Jazlina Syahrul1 , Zulfitri Azuan Mat Daud1
1Department of Dietetics, Hospital Pengajar Universiti Putra Malaysia (HPUPM)
Patient is 75 years old lady admitted to ICU due to Covid Associated Pulmonary Aspergillosis (CAPA) and fluid overload secondary to End Stage Kidney Disease (ESKD). Patient was seen at Day 4 in ICU and referred for expert review for diarrhea management.
Upon assessment, no dry weight was available thus dosing weight of 64 kg at BMI of 25kg/m² was used. Blood results showed that the patient had low hemoglobin with increasing trend of septic parameters and electrolytes. Patient was on 2 types of antibiotics, intubated with inotropic support and was dialyzed according to nephrologist’s review with restriction of fluid (ROF) was kept at 1L/day. Patient had started feeding since day 1 in ICU and noted no bowel output for 2 days, thus initiation of laxative was done at day 3. However, patient started having loose and watery stool after day 3 in ICU with score of 24-46 (king’s stool chart). Patient had no abdominal distension however had develop skin breakdown due to diarrhea.
Altered GI function related to change in GI tract motility as evidenced by the presence of diarrhea with score of 24-46 (king’s stool chart)
To resolved diarrhea with optimization of energy and protein intake. Patient was prescribed with 100ml renal specific formula, 3 hourly with the additional of hydrolyzed guar gum in every feeding. Intermittent continuous feeding also was initiated at day 7 of ICU for better toleration.
Monitoring & Evaluation
Patient’s diarrhea resolved after 5 days of initiation of soluble fiber (day 10 in ICU). Patient's achieved 80% of energy adequacy in day 10 of ICU and improvement of wound also noted. While resolving diarrhea, patients had few episodes of hemodynamically instability. This had hindered the aim to increase dietary protein intake thus optimization was only be able to achieve after day 11 in ICU.