Nutrition Care Process:Gunshot Wound to the Abdomen

Hailey KochNorthbay Medical Center

June 3, 2014

Overview

• Background of Patient• Metabolic Stress Response (Trauma)• Physician’s Assessment• Nutrition Assessment• Nutrition Diagnosis• Nutrition Prescription• Nutrition Intervention• Monitoring/Evaluation• Colostomy Nutrition Management

Background

• 27 y.o. male (RENO)• Admitted to ER with Gunshot Wound to Abdomen and L.

Wrist– May 1, 2014 @ 7:30 pm

• Awake and alert when admitted • PMH: Asthma, GSW to L. Wrist 2006• Taken to OR for exploratory laparotomy, partial

colectomy w/ Hartman’s pouch & colostomy, and bladder repair

• Transferred to ICU

GSW Depiction

GI Surgery

Exploratory Laparotomy Partial Colectomy & Colostomy

Photo Courtesy of http://www.med.nyu.edu/contentChunkIID=100983

Metabolic Stress (Trauma)

• Def: Hypermetabolic, catabolic response to acute injury or disease

• The physiologic response to stress can be divided into three phases:– Ebb phase– Flow phase– Recovery phase

Physiologic Response to Stress

• Ebb Phase: 2-48 hr post-injury– Shock resulting in hypovolemia– Decreased O2 available to tissues– Decreased cardiac and urinary output

Physiologic Response to Stress

• Flow Phase: 3-10 days– Hemodynamically stabilizing – Hypermetabolism– Catabolism– Altered immune and hormonal response

• Recovery Phase: 10-60 days– Resolution of stress– Return to anabolism – Normal metabolic rate

Physiologic Response to Stress“Fight or Flight” Response

• Goal: mobilize nutrient stores to meet immediate energy demand

– Glucagon: Stimulate gluconeogenesisPromote protein catabolism

– Cortisol : Stimulate gluconeogenesisFree fatty acid mobilizationIncrease skeletal muscle catabolism

– Catecholamines: GlycogenolysisIncrease fatty acid release

Physiologic Response to Stress

Physiologic Response to Stress

• Acute Phase Proteins:– Markers of Stress

Response– Positive v. Negative

• Fibronectin• C-reactive protein (CRP)• Ceruloplasmin• Albumin• Pre-albumin

• Regulated by:– Cytokines

• Interleukins• Leukotrienes• Interferon• Tumor Necrosis factor

(TNF)

Summary of Metabolic Abnormalities

• Increased levels of glucagon, cortisol, catecholamines• Hyperglycemia & insulin resistance• Increased BMR• Increased rate of gluconeogenesis• Catabolism of skeletal muscle• Increased urinary nitrogen excretion (negative

nitrogen balance)• Increased synthesis of + acute phase proteins• Decreased synthesis of – acute phase proteins

Nutrition Assessment in Stress

• Social & Medical History• Food/Nutrition Related History• Anthropometric Measurements• Biochemical Data• Medical Tests & Procedures

Social & Medical Hx

• Married w/ two young children• Lives w/ wife, children and mother• GSW occurred in park while playing basketball w/

son• PMH of asthma, GSW to left wrist in 2006,

Schizophrenia• No known surgical hx• No known drug or food allergies• Family medical hx of mental illness (unspecified)

Food & Nutrition Related Hx

• Pt had good appetite and adequate intake PTA• Wife is main meal preparer• Meal pattern consists of no breakfast, medium

lunch and large dinner• Food preferences include sandwiches, tacos,

milk, and canned fruits• No nutrition-related medications PTA– Risperidone d/c 5 years ago

Admission Anthropometric Data

• Ht: 175.3 cm (5’8”)• Wt (Admit): 90.9 kg (200#)• UBW: 93.1 kg (205#)• ABW: 80 kg • IBW: 73 kg %IBW: 137% • BMI: 32.51 kg/m2

