Clinical Case Study: Obstruction VS TPN

Clinical Case Study: Obstruction VS TPN

Table of Contents

• General information
• Admission report
• Special history
• Pathology and status
• Complete Nutrition care process (NCP)
• Summary
• References

For: Caroline Leblanc, RD @ CCH

Project made by Nora Shero, nutrition student

Clinical Intern, nov 2014, UofOttawa

Pathology and status

Plan and f/u

P.MD. got to CCH from a post-op SBO done in OH + Infected bowel

N/V & Partial SBO NPO + CF with antiobiotics

Prognosis: Unknown

P.M.D. got transferred from CCH to OH because FMD will continue the case.

Results in Ottawa after f/u with RD:

• OCT6: Same rate for TPN as in CCH (80 cc/hr for dextrose + a.a & lipids @ 10 cc/hr with IV @ 40 cc)

• OCT9: STOP TPN! Pt is now having normal BM and eating regular meals. Tolerating well.

• OCT12: P.M.D. IS D/C HOME!!!!!!

CASE STUDY REPORT

Image 2

Image 1

Crohn's Disease

Nutritional support

TPN risks

Complications (1):

• Hyperglycemia (Most common)
• Liver disease
• Lower immune sysem
• Sepsis
• Respitory complications
• Hypoglycemia
• Essential fatty acid deficiencies
• HyperTG
• Refeeding syndrome

Partial SBO generally require TPN due to NPO for several days to help promote bowel healing (8)

P.M.D. will receive TPN via PICC

PICC catheter in vena cava or right atrium with peripheral vein access (1)

• Chronic and recurrent IBD, unknown etiology that might affect all GIT (2,3)

• Affect 130 out of 100 000 people, both sexes between 15-30 years of age (3)

• May affect any part of GIT, but involves both large intestine + distal ileum 50-60% of the time (2,3,4,5)

• Rarely affects colon or small intestine alone (15-25%)

*PICC only for long term use > 10-14 days

Crohn's Disease

Clinical symptoms:

Diarrhea/malabsorbtion, fever, abdo pain, anorexia, wt loss, anemia, food intolerances, malnutrition, growth failure and extraintestinal manifestions (2,3,4,5,6,7)

Anatomy & Physiology:

Abscesses, fistulas, fibrosis, submucosal thickening, localized strictures, narrowed segments of bowel and partial (80%) or complete obstruction of the intestinal lumen (2,3,4)

OBSTRUCTION: Severe narrowed segments of bowel caused by inflammation or edema ***May need nutritional support (8)

*N.B.:

Wounds can be distributed at different segments in GI and without affecting necessary all areas (2,3)

Image 4

*Nutritional deficiencies: Iron, vit B12, folic acid, vit D, Ca+, Zn & Electrolytes (2,3, 9,10,11)

Image 3

Admission report

*Obstructions are caused 60% from adhesions and 5% from IBD (15)

General information

• Date of admission: Saturday September 13th, 2014 @ 9:45 pm with ambulatory entry
• Pt's vitals: Normal body Temp @ 36.9 °C and BP @ 127/74
• Reason for admission: 4 times vomiting in same the day & extreme ABDO pain @ lower left quadrant
• Diagnosis on admission: Post-op Small bowel obstruction (partial SBO) *infected GI
• Other conditions upon admission: NG suction, NPO, IV RL @ 125 cc/hr, Gravol q 4hrs (PRN), Morphine 5-10 mg (PRN), Cipra 500 mg BID, Flagyl 500 mg TID, no BM and ileostomy

Nutritional Care Process

• Department: Surgery
• Pt's initial: P.M.D.
• 27 year old man, from Cornwall

• Status:

lives with girlfriend @ home

no children

full time job as a mental health worker

Special history

Nutritional Care Process

Medical Hx:

• Crohn's Disease + ileostomy, Asthma, wound in lower abdo
• Large intestine removal: 2000 *colostomy
• 3 SBO with resection: 2002, 2004 and august 2014
• Gallbladder removal: 2004

*P.M.D already had a surgery for a SBO @ OH last month

Weight Hx:

