Learning Issues : Case 3 1. What is a CABG Coronary Artery Bypass Graft is a triple bypass surgery in the heart using an artery from another part of the body. In this case, the femoral artery of the patient is being used for the bypass. (Merck Manual ) 2. Why would calcium levels go down in terms of the interactions of calcium with biochemicals in the body? In the body, calcium can bind with cholesterol to form plaques in the artery which could result in hardening of the arteries. This calcium binding could cause calcium levels to drop in the body. However, the lab values do not provide any information regarding increased cholesterol levels. Between admission day and post operative day, serum albumin decreased below the normal range and calcium decreased as well. This is not surprising because a lowered serum albumin can cause calcium to decrease artificially. (RD Notebook) 3. What kinds of medications is the patient on? Hygroton is an antihypertensive drug and a thiazide diruetic. The patient has a medical history of HTN. Nitrobid is an antianginal and vasodilator medication. The patient most likely was placed on this medication due to his unstable angina. Propranol – anti-HTN, anti-anginal, anti-migraine, anti-dysrythmic, post MI and antiglaucoma. The patient presents with hx of HTN, MI, and current unstable angina. Propulsid (cisapride) – for the prevention of acid reflux Lasix (furosemide) – potent diuretic that causes water and electrolyte depletion in the body. It is used to treat excessive fluid retention and edema caused by heart failure, cirrhosis, and kidney failure. It is a strong K diuretic. (RD Notebook – Medications section) 4. What is Angina? Angina pectoris is caused by coronary artery obstruction due to artherosclerosis. Symptoms include chest discomfort and pressure precipitated by exertion. The pain occurs because the oxygen demands exceed the ability of the body. (Merck Manual) 5. What does unstable angina at rest mean and what are it's implications? Angina at rest is known as angina decubitus and is accompanied by increased heart rate and a rapid rise in blood pressure. Unstable angina is caused by a coronary artery obstruction and is a medical emergency that must be controlled immediately in a cardiac unit. The patient is presenting with unstable angina at rest which makes him highly at risk for an MI if it is not controlled or relieved in some way. (Merck Manual On-Line, Mayo Health Clinic On-Line site, and RD Notebook Links) 6. What is hemodynamic stability and what does it mean for feeding? Hemodynamic stability is the ability of the pt. To maintain adequate blood volume and pressure. It can be affected through parenteral nutrition and should be monitored carefully (Krauss – Therapeutic Nutrition Text) 7. Calculation of serum osmolality : 2 (Na+) + (glucose / 20) + (BUN / 2.8) 2 (125 mEq/L) + (140 mg/dl / 20) + (19 mg/dl / 28) = 250+7+0.68 = 257.7 Normal serum osmolality range : 280-300 mOsm / kg Elevated range: > 300 mOsm/kg Decreased range: < 280 mOsm/kg Decreased serum osmolality can occur with excess fluid intake, adrenal disease, and inappropriate ADH secretion. (RD Notebook) 8. What are the implications of respiratory failure in this patient? Respiratory failure is caused by various acute pulmonary injuries and is characterized by non-cardiogenic pulmonary edema, respiratory distress and hypoxemia. (Merck Manual) 9. What is the insulin sliding scale? The insulin sliding scale is used in times of stress Insulin Sliding Scale: 200-250 mg/dl glucose 5 doses for stress 251-300 mg/dl glucose 10 doses for stress 301-350 mg/dl glucose 15 doses for stress 351-400 mg/dl glucose 20 doses for stress (Skipper – Dietitian's Handbook) Our Pt. had undergone a "Cholecystectomy" in 1986. A Cholecystectomy refers to the removal of the gallbladder, or to establish an opening in the gallbladder in order to permit drainage and to ease in stone removal. This procedure is used to treat cholecystitis, to treat cholelithiasis (stones), or to remove polyps or carcinoma. Our Pt. may have needed this procedure due to his life-style (smoking, poor diet). (Pgs 403-6 Dietitian's Hand- book) The term "occlusion" as it relates to our Pt. is referring to the blockage of the organs. Occlusion means for 2 things to come together, and in this case it is referring to arteries. This can occur when arteriers are partially obstructed. (Therapeutic Book) Complete Blood Cell Count or CBC is referring to these constituents in the blood: RBC's, Hemaglobin, Hematocrit, Mean Cell Volume, Mean Cell Hemoglobin, Mean Cell Hemoglobin concentration, and WBC's. CBC with differential includes all of these constiuents of the blood, plus the percentages of the leukocytes in the blood. Lymphocytes are included in the Leukocyte List. The Differential aspect of this test is needed in our case because Lymphocytes relate to immune function and protein status. A depressed lymphocyte percentage indicates a lowered immune funtion. (Thera Book and Dietitian's Hand-book) Our Pt.'s serum glucose had increased significantly post-op due to his stressed state. A decrease in sodium could indicate a need for hydration in the pt. (Interpretation of Diagnostic Lab Tests) SOB an it's relationship with pedal edema? In left ventricle failure, CO declines and pulmonary venous pressure increases. Elevated pulmonary capillary pressure to levels that exceed the oncotoc pressure of the plasma protein's leads to increased lung water, reduced pulmonary compliance, and a rise in the oxygen cost of the work of breathing. As you said in your email, SOB could be caused by pulmonary edema- peripheral and pulmonary edema are symptoms seen in both sided heart failure. The pt. Does not have CHF, but has 1+pedal edema (I am making an assumption that this is edema in one foot-couldn't find information on this) and pulmonary edema leading to ASOB. He may have been headed towards CHF, but because of the CABG his problems may have been prevented. Serum albumin, transferrin, and prealbumin levels that are low? From the dietitian's handbook on the chapter of metabolic stress- The immune system in metabolic stress is regulated by cytokines, such as TNF (Tumor Necrosis Factor) and interleukins. This response is characterized by an increase in several factors, such as white blood cells. The systemic inflammatory response is associated with alterations in nutrient metabolism, body composition, and nutritional requirements. During hypermetabolic stress there is a decreased hepatic protein synthesis. Hepatic transport protein (albumin, transferrin, prealbumin) concentrations are useful indicators of hepatic protein production and should be monitored for alterations. During periods of acute stress, hepatic reprioritization occurs because the liver begins producing acute-phase reactants instead of transport proteins, this results in a decrease in serum protein levels. Serum proteins, such as albumin, may not respond to nutrition support. C-reactive protein should be measured because they rise as albumin levels fall in response to the inflammatory process. Once stress begins to resolve, C-reactive PRO begins to decline and albumin increases in cases of adequate nutrition support. How does a Cardiac Angiography work and how does it apply to this case specifically. www.thriveonline.oxygen.com Coronary angiography is usually performed in conjunction with cardiac catheterization. You are given a mild sedative prior to the test. An intravenous catheter is started in your arm to allow for the administration of medication during the procedure. A radiologist or cardiologist inserts the catheter through a small incision in a vein in your arm, neck, or groin after cleansing the site and numbing the site with a local anesthetic. The catheter is then carefully threaded into the heart using X-ray images called fluoroscopy to guide the insertion. When the catheter is in place, dye is injected to view the blood vessels within the heart. When referring to intake and output, what is included? Looking at the last case, we saw that intake and output is not just referring to fluids. It includes both PO intake and IV fluids and the output refers to urine and gastric emptying. We still do not know if insensible losses are included (like sweating), but in most cases, it is a small amount and usually estimated. Propulsid- It is a medication used to accelerate gastric emptying. It has since been taken off the market b/c of cardiac arrhythmias. It is metabolized by cytochrome P450.