronutrients to increase immune system

4. To inculcate hygiene practise To educate patient and caregiver on hygiene of the tube by flushing with 30 ml of water before and after feeding.

NUTRITION INTERVENTION Calculation of Energy Requirements

BMI= 19.19 Weight = 51kg Height = 163cm Age= 16 years old

Harris – Benedict calculationsTEE = 66.5 + 13.8(W) + 5(H) – 6.8(A) = 66.5 + 13.8(51) + 5(163) – 6.8(16) = 1476.5 kcal/dayBEE = 1476.5 × AF × IF

= 1476.5 × 1.2 × 1.3 = 2303.34 kcal/day

* AF= 1.2 (in bed) IF=1.3 (major surgery)

WHO FormulaBEE = 17.5 (W) + 651

= 17.5 (51) + 651 = 1543.5 kcal/day

Average calorie intake = 2303.34 + 1543.5 2 = 1923.42 kcal/day ~ 2000

kcal/day 

CHO = 55 x 2000 = 1100 100 4= 275 g

PRO = 1.5 g/kg x 5.1 kg = 76.5 g x 4 x 100 2000= 15.3 %

Fat = 100% - 15.3% - 50%= 29.7 x 2000 = 594 100 9= 66 g

Step 1

Perative (RTU)

50 ml 3 hr / 8x /d

kcal = 50 ml x 8= 400 x 1.3= 520 kcal

CHO = 0.1772 g x 50 ml= 8.86 x 8= 70.88 g

PRO = 0.0666 g x 50 ml= 3.33 g x 8= 26.64 g

Fat = 0.0374 g x 50 ml= 1.87 g x 8= 14.96 g

If pt can tolerate 1-2 feeding, go to step 2

Step 2

Perative (RTU)

100 ml 3 hr / 8x /d

kcal = 100 ml x 8 = 800 ml x 1.3 kcal = 1040 kcal

CHO = 0.1772 g x 100 ml = 17.72 g x 8 = 141.76 g

PRO = 0.0666 g x1500 ml= 6.66 g x 8= 53.28 g

Fat = 0.0374 g x 100 ml= 3.74 g x 8= 29.92 g

If pt can tolerate 1-2 feeding, go to step 3

Step 3

Perative (RTU)

150 ml 3 hr / 8x /d

kcal = 150 ml x 8= 1200 ml x 1.3 kcal= 1560 kcal

CHO = 0.1772 g x 150 ml= 26.58 g x 8= 212.64 g

PRO = 0.0666 g x150 ml= 9.99 g x 8= 79.92 g

Fat = 0.0374 g x 150 ml= 5.61 g x 8= 44.88 g

Add Modular formula = MCT oil to increase calorie intake per day without increase protein intake.

10 ml 6 x/d

Kcal = 10 ml x 7.7 kcal= 77kcal x 6= 462 kcal

Fat = 0.98 g/ml x 10 ml= 9.8 g x 6= 58.8 g

Thus , 150 ml Perative (8 times/day) + 10 ml MCT oil (6 times/day) resulting :

Total calorie = 1560 kcal + 462 kcal

= 2022 kcal

Total CHO = 212.64 g

Total PRO = 79.92 g

Total Fat = 44.8 g + 58.8 g

= 103.68 g

* Before and after feeding, flush with 30 ml water