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Acute Pancreatitis

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Jillian Olander

on 14 November 2014

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Transcript of Acute Pancreatitis

Acute Pancreatitis
Case #13

Samantha Stanis
Jillian Olander

Nutrition Intervention
Nutrition Diagnosis
Pertinent nutrition problems include inadequate oral food/beverage intake, altered GI function, and increased nutrient needs


Understanding the Diagnosis and Pathophysiology
The pancreas has both endocrine and exocrine functions.
Endocrine: Secretion of insulin and glucagon which is important in the regulation of glucose and sugar.
Exocrine: Secretion of pancreatic juice which contains digestive enzymes that aides in digestion of fats, carbohydrates, and proteins.
Understanding the Nutrition Therapy
NPO tube- no food intake orally
NG tube- Nasogastric tube
This allows pancreatic rest & gastric suction to assist with vommiting and nausea
Enteral feeding- a complete food source directly inserted into the stomach, also okay if the pt is hemodynamically stable
Immune-modulating formula- decreases risk of infection
Nutrition Assessment
Kelin Baar
Dana Bolduc

Patient History and Summary
Jon Mahon
29 yr old white male
Summary: Pt presented in ER 48 hrs ago. Returned with increased abdominal pain. Admitted to the MICU (Medical Intensive Care Unit)
History: Acute abdominal pain with N,V, high alcohol intake.
Demographics: Single w/ no children. In school full time, works as a research assistant. Jewish. Caucasian. Lives with roomate
Admitting H/P & Vital Signs
Pt states, "my stomach hurts so bad-- I just can't stand it. I can't seem to quit vomiting and I cannot keep anything down.
General appearance: Pale, obese male in obvious distress.
Vital Signs:
Temp 101.7,
Pulse 108
Resp Rate 27
BP 132/95
Height 5'11''
Weight 245 lbs
Abdomen: Hyperactive bowel sounds. Extreme tenderness, rebound and guarding.
Nursing Assesment
Abdominal appearance: Obese
Palpation of abdomen: Tense
Bowel function: Continent
Bowel sounds: Present in all 4 quadrants
Tubes/ostomies: N/A
Urine appearance: Cloudy, amber
Skin color: Pale
Admission Orders
R/O Small bowel obstruction vs. pseudo cyst vs. biliary tract disease
CBC, CMP, Amylase, Lipase and Mg
Repeat CBC, Amylase Lipase in 12 hrs
Repeat Chem 7 every 6 hrs
Radiology
Abdominal series
Abdominal CT and U/S
Vital signs every 4 hours
I & O recorded every 8 hours
NG tube to low intermittent suction
Notify MD for:
Fever >101
WBC >16,000
Calcium <8 mg/dL
D5W 40 MEq KCl 125 mL/hr
Scheduled Medications
Imipenen 1000 mg every 6 hrs
Pepcid 20 mg IVP every 12 hrs
Meperidine 50-150 mg IV every 3 hrs prn
Ondansetron 2-4 mg IV every 4-6 hrs prn
Colace (docusate) 100 mg po two times daily prn; if no bowel movement
Milk of Magnesia (MOM) 30 mL po daily prn
Ativan 0.5-1 mg po every 8 hrs prn
Nutrition
Meal Type: NPO
Fluid requirement: 1900-2400 mL
History: Pt states he gained wt over the past 5 years- almost 50 lb. Eats out usually for dinner, drinks coffee at breakfast with a bagel or toast. Lunch is usually a sub sandwhich or pizza. Pt states he has eaten very little in the past few days. When questioned about alcohol intake, Pt states he didnt realize how much he was drinking. Pt was trying to stop his antidepressants and guesses he increased his alcohol intake.
Abnormal Values
Amylase
Lipase
WBC
Bilirubin
Alkaline Phosphatase
ALT
Glucose
Creatinine
Cholesterol
Triglycerides
Lactate Dehydrogenase
CRP
APACHE Score
Stands for Acute Physiology and Chronic Health Evaluation
Severity of disease classification system
Measurements are taken within 24 hour of admssion.
Includes 12 factors measured on a scale of 1-4.
Maximum score of 71.
Pt had a score of 4 which is 4% mortality and mild acute pancreatitis
Complications of Pancreatitis
Pancreatic infections which may require treatment or surgery.
Damage to insulin producing cells may lead to diabetes
Long term pancreatic inflammation is a risk factor for pancreatic cancer
Psuedocysts may form. If the cysts rupture it may cause internal bleeding or infection
Malnutrition
Kidney failure
Acute Respiratory Distress Syndrome (ARDS)
I clicker question
Mr. Mahone is taking Pepcid every 24hrs, what is the function of Pepcid?
a) Narcotic
b)Acid reducer/ relieves heart burn
c) Anti Anxiety
d)Antimicrobial
Medication functions
Impemen: anti-microbial
Pepcid: acid reducer, relieves heartburn; reacts with folic acid, B-12, iron and zinc. Also several herbs.
Meperidine: narcotic analgesic
Ondansetron: eliminates nausea and vomiting.
Colace (docusate): softens stool
Milk of Magnesia: laxative; Phosphate interactions.
Ativan: anti-anxiety
High alcohol intake
Obese
Frequent consumption of fast food
Gained 50# over past 5 years
Dehydrated
Fever
Clammy and diaphoretic skin
Hypoactive bowel sounds
Calorie requirement: 1900-2000 Kcal
Protein requirement: 102-117 g pro/d
Fluid requirement: 1900-2400
Intake: 4500
Output (including feces) 4879

