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COLECTOMY AND WOUND DEHISCENCE
Casey Allred February 15, 2013
REVIEW OF THE DISEASE
A wound is a disruption of the normal function and structure of the skin and
underlying tissue. Different types of wounds include pressure ulcers, diabetic ulcers,
surgical wounds, venous and arterial wounds. While most surgical wounds heal without
any problem, 14 to 16% of infections from treatments in the hospital come because of
surgical wounds. In order for a wound to heal, keratinocytes, fibroblasts, endothelial
cells, macrophages, and platelets must be activated (1).
There are three phases of wound healing that occur: inflammatory, proliferative,
and maturation. The inflammatory phase is the first phase after acute injury and is
characterized by pain, swelling, redness, and function loss. Second is the proliferative
phase where granulation tissue is formed from glycosaminoglycans, proteoglycans, and
collagen to facilitate wound healing. The final phase is the maturation phase or the
remodeling phase. This includes collagen cross-linking, collagen remodeling, wound
contraction, and repigmentation of the wound. Factors that affect wound healing include
impaired arterial or venous circulation, age greater than 65, immune compromise,
dehydration, immobility, neuropathy, obesity, malnutrition, nutrient deficiencies, and
diseases such as diabetes (1).
Specific nutrients that aid in wound healing include glutamine for increased
proliferation and energy, and zinc for cellular replication and collagen formation. Zinc
supplementation is only a benefit if there is a deficiency (2). Vitamin C is another
nutrient that is beneficial in wound healing because of its role in collagen formation and
possible resistance to infection. Overall, a diet with adequate calories and protein is vital
for wound improvement (1).
PATIENT PROFILE DW is a 38-year-old Caucasian male. He is divorced and has one daughter. He
uses tobacco, crack cocaine and methamphetamine. DW has a history of diverticulosis
and seizure disorder.
PRESENT ILLNESS
DW came to the hospital with worsening abdominal pain and distention after
having pain for several months especially in the left lower quadrant. He also had nausea
and vomiting with some diarrhea and was unable to tolerate any PO intake. A CT scan
showed a large bowel obstruction with a sigmoid mass and possible malignancy. He was
admitted to the hospital on January 4. A sigmoidoscopy was performed to explore the
obstruction, which proved to be a non-malignant diverticular stricture. DW underwent a
sigmoid colectomy to remove the obstructed bowel. Eight inches were removed from the
colon, and an end-to-end anastomosis was done to reconnect the colon. For safe measure
the surgeon also performed a loop ileostomy to insure healing of the colon and removed
his appendix to prevent future problems.
Just as it appeared DW was recovering well from his surgery, the anastomosis
dehisced spilling fecal matter into his peritoneal cavity and causing peritonitis. He was
taken back to the OR where his abdomen was washed out, the anastomosis was taken
down and a descending mucous fistula was put in place. DW was moved to the ICU on
January 10 to be treated for respiratory failure for whch he was intubated and sedated
with propofol. Because of the anastomotic leak, DW developed peritonitis, sepsis, and
septic shock for which he was treated with antibotics. The sepsis led to acute kidney
injury, and DW was given fluid resuscitation to help normalize his kidney function.
On January 11, DW became tachycardic and suffered a post-op ST elevated
myocardial infarction. This was difficult to treat because of his instability. On January
13, the abdominal surgical wound became infected with E coli, pseudomonas, and gram
positive bacteria and two days later began to gape open and ooze. Because of this
dehiscence his surgical staples were removed to enable the Wound Care team to place a
wound vac to keep the wound clean and help it heal more quickly. At this point his
respiratory system improved, and he was extubated. However, the fascial tissue in the
wound continued to die and break down to the point that on January 18, when the wound
vac was taken off, his bowels eviscerated, and he immediately was taken to surgery for
debridement. Necrotic tissue, debris, and cloudy brown fluid were removed, and
retention sutures were put in place to assist in holding the wound together and to protect
his exposed bowels. DW continued to improve and was moved from the ICU a few days
later. On January 23, a CT scan showed dilated small bowel loops, developing abscesses,
and fluid collection. The abscesses and fluid were drained, and DW continued to
improve until he was discharged to a skilled nursing facility on February 7. Below is a
list of the medications DW was given during the course of this hospitalization (3).