Admission Biochemical Data

Lab Value Normal Range

Glucose 66 mg/dL Low 70-110 mg/dL

Creatinine 1.7 High 0.7-1.2 mg/dL

Na (Sodium) 143 136-145 mmol/L

K (Potassium) 2.5 Low (critical) 3.3-5.1 mmol/L

Chloride 105 98-107 mmol/L

Lactic Acid 3.9 High 0.5-2.2 mmol/L

Platelets 266 30-400 10∧3/uL

Hgb/Hct 14.1/41.9 Low 13.3-16.5 g/dL, 40-50%

Medical Tests & Procedures

• DX Chest 1 View, DX Pelvis Limited• CT Abdomen, Wrist X-Ray Complete• FAST Ultrasound• Bladder Repair• Partial colectomy w/ Hartmann’s pouch• Colostomy • Repair of comminuted fracture in L. Wrist

Nutrition Interventions

• Initiate nutrition support within 24-48 hrs of admission

• Plan for Enteral Nutrition if feeding route feasible• Plan for Parenteral Nutrition via Peripheral or

Central route if EN not feasible• Early feeding post-op will prevent further protein

catabolism & meet increased energy needs

Overview

• Background of Patient• Metabolic Stress Response (Trauma)• Physician’s Assessment• Nutrition Assessment• Nutrition Diagnosis• Nutrition Intervention• Monitoring/Evaluation

Physician’s Assessment (5/2)

1. Status post-GSWsa. LLQ abdomen w/ exit wound at perirectal areab. L. wrist w/ displace R. radial styloid fracture

2. Acute Renal Failure3. Electrolyte Imbalance4. Uncontrolled HTN5. Hematuria & some pyuria, 2° to bladder

injury

Nutrition Assessment (5/2)Anthropometrics & Physical

• Ht: 175.3 cm Wt: 90.9 kg• UBW: 93.1 kg ABW: 80 kg • IBW: 73 kg %IBW: 137% • BMI: 32.51 kg/m2

• Ventilator dependent• Sedated on Propofol post-surgery• Physical appearance – muscular build

Nutrition Assessment (5/2)Biochemical

Value Normal Range UnitsNa 139 136-145 mmol/L

K 4.6 3.3-5.1 mmol/L

BUN 9 8-26 mg/dL

Creatinine 1.4 High 0.7-1.2 mg/dL

Glucose 147 High 70-110 mg/dL

Albumin * -- 3.5-5.0 gm/dL

Phosphorus -- 2.3-4.7 mg/dL

Mg -- 1.5-2.5 mg/dL

Hgb/Hct** 9.6/27 Low 13.3-16.5/40-50 g/dL; %

*Value not available for Albumin, however value for Calcium low (6.6) which may be indicative of low albumin

**Value for H&H consistent w/ significant blood loss estimated at 1750 ml

Nutrition Assessment (5/2)Estimated Energy Requirements

Nutrient Needs Formula

Calorie 2800-3200 kcal 35-40 kcal/kg ABW

Protein 104-120 g 1.3-1.5 g/kg ABW

Fluid 2400-2800 ml 30-35 ml/kg ABW

*based off ABW

Nutrition Diagnosis& Intervention (5/2)

• PES: Inadequate protein, energy intake r/t altered GI function d/t GSW AEB unable to meet needs as pt is NPO and in surgery this day

• Plan: Continue NPO and discuss nutrition POC w/ MD. Will recommend EN when feasible; Propofol will provide ~150 kcal/day

While You Were Out…

• Saturday 5/3:– Weaned off ventilator, extubated– Weaned off Propofol– Abdomen: soft, non-tender, BS present

• Physician’s Assessment– Post trauma day #2, Post-op day #1 – Acute blood loss anemia– Respiratory failure 2° to massive transfusion

• Plan – PPN started @ 100 ml/hr x 14 hr (1470 kcal, 70 g pro)

While You Were Out…

• Sunday 5/4– L. wrist fracture repair– BP stable; Hgb decreased and received transfusion– Abdomen: soft, nontender, BS present

• Physician’s Assessment– S/P GSWs– Acute Respiratory Failure – now extubated– Likely Aspiration Pneumonitis – now improved

