1. Introduction

2. Patient History

3. Pathophysiology

C.T. was a previously healthy 15 year old male living in Reno, Nevada who developed a cough two months ago. He originally thought the cough was related to allergies. He also had fatigue, body aches, epistaxis (bloody noses), weight loss, and was staying in his room a lot. He was evaluated a couple of times by his primary care physician where a chest xray was completed and shown to be normal. Three weeks ago his eyes were noted to be red but again thought it was related to allergies. Mother reported that his skin color was different and he was evaluated again by his primary care physician and labs were drawn. When his labs came back a few days later, he was sent to Reno Children’s hospital where he was admitted for further evaluation and care.

In the ED, he had abnormal labs of sodium at 129, potassium 5.4, BUN of 110, creatinine of 11.1 and a bicarbonate of 17. Nephrology was consulted for renal failure. ANCA antibodies were sent to be tested and came back positive. A hemodialysis catheter was placed for renal failure and dialysis was performed for two consecutive days. He was then intubated for a renal biopsy. While suctioning, he had a significant bit of mucus plugs and old blood but he was able to be extubated after the procedure and was on 1 Liter of oxygen through his nasal cannula, but acutely had hypoxia and required an increase of oxygen from 1 L to 4 L without increased WOB. He then was escalated to 20 L high flow nasal cannula with an FIo2% 80%. Due to his diagnosis of ANCA Vasculitis, the decision was made to transfer him to Primary Children’s hospital for a rheumatology consultation. He was then admitted to the Pediatric ICU due to hypoxia requiring HFNC and high risk for pulmonary hemorrhage. He was intubated upon admission.

4.   Present Medical Status and Treatment

1. ’s hospital course was complicated by shock requiring vasoactive medications,acute hypoxemic respiratory failure requiring mechanical ventilation, pulmonary hemorrhage requiring VV ECMO, acute renal failure requiring CRRT, bilateral pneumothoraces and pneumomediastinum, seizure, and pericardial effusion s/p pericardiocentesis and pericardial drain placement. Infectious concerns during admission include influenza A with persistent lactobacillus bacteremia and pleural effusion, invasive pulmonary aspergillosis and pericardial fluid positive for Rhizopus.

The patient was currently working through trach adjustments and ventilatory management, and significant weight loss was observed and recorded during the current admission. Began trophic feeding to preserve gut function until he tolerated feedings.

Aim to transition to full feeds with an NG tube in place.

C.T. was diagnosed with ANCA Vasculitis is a very rare auto-immune disease that  is characterized by a condition that causes vessel inflammation sometimes causing necrosis and can quickly lead to mortality and morbidity.¹¹

5.   Medical Nutrition Therapy

Nutrition History:

-C.T. was a previously healthy 15 year old male who had no issues eating. He was on a regular diet prior to admission and was not taking any oral supplements or medications. Mom reported that the patient has appeared to have lost weight recently and stated that his usual body weight is around 57 kg.

-Upon admission to Primary Children’s hospital, C.T. likely received 75% goal nutrition over the past week via his previous hospital stay. TPN was initiated within 3-5 days of admission.

-C. T. is currently determined to be at a “high” nutrition risk level

Current Prescribed Diet: NPO

• NPO diet prescribed upon admission due to hospital and ASPEN critical care protocol. Will start TPN after 3-5 days of NPO status.
• Current Needs:

○ Intubated: 30 kcal/kg 1.5 g/kg protein,  40 ml/kg fluids

○ Extubated: 38-44 kcal/kg, 0.9 g/kg protein, 40 ml/kg fluids

• Feeding Goal TPN: D12%, AA 1.5 g/kg, SMOF 0.88 g/kg (GIR 2.9 mg/kg/min) =

29.2 kcal/kg & 40 mL/kg; carnitine added at 15 mg/kg/d

• Feeding Goal NG:

○ Intubated: Nepro at 38ml/hr x 24hrs = 30 kcal/kg, 1.4 g/kg protein, 17 ml/kg fluid

○ Extubated: Nepro at 55 ml/hr x 24 hrs = 44 kcal/kg, 2g/kg protein, 24ml/kg

Other

Nutrition Goals: Meet nutrition needs to aid age-appropriate weight gain

Nutrition Interventions: NPO, Nutrition support when medically appropriate

Nutrition Diagnosis

6.   Prognosis

C.T. is currently in a medical state needing complete 24 hour support including kidney, cardiovascular, and pulmonary support around the clock. The current stabilization process is prioritized to maintain renal function and transition off of NPO status to begin enteral feedings. Pt will remain in ICU until no longer needing ventilatory support and medications that require ICU care. Transition aims to transition to medical and rehab floor as the patient continues to stabilize and eventually return back home. Patient and family are receiving support via social workers from the hospital and hoping to be able to transition home soon.

7.   References

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3. Michiels C. Physiological and pathological responses to hypoxia. Am J Pathol. 2004;164(6):1875-1882. doi:10.1016/S0002-9440(10)63747-9
4. Dixit SB, Tiwari NR, Zirpe KG, et al. How Have Nutrition Practices in the ICU Changed in the Last Decade (2011-2020): A Scoping Review. Cureus.

2021;13(6):e15422. Published 2021 Jun 3. doi:10.7759/cureus.15422

5. Ogobuiro I, Tuma F. Physiology, Renal. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 26, 2021.
6. Friedrich S, Meybohm P, Kranke P. Nulla Per Os (NPO) guidelines: time to revisit?.

Curr Opin Anaesthesiol. 2020;33(6):740-745.

doi:10.1097/ACO.0000000000000920

7. Mehta Y, Sunavala JD, Zirpe K, Tyagi N, Garg S, Sinha S, Shankar B,

Chakravarti S, Sivakumar MN, Sahu S, Rangappa P, Banerjee T, Joshi A, Kadhe G. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med. 2018 Apr;22(4):263-273. doi:

10.4103/ijccm.IJCCM_3_18. PMID: 29743765; PMCID: PMC5930530.

8. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10.1016/j.clnu.2018.08.037
9. Binda V, Moroni G, Messa P. ANCA-associated vasculitis with renal involvement. J Nephrol. 2018;31(2):197-208. doi:10.1007/s40620-017-0412-z

10.Bindroo S, Quintanilla Rodriguez BS, Challa HJ. Renal Failure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 24, 2022.

11.Yates M, Watts R. ANCA-associated vasculitis. Clin Med (Lond). 2017 Feb;17(1):60-64. doi: 10.7861/clinmedicine.17-1-60. PMID: 28148583; PMCID: PMC6297586.

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