Gaceta Sanitaria (Jan 2021)
Medical nutrition therapy in hemodynamically unstable patients due to cardiogenic shock with infected bronchiectasis and severe protein-energy malnutrition
Abstract
Objective: Cardiogenic shock is defined as tissue hypoperfusion due to cardiac dysfunction. It is associated with hemodynamic unstability and elevated arterial lactate as one indicator for anaerobic metabolism. Hypercatabolic state in this condition leads to increasing nutritional requirement and negative nitrogen balance. Therefore, medical nutrition therapy by considering metabolic tolerance can prevent further metabolic deterioration and loss of lean mass and improve the patient's clinical outcome. Methods: A 44-years-old female patient with severe protein-energy malnutrition (Subjective Global Assessment Score C; MUAC 15 cm) suffered from hemodynamic unstability due to cardiogenic shock and infected bronchiectasis at the infection center of Wahidin Sudirohusodo Hospital. Intake was postponed due to mean arterial pressure 56 mmHg on vasopressor support and oxygen saturation below 93%. Physical examinations showed loss of subcutaneous fat, lung crackles and wheezing, muscle wasting, and pretibial edema. Laboratory assessments showed elevated arterial lactate (3.2 mmol/L), hypoalbuminemia (2.4 g/dL), lymphocytopenia (650/μL), elevated liver enzymes (SGOT 780 U/L; SGPT 868 U/L), and urine urea nitrogen (5 g/24 h). Nutritional therapy was started after mean arterial pressure ≥65 mmHg with a stable dosage of the vasopressor drug and decreased arterial lactate level to 2.2 mmol/L then given gradually with a target calorie of 1500 kcal and protein 1.5–1.8 g/kg ideal body weight/day using high protein diet. Arterial lactate and blood gass analyses were controlled every day to determine the target of nutritional therapy day by the day. Snakehead fish extract, zinc, vitamin B complex, Thiamine, vitamin C, vitamin A, vitamin D3, and Curcumin were supplied. Result: After 15 days of nutritional therapy, the patient was discharged from the hospital with stable hemodynamic without vasopressor support, adequate nutritional intake, improvement of anthropometric parameters, and laboratory test results (arterial lactate 1.6 mmol/L, albumin 3.1 g/dL, lymphocyte 1.871/μL, SGOT 34 U/L, SGPT 41 U/L, urine urea nitrogen 0.72 g/24 h). Conclusion: Adequate nutritional therapy, which is planned by evaluating hemodynamic tolerance, can improve patient clinical outcomes and positive nitrogen balance in the hemodynamically unstable patient.
