Case Study Patient with Colon CancerIleostomy placement Laura

+ Case Study: Patient with Colon Cancer/Ileostomy placement Laura Salinas KSC Dietetic Intern 12 -13

+ Today, we will discuss 1. Pathophysiology of colon cancer/colectomy/ileostomy 2. Medical Nutrition Therapy & Nutrition Care Process Diagnosis & Hospital course Nutritional Assessments MNT recommendations & Diet Orders Goals Interventions Evaluation/reassessment

+ Northeast Methodist Hospital Operational Vision: To meet the needs and exceed the expectations of those we serve by working together as a team in a culture dedicated to never-ending improvement. 179 Licensed beds n NEMH offers a full array of services: n ER n CABG & cardiac catheterizations n Inpatient rehabilitation n Orthopedic surgery n Oncology/Cancer Care n ICU/PCU n Inpatient and outpatient surgeries and procedures

+ Role of the RD at NEMH n 2 Full Time Registered Dietitians n Screening, Evaluations, Assessing Nutritional Needs n n n N/V, Skin comp, decreased intake, weight loss, difficulty swallowing, TPN/EN, >65 with surgery, Kidney dx, Cancer, DM, GI, Stroke, Liver Dx n Ventilated patient automatically trigger n LOS > 6 days or NPO > 3 days Works with full health care staff n n Screening triggers with a score of 7: Diet office, RN, Doctors, ICU & Rehab rounds Consultations & Diet Educations

+ Meet Ms. A n 42 year old female admitted June 3, 2013 n Diagnosis: Colon Cancer, Laparoscopic Right Hemicolectomy n Severe Iron Deficiency Anemia n n Iron 18 mcg/d. L, Iron Saturation 5%, Hgb 9. 8 g/d. L Colonoscopy n polyps with tubulovillous adenoma with high-grade dysplasia n Medical History: Hyperlipidemia, Bipolar Disorder, Anemia, Gastric Bypass (2004) n Diet Order: Clear Liquid Diet (POD #1) n Labs (POD #2): Glu 115, Ca 8. 0, PO 4 1. 7, Mg 1. 4, Alb 2. 6, Hgb 8. 5, Hct 25. 7 n (POD #3): Iron 9 mcg/d. L, Iron Sat. 4%, Transferrin 184 mg/d. L

+ Colon Cancer: Pathophysiology n Most cases of colon cancer begin as small benign clumps of cells called adenomatous polyps. n Over time, polyps can develop into colon cancers. n Treatment: n n Surgery n Early stage n Invasive*** n Advanced Chemotherapy Radiation Therapy Targeted Drug Therapy

+ Digestive System http: //digestive. niddk. nih. gov/ddiseases/pubs/ileostomy/

+ Site of Nutrient Absorption http: //www. tuberose. com/Digestion. html

+ Right hemicolectomy

+ What went wrong? n POD #4 (6/7/13) n Pt experiencing persistent abdominal pain and dark urine n Enema revealed brownish/red stool n Temperature spiked to 100. 4 F. n Hold heparin, protonix, KUB ordered n KUB revealed ileus with free air n Lab Values: Na 134, Cl 97, BUN 28, ALB 2. 2, GFR 58, GLU 114, CA 8. 4, MG 2. 7 n Nutrition Status n Diet Order: Bariatric/Gastric Bypass Diet

+ Clinical Course n POD #5 (6/8/13) n Nutrition Status n Declining – notes indicate pt is unable to eat n Pain with passing gas and burping n Phenergan for N/V n POD #6 (6/9/13) n Pt required 2 units of blood (327 cc)

+ Clinical Course n POD #7 (6/10/13) n Problem List: n S/P right hemicolectomy n Severe Iron Deficiency Anemia n PMH of gastric bypass – limited ability to absorb oral iron n n Anemia n n IV replaced Hypomagnesemia n n Acute on chronic; blood loss from surgery; iron deficiency Hypophosphatemia n n IV iron IV replaced Ileus

+ Clinical Course n POD #7 (6/10/13) n Acute events: n n severe abdominal pain/abdominal distention n Nausea & vomiting n KUB showed ileus and nonspecific inflammation n Likely anastomotic leak Ms. A to OR for washout and Ileostomy n n 2 L washed out of the abdomen Nutrition Status: NPO n TPN & Lipids ordered through triple lumen IJ