• 22.9% progressive and severe wt loss since January 2014

Pt lost 18.2 kg with UBW @ 79.5 kg

• CBW @ 61.4 kg

Family and psychosocial Hx:

• Works full time night shifts as a mental health worker for ID groups with an average salary
• Sometimes goes grocery shopping with Gf *mostly processed food sugar/fat
• Consumes 1 g of marijuana daily due to abdominal pain

NUTRITIONAL AX

Anthropometric Data

• Height: 175 cm
• CBW: 61.4 kg
• BMI: 20.0 kg/m2, healthy
• UBW: 79.5 kg, severe wt loss of 22.8% in past 9 months
• IBW: 67.4 kg @ BMI=22 kg/m2

Estimated nutritional requirements

• Energy: (25-30) kcal/kg x IBW= [1700-2050] kcal
• Protein: (1.0-1.5) g/kg x IBW= [68-102] g *catabolism
• Fluid: 30 mL/kg x IBW= 2050 mL

Signs & Symptoms:

• N/V
• Abdo pain
• Diarrhea

Nutritional Intervention:

• TPN via PICC @ goal rate 80 cc/hr for a.a. + dextrose with added lipids @ 15 cc/hr 2410 ckal, 96 g proteins and IV @ 125 cc/hr (3000 cc)
• 40 cc/hr x 24 hrs + increase 20 cc/hr every 24 hrs until 80 cc/hr for a total of 1920 cc
• Total of TPN solution 2280 cc (a.a + dextrose and lipids)

Useful Lab Values

(16)

Nutritional Dx

Altered GI function

r/t obstruction and Crohn's disease as evidenced by N/V & need for TPN via PICC

P.M.D. isn't at risk of Refeeding syndrome

Progress medical notes

DAY 10-SEPT22

• ø change
• Starting TPN via PICC (stable electrolytes)
• Pt nervous, but doesn't see any other alternatives

DAY 15-SEPT27

• IV @ 40 cc/hr
• Pharmacy ordered to add morphine 5-10 mg q 4 hrs in each TPN bag

DAY 21-OCT3

• Pharmacy suggests to reduce lipid rate @ 10 cc/hr 2° increased Phosphorous in past 10 days as per lab values
• Pt is now receiving Tylenol 650 mg QID to help reduce pain

DAY 1- SEPT13

• NG suction
• NPO + IV @ 125 cc/hr 2°post-op SBO
• Pt c/o N/V + abdo pain
• ø BM (ø stool in ileostomy since yesterday)
• low Hb
• IV Gravol 50 mg PRN, Cipro 500 mg and Flagyl 500 mg

DAY 6- SEPT18

• Waiting PICC line for TPN
• NPO + IV @ 125 cc/hr
• AXR showing persistant + dilation of SB due to air fluid level
• Less pain, but hard time breathing
• Increased diarrhea in ileostomy
• Vit K 10 mg weekly, BW daily and weight weekly
• Still anemic

DAY 8- SEPT20

• ø change
• Pt is tolerating 2 chocolate boost daily providing 240 kcal and 10 g of proteins each

Transfer OH

N.B.: OCT6 P.M.D. gets transfered to OH with ø c/o N/V. Still c/o diarrhea 2° lactulose. Pt mentionnend feeling less abdo pain @ this time. TPN still at 80 cc/hr for dextrose + a.a, but with lipids running now @ 10 cc/hr + IV @ 40 cc/hr. Tolerating well. Will f/u with RD @ OH for TPN tolerance and plan.

References

Thank You!

Images:

Image 1 : http://www.calgarycmmc.com/crohns.htm

Image 2: http://www.health-writings.com/intestinal-obstruction_8358/

Image 3: http://jim2b.blogspot.ca/2013/08/running-with-crohns-bowel-obstruction.html

Image 4: http://www.dreamstime.com/stock-images-peripherally-inserted-central-catheter-picc-image25455734

Image 5: http://dismaridiet.atspace.co.uk/p.php?n=crohns-diet

Books:

1-BEAUCHAMPS, J. (2014): Soutien nutritionnel. Notes de cours, Nutrition clinique 3, NUT4502. Université d'Ottawa, Canada.