• Plan– NPO at this time

Nutrition Assessment (5/3 & 5/4)Biochemical

5/3 5/4 Normal Range Units

Na 141 140 136-145 mmol/L

K 3.5 3.4 3.3-5.1 mmol/L

BUN 7 8 8-26 mg/dL

Creatinine 1.1 0.9 0.7-1.2 mg/dL

Glucose 127 high 144 high 70-110 mg/dL

Albumin * 2.1 low 2.0 low 3.5-5.0 gm/dL

Phosphorus 2.0 low 1.7 low 2.3-4.7 mg/dL

Mg -- 1.8 1.5-2.5 mg/dL

Hgb/Hct 8.1/23.3 low

7.9/22.2low

13.3-16.5/40-50 g/dL; %

Nutrition Assessment (5/5)Anthropometrics & Physical

• Ht: 175.3 cm Wt: 90.9 kg• Currently on TPN via PICC line• Post-op changes w/ colostomy– Hypoactive BS, No BM or flatus– Awaiting return of bowel function

• NG output green/bilious and increasing – 80 ml (5/3), 920 ml (5/4)

Physician’s Assessment

• S/P GSWs • HTN• Anemia – stable w/ transfusion; d/t blood loss• Mild hypokalemia – replaced• S/P acute respiratory failure – off ventilator• Plan: – Pain control– Continue TPN 1-2 days– Increase physical activity

Nutrition Assessment (5/5)Biochemical

Value 5/5 Normal Range Units

Na 140 136-145 mmol/L

K* 3.4 3.3-5.1 mmol/L

BUN 9 8-26 mg/dL

Creatinine 0.8 0.7-1.2 mg/dL

Glucose 158 70-110 mg/dL

Albumin* 1.9 low 3.5-5.0 gm/dL

Phosphorus* 2.1 low 2.3-4.7 mg/dL

Mg 2.4 1.5-2.5 mg/dL

Hgb/Hct 11.8/34.3 low 13.3-16.5/40-50 g/dL; %

*Refeeding syndrome unlikely on PPN; electrolyte losses likely r/t surgery, fluid losses via NG, and surgical drains

Nutrition Diagnosis & Intervention (5/5)

• PES: Inadequate protein, energy intake r/t altered GI function d/t GSW AEB pt is on TPN @ 75 ml/hr providing 1890 kcal, 90 g pro which meets 68% kcal and 87% pro needs

• Plan: Recommend TPN nutrition change– Will recommend advance TPN rate to 100 ml/hr

(2520 kcal, 120 g pro)– EN contraindicated at this time– TPN to continue next 1-2 days

TPN Recommendation

• D25, AA 5% @ 100 ml/hr + 250 ml 20% lipid– Provides: 2520 kcal, 120 g pro, 2650 ml fld (2040 Kcal CHO, 480 Kcal protein, 500 Kcal fat)

• Check:– Glucose infusion rate (4-6 mg/kg/min):

• 4.6 mg/kg/min ✔• Monitor:– Glucose, Electrolytes

TPN Recommendation

Nutrient Estimated Requirements TPN Provides

Calorie* 2800-3200 kcal 2520 kcal

Protein 104-120 g 120 g pro

Fluid 2400-2800 ml 2650 ml

Follow-Up 5/6

• TPN Advanced to 100 ml/hr to provide 2520 kcal, 120 g pro

• NG output is minimal, slightly green• Colostomy output is minimal serous fluid– No BM, flatus

• Goal: meet est needs via TPN• Plan: when colostomy output occurs, start oral

diet and d/c NG tube

Follow-Up 5/7• Pt tolerating TPN @ advanced rate of 100 ml/hr (2520 kcal,

120 g pro)• Pt given 250 ml 20% lipid this day to provide 500 kcal• Some colostomy output, increased BS, no flatus• Goal:

– Meet est needs via nutrition support– Tolerate clear liquid diet

• Plan:– d/c NG tube and start clear liquid diet– Continue TPN for 1+ day and d/c if pt tolerating oral diet– Reglan IV q 6 hr 10 mg

Follow-Up 5/8

• Ht: 175.3 Wt: 101.4 kg UBW: 93.1 kg (stated)• Pt transitioned from clear liquid to soft/low residue diet• Finishing TPN administered on 5/7• Colostomy functioning w/ stool present; BS present• Goal:

– Meet est needs via PO intake >75%• Plan:

– monitor tolerance of soft diet – d/c TPN after current bag– discharge education

Summary PPN started @ 100 ml/hr x 14 hr (1470 kcal, 70 g pro)

TPN @ 75 ml/hr x 24 hr (1890 kcal, 90 g pro)

TPN @ 100 ml/hr x 24 hr ( 2520 kcal, 120 g pro)