Medication Function Possible Nutrition Related Side Effects
Depakote Anti-seizure N/V/D, constipation Fentanyl Narcotic for pain Anorexia Propofol Sedative Diarrhea Piperacillin Antibacterial agent that
blocks bacterial cell wall growth
Dry mouth, taste changes, N/V/D
Famotidine Histamine-2 blocker that decreases stomach acid
Decreases iron and vitamin B12 absorption, N/V/D, constipation
Zosyn Antibiotic combination of piperacillin and tazobactam
Dry mouth, taste changes, N/V/D
Protonix Proton pump inhibitor that Decreases iron and B12
decreases stomach acid absorption, nausea, abd pain, diarrhea
Vasopressor Increase blood pressure Levofloxacin Broad spectrum antibiotic
(including E. coli and pseudomonas)
Taste loss, N/V/D, constipation, abd pain, flatulence
Vancomycin Antibiotic to treat gram positive infections
Bitter taste, nausea
Valproic acid Anticonvulsant and mood stabilizing drug
Increases appetite, weight, and vit D absorption, anorexia and decreased weight
Aldactone Potassium-sparing diretic Anorexia, decreased weight, increased thirst, dehydration, dry mouth, N/V/diarrhea, gastric bleeding
Lasix Diuretic Increased thirst, anorexia, N/V/D, cramps, constipation
Phenylephrine Maintain adequate blood pressure
Anorexia, N/V
NUTRITION ASSESSMENT
Food/Nutrition Related History
For about one month prior to admit, DW had a decreased appetite and N/V/D, but
he reported he did not lose any weight at his time. He usually ate about eight small meals
each day.
After surgery, DW was put on a clear liquid diet and advanced to fulls the next
day because he was tolerating it very well. He was then advanced to a post-op surgical
diet because he was having good ostomy output and tolerating 75-100% of his meals.
However, on January 10, DW began to have decreased bowel function, and the
anastomotic leak was discovered. He was put on TPN via PICC so that he could continue
to receive nutrition. In order to maintain the gut, a small bowel feeding tube (SB FT)
was placed on January 11 but was not able to be advanced to the bowel and remained in
the stomach until the next day when it was repositioned in the small bowel. However, the
tube became clogged, so the feedings were not started until January 13 with a rate at 20
ml/hr of Impact Peptide 1.5 to ensure tolerance of the formula. At this time, DW’s
prealbumin was severely depleted at 3.0 so he was given 45 g of Glutamine and a
multivitamin for extra nutrients. TPN was also discontinued at this time.
On January 14 his TF rate was increased to 55 ml/hr to provide more kcals and
protein. Because his prealbumin remained low, 36 g of Beneprotein was added, along
with 220 mg of Zinc Sulfate and 1000 mg of vitamin C to promote wound healing. Once
DW was extubated, his TF was increased to 80 ml/hr, and he was not given any more
Beneprotein because he was getting enough protein from the formula. On January 19 his
diet was advanced to clear liquids and continued to advance to a regular diet. Although
DW was tolerating a normal diet, he had a poor appetite and was not eating very much,
so he remained on the TF until he pulled it the next day. It was replaced and bridled the
next day although the goal TF rate was never reached in the next several days. On
January 24, DW was switched to a nocturnal TF in order to promote PO intake during the
day, and he was given more Glutamine because his prealbumin level had dropped.
However, that night three liters of fluid was collected from his NG tube indicating a small
bowel obstruction. TPN was started once more along with a trophic TF to maintain the
gut. DW was not able to tolerate the small amount coming from the TF, and so it was
held for several days while he received TPN. On January 28 the TF was started again at
10 ml/hr and increased by 10 ml/hr for the next two days until it was at 50 ml/hr. TPN
was discontinued on February 1. DW was receiving nutrition from the TF and a regular
diet at this time. Although he was tolerating PO intake, DW had a poor appetite and was
eating less than half of his meals. He did not like Boost so he was given Magic Cup and
Instant Breakfast to supplement his PO intake. His TF was stopped on the February 3,
and DW was encouraged to increase his PO intake to make up for the lack of calories and
protein in his diet. Below is a table that portrays DW’s diet and nutrition support
throughout his hospitalization.
