Essential Fatty Acid Deficiency for One, Headaches for All

Challenging patients make up the primary reason why you became a dietitian as well as the daily headaches when you become one. I’m not talking about foodservice complaints or complicated social or placement concerns. Rather, the patient where medical nutrition therapy is a complex and fascinating area.

Recently, I had a patient with complex nutrition-related problems. Due to severe gastroparesis, TPN had been initiated on a prior admission. The patient had been evaluated for placement of a G-J tube and had been referred to a tertiary care center but had not followed up. She was currently receiving a 2-in-1 PN formulation with no lipids because of her egg allergy.

When assessing her nutrition status, this patient appeared to have the signs and symptoms of essential fatty acid deficiency. Unfortunately, a lab test for a triene:tetraene ratio is expensive and time-consuming, difficult to perform. However, she had hyperlipidemia, hair loss, and dry, scaly skin which are all signs of an essential fatty acid deficiency. The outpatient infusion center had cycled her PN regimen but due to her drinking juice during the day, fat mobilization which would have released essential fats was repressed.

Troubleshooting

Trying to figure out how to best get essential fats into her system was a challenge.

After doing some research, we decided that to meet the goal of 100 grams of fat per week, we could try applying topical oil as some fats can be absorbed through the skin. Providing 2 tablespoons of safflower oil each day rubbed into each arm would provide 140 grams per week. We didn’t know how much of that oil would actually be absorbed but this regimen seemed reasonable as a starting point.

Talking to the Team

Of course, you never do your work in a bubble. After discussing our recommendations with the dietitians, I then went to talk to our intensivist with my recommendations. He appeared incredulous that our recommendations could even be a treatment option but was agreeable to trying. The patient’s nurse and our pharmacist were also surprised but all on board. Having such a great team that was willing to try new and unusual methods has been an asset at my hospital. At my prior place of employment, I’m not sure this suggestion would have been considered.

Following Up

After a week of providing topical oil, I was following up with the patient. She didn’t love how the oil made her feel “sticky” but was agreeable to continuing the regimen. Overall, not much had changed in that week. Clinically, she was doing better but we hadn’t seen any changes that could be attributed to her fatty acid deficiency resolving. In the studies I had read, it seemed like at least a month was needed to show any significant improvement.

Although she remained inpatient for about two weeks, our patient eventually left and planned to be evaluated for a J-tube at a tertiary care center. I’d love to know if what we did was effective or what will happen with her care, but it seems unlikely that she’ll be back anytime soon. A few things that I’ve learned from our experience:

· If you have a good medical team, it’s well worth the time and effort to discuss unusual treatment methods (provided there is some basis or rationale behind them)

· Everyone has to be on board- if our pharmacist, intensivist, patient, her family, and even nurses didn’t agree with our recommendations, it’s unlikely we would have been able to try our recommendation

· Accept that resolution may not be possible- In a research-based institution, we likely would have more closely monitored her case, even after discharge.

Ultimately, cases like this make me satisfied that I’m a dietitian. Sure, the diet educations and malnutrition consults can be complex in their own way but this was a uniquely challenging situation that was both frustrating and fulfilling. I hope all of you find the same complexity in your job that makes you appreciate your career.