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A Case-Based Approach Focusing on Nutrition and Sham Feeding for Managing Postoperative Ileus. Robert MacLaren, PharmD, BSc (Pharm), FCCM, FCCP Associate Professor School of Pharmacy University of Colorado Critical Care Pharmacy Specialist University of Colorado Hospital Aurora, Colorado.
A Case-Based Approach Focusing on Nutrition and Sham Feeding for Managing Postoperative Ileus
Robert MacLaren, PharmD, BSc (Pharm), FCCM, FCCP
School of Pharmacy
University of Colorado
Critical Care Pharmacy Specialist
University of Colorado Hospital
It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.
Dr. MacLaren has received grants/research support from Hospira.
Describe the importance of improving time to gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care
Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures
Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice
Evaluate the evidence regarding the use of preoperative therapies, nasogastric tubes, enteral nutrition, and sham feeding for the management of postoperative ileus (POI)
Describe how to use these modalities to manage POI and improve time to bowel recovery
Given a case scenario, implement therapeutic strategies using these modalities to improve time to bowel recovery and patient outcomes
RR is a 44-year-old female (5’5”, 70 kg) with known diverticulosis who is admitted with rectal bleeding
She was discharged two weeks ago after one week of hospitalization for diverticulitis for which she received antibiotic therapy (levofloxacin 500 mg IV/PO daily and metronidazole 500 mg IV/PO tid); an abdominal computerized tomography scan at the time revealed diverticulitis of the sigmoid colon with no abscesses
Her physical exam is normal, vital signs are within normal limits except heart rate of 100-120s, and all laboratory values are within normal limits except hemoglobin = 10 g/dL and hematocrit = 31.5 (values of both at prior discharge were 14 g/dL and 42, respectively)
The anemia is believed related to bleeding diverticulosis and her stools are guaiac-positive
Her past medical history is significant for hypothyroidism (levothyroxine 0.75 mg PO daily) and diverticulosis with a single attack two years prior
RR does not smoke, rarely drinks alcohol, and her family history is noncontributory
In the emergency room, RR is administered normal saline (2 L) and two units of packed red blood cells that result in hemoglobin and hematocrit values of 11 g/dL and 33, respectively
A colonoscopy is performed that reveals a brisk bleed from diverticulosis of the sigmoid colon; local epinephrine is injected but blood continues to ooze
The surgery team is consulted and the decision is to monitor her and only perform surgery if she requires additional blood products
Levofloxacin 500 mg IV daily and metronidazole 500 mg IV tid are initiated
She is preemptively administered a preoperative bowel preparation (Fleet's Phospho-soda solution 45 mL PO q 12 hours x 2)
Over the course of the next 12 hours, RR requires two additional units of red blood cells
The surgical team decides to perform a laparoscopic sigmoid resection
In preparation for surgery, RR receives metoprolol 2.5 mg IV x 1, lorazepam 1 mg IV x 1, and vancomycin 1 g IV x 1
Do bowel preparation or anxiolytic prophylaxis before colorectal surgery reduce gastrointestinal dysfunction?
Guenaga KK, et al. Cochrane Database Syst Rev. 2009;Jan21(1):CD001544.
Story S, et al. Dig Surg. 2009;26:265-275.
White PF, et al. Anesth Analg. 2007;104:1380-1396.
Hallerback B, et al. Scand J Gastroenterol. 1987;22:149-155.
Conclusion: The preoperative practices of bowel preparation and NPO are not supported by data; preoperatively reducing the stress response with anxiolytics and/or β-blockers may hasten GI recovery
Intraoperatively, RR is sedated with fentanyl and propofol
During surgery, the laparoscopic sigmoid resection removes 10 cm of colon, including bleeding diverticulosis, and a colo-colonic anastomosis is performed
Estimated blood loss is minimal and RR remains hemodynamically stable during the two-hour surgery
In the PACU, the nasogastric tube is removed and she is transferred to the step-down unit for monitoring
Transfer orders include bisacodyl 10 mg po tid, hydromorphone 1-2 mg PO qid PRN, ibuprofen 600 mg PO qid, liquid diet as tolerated, ambulate as tolerated
PACU: post anesthesia care unit
NG tube immediately following surgery?
Nelson R, et al. Cochrane Database Syst Rev. 2007;Jul 18(3):CD004929.
Conclusion: NG tubes offer no benefit in most patients after abdominal surgery, may predispose patients to infectious complications, and should be removed quickly after surgery
Postsurgery day 1
Hemoglobin and hematocrit are stable at 12 g/dL and 37, respectively
RR is extremely nauseated and unable to eat despite ondansetron 8 mg IV tid, promethazine 25 mg IV x 2, and metoclopramide 10 mg IV x 1
Pain scores are 1-2/10 and she has only required hydromorphone 1 mg PO x 1
She is ambulating with difficulty due to feeling nauseated
The care team orders one stick of gum qid x 15 minutes
Conclusion: Gum chewing appears effective for expediting GI recovery, especially in the absence of adequate oral nutritional intake
Postsurgery day 2
RR remains hemodynamically stable
Her nausea is slightly improved and she is able to partially tolerate a soft diet (eg, Jell-O®) in small portions
She continues to receive antinausea medications
RR is unable to advance her diet despite ondansetron 8 mg IV tid, promethazine 25 mg IV x 3, and metoclopramide 10 mg IV x 1
Pain scores are 1-2/10 with no additional use of hydromorphone
Flatus is present but bowel movements are absent
She is able to ambulate
The care team orders a small-bore nasogastric tube for enteral nutrition supplementation
Lewis S, et al. J Gastrointest Surg. 2009;13:569-575.
Conclusion: Enteral nutrition support may reduce complications and morbidity when initiated early after intestinal surgery