Date Diet Order TF (kcal, g protein)
TPN Supplement
1/4 NPO 1/5 (surgery) NPO 1/6 Post-op clear
liquid
1/7 Full liquid 1/8 Post-op surgical
diet
1/9 NPO 1/10 return to OR
NPO 1620 kcals 130 g 10% AA 1100 kcals D70W
1/11 (and TPN weaned)
TF placed 1700 kcals 130 g 10% AA, 1180 kcals D70W
1/12 TF delayed 1700 kcals 130 g 10% AA, 1180 kcals D70W
1/13 Impact Peptide 1.5 @ 20
D/C TPN
1/14 2250 kcal 169 g Impact Peptide 1.5 @ 55
Glutamine 15 g TID Theragran-M (MV) daily
1/15 2400 kcal 205 g IP 1.5 @ 55
Glut 15 g TID Beneprotein 12 g TID MV
1/16 (admit wt 92 kg)
2870 kcal 217 g IP 1.5 @ 55
Glut 15 g TID Bene 12 g QID MV Zinc sulfate 220 mg daily Vit C 500 mg bid
1/17 (admit wt 92 kg)
2532 kcal 228 g IP 1.5 @ 60
Glut 15 g TID Bene 12 g QID MV Zinc 220 mg Vit C 500 mg bid
1/18 (admit wt 92 kg)
3150 kcal 225 g IP 1.5 @ 80
Glut 15 g TID Bene 12 g QID MV Zinc 220 mg Vit C 500 mg bid
1/19 Clear liquid 3150 kcal 240 g IP 1.5 @80
Glut 15 g QID MV Zinc 220 mg Vit C 500 mg bid
1/20 Full liquid/Regular diet
Pt pulled TF Glut 15 g QID check for QID MV Zinc 220 mg Vit C 500 mg bid
1/21 (admit wt 92 kg)
Regular diet TF replaced and bridled 3180 kcal 240 g IP 1.5 @ 80
Glut 15 g Daily MV Zinc 220 Vit C 500 mg bid
1/22 Regular diet 3180 kcal 240 g IP 1.5 @ 80
Glut 15 g Daily MV Zinc 220 Vit C 500 mg bid
1/23 Regular diet 3180 kcal 240 g IP 1.5 @ 80
Glut 15 g Daily MV Zinc 220 Vit C 500 mg bid
1/24 NPO/clear liquid 2190 kcal 165 g Glut 15 g TID
(based on IBW) Nocturnal: IP 1.5 @ 80 ml/16hr 60 DO
MV Zinc 220 mg Vit C 500 mg BID
1/25 Clear liquid Trophic TF 20ml/hr
2400 kcals 200 g 15% AA 1600 kcals D70W
Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
1/26 Clear liquid 2400 kcals 200 g 15% AA 1600 kcals D70W
Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
1/27 Clear liquid 2400 kcals 200 g 15% AA 1600 kcals D70W
Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
1/28 Clear liquid 360 kcal 23 g IP 1.5 @ 10
2400 kcals 200 g 15% AA 1600 kcals D70W
Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
1/29 Clear liquid 720 kcal 46 g IP 1.5 @ 20
2500 kcals 225 g 15% AA 1600 kcals D70W D/C TPN
Glut 15 g TID MV Zinc 220 mg
Vit C 500 mg BID
1/30 Clear liquid 1080 kcal 68 g IP 1.5 @ 30
2500 kcals 225 g 15% AA 1600 kcals D70W D/C TPN
Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
1/31 Full Liquid 1800 kcal 112 g IP 1.5 @ 50
Wean to 60% Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
2/1 Regular 1800 kcal 112 g IP 1.5 @ 50
D/C TPN Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID
2/2 Regular 1800 kcal 112 g Glut 15 g TID
IP 1.5 @ 50 MV Zinc 220 mg Vit C 500 mg BID
2/3 Regular TF Stopped MV Zinc 220 mg Vit C 500 mg BID
2/4 Regular MV Zinc 220 mg Vit C 500 mg BID Instant breakfast Magic cup
2/5 Regular TF end officially MV Zinc 220 mg Vit C 500 mg BID IB/MC
2/6 Regular MV Zinc 220 mg Vit C 500 mg BID IB/MC
2/7 Regular MV Zinc 220 mg Vit C 500 mg BID IB/MC
Anthropometrics
Height 72” (6’) Weight 92 kg (203#) BMI 27.6 IBW 80.8 kg %IBW 114% Weight Gain 45# %Weight Gain 22%
Upon admit to the hospital, DW was slightly overweight. At McKay-Dee, when a
patient has a BMI over 27, the IBW is used to calculate calorie and protein needs.