+ Anastomotic Leak n Complication affects 2 -10% of patients undergoing GI surgery n Negative impact on oncologic outcome in patients undergoing curative resection for colon cancer n Increased risk for AL: n Patients with Albumin <3. 5 g/d. L *Ms. A: Alb 2. 2 g/d. L n Intraoperative blood loss of 200 m. L or more n OR time >200 minutes n Intraoperative transfusion requirement http: //archsurg. jamanetwork. com/article. aspx? articleid=405870

+ Washout and Ileostomy

+ Nutrition Assessment n 6/10/13* Initial Nutrition Screening Assessment n n Diet Order: NPO Weight: 226 lb (reported by patient) Estimated needs: 1659 -1990 (MSJ*1. 0 -1. 2) n Actual weight n Protein needs: 113 -135 gm/day (1. 1 -1. 3 gm/kg) n Labs: NA 133, GLU 100, CR 0. 5, ALB 1. 9, WBC 15. 6, H/H 9. 6/30. 0 n Meds: Insulin, Lovenox, Protonix, Pepcid, Phenergan, Lasix, Zofran, Morphine, Narcan, Bactroban, Ativan

+ Nutrition Assessment n 6/10/13* Initial Nutrition Screening Assessment n Diet Order: NPO Weight: 226 lb (reported by patient) n PES: Altered GI function related to altered GI structure as evidence by CT scan showing air/fluid in RLQ, patient experiencing n/v, abdominal distention, and no BM. n Goal: n n Determine nutritional status & GI function post op n Advance oral diet if functional; if not, consider nutrition support Intervention: Monitor symptoms, lab values, & diet changes

+ Clinical Course n POD #8 (6/11/13) n Ms. A S/P exploratory laparoscopy after finding free air on KUB n Ileostomy Placement n Postoperatively Hypotensive (secondary to third spacing of fluid or septic shock) n n Requiring high doses of Levophed ICU: Intubated/sedated (propofol) n TPN running at goal rate of 75 cc/hr with 150 cc 20% lipids n 2 JP drains to left abdomen with bloody output n Ileostomy with liquid brown output http: //www. cc. nih. gov/ccc/patient_education/pepubs/jp. pdf

+ Academy’s Recommendation n “Enteral nutrition should always be considered as the first line of nutrition support, with parenteral nutrition used only when the GI tract is nonfunctional either as a result of physical or physiologic (obstruction) events. ” “In some cases, the GI tract may be functional but cannot be accessed due to anatomical or pathophysiologic conditions; in those cases, parenteral nutrition should be considered. ”

+ MNT Recommendation: TPN n TPN with Lipids n Clin 5/25 n n 1050 kcal/L n Amino Acid: 50 g/L (5%) n Dextrose: 250 g/L (25%) Clin 5/25 at a rate of 75 m. L/hr with 150 m. L of 20% lipid per 24 hour infusion: n 2100 total kcal n 1700 non-protein kcal n 90 gm protein

+ Clinical Course n n POD #10 (6/13/13) n Weight: 255 lb n Ms. A remains critically ill – TPN still running POD #12 (6/15/13) n n Orders to extubate – TPN still running POD #13 (6/16/13) n Weight: 246 lb n Ms. A advanced to Full Liquid Diet – TPN still running

+ MNT recommendations: PES: Malnutrition related to alteration in GI structure and function as evidence by lap right colectomy and anastomotic leak repair with ileostomy placement, NPO status, critically ill, and ventilated/sedated. Goal: Monitor TPN & provide adequate energy to meet increased needs. Intervention: Monitor TPN, lab values, weight changes, and diet advancement

+ Clinical Course n POD #16 (6/19/13) n Weight: 242 lb n Ms. A advanced to Bariatric/Gastric Bypass Diet & TPN d/c n n MD notes indicate Ms. A tolerating PO with imodium POD #18 (6/21/13) n Ileostomy bag continually leaking n Ms. A not eating well, nausea Malnutrition related to altered GI structure/function as evidence by s/p lap right colectomy, ileostomy, and 25% full liquid diet intake. n POD #23 (6/26/13) n Ms. A discharged to Heartland for Rehab

