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Clinical Case Study The long road back to eating. Birgit Humpert , KSC Dietetic Intern 2012-2013. Dartmouth-Hitchcock Medical Center. Our mission

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clinical case study the long road back to eating

Clinical Case StudyThe long road back to eating.

Birgit Humpert, KSC Dietetic Intern 2012-2013

slide2

Dartmouth-Hitchcock Medical Center

Our mission

We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.

Our vision

Achieve the healthiest population possible, leading the transformation of health care in our region and setting the standard for our nation.

slide3

DHMC

  • Mary Hitchcock Memorial Hospital
    • Teaching hospital
    • Only Level 1 trauma center in NH
    • 396 inpatient beds
    • Major tertiary-care referral site for the region
  • Dartmouth-Hitchcock Clinic
  • Geisel School of Medicine at Dartmouth
  • Veterans Affairs Center at WRJ, Vermont

Also

Children’s Hospital at Dartmouth –CHaD

Norris Cotton Cancer Center

role of the rds
Role of the RDs
  • Team of 21 Dietitians and Diet Technicians.
  • 4 RD and 3 DT only inpatient
  • 7 in- and outpatient
  • 5 only outpatient
  • 1 employee wellness
  • Work with other members of the medical team to ensure the best treatment for the patient.
my patient
My patient

Mrs. H.

  • 56 years old
  • married, lived with her husband
  • Original problem: gallbladder cancer
    • in November laparoscopic cholecystectomy,
    • radiation therapy after
  • Now: new mass, surgery
gallbladder
Gallbladder

Image: retrieved from National Cancer Institute

diseases of the gallbladder
Diseases of the gallbladder
  • Cholelithiasis
  • Cholecystitis
  • Gallbladder cancer
gallbladder cancer
Gallbladder cancer
  • Uncommon
  • Risk factors:
      • being female
      • Being Native American
      • Patients with large gallstones
      • With extensive gallbladder calcification due to cholecystitis
  • Signs and symptoms: Jaundice, pain above stomach, N/V, bloating, lumps
  • Difficult to detect and diagnose
  • Most often adenocarcinom
pathophysiology of cancer
Pathophysiology of Cancer
  • Initiation: abnormal cells are formed
  • Promotion: abnormal cells multiply
  • Progression: tumor growth
surgery 1 17
Surgery 1/17

DAY 0

  • Excission of the tumor and lymph nodes
  • Gastric antrectomy
  • Antecolic anterior gastrojejunostomy
  • Choledochojejunostomy
slide11

http://studynursing.blogspot.com/2011/01/gastrojejunostomy.htmlhttp://studynursing.blogspot.com/2011/01/gastrojejunostomy.html

first nutrition assessment
First nutrition assessment

DAY 7

Assessment:

  • Anthropometrics: 80.8 kg, 69.4 kg (admission), 68-70 kg UBW, 160 cm, BMI 27.1
  • Pertinent labs: Hgb 9.4, albumin 2, creatinine0.39
  • Meds: pain meds, antibiotics, IV fluids, metoprolol, fluconazole, heparin, esomeprazole, Reglan, Senna, Dulcolax
  • Needs: 1400 kcal (20 kcal/kg), 140 g protein (2 g/kg)
slide13

Diagnosis: malnutrition in intraabdominal disease, postoperative ileus

PES Statement:

NI-5.2 Malnutrition related to alterations in gastrointestinal tract structure/function AEB inability to eat sufficient energy and protein.

Intervention: TPN

176 g dextrose, 135 g AA, 40 g lipids

slide14

Same day:

  • Difficulty breathing, tachicardia, ECG abnormalitites, transferred to ICU
  • Duodenal stump leak
  • gastrostomy and feeding jejunostomy
consult for tf recommendation
Consult for TF recommendation

DAY 11

  • Assessment:
  • Anthropometrics: 80.8 kg, 69.4 kg (admission), 160 cm, BMI 27.1
  • Labs: Na 137, K 2.4, ch 104, CO2 26, BUN 20, creatinine 0.32, glucose 108, PAB 3
  • Meds: same + lasix
  • In: 5442 ml, out 3530 ml
  • Needs: 1400 kcal, 140 g protein
  • Diagnosis:
  • NI-5.2 Malnutrition related to alterations in gastrointestinal tract structure/function AEB Prealbumin of 3.
slide17