However, when DW’s abdominal wound became infected and his prealbumin was
severely depleted, his admit weight of 92 kg was used to calculate estimated needs in
order to provide a more accurate amount of what his body needed.
DW had a lot of fluid retention and edema during his stay. Below is a graph
depicting his weight throughout his hospitalization (4).
DW gained about 45# of fluid, a 22% weight gain, and was given diuretics to
achieve his normal weight. Along with diuretics, the improvement of his protein stores
most likely helped reduce the fluid retention. DW’s weight returned to normal before he
was discharged.
Biochemical
The most significant lab that was used to assess nutrition status was prealbumin.
Throughout the course of DW’s illness, his prealbumin was extremely low, and although
it did improve, it never normalized before he left. This indicated a severe protein
depletion but was most likely also decreased because of inflammation. Below is a graph
depicting his prealbumin levels along with CRP (4). Prealbumin and CRP are typically
inversely related. On Jan 21, an important change occurred that confirmed DW’s protein
stores were improving. Prealbumin increased from 3.0 to 3.9 with a decrease in CRP
from 22.7 to 21.3. Although this was a small increase of prealbumin with a small
decrease of CRP, it was the first sign that he was receiving enough protein. Towards the
end of his stay, DW’s prealbumin continued to increase despite the increase in CRP,
which also indicated that his protein needs were being met.
BUN was also an important lab that was monitored. These levels were elevated at
the beginning of his stay most likely because of the amount of inflammation, sepsis, and
the stressed metabolic state that he was in (5). With adequate fluid resuscitation BUN
normalized. Because of DW’s increased need for protein to facilitate wound healing, he
was receiving about 2.5 g/kg of protein which is a very high amount. BUN was
monitored carefully to insure that his kidneys were able to tolerate the amount of protein
in his diet. The normalized levels of BUN during the periods of high protein intake
indicated that his body was using the protein for tissue proliferation.
Because toxicity with a zinc supplementation can be detrimental, DW’s zinc level
was measured on Jan 31 and found to be low at 55 (normal: 60-120). Supplementing
with zinc was therefore safe and beneficial for DW.
Nutrition-Focused Physical Findings
Because of the 45# fluid gain that DW experienced throughout his hospitalization,
his skin was very tight, and he was extremely swollen and puffy. His feet looked like
balloons because they were so stretched and swollen. He also looked very pale
throughout most of his hospitalization until toward the end when he was recovering.
Besides the abdominal wound, he also had a stage II pressure ulcer on his coccyx and a
necrotic sore on his wrist. Below are pictures that depict the healing progression of his
abdominal wound.
The wound began to dehisce so the surgical staples were removed and the fascia was exposed. The yellow/brown tissue indicates necrotic fascial tissue (slough). The sutures inside the wound are beginning
to be pulled and stretched.
DW’s abdomen was very distended with a lot of fluid retention. Wound gaped open more widely and is pale pink indicating unhealthy tissue with even more slough and bowel exposure. Sutures are pulled even
tighter still.
Wound after emergency surgery due to eviscerated bowel. Surgeon pulled surrounding muscle tissue and skin to provide covering for bowel and placed retention sutures for more support. Wound remains pale
pink.
Beefy red color and begin to see granulation tissue. Still a little bit of slough.
Continual increase in granulation with beefy red color. Not as much undermining. Still some slough but
too close to bowel to remove.
Wound has closed dramatically. Healthy tissue indicated by granulation and beefy red color.
Comparative Standards
Based on Calories: 25-30 kcals/kg
Protein: 1.5-2.0 g protein
Fluid: 30 ml/kg
1/5: IBW 80 kg 2000-2400 kcals 120-160 g 2400 ml
Based on Calories: 30 kcals/kg
Protein: 2.5 g protein Fluid: 30 ml/kg
1/16: ABW 92 kg 2750 230 2760 ml
Client History
Because DW had some appetite loss along with nausea and vomiting for a month
prior to admit, it was important to provide enough calories and protein soon after his
surgery. When the anastomotic dehiscence occurred he was immediately started on TPN
because of his poor PO intake before hospitalization.
NUTRITION DIAGNOSIS
Increased nutrient needs related to healing as evidenced by multiple GI surgeries
and open abdominal wound with vac.