Clear Liquid+

Finish TPN @ 100 ml/hr

Soft/Low Residue

Nutrition Interventions: Education

• Purpose of TPN• Diet advancement– Clear liquid to Soft/low residue

• Nutrition Management for Colostomy– Visual & verbal instruction– Customizing diet

• Follow-up on adequacy of intake

Overview

• Background of Patient• Metabolic Stress Response (Trauma)• Physician’s Assessment• Nutrition Assessment• Nutrition Diagnosis• Nutrition Prescription• Nutrition Intervention• Monitoring/Evaluation• Colostomy Nutrition Management

COLOSTOMY

a procedure in which the rectum only is surgically removed, and the end of the colon is attached to the stoma

Colostomy: Nutritional Management

• Goals:– Avoiding digestive problems such as diarrhea &

constipation– Identifying and limiting consumption of foods that cause

gas & odor– Choosing foods that will promote normal bowel function

• Plan: – Soft/low residue diet– Small frequent meals– Adequate hydration

Colostomy: Nutritional Management

• Tips for Success:– Small bites, chew thoroughly– SMFs at same time each day– Avoid spicy or fried foods or those high in sugar– Some odor-causing foods include onions, eggs, fish,

broccoli and cabbage– Some gas-causing foods include beans & cruciferous

vegetables– Stool thickening foods include banana, pasta, rice,

applesauce

Conclusion

• Traumatic multiple GSW resulting in metabolic stress response and subsequent colon resection & colostomy

• Nutrition interventions initiated by MD and challenged by dietetic intern to deliver appropriate MNT

• Nutrition education provided throughout hospital stay to inform family & patient of diet progress

• Recovery & healing is now the responsibility of the family & patient

Questions??

Thank you to the dietitians at NBMC for their guidance & instruction

References• Academy of Nutrition and Dietetics. (2014). Colostomy Nutrition Therapy.

• Arabi, Y.M., Dabbagh, O.C., Tamim, H.M., Al-Shimemeri, A.A., Memish, Z.A., Haddad, S.H., Syed, S.J., Giridhar, H.R., Rishu, A.H., Al-Daker, M.O., Kahoul, S.H., Britts, R.J., Sakkijha, M.H. (2008). Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Critical Care Medicine, 36, 3190-7.

• Dickerson, R.N. (2011). Optimal caloric intake for critically ill patients: first, do no harm. Nutrition in Clinical Practice, 26, 48-54.

• Gallo, F., Haupt, E., Devoto, G.L., Marchello, C., Garbarini, R., Bravo, M.F., Boicelli, R., Deiana, F., Racchi, O. (2011). Seriate prealbumin and C-reactive protein measurements in monitoring nutritional intervention in hospitalized patients: a prospective observational study. Mediterranean Journal of Nutrition and Metabolism, 4, 191-195.

References• Green, D.M., O’Phelan, K.H., Bassin, S.L., Chang, C.W., Stern, T.S., Asai, S.M. (2010). Intensive versus

conventional insulin therapy in critically ill neurologic patients. Neurocrit Care, 13, 299-306.

• Maday, K.R. (2013). Energy estimation in the critically ill: a literature review. Universal Journal of Clinical Medicine, 3, 39-43.

• McClave, S.A., Martindale, R.G., Vanek, V.W., McCarthy, M., Roberts, P., Taylor, B., Ochoa, J.B., Napolitano, L., Cresci, G. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. Journal of Parenteral and Enteral Nutrition, 33, 277-316.

• Nelms, M., Sucher, K.P., Lacey, K., Long Roth, S. (2011). Metabolic stress and the critically ill. In Y. Cossio & P. Williams (Eds.), Nutrition Therapy & Pathophysiology (683-691). California: Wadsworth.

• Sauerwein H.P., Strack van Schijndel R.J. (2007). Perspective: How to evaluate studies on peri- operative nutrition? Considerations about the definition of optimal nutrition for patients and its key role in the comparison of the results of studies on nutritional intervention. Journal of Clinical Nutrition, 26, 154-158.

• Smith, D.M., Loewenstein, G., Ubel, P.A. (2007). Sensitivity to disgust, stigma and adjustment to life with a colostomy. Journal of Research in Personality, 41, 787-803.