Alcohol Intake
6 pack a beer/ day
About 900 calories
4-5 shots of bourbon/day
About 485 calories
Mixed drinks and wine on weekends
Depends on the drink
At least 1385 empty kcal/day
70% of daily calories coming from alcohol

Acute Pancreatitis
Sudden swelling and inflammation of the pancreas
Works Cited

Nutrition Diagnosis
Inadequate oral intake related to limited food acceptance due to acute pancreatitis as evidenced by abdominal pain, poor skin tugor, dry skin and mucous membranes, patient self report of limited oral intake 3 days PTA and NPO since admission

Altered GI function related to compromised exocrine function of pancreas as evidenced by recent diagnosis of acute pancreatitis and current NPO status

Increased nutrient needs related to compromised pancreatic function as evidenced by C-reactive protein of 18 mg/dL indicating increased stress and metabolic requirements
It is recommended that Mr. Mahon's feedings be initiated in the jejunum and that either a chemically defined/fat-free formula or small peptide formula w/ MCT be delivered

MCT will be better absorbed and the small peptides better tolerated in the jejunum

One option is using Perative, which contains MCTs and small peptides, is calorically dense (1.3 cal/mL), is high in protein (20.5% of calories), meets/exceeds DRI for 24 vitamins and minerals, and is suitable for many people (Kosher, Gluten-Free, Lactose Intolerant)
Nutrition Intervention
Perative: 1503 mL (total volume) / 22 hrs = 68 mL/hr (rounded to 70 mL/hr)
70 mL/hr x 24 hrs = 1680 mL
1680 mL x 0.0667 g pro/mL = 112 g pro
1680 mL x 1.3 kcal/mL = 2184 kcal

1327 mL H2O
1950 - 1327 = 623 mL of free H2O

Initiate at 25 mL/hr, advancing to 20-40 mL/hr every 6-8 hrs until goal of 70 mL/hr is reached