NUTRITION INTERVENTION
Problem: Increased nutrient needs related to healing as evidenced by multiple GI surgeries and open abdominal wound with vac. Intervention: Enteral Nutrition, Parenteral Nutrition, Meals and Snacks, Medical Food Supplements, Vitamin and Mineral Supplements Long-Term Goal: Meet nutrition needs.
Short-Term Goal: Build up protein and vitamin/mineral stores.
Specific Intervention and Client Objectives
1. Intervention: Enteral Nutrition (ND-2.1) a. TF via SB FT: Impact peptide 1.5 @ 55 ml/hr
• Objective: Preserve the gut and provide patient with enough calories and protein to meet needs.
2. Intervention: Parenteral Nutrition (ND-2.2) a. PN via PICC: 200 g 15% AA, 1600 kcals D70W
• Objective: Meet calorie and protein needs.
3. Intervention: Meals and snacks (ND-1) a. Clear liquid, Full liquid, Regular diet
• Objective: Meet calorie and protein needs.
4. Intervention: Medical Food Supplements (ND-3.1) a. Glutamine, Beneprotein, Magic Cup, Carnation Instant Breakfast
• Objective: Facilitate wound healing with added protein and calories.
5. Intervention: Vitamin and Mineral Supplements (ND-3.2) a. Zinc sulfate, vitamin C, Multivitamin
• Objective: Facilitate wound healing.
NUTRITION MONITORING AND EVALUATION
The goal for DW was to provide enough calories, protein, zinc, and vitamin C to
meet his needs for wound healing. He was monitored quite frequently throughout his
hospitalization. When he was in the ICU, he was monitored every day to make sure he
was tolerating the nutrition support and to assess his prealbumin levels. Once he was
advanced to a regular diet, DW’s PO intake was monitored every day or every other day.
Intervention Goal/Expected Outcome
Indicator(s) Criteria for evaluation
Parenteral Nutrition/IV Fluid Intake (FH-1.3.2)
Meet calorie and protein needs
PN via PICC: 200 g 15% AA, 1600 kcals D70W
Meet Goal PN rate
Enteral Nutrition Intake (FH-1.3.1)
Meet calorie and protein needs
TF via SB FT: Impact peptide 1.5 @ 55 ml/hr
Meet Goal TF rate
Protein Intake (FH-1.5.2), Vitamin Intake (FH-1.6.1), Mineral/Element Intake (FH-1.6.2)
Provide extra protein and nutrients to facilitate wound healing
Glutamine 15 g TID, Beneprotein 12 g QID, Theragran-m daily, Zinc sulfate 220 mg daily, Vitamin C 500 mg bid
Meet indicator amount
Food Intake (FH-1.2.2)
Meet kcal and protein needs
(FH-1.2.2) Amount of PO intake
75-100% of meals or 2000-2400 kcals and 120-160 g protein
APPROPRIATENESS OF CARE
Overall, I think that DW’s nutrition care was mostly appropriate, but there are a
few occurrences that were inappropriate. On occasion his TF would be turned off or not
advanced to the goal rate when it should have been. I also felt that his TF was pulled
prematurely. DW was only consuming 25-50% of his meals, which would not have met
his needs. A few times the nurse would forget to give him the glutamine he needed
which decreased the amount of protein he received for wound healing. Once DW was
out of the ICU, instead of using his actual body weight to calculate his needs, ideal body
weight was used. Although his BMI was high at admit indicating IBW should be used, it
may have been more beneficial to err on the side of caution by giving a little too much
protein as long as the extra protein did not elevate BUN. Also, if there could have been
extra precautions taken with his colectomy, perhaps the anastomotic leak could have been
prevented, and a lot of time, money, and pain could have been saved for the patient.
REFERENCES
1. Nutrition Care Manual. Wound Care. Available at http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=19869. Accessed on February 13, 2013.
2. Fullmer S. Lecture slides. Clinical Nutrition, Brigham Young University, October
2010.
3. Pronsky ZM, Crowe JP. Food Medication Interactions. 16th ed. Birchrunville, PA. 2004.
4. ChartGo. Create graphs online. Available at http://www.chartgo.com/modify.do.
Accessed December 4, 2012.
5. Pagana, K.D., Pagana, T.J. Mosby’s Manual of Diagnostic and laboratory Tests. 3rd ed. St. Louis, Missouri. 2006.
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