Intervention:

  • Peptamen Bariatric at 56 ml/hr + 3 scoops protein powder
  • Initiate at 20 ml/h, advance 20 ml/h q 8-12 h as tolerated
  • At goal: 1419 kcal, 143 g protein, 1129 ml free water, 90% RDA vitamins/minerals

Monitoring/Evalutation:

  • TF rates, tolerance, lab values
advancement of tf
Advancement of TF
  • Pt complains of bloating and feeling of tightness
  • Also struggeling with pain control and diarrhea
  • TF is advanced more slowly
  • 7 days after tube placement up to 30 ml/h, 25% of goal
  • Still TPN (Clinimix with electrolytes) 1200 ml to provide 853 cal, including 60 g protein
octreotide
Octreotide
  • Mimics the action of naturally occuringsomatostatin
  • Used to treat severe diarrhea
  • Decreases pancreatic and GI secretion
  • Inhibits gastrin, CCK, secretin, motilin
  • Reduces smooth muscle contractions and blood flow within the intestine
new tpn assessment
New TPN assessment

DAY 19

  • TF temporarily stopped due to leak from choledochojejunostomysite
  • Labs: Na 134, creatinine 0.52
  • Needs: 1750 kcal, 150 g protein, 2400 ml continously
  • Provided as premixed formula: (1032 cal, 151g protein, 125 g CHO, 0 g lipids)
tf restarted
TF restarted

DAY 22

  • Assessment:
  • Weight: 86.9 kg
  • Labs: Na 133, creatinine 0.39, Ca 6.8, Phos 1.4
  • In: 3150 ml, Out: 3132 ml
  • Recommendation:
  • Continue TPN
  • Trophic feeding through J-tube
  • Bile reinfusion
  • Assess stool output prior to increasing TF rate
bile reinfusion
Bile reinfusion
  • Bile important for absorption of fat and fat soluble vitamins, necessary for micelle formation
  • 95% is recycled daily
  • Loss of bile salt can decrease fat absorption up to 50%
  • 1) reduce fat content of the diet
  • 2) or collect bile and re-infuse
    • Collect bile, strain with kidney stone strainer
    • Y-site into TF line
    • 100-200 ml every 4 hours or continuously together with enteral nutrition
    • via pump, gravity or syringe

Source: Practical Gastroenterology

Parrish, C.R., Quatrara, B. (2010). Reinfusion of Intestinal Secretions: A viable Option for Select Patients. Nutrition Issues in Gastroenterology, Series #83, April 2010

preparing for discharge
Preparing for discharge

DAY 25

  • Nocturnal TF considered: Peptamen bariatric at 120 ml/hr over 12 hours recommended
  • Also still gets TPN cyclic (960 ml over 12 h at night) to provide 800 cal from 115 g protein, 100 g CHO, 0 g lipids
  • Still poor tolerance, feels full and nauseated, can’t exceed 20 ml/h
progress
Progress

DAY

23-33

  • Persistent leak
  • Preperations for discharge ongoing, teaching of family regarding TF and TPN, rehab considered
  • Peritoneal fluid collection, drain placed
  • Diarrhea on and off
  • Changed mental status
  • Rehab denied because of TPN
change in tf
Change in TF

DAY 35

Assessment:

  • 78.6 kg
  • Labs: mostly WNL, phos 1.5, albumin 1.5, BUN 23, creatinine 0.21, prealbumin 5
  • Meds: zosyn, liquid tylenol, lomotil, zofran, nexium
  • Needs: 1400-1600 kcal, 140 g protein

Recommendation:

  • Replete at 67 ml/hr x 12 h to provide 50-60% of needs (804 kcal, 50 g protein, 676 ml free water, 80% RDA for vitamins/minerals
evaluation
Evaluation

DAY 37

S: Why do I have to get so much tube feeding?

