A 73-year-old smoker is brought to the emergency department with fever and shortness of breath. His medical problems include hypertension and prior ischemic stroke with mild residual right-sided weakness. His trachea is cannulated in the emergency department due to respiratory distress. Intravenous antibiotics are initiated.
In the intensive care unit, his temperature is 38.9 C (102 F), blood pressure is 165/90 mm Hg, pulse is 116 /min, and respirations are 18/min on ventilator. Examination reveals crackles over the right lung field and normal first and second heart sounds. The abdomen is soft and non-tender. Bowel sounds are diminished.
Laboratory results are as follows:

Chest-x ray reveals a dense right middle-lobe infiltrate.
Which of the following is the most appropriate next step in management?

Question

A 73-year-old smoker is brought to the emergency department with fever and shortness of breath.  His medical problems include hypertension and prior ischemic stroke with mild residual right-sided weakness.  His trachea is cannulated in the emergency department due to respiratory distress.  Intravenous antibiotics are initiated.
In the intensive care unit, his temperature is 38.9 C (102 F), blood pressure is 165/90 mm Hg, pulse is 116 /min, and respirations are 18/min on ventilator.  Examination reveals crackles over the right lung field and normal first and second heart sounds.  The abdomen is soft and non-tender.  Bowel sounds are diminished.
Laboratory results are as follows:

Chest-x ray reveals a dense right middle-lobe infiltrate.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9718_4386_853d_9d59675ad796_MD0002_00 Nutrition is crucial to the care of a critically ill patient. Nutrition support is necessary to prevent cumulative caloric deficits and to aid recovery. Enteral nutrition (EN) is preferred as it is more physiologic and helps maintain intestinal structure and gut-barrier function. Early EN (within 24 to 48 hours) has been shown to decrease hospital length of stay and mortality. EN is withheld if the patient is severely hemodynamically unstable with decreased intravascular volume due to the risk of bowel ischemia. Absence of bowel sounds or flatus is not a contraindication to early enteral feeding, even in patients who have undergone surgery for bowel perforation or colorectal disease. In this patient, the overall benefits outweigh the increased risk of vomiting. Gastric feeding is preferred because of ease of tube placement and earlier feeding initiation. Prokinetic agents (metoclopramide or erythromycin) can be attempted if there is feeding intolerance. Post-pyloric tubes can be placed if there is feeding intolerance or the patient is at high risk for aspiration. Meta-analyses comparing gastric and small-bowel feeding show no differences in pneumonia, ICU length of stay, or mortality. (Choice E) Parenteral nutrition (PN) can be considered if EN is not feasible after 7 days. PN is associated with metabolic disorders such as hyperglycemia and hypertriglyceridemia, intestinal mucosal atrophy, and increased infections. Educational objective: Early enteral nutrition is an important aspect of care for critically ill patients but should be withheld in those who are severely hemodynamically unstable with decreased intravascular volume. __________ References: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive summary. (http://www.ncbi.nlm.nih.gov/pubmed/19373044)

A 73-Year-Old Smoker Is Brought to the Emergency Department with Fever