This will provide 2184 kcals and 112 g protein
Nutrition Intervention
Recommendations to help improve tolerance of enteral feeding:
Initiate EN early after admission to reduce the period of ileus
Infuse EN distally into GI tract (recommended for NJ route)
Begin at low infusion rate and steadily increase
Choose formula containing small peptides and MCT or a nearly fat-free elemental formula
Initiate continuous feed rather than a bolus feed
Nutrition Monitoring and Evaluation
Factors to be monitored to assess tolerance and adequacy of nutrition support:
Amount of formula delivered vs. amount recommended
Body weight
Fluid status
Electrolytes, nitrogen balance, lipids, and other lab values
Nausea/vomiting
Nutrition Monitoring and
Evaluation
After acute pancreatitis is resolved...
Follow low-fat diet, high protein and carbohydrates
Avoid alcohol
30-35 kcals/kg
Pancreatic enzyme replacement- 30,000 units of lipase activity per meal and 20,000 units with snacks
Fat-soluble vitamin supplementation
Water-soluble vitamins (esp. thiamin, riboflavin, niacin)
If pain still occurs stop solid foods and go back to enteral feeding
Medication/ Nutritions related side effects.
Impemen: N/V, Cramps, diarrhea
Meperidine: dry mouth, N/V, GI pain, constipation, reacts with yeast.
Odansetron: dry mouth, GI pain, constipation
Colace: electrolyte imbalance, avoid mineral oil.
Activan: No Grapefruit
Roth, Ruth A. Nutrition & diet therapy. 11th ed. New York: Delmar Cengage Learning, 2014. Print.

http://en.wikipedia.org/wiki/APACHE_II

Nahikian-Nelms, Marcia and Sara Long Roth, Medical Nutrition Therapy: A Case Study Approach. 4th Edition. Belmont, CA Wadsworth/Thomson Learning
Alcoholism
Gallstones
Smoking
Certain medications
High calcium levels or triglyceride levels
Celiac disease
Infection
Heredity
Cystic Fibrosis
Kidney Failure
Etiology
A: Mr. Mahon, 29 yo male
Dx: Acute Pancreatitis
PmHx: Depression
Ht: 71" Wt: 245# BMI: 34
ADIME
A: Mr. Mahon, 29 yo male
Dx: Acute Pancreatitis
PmHx: Depression
Ht: 71" Wt: 245# BMI: 34 IBW: 172# +/-10% % IBW= 142%
Meds: Imipenen, Pepcid, Ondanstetron, Colase, M.O.M., Ativan

Labs:
BUN (mg/dL) 8-18 30 !↑
Creatinine serum (mg/dL) 0.6-1.2 1.6 !↑
Alkaline phosphatase (U/L) 30-120 256 !↑
ALT (U/L) 4-36 38 !↑
AST (U/L) 0-35 56 !↑
CPK (U/L) 30-135 F
55-170 M 219 !↑
Lactate dehydrogenase (U/L) 208-378 402 !↑
Lipase (U/L) 0-110 980 !↑
Amylase (U/L) 25-125 543 !↑
CRP (mg/dL) < 1 18 !↑

EER: 1954 kcals/d
EPR: 102-117 g pro/d
Diet HX: Patient states that he has gained weight over the last 5 years—almost 50 lbs. Eats out usually for dinner—drinks coffee at breakfast with a bagel or toast—lunch is usually a sub sandwich or pizza. Patient states that he has eaten very little over the past 3 days because of pain, nausea, and vomiting. When questioned about alcohol intake, patient states that he didn’t realize how much he had been drinking but states he was trying to stop his anti-depressant medications and guesses he increased his alcohol intake.
Physical assessment – GI: Hypoactive bowel sounds  4; acute abdominal pain with extreme tenderness, rebound, and guarding; intact, dry mucous membranes
Skin: dry, tears
D: Altered GI function related to compromised exocrine function of pancreas as evidenced by recent diagnosis of acute pancreatitis, elevated lipase and amylase.
I: Recommend to initiate Perative @ 25 mL/hr, advancing 20-40 mL/hr every 6-8 hours until goal of 70 mL/hr is reached, which will provide 2184 kcal and 112 g pro.
M/E:
Monitor tolerance to Perative: body weight, I/O, fluid status, electrolytes, nitrogen balance, glucose, any adverse signs of intolerance.
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