We report the case of a 77-year-old man who came to the hospital emergency department complaining of vomiting for one week associated with absence of deposition, with pain in the right inguinal region lasting three days.
There is no cognitive impairment but severe social impairment.
Love that for a year only consumes liquids with a loss of 15kg of weight during this period (normal weight approximately 70kg; current weight at admission of 55kg).
She hasn't been living in bed-sillion for fifteen days, lives with her 87-year-old blind woman and has poor body hygiene.
The patient had a personal history of basal cell epithelioma with supranasal sinus not intervened and gastric ulcus previously treated with cimetidine.
On physical examination at admission, signs of peripheral hypoperfusion, severe inguinoÆs self irreductible right-sided hypoxia, with probable painful intestinal content, abdominal distendable herniation were observed.
Intestinal obstruction secondary to incarcerated inguinal hernia was diagnosed, so it was decided to surgically intervene, performing resection of the ischemic intestinal segment and perforated with laterolateral anastomosis and herniorrhaphy.
Diffuse peritonitis and hemodynamic instability were observed during surgery.
The presence of signs of shock and decreased level of consciousness despite being without sedation, the patient is admitted to the Intensive Care Unit (ICU).
Antibiotic treatment with imipenem was started presenting a favorable evolution during the first four days, until the beginning of progressive increase of signs of infection and inflammation (leucocytosis of 38,320 leucocytes/mm3) and acute drainage gdL, suggestive of bile leaks with voiding fluid voiding fluid voiding fluids, urine with voiding fluids of 3, dL.
These findings were treated surgically.
From the nutritional point of view the patient presents a protein-protein, with severe hypoalbuminemia and hypoproteinemia severe albumin g/dL and iv protein malnutrition secondary to stabilization (albumin 1.4 g/dL and severe protein iv).
Total parenteral nutrition (TPN) was initially prescribed with a macronutrient intake corresponding to a 70kg patient with severe metabolic stress.
From the mental health service, the patient is identified as a patient at high risk of suffering RS, given his/her condition and previous psychosocial problems (foot > 20% depression in a year, severe problems).
Associated complexity of acute renal failure and high risk of RS is recommended a progressive start of nutritional support adapting macronutrient intake to the real weight and not ideal of the patient.
Taking into account the recommendations of the main clinical guidelines for the prevention of RS6, prophylactic administration of thiamine is recommended, and parenteral nutrition is initiated with a calorie intake of approximately 15 39% kcal / kg of total protein intake of 22%.
During the first days, the intake of phosphate, potassium and magnesium is restricted due to renal hyperphosphatemia (phosphate 8.91 mg/dL), hyperkalemia (potassium 5.27 mEq/L) and hypermagnesemia.
On consecutive days, protein-caloric intake slowly increases, with special precaution with nitrogen intake during the first week due to renal failure.
From the tenth day onwards nutritional requirements are finally met.
The energy intake is 30 kcal/kg (calorie distribution of 48% proteins, 30% lipids and 22% proteins), with a protein intake of 1.6g/kg, adapted to the patient's metabolic situation.
During the first days the analytical and nutritional parameters evolve favorably in parallel to the improvement of renal function, until the appearance of abdominal sepsis and all the complications described above.
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Given the age of the patient, the current disease and the poor prognosis of the complications developed, it was decided in a joint session to limit the therapeutic effort, dying on the 17 day of admission.
