Rebekah Vukovich Dietetic Intern

CASE STUDY

Introduction to patientPast medical history Primary diseases/conditions Short bowel syndrome Patient’s current hospital admissions

Nutrition Care Process

OUTLINE

Female Age: 63Weight:

First admission: 44kg Second admission: 49kg 28% wt. loss in past 10 months

Height: 152.4 cmBMI: 18.9 (first admission) Social history: Married, retired, previously

residing in extended care facility, home health care

Primary problem: Multiple abdominal surgeries with complications, malnutrition, long-term TPN

INTRODUCTION

Partial gastrectomy RNY gastrojejunostomy Colostomy G-tube GI bleed GERD Ulcers HTN Tracheostomy (December) MI COPD Depression CAD TIA Cardiac stents Rheumatoid arthritis

PAST MEDICAL HISTORY

3/2011 Cardiac arrest, myocardial infarction

6/2012 Perforated duodenal ulcer, peritonitis, graham patch over ulcer

7/2012 Small bowel obstruction

3/2014 Hematemesis, hiatal hernia, chronic gastritis, gastric ulcer

5/2014 GI bleed, hiatal hernia, gastric ulcer

7/2014 Upper GI bleed, peptic ulcer, anemia, partial gastrectomy, RNY

gastrojejunostomy, G-tube placed10/2014

Chronic antral ulcer, gangrene, colectomy, ileostomy12/2014

Hyperkalemia, dehydration, AKI

PREVIOUS HOSPITAL ADMISSIONS

Open sores or lesions, disrupt mucosal integrity Gastric ulcer Esophageal ulcer Duodenal ulcer

Causes: Stomach acid Helicobacter pylori infection Long-term NSAIDs use

Symptoms: Burning stomach pain Starts between meals or during the night May come and go, duration varies Less common: N/V, belching, poor appetite, weight loss

PEPTIC ULCER

Complications Bleeding Perforation Obstruction

Treatment Worsen if not treated Acid-suppressing medication Antibiotics Surgery

Nutrition Therapy Alcohol Coffee and caffeine Spices Probiotics Omega 3, 6

PEPTIC ULCERS

Billroth II Due to recurrent GI bleeds Chronic antral ulcer Procedure Nutritional complications

Obstruction, dumping, abdominal discomfort, diarrhea, weight loss, impaired digestion and absorption

Micronutrient defi ciencies: iron, calcium, Vit. D, ribofl avin, folate, Vit. B12

Diet Avoid: concentrated sweets Lactose Small, frequent meals Lying down after meals Emphasize protein and fat Fiber

GASTRECTOMY WITH RNY GASTROJEJUNOSTOMY

Anatomy Diet recommendations:

High-calorie high-protein Low residue Foods that cause gas and odor

Malabsorption Bile acid Fat Vitamin B12

Increased loss Fluid Sodium Potassium

ILEOSTOMY

>40-50% small intestine removed Particularly ileum and ileocecal valveLoss of small bowel absorptive area Complications

Diarrhea, dehydration, steatorrhea, weight loss, muscle wasting, bone disease

Malabsorption with loss of absorptive areaPrognosis:

Adaption of remaining bowel Length of residual bowel Ileocecal valve Small and large bowel continuity

SHORT BOWEL SYNDROME

Post-op feedings If >1/2 removed, start TPN Elemental formula MCT triglycerides 6-10 small meals/day

Supplements/Medications Initially, control hydroelectrolitic

disturbances/rehydrate PN started earlyPN essential for long-term survival

SHORT BOWEL SYNDROME

Long-term TPN Complications Systemic recurrent infections (vein catheter

contamination), thrombosis of two or more central veins, and hepatic malfunction

Satisfactory results with the use of EN To reduce/eliminate PN

Antimotility agents Oral diet: iso-osmolar, hypercaloric, fractionated

form, addition of soluble fibers Restriction of lipids, lactose, and calcium oxalate. Oral rehydration Vitamin/mineral supplement

DIET AND SHORT BOWEL SYNDROME

Long-term retrospective clinical study10 patients with severe SBS after intestinal surgery

resection No chronic conditions Examined every 12 months Measured: body weight, height, BMI, basal energy

expenditure, percentage of involuntary loss of usual body weight (%UWL), fat-free mass, fat mass, total protein, albumin, total lymphocyte count

Calculated home parenteral nutrition (HPN) and home enteral nutrition (HEN) provided

RESEARCH STUDY

Signifi cant and progressive increase in %UWL 20% of body weight loss by the end FFM and FM signifi cant decrease Serum albumin, total protein, and total lymphocyte count

did NOT change signifi cantly HPN withdrawn in 8 patients (permanently in 5, and

temporarily in 3) Most frequent complications: infection from central venous

catheter (at least 1x in each patient, 30 total instances) Bone disease in 7 pt., deep vein thrombosis in 3 pt., chronic

calculous cholelithiasis in 5 pt. Bone disease: use of cyclic HPN, may contribute to urinary calcium

loss All patients survived for 2 years, seven for 5 yrs., and six for

7 years of more

RESULTS

References a study of 124 patients with SBS, survival of 94% at 1 year, 86% at 2 years, and 75% at 5 years Death rate: 22% r/t HPN

Duration of PN correlates significantly with length of RSB (length of the residual small bowel after the Treitz angle)

Long-term Enteral Nutrition + Oral Intake achieved the minimal energy requirement at only 2 periods of the study

Inability to use EN exclusively in severe SBSPatients who reduced PN, survived for longer periodsUse of HEN + OI reduced complications of prolonged

PN

RESULTS

Slow and progressive introduction of oral diet Control electrolytes No benefit to restricting lipids and oxalate if there is

no colon Intestinal absorption up to 50% in SBS Hypercaloric: 1.5-2.0 of BEE

Factors impairing intake: bacterial overgrowth, nausea, flatulence, poor appetite, fear of eating outside the home

Consider intermittent use of PN throughout the year.

