Overfeeding in a patient with kwashiorkor syndrome

Abstract

The patient was a 56-y-old white female admitted on October 21, 1995, for acute abdominal pain with an ultimate diagnosis of mesenteric ischemia and gangrenous cholecystitis. She subsequently underwent a cholecystectomy and small and large bowel resection with a jejunocolostomy. On admission she was 5 ‘5” ( 165 cm), 102 pounds (46.3 kg), with an ideal body weight of 125 pounds. An albumin level done postoperatively was 2.6 g/dL. Postoperatively she was ventilator-dependent and had an ileus. She was started on 1000 kcaYd of total parenteral nutrition (TPN) which included 19% of calories as protein (47.5 g/d). On October 24 and 25, she became febrile and was re-explored to rule out ischemic small bowel. Upon re-exploration, no necrotic small bowel was found. On October 26, she extubated herself and was ultimately transferred to the ward. Her TPN was increased to 1600 kcal/d, 19% of calories as protein (76 g/d). She did well until October 31, when she developed two fistulas through her abdominal wound. She was kept NPO, the TPN was continued, and somatostatin was begun. Because she was felt to be hypermetabolic, her TPN was increased to 1800 kcaYd with 24% of calories as protein (108 g/d). Laboratory values revealed a total protein level of 5.3 g/dL and a serum albumin level of 1.8 g/dL. She was continued on 1800 kcalld of TPN with 24% of calories as protein through November 21, with intermittent spiking fevers (no source was identified). Hypomagnesemia developed ( 1.5 g/dL), but the remainder of the electrolytes and Ca, PO4 were all normal. The patient’s serum albumin level on November 22 was 2.0 g/dL. Her TPN was subsequently increased to 2200 kcal/d with 24% of that amount provided as protein ( 132 g/d), under the housestaff impression that her energy needs had not been met. On November 27 she became hypercapneic and tachycardic and was transferred to the SICU with ventilatory failure and atria1 fibrillation with a rapid ventricular response rate. Laboratory values at the time of transfer revealed: Na = 140 n-Q/L, K = 4.1 mEq/L, Cl = 105 mEq/L, HCOs = 25 mEq/L, blood urea nitrogen (BUN) = 29 mg/dL, Crt = 0.9 mg/dL, Glucose = 292 mg/dL, Ca = 7.9 mg/dL, PO, = 4.1, Mg = 2.1 mg/ dL, and Albumin = 2.6 g/dL. She subsequently underwent Swan-Ganz catheter placement with cardiac output = 4.5 L/ min, C.I. = 3.2 L * min-’ * m2 -I, SVR = 1400 dyne-set/cm-5, PA = 44126 mmHg, CVP = 21 mmHg, and PCWP = 22 mmHg. Arterial blood gases on 80% FI02 assist control ventilation (A/C) were pH 7.49, Paco2 = 35 mmHg, and Pa02 = 98 mmHg. She was started on broad-spectrum antibiotic coverage. Her subsequent hospital course was complicated by sepsis, congestive heart failure, and rapid ventricular-response atria1 fibrillation, which did not respond to a diltiazem drip (rate = 135 beats/mm). An echocardiogram revealed a normal left ventricular size, left ventricular hypokinesis, a mildly dilated left atrium, and moderate mitral and tricuspid regurgitation. She was started on digoxin without apparent response.