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Clinical Case Study

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Katie Castellano

on 26 January 2013

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Transcript of Clinical Case Study

MNT Rotation Clinical Case Study Patient: RB Nutrition History Age: 22
Race: AA
Sex: Female
Date of Admission: August 7, 2012 Diagnosis:
Ischemic bowel; also known as short bowel syndrome (SBS)

Care Path/Standards of Care:
Initial procedure of right hemicolectomy with enterectomy, and tube duodenostomy, and colostomy.

TPN started August 12, 2012 Chief Complaint:
Abdominal Pain S/P C-Section Definition: Intestinal ischemia and infarction is damage to (ischemia) or death of (infarction) part of the intestine due to a decrease in its blood supply.

Etiology: The risk of acute mesenteric venous thrombosis increases in patients with hypercoagulable states

Cramping and abdominal pain
Bloody stools
Frequent urge to defecate
Nausea or vomiting
Abdominal distension Review of Diagnosis Treatment: Treatment usually requires surgery. The section of intestine that has died is removed, and the healthy remaining ends of bowel reconnected.

... In this case, what was left was part of her duodenum and colon.

Nutritional Implications:
Severe Malabsorption
Dehydration (fluid and electrolyte disturbances)
Malnutrition Review of Diagnosis cont. PTA: Regular diet

Through LOS: TPN; NPO; CL Patient's Medical Treatment Past Medical/Surgical hx:
March '09: paraplegia secondary to MVA
August 7, 2012: C-section
August 8, 2012: laparotomy with removal of small and large bowel with placement of colostomy and tube duodenostomy
August 17, 2012: 2 drains to the pelvic and perihepatic region. they were discontinued on August 31, 2012
August 22, 2012: Thoracentesis with cytology showing no malignant cells. Repeat thoracentesis on August 31, 2012
August 30, 2012: S/P placement of left lower quadrant abdominal drain. It fell out on Sept 1, 2012
On August 31, S/P chest tube placement
On September 5, 2012: percutaneous gastrostomy tube (PEG) placement
On October 15, 2012: colostomy takedown with segmental resection of colon
November 5, 2012: Colonoscopy with ulcerated area in the duodenum
On November 14, 2012: Mediport placement Physical Exam Ht: 5'6"

Wt: 136 #; Usual wt: 147#

How Long ago: August

Frame size: M; determined per nursing report in Meditech

Ideal BW: 130#; % Ideal BW: 104%

%UBW: 92.5% Medications Labs with Nutritional Significance Assessment of Nutritional Status Adequacy of fat stores:
None due to malabsorption from GI

Adequacy of visceral protein:
Alb, pre-alb = severely depleted

Adequacy of somatic protein:
Creatinine = severely depleted

Nutritional problems:
Super altered GI tract; malabsorption

Estimated caloric needs:
2200-2550 calories using Miff (1.3-1.5)

Estimated protein needs:
85-95 g pro; 1.4-1.6 g/kg

Other nutritional needs:
Fluid: 2-2.2 L; everything else is provided in TPN Initial MNT Assessment PES: Pt at increased nutritional risk R/T C/S, post-partum on a non-ob floor as evidenced by NPO status and possible GI bleed
- Altered labs: (8/8/12) BUN/CR 19/1.5; K 6.2; ALB 2.2, H/H 8.2/21.4
- Meds: Reglan

- Diet advancement
- Labs WNL
- Weight Stable

- Recommend advance diet as tolerated and medically able starting with clears
- Recommend monitor labs regularly
- Recommend monitor weights daily Patient's Med TX cont. Psycho-Social/Family hx:
Emotionally withdrawn from baby after delivery
Attentive significant other and primary caregiver of baby while still alive
Mother is primary caregiver to pt

Current tx:
Closure of colostomy;
Anastamosis of duodenum and colon;
JP drain to bulb suction;
Clamped PEG;
Foley to gravity;
TPN http://emedicine.medscape.com/article/193391-overview
http://www.med.nyu.edu/content?ChunkIID=96868#treatment Outcomes of Care Health Outcome: Pt is alive and having her nutrient needs met through TPN; RD planning for D/C home TPN needs; oral intake more for pleasure than nutritional value; pt readmitted 3 weeks later due to sepsis

Potential Resources saved: N/A; PT would have died without TPN Protonix
Ativan ... Prior to D/C MNT F/U Evaluation:
Estimated Nutrient Needs:
2200-2500 Total KCALS (higher due to post-partum)
85-95 g pro
2-2.2 L fluid
- Pt with Paraplegia
- Sm and Lrge bowel resection
- Most likely will need long-term/Permanent TPN Supp
- Altered Labs: (8/13/12) Gluc 127, CR 0.4, NA 147, PREALB 11.8
- TPN 2 L Central Concentrated

- Recommend continue with TPN
- Add Lipids to formula to provide a total of 1920 kcals, 100 g pro
Upon D/C, recommend consult Palmetto Infuscience to set-up home TPN; with customized TPN, Recommend 2 L Daily of Dex 20%, AA 5%, Lipids 20% 250 cc to provide 2260 kcals, 100 g pro
- Monitor Labs regularly
- Monitor weights daily Research *The EAL provided no research for SBS

* Journal of Gastroenterology
- "Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome"

Aim of study: to assess prognostic factors such as survival and PN-dependence probabilities, taking into account both small bowel remnant length and the type of digestive circuit of anastamosis.

Method: From 1980 to 1992, a total of 124 consecutive adults with nonmalignant SBS were enrolled at 2 home PN centers. Survival and PN-dependence were analyzed using the Cox model and linear discriminant analysis was used for PN dependence.

Results: at 2 and 5 years, respectively, survival and PN-dependence probabilities were 86% and 49% and 75% and 45%. Survival was negatively related to end-enterostomy, to small bowel lengths <50 and 50-99 cm and to absence of terminal ileum and/or colon in continuity in the multivariate analysis. The "cutoff values of small bowel lengths separating transient and permanent intestinal failure were 200, 65, and 30 cm in end-enterostomy, jejunoileocolic type anastamosis, respectively. "

Conclusion: For adult SBS patients, it was seen that small bowel length of <100 cm is highly predictive of permanent intestinal failure. Weaning off PN and survival probabilities is enhanced by the presence of terminal ileum and/or colon continuity. Probability of permanent intestinal failure is 4% after two years of PN. Such rates may lead to the selection of other treatments, especially intestinal transplantation, instead of PN, for permanent intestinal failure caused by SBS. GI Transplantation Services
University of Alabama

UCLA Transplant Center

Stanford University Medical Center

Georgetown University Hospital

University of Miami School of Medicine

Northwestern Memorial Hospital

Rush-Presbyterian-St. Luke’s Medical Center

University of Illinois at Chicago
Division of Transplant Surgery

Children’s Memorial Hospital

The Clarian Transplant Center

University of Iowa Hospitals & Clinics Tulane University School of Medicine

Massachusetts General Hospital

University of Massachusetts

University of Minnesota

The Children’s Mercy Hospital

St. Louis Children’s Hospital

University of Nebraska Medical Center

Mount Sinai Medical Center

University of Rochester Medical Center

Columbia Presbyterian Hospital

Oklahoma Transplant Cincinnati Children’s Medical Center

School of Medicine

Children’s Hospital of Pittsburgh

**Medical University of South Carolina

Baylor University Medical Center

Hepatology and Transplantation program
Children’s Medical Center
Dallas, Texas

University of Washington

University of Wisconsin Can be found on Intestinal Transplant Association (ITA); Website: tts.org/ita Medications
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