NUTRITION RECOMMENDATIONS FROM STUDY

IV fluidsTPN M/VLasix Novolog LipitorFiberCon Lomotil Imodium Protonix Zofran Codeine Sulfate

ADMISSION 1 MEDICATIONS

Test Value Normal Range

Hemoglobin 10.4 g/dL 11.6–14.8 g/dL

WBC 15.6 K/mm3 3.8-10.4 K/mm3

Glucose 173 g/dL 60-110 mg/dL

Sodium 132 mmol/L 137-145 mmol/dL

Phosphorus 3.1 mg/dL 3.6–5.0 mg/dL

Free Triiodothyronine

2.26 pg/mL 2.77–5.27 pg/mL

ADMISSION 1 LABS

Severe sepsis due to abdominal abscess, complicated by septic shock r/t recent removal of duodenostomy tube

Advanced COPDRight lower quadrant fluid collectionAcute abdominal pain r/t mesenteric edemaPeritonitisLeukocytosisHypertension Treatment:

Guided drainage IV fluids IV antibiotics Oxygen

PRESENT MEDICAL STATUS AND TREATMENT

ADMISSION 1

Surgeon recommends complete bowel shut down and rest with minimum 2 weeks of TPN for malnutrition and duodenal leak.

Diet History: soft diet at nursing homeWeight History: Admission 44kg (22% in <3 months;

severe) 12/2/14 41.8kg 10/23/14 56.5kg 3/8/14 61.3kg

Nutrition-Focused Physical Assessment: Orbital Triceps Temporal Clavicle Shoulders Interosseous Hand-grip strength

ADMISSION 1NUTRITION ASSESSMENT

Diet order: Clear Liquids, NPO, TPNNutrition Needs:

Calories: BMR = 917; stress factor 1.4 (sepsis) = 1375 Protein: 1.2-2.0g/kg (sepsis, catabolic) = 52-88 Fluid: 30 ml/kg = 1200 ml/d

TPN: Clinimix 5/15 2L w/ 500 ml 20% lipids providing 1920 kcal and 100 gm

protein 1320mL w/ 250 ml 20% fat emulsion, providing 1437kcal

(104%) and 66g protein (75-127%)Nutrition Diagnosis: Malnutrition r/t chronic illness of

sepsis and altered GI function as evidenced by 22% wt. loss past 3 months, poor grip strength, subcutaneous fat loss, muscle atrophy and poor po intake for 3 days which meets the parameters for severe protein-calorie malnutrition (PCM).

ADMISSION 1NUTRITION ASSESSMENT

WeaknessHyponatremia Acute respiratory failureLeukocytosis UTI Sepsis

Polymicrobial septicemia Fungal septicemia

Short bowel syndrome Treatment

Normal saline Antibiotic 2 units packed red blood cells

PRESENT MEDICAL STATUS AND TREATMENT ADMISSION 2

Fatigue and weakness past 2 weeksTrigger: poor po >5 days and 10# wt. loss in past 6

months Weight: admission 49kg, Discharge 62.2kg I>O Diet history: since previous discharge

Regular diet: 2-3 meals/day Steak, potatoes, chicken, fish, mac & cheese, hamburger,

yogurt, oatmeal, pudding. No cottage cheese. Denies GI discomfort.

Eating less past 2 weeks Stated she was drinking adequate fluids (ginger-ale,

Pedialyte, Powerade, popsicles) TPN: 1320 ml with 250 ml 20% lipids

ADMISSION 2NUTRITION ASSESSMENT

Nutritional Needs: Calories: RMR = 971, stress factor 1.3 (infection, hx COPD)

= 1262 Protein: 1-1.3 g/kg (potential malabsorption, infection,

chronic illness) = 49-74 g Fluid: 30ml/kg = 1470 ml

Current diet: Purred diet, Clear Liquids, Full Liquids TPN: Clinimix 5/15 1320 ml w/ 250 ml 20% lipids,

which provides: 1437 kcal (114% of estimated needs) and 66 g protein (90-135% of estimated needs).

NUTRITION ASSESSMENT

Diagnosis Inadequate oral intake r/t poor appetite and fatigue as

evidenced by reported poor po intake >5 days. Intervention

Meals and Snacks: Encourage small, frequent meals. Decrease amount of fluid consumption with meals, have fluids between meals.

Nutrition Support: Continue TPN Supplement: Place order for Ensure TID.

Monitoring and Evaluation Meals and Snacks: Monitor for intake and tolerance. Nutrition Support: Monitor for tolerance and order change. Supplement: Monitor for consumption and need for lower-

sugar formula Anthropometrics: Maintain wt. +/- .5 to 1kg of admission wt. Biochemical: Monitor Hgb, Hct, sodium, BUN, glucose, and

iron.

ADMISSION 2NUTRITION CARE PROCESS

Two weeks of therapy for bacteremia and fungemia.

Long-term TPN Home health care

DISCHARGE

Questions?

THANK-YOU!