O: Meds: dulcolax supp. Ordered

Labs: phos 1.1

A: TF: average daily intake 231 ml (goal 804 ml) with steady increase, 29%

  • Currently TF and TPN combined provide 74% of energy and 92% of protein needs

P: TPN increased, phos provided

hypophosphatemia
Hypophosphatemia
  • Caused by inadequate intake, excessive loss (diuretics), redistribution
  • Results in anorexia, weakness, bone pain, dizziness, rhabdomyolysis, red blood cell dysfunction, heart failure, sudden death,
readmission
Readmission

DAY 48

  • Blood in gastrostomy tube
  • Fever, blood culture positive for G+ cocci
  • Pneumonia
  • CT scan revealed pyleophlebitis and liver abcess
  • TPN, TF is running at 20 ml, team does not want to increase
  • Pt is allowed ice chips
reassessment
Reassessment

DAY 51

  • Labs: Na 131, K 3.4, ALT 555, AST 484, creatinine 0.34, Ca 7.4, PAB 3
  • Needs: 1650 kcal (25 kcal/kg), 100-135 g protein (1.5-2 g/kg)
  • Diet order: starting clear liquids today
  • Plan:
  • Cyclic TPN, recommendation for TF advancement Replete 70 ml/h, to provide 1680 kcal, 105 g protein, 1420 ml free water, 100 % RDA vit/min
evaluation1
Evaluation:

DAY 56

“It was great to eat, it’s been months. I had cereal for breakfast.”

Assessment:

  • Cyclic TPN, TF running at 40 ml/h over 14 h, pt gets full fast, declines snacks
  • diet order: mechanical soft

Plan:

  • Replete 65 ml/h over 12 hours to allow 2 more hours off TF, may encourage appetite
  • Encouraged high protein food
tf stopped discharge
TF stopped/discharge

DAY 61

  • TF stopped since she is eating and getting Boost
  • TPN continued, provides 740 kcal, 100 g protein, 100 g CHO
  • Reassessment on 3/19:
  • 74 kg, PAB 3
  • Pt discharged home with VNA
update
Update

DAY 82

  • Weight: 68.9 kg
  • Still on TPN, pt wants off
  • Recall: cereal with 2% milk for breakfast, toast w butter or grilled-cheese sdw with chicken-noodle soup for lunch, ½ Hamburger w potato wedges for dinner, vitamin water

800-900 kcal, 35-40 g protein

Needs: 1700 kcal, 105 g protein

Recommendations:

  • Add 500 kcal w calorie-dense food and fluids
  • Increase protein
slide33

Resources:

Calandra, T., Marchetti, O. (2004) Clinical Trials of Antifungal Prophylaxis among

Patients Undergoing Surgery. Clin Infect Dis. (2004) 39 (Supplement 4): S185-S192. doi: 10.1086/421955

Charney, P., Malone A.M. (2009). ADA Pocket Guide to Nutrition Assessment. 2nd

edition. American Dietetic Association Chicago, IL.

Gallbladder and Bile Duct Disorders (2007). The Merck Manual for Health Care

Professionals, retrieved from www.merckmanuals.com/professional/hepatic_and_biliary_disorder s/gallbladder_and_bile_duct_disorders/tumors_of_the_gallbladder_and_bile_ducts.html?qt=gallbladder%20cancer&alt=sh

Gallbladder Cancer (2011) Retrieved from http://www.mayoclinic.org/medicalprofs/gallbladder-carcinoma- management.html

General Information about Gallbladder Cancer (2011). Retrieved from http://www.cancer.gov/cancertopics/pdq/treatment/gallbladder/Patient/ page1

Insel, P. (2011) Nutrition (4th ed.) Sudbury MA: Jones and Bartlett

Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &

Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

Octreotide(2012) Mayo Clinic. Drugs and Supplements. Retrieved from http://www.mayoclinic.com/health/drug-information/DR601739

Parrish, C.R., Quatrara, B. (2010). Reinfusion of Intestinal Secretions: A viable

Option for Select Patients. Nutrition Issues in Gastroenterology, Series #83, April 2010.