Nutritional Support in Small Bowel Obstruction Lisa SharpGomez

Nutritional Support in Small Bowel Obstruction Lisa Sharp-Gomez, Dietetic Intern February 9, 2016

JW’s History �JW is an 81 year old caucasian female with a history of osteoporosis, rheumatoid arthritis and hypertension, c-section and hysterectomy �JW arrived in the ED on 9/12/15 with complaints of nausea, vomiting and abdominal distention for the past 24 hours.

History, cont �JW was 5’ and 112 lbs. �BMI 22. 0 �Non smoker �Non drinker �Very twisted hands due to rheumatoid arthritis. �Used a walker and a cane at home

Initial Assessments �Ileus �Small Bowel Obstruction �Enteritis �UTI �Possible pneumonia �Possible thoracic compression fracture

Diagnostic tests �Urinalysis �Blood work �KUB �Xray �CT scan

Conservative Management �NPO �Clear liquids �Stool softeners/ laxatives �Enema �IV fluids �PT/OT/IS �NG tube

Initial Nutrition Goals �NPO initially, with advance to clear, full and then to regular diet as tolerated. �Ensure Clear was offered �Magic Cup was offered

“I should be feeling better. ” � 9/19/15 Day 7: ◦ JW looked anxious, tired and in pain ◦ Weak ◦ Spitting up into tissue

Diet Timeline � 9/12 � 9/13 � 9/14 � 9/15 � 9/16 � 9/17 � 9/18 � 9/19 � 9/20 admission NPO Clear liquid – minimal po regular – however, no po taken NPO – NG tube 1400 ml out NPO – addt’l 600 ml out NPO - surgery

Surgical Intervention 9/21/15 �CT scan definitively identified a small bowel obstruction �Laparoscopic procedure identified sigmoid colon diverticulitis, sigmoid colon adhesions onto the bladder, a colovesicle fistula and small bowel adhesions in the area of the ileocecal valve. �A colostomy was placed at the end of the decending colon.

Remember that UTI? �JW’s urine had tested positive for e. Coli when she arrived in the ED. She was treated with Levaquin. After the fistula was repaired, all repeat urine cultures were negative.

Bowel healing �After surgery, it was felt that bowel rest was needed. �A PICC line was placed on 9/21 and TPN was started.

TPN �Total Parenteral Nutrition ◦ Used to provide nutrition when the GI tract is not functioning. ◦ Provides proteins, carbohydrates and fats via a PICC line or central line, directly into the blood stream.

When? Why? �In a previously well-nourished patient, use of PN provides little benefit over the first week of hospitalization in the ICU (ASPEN, 2016) �Start TPN only if EN is not feasible. Delay for at least a week unless malnourished before admission. (Escott-Stump pg 911)

TPN initiated on 9/21 �JW had been essentially NPO for 9 days. �PICC line was placed and TPN initiated at a rate of 50 ml/hr.

Formula � 50 ml/hr x 24 hr = 1200 ml � 1200 ml of a 20% dextrose solution provides 240 g of carbohydrate x 3. 4 kcal/g (for dextrose) = 816 kcal � 1200 ml of a 4. 25% amino acid solution provides 51 g of protein x 4 kcal/g = 204 kcal � 250 ml of 20% lipids provides 500 kcal. ◦ Lipids were added every other day � Grams of CHO/kg/min = 2. 96 (recommended goal is < or = 4) � Energy provided was averaged over a 7 day period, providing 1270 kca and 51 g protein per day.

Calorie Goals �Nutrition goals for JW were set early during her stay. �Calorie needs per day (2530 kcal/kg)=1266 – 1350 �Protein needs per day (. 8 – 1 g/kg) = 42 -51 g

Daily Management �JW had labs drawn daily to determine her levels of micronutrients. Potassium, phosphorus and magnesium were of greatest concern. �These levels did drop on the second day of TPN, but there were no symptoms of refeeding syndrome noted.

Refeeding Syndrome

Management, cont. �When TPN was initiated, JW’s blood glucose levels rose. �Per ASPEN 2016 guidelines: There is moderate evidence to suggest that there is a benefit to maintaining blood glucose levels in a goal range of 140 180 mg/d. L. (Mc. Clave, et al 2016) �Glucose abnormalities occur in >90% of patients receiving TPN. (Escott-Stump, 2012) �Insulin was added to JW’s TPN solution to maintain her blood sugars in this goal range.

Weaning �On 9/24, JW had some clear liquids. �On 9/25, JW had liquids and ice cream. PO increased daily and TPN was discontinued on 9/28. JW was on TPN for 7 days.

Going home �Discharged 10/1/15 �Otterbein ECF

References � � � Al Salamah, S. , Fahim, F. , Hameed, A. , Abdulkarin, A. , Al Mogbal, E. , Al Shaer, A. , (2012). How Predictive Are The Signs And Symptoms Of Small Bowel Obstruction. Oman Medical Journal. 27(4). 281 -284. Ansari, P. (2015). Ileus. Retrieved from https: //www. merckmanuals. com/professional/gastrointestinal-disorders/acute-abdomen-andsurgical-gastroenterology/ileus Becker, J. , Stucchi, A. , Reed, K. , (2013). Abdominal Adhesions. Retrieved from http: //www. niddk. nih. gov/health-information/health-topics/digestive-diseases/abdominaladhesions/Pages/facts. aspx Escott-Stump, S. (2012). Nutrition And Diagnosis-Related Care. Baltimore, MD: Lippincott Williams & Williams Flomax® (tamsulosin) for Urinary Issues in Women. (2014). In Institutional Care Pharmacy. Retrieved from http: //www. icppharm. com/News-Resources/Articles/Flomax%C 2%AE-%28 tamsulosin%29 -for. Urinary-Issues-in-Women. aspx Hacking, C. , Galliard, F. , (2015), Colovesicle fistula. Retrieved from http: //radiopaedia. org/articles/colovesical-fistula Lehner, J. (2014). Enteritis. Retrieved from https: //www. nlm. nih. gov/medlineplus/ency/article/001149. htm

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