+ Re-admit: July 3, 2013 n Diagnosis: Sepsis; Intra-abdominal abscess; Peritonitis n Nutritional Indicators with Ileostomy: n Inadequate oral intake; Inadequate fluid intake n Fluid and electrolyte imbalances n Evidence of malabsorption n Weight loss 15# since past admission n Reduced visceral protein stores Albumin 2. 1 n Vitamin & Mineral Deficiencies

+ Nutritional Assessment n 7/3/13* Initial Nutrition Consult for Supplementation n Diet Order: Full Liquid Weight: 212 lb (reported by patient) n Estimated needs: 1770 -1930 (MSJ*1. 1 -1. 2) n Protein needs: 82 -109 gm/day (1. 5 - 2. 0 gm/kg IBW) n Labs: NA 131, GLU 101, ALB 1. 7, MG 1. 7, WBC 19. 2, H/H 11. 5/34. 5 n Meds: Lactinex, Pepcid, Zofran, Imodium, Folic Acid, Marinol

+ Nutritional Assessment n 7/3/13* Initial Nutrition Consult for Supplementation n Diet Order: Full Liquid Weight: 212 lb (reported by patient) n PES: Malnutrition related to altered GI structure/function & complications as evidence by inadequate oral intake and increased protein/kcal needs. n Goal: n n Pt will tolerate oral diet >75% to meet estimated nutrition needs. n Pt will consume meals with supplements to meet estimated needs n Correct protein calorie malnutrition and promote repletion of visceral protein stores Intervention: monitor PO intake/tolerance; monitor lab values

+ Clinical Course: Goals n 7/5/13: Calorie count consult received n n Intervention n n Goal to correct protein/calorie malnutrition n Optimize postoperative healing needs n Correct nutrient deficiencies & meet estimated needs n Prevent dehydration and electrolyte imbalances Calorie Counts (7/5/13 -7/8/13) Ensure Enlive Q 4 hrs n Each Ensure Enlive provides 200 kcal & 7 gm protein Food Preferences/Monitoring by dietary staff & RD Diet Education n n Minimize symptoms of malabsorption/maldigestion Prevent gas/odor/obstruction

+ Clinical Course: Nutrients n Nutrients of greater concern n Iron n B 12 n Sodium n Potassium n Chloride n Total kcal n Total protein

+ Clinical Course n 7/10/13 n Continuing calorie count n Patient visited on many occasions to encourage PO n Ms. A voiced that she is trying to get her appetite up n Frustrations with ileostomy bag leaking/coming off n Explained symptoms and foods to avoid n Low intakes continually on calorie counts n 7/6: 753 kcal, 49 gm protein n 7/7: 766 kcal, 39 gm protein Inadequate oral intake related to dx/hx and poor appetite as evidence by patient unable to meet estimated needs in two 24 hour calorie counts.

+ Plan for d/c: n Low-fiber diet that provides adequate energy, protein, fluid, and electrolytes (Sodium/Chloride/Potassium) for healing n Increase sodium intake because of losses n Smaller more frequent meals with supplementation n Limit fluids with meals to decrease output n Education: supplementation and higher kcal/protein needs n Obstruction/Odor/Gas n Avoid chewing gum, drinking straws, carbonated beverages

+ Questions? Thank You!

+ References: American Cancer Society. Ileostomy: A Guide. Available at: www. cancer. org/acs/groups/cid/documents/webcontent/002870 -pdf. pdf National Institute of Health. How to Care for the Jackson-Pratt Drain. Available at: http: //www. cc. nih. gov/ccc/patient_education/pepubs/jp. pdf Nutrition Care Manual. Available at: www. nutritioncaremanual. org Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk Factors for Anastomotic Leak Following Colorectal Surgery: A Case-Control Study. Arch Surg. 2010; 145(4): 371 -376. doi: 10. 1001/archsurg. 2010. 40. UPMC. Ostomy Nutrition Guide. Available at: www. upmc. com/patientsvisitors/education/nutrition/pages/ostomy-nutrition-guide. aspx