Clinical Case Study The long road back to

Clinical Case Study The long road back to eating. Birgit Humpert, KSC Dietetic Intern 2012 -2013

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.

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 –CHa. D Norris Cotton Cancer Center

Role of the RDs � Team � 4 � 7 � 5 � 1 of 21 Dietitians and Diet Technicians. RD and 3 DT only inpatient in- and outpatient only outpatient employee wellness � Work with other members of the medical team to ensure the best treatment for the 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 Image: retrieved from National Cancer Institute

Diseases of the gallbladder 1. 2. 3. Cholelithiasis Cholecystitis 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 � Initiation: abnormal cells are formed � Promotion: abnormal cells multiply � Progression: tumor growth

Surgery 1/17 � Excission of the tumor and lymph nodes � Gastric antrectomy � Antecolic anterior gastrojejunostomy � Choledochojejunostomy DAY 0

http: //studynursing. blogspot. com/2011/01/gastrojej unostomy. html

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, creatinine 0. 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)

� 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

� Same day: � Difficulty breathing, tachicardia, ECG abnormalitites, transferred to ICU � Duodenal stump leak � gastrostomy and feeding jejunostomy

Enteral and parenteral nutrition

Consult for TF recommendation � Assessment: DAY 11 80. 8 kg, 69. 4 kg (admission), 160 cm, BMI 27. 1 � Labs: Na 137, K 2. 4, ch 104, CO 2 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 � Anthropometrics: � Diagnosis: � NI-5. 2 Malnutrition related to alterations in gastrointestinal tract structure/function AEB Prealbumin of 3.

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 � 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 � Mimics the action of naturally occuring somatostatin � 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 � TF temporarily stopped due to leak from choledochojejunostomy site � Labs: Na 134, creatinine 0. 52 � Needs: 1750 kcal, 150 g protein, 2400 ml continously � Provided as premixed formula: (1032 cal, 151 g protein, 125 g CHO, 0 g lipids) DAY 19

TF restarted � Assessment: � Weight: DAY 22 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 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 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 � Persistent DAY 23 -33 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 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 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 � 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 � Blood DAY 48 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 � Labs: DAY 51 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

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 since she is eating and getting Boost � TPN continued, provides 740 kcal, 100 g protein, 100 g CHO � Reassessment � 74 � Pt kg, PAB 3 on 3/19: discharged home with VNA DAY 61

Update � Weight: DAY 82 68. 9 kg � Still on TPN, pt wants off � Recall: cereal with 2% milk for breakfast, toast w butter or grilled-cheese sdw with chickennoodle 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

Resources: Calandra, T. , Marchetti, O. (2004) Clinical Trials of Antifungal Prophylaxis among Patients Undergoing Surgery. Clin Infect Dis. (2004) 39 (Supplement 4): S 185 -S 192. doi: 10. 1086/421955 Charney, P. , Malone A. M. (2009). ADA Pocket Guide to Nutrition Assessment. 2 nd 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_bil e_ducts. html? qt=gallbladder%20 cancer&alt=sh Gallbladder Cancer (2011) Retrieved from http: //www. mayoclinic. org/medicalprofs/gallbladder-carcinomamanagement. html General Information about Gallbladder Cancer (2011). Retrieved from http: //www. cancer. gov/cancertopics/pdq/treatment/gallbladder/Patient/ page 1 Insel, P. (2011) Nutrition (4 th ed. ) Sudbury MA: Jones and Bartlett Nelms, M. , Sucher, K. P. , Lacey, K. , Roth, S. L. (2011). Nutrition Therapy & Pathophysiology (2 nd ed. ). Belmont, CA: Wadsworth Octreotide (2012) Mayo Clinic. Drugs and Supplements. Retrieved from http: //www. mayoclinic. com/health/drug-information/DR 601739 Parrish, C. R. , Quatrara, B. (2010). Reinfusion of Intestinal Secretions: A viable Option for Select Patients. Nutrition Issues in Gastroenterology, Series #83, April 2010.