Clinical Nutrition Management of Acute Mesenteric Ischemia

Clinical Nutrition Management of Superior Mesenteric Artery ThrombosisDana Magee

ARAMARK Distance Dietetic InternshipOverviewDisease Description Evidenced Based Nutrition RecommendationsCase PresentationNutrition Care ProcessAssessmentNutrition DiagnosisInterventionsMonitoring and EvaluationConclusionAcute Mesenteric Ischemia (AMI)Inadequate blood flow to the bowel caused by:Non- occlusive Mesenteric Ischemia (NOMI)Mesenteric Vein Thrombosis (MVT)Acute Mesenteric Atrial (AMA) Embolus Acute Mesenteric Atrial (AMA) Thrombosis

http://emedicine.medscape.com/article/191560-overview#showall3Occlusive Mesenteric IschemiaEmbolusThrombosis50% of AMI cases25% of AMI casesOccurs in distal branchesOccur at origin of SMAQuick onsetGradual onsetLow collateral blood flowLarger portion of bowel affectedSmaller portion of bowel affectedCan affect multiple arteriesAssociated with MI, mitral stenosis, Afib, endocarditis, mycotic aneurysm, dislodged plaqueAssociated with CAD, stroke, PAD, dehydration, MI, HF4Acute Mesenteric IschemiaRisks for AMIAge over 50 years oldAtherosclerosis (African Americans as higher risk)AFibHypercoaguable states (Critical Care)EpidemiologyAMI accounts for .1% of hospital admissions in USMortality rate is 71% (AMA thrombosis is highest mortality rate)

5Signs and SymptomsAbdominal pain out of proportion to expectationBenign abdominal examsFear of eating due to postprandial pain N,V, DGI bleedBad breathAFibSigns of sepsis6SMA BlockageIschemia can lead to:Vomiting and diarrheaGI bleedNecrotic bowel (8-12 hrs)Bacterial overgrowthPerforated bowelSepsisHFMulti- organ system failure

http://emedicine.medscape.com/article/191560-overview#showall7DiagnosisAortography gold standardDistinguish between SMA thrombosis and embolismCT scan / ultrasoundNot as specific or sensitiveCan see blockage of SMACan rule out other reasons for abdominal painLab results helpful- not for diagnosisCBC, PPT, acid base balance, lactateTreatmentImmediate exploratory surgery Remove ischemic/ necrotic bowelEmbolectomyIn surgery:PeristalsisColoringDoppler ultrasonographyIV fluorescent under WoodlampSecond look surgery

Case PresentationPresented with abdominal pain out of proportionAdmitting diagnosis: SMA thrombosisPMH: A-Fib, stroke, CAD, HTN, cardiomyopathy.

http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htmCase PresentationCT scan showed SMA thrombosisStarted on TPNExploratory laparotomy30 cm small bowel resected, NGT decompressionSecond look surgeryGI bleedPacemakerEvidenced Based GuidelinesEarly or late parenteral nutrition: ASPEN vs. ESPENCasaer MP, Mesotten D, Hermans G et alObjective: Comparing the early initiation of PN (European) vs. late initiation of PN (American and Canadian)Prospective, randomized, controlled, parallel- group, multicenter trial in BelgiumCasaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.

Evidenced Based GuidelinesProtocol:2312 patients receiving PN in 48 hours 2328 patients receiving PN after seven daysPatients must be at nutritional riskExcluded patients with BMI