Medical Nutrition Therapy In Hemodynamically Unstable Patient Due To Cardiogenic Shock With Infected Bronchiectasis and Severe Protein-Energy Malnutrition
Marsella CP (a), Taslim NA (b), Syam N (b), Syauki AY (b)

(a) Clinical Nutrition Specialist Program
Department of Nutrition, School of Medicine
Hasanuddin University, Makassar, Indonesia

(b) Department of Nutrition, School of Medicine
Hasanuddin University, Makassar, Indonesia

Abstract

Objectives
Cardiogenic shock is defined as tissue hypoperfusion due to cardiac dysfunction. It is associated with hemodynamic unstability and elevated arterial lactate as one of indicator for anaerobic metabolism. Hypercatabolic state in this condition leads to increase nutritional requirement and negative nitrogen balance. Medical nutrition therapy by considering metabolic tolerance has role to prevent further metabolic deterioration and loss of lean mass as well as improve clinical outcome of patient.

Case Report
A 44-years-old female patient with severe protein-energy malnutrition (Subjective Global Assesment Score C; MUAC 15cm) 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 oedema. Laboratory assessments showed elevated arterial lactate (3.2mmol/L), hypoalbuminemia (2.4g/dl), lymphocytopenia (650/ul), elevated liver enzymes (SGOT 780U/L; SGPT 868U/L), and urine urea nitrogen (5g/24hours). Nutritional therapy was started after mean arterial preassure >65mmHg with stable dosage of vasopressor drug and decreased arterial lactate level to 2.2 mmol/L then given gradually with a target calorie of 1500 kcal and protein 1.5-1.8g/kg ideal body weight/day using high protein diet. Arterial lactate and blood gass analysis were controlled everyday to determine target of nutritional therapy day by the day. Supplementations of zinc, vitamin B complex, Thiamine, vitamin C, vitamin A, vitamin D3, and Curcumin were given. After 15 days of nutritional therapy, patient was discharged from hospital with stable hemodynamic without vassopressor support, adequate nutritional intake, improvement of anthropometric parameters, and laboratory test results (arterial lactate 1.6mmol/L, albumin 3.1g/dl, lymphocyte 1,871/ul, SGOT 34U/L, SGPT 41U/L, urine urea nitrogen 0.72g/24hours).

Conclusions
Adequte nutritional therapy which is planned by evaluation of hemodynamic tolerance can improve clinical outcome of patient and positive nitrogen balance in hemodynamically unstable patient.

Keywords: Nutritional therapy, cardiogenic shock, unstable hemodynamic, malnutrition, metabolic changes

Topic: Dietetics and nutrition