Case 8
Despite careful reintroduction of nutrients, Misou has developed hypophosphatemia. Frustrating, but unfortunately not uncommon. You initiate intravenous potassium phosphate supplementation at 0.01 to 0.03 mmol/kg/hr. Misou's total potassium requirements should be provided 50% by the potassium phosphate and 50% by intravenous potassium chloride, not to exceed 0.5 mEq/kg/hr. You plan to recheck the phosphorus and potassium concentrations again in six hours and adjust the supplements as needed. Misou's owners decline a blood transfusion at this time since Misou seems to be stable otherwise.
Day 4: Misou is stable this morning and her phosphorus concentration has normalized, so you discontinue the potassium phosphate. Her packed cell volume is 23%. You notice, however, that she seems more nauseated, so you decrease the frequency of her nasoesophageal tube feedings from four times a day to three times a day and start treatment for possible ileus with metoclopramide (0.02 mg/kg/hr intravenously) for its antiemetic and prokinetic effects.
Here are the results of a recheck CBC and serum chemistry profile on day 6:
CBC
Patient values
Reference range
WBC (/µl)
13,500
3,500-16,000
-Neutrophils (/µl)
10,100
2,500-8,500
-Monocytes (/µl)
900
0-600
-Lymphocytes (/µl)
1,200
1,200-8,000
-Eosinophils (/µl)
1,300
0-1,000
Hct (%)
23
29-48
Hgb (g/dl)
7.6
9.3-15.9
RBC morphology
Normal
Platelets (/µl)
210,000
200,000-500,000
Serum chemistry profile
Patient values
Reference range
BUN (mg/dl)
14
14-36
Creatinine (mg/dl)
0.9
0.6-2.4
Phosphorus (mg/dl)
3.1
2.4-8.2
ALP (IU/L)
188
6-102
ALT (IU/L)
89
10-100
GGT (IU/L)
5
1-10
Total bilirubin (mg/dl)
3.9
0.1-0.4
Glucose (mg/dl)
167
64-170
Sodium (mEq/L)
149
145-158
Potassium (mEq/L)
4.3
3.4-5.6
Triglycerides (mg/dl)
240
25-160
QUESTION 8
What is your next step for Misou given these laboratory results?
a) Her ALP activity has decreased, so continue her current treatment plan and nasoesophageal feedings.
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