2-GIROUX, I. (2013): Maladies inflammatoires de l'intestin, Maladie de Crohn's. Notes de cours, Nutrition clinique 1, NUT3502. Université d'Ottawa.

LEE, R. & NIEMAN, D. (2013): Nutritional Assessment. McGraw-Hill international edition, 6th edition, Singapore, 500 pages.

3-MAHAN, K. & al (2012): Krause's, Food and the Nutrition Care Process, Elsevier, 13th Edition, Missouri, USA, 1227 pages.

References

Web sites:

4-Crohn's and Colitis (2012)

http://www.crohnsandcolitis.org.uk/information-and-support/information-about-ibd/what-is-IBD

5-Crohn's and Colitis, Foundation of Canada (2013): Food for thought

http://www.isupportibd.ca/pdf/brochure-food-for-thought.pdf

6-GI Society, Canadian society of intestinal research (2014)

http://www.badgut.org/information-centre/a-z-digestive-topics/crohns-disease/

7-GI System-IBD (2007)

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=5877&pqcatid=146&pqid=5841

8-HAYANGA, A. & al (2005): Current management of SBO. Ch. 1. Advances in surgery. Vol 39, p. 1-33.

http://www.casesurgery.com/education/service/uhhs/emergency/abdomen/3_Hayanga.pdf

9-IBD Evidence summary (2014)

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=5877&trid=5873&trcatid=42

10-IBD Practice guidance summary (2014)

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=5877&trid=5874&trcatid=43

11-IBD in adults (2013): Dietitians of Canada

http://www.pennutrition.com/viewhandout.aspx?Portal=UbY=&id=JM3tXQw=&PreviewHandout=bA==

12-MedLine Plus (2014): Intestinal obstruction

http://www.nlm.nih.gov/medlineplus/ency/article/000260.htm

13-MedLine Plus (2013): Intestinal obstruction repair

http://www.nlm.nih.gov/medlineplus/ency/article/002927.htm

14-National digestive diseases information clearinghouse (2014): Ostomy surgery of the bowel

http://digestive.niddk.nih.gov/ddiseases/pubs/ostomy/index.aspx#sec5

15-WALFISH, A. & SACHAR, D. (2013): Overview IBD

http://www.merckmanuals.com/professional/gastrointestinal_disorders/inflammatory_bowel_disease_ibd/overview_of_inflammatory_bowel_disease.html?qt=&sc=&alt=

16-Metabolic TPN complications

http://www.austincc.edu/adnmob/rnsg1140/central/metabolic.htm

Diet Hx

Complications with post-op bowel obstructions

Bowel obstructions are corrected noninvasively or surgically r/t severity (12,13)

Both methods increase higher risk of developping more scar tissue in intestines....

THAT COULD CREATE ANOTHER BOWEL OBSTRUCTION!!!

Prior to admission

Regular diet

While In CCH

Days 1-37: NPO + IV fluids with antibiotics

*Day 8: Tolerating 2 chocolate Boost daily

*Day 10: Started TPN via PICC till OH transfer

Diet Hx

*PM.D. Nutritional requirements: E=[1700-2050] kcal, prot= [68-102] g & Fluid=2050 mL

P.M.D. CASE

Recommendations during remission (5,9,10,11) :

• Avoid alcohol, sugar, fructose, caffeine and greasy foods
• Eat smaller meals every 2-3 hrs
• Increase Protein intake
• Identify tolerated/safe food
• Increase food that will help thicken your stool
• Don't drink fluids with your meals *45 min in between
• Try to increase Soluble fibre
• Supplements may be required if there is malabsorption or lactose intolerance (Omega3, Iron, Vit D B9 B12, Na/K,...)
• Probiotics

TPN Requirements...

Same for E and proteins. Therefore, if a.a estimated @ 96 g:

• Goal rate @ 80 cc/hr (Start 40 cc and increase of 20 cc every 24hrs)
• CHO 4.0 mg/kg/min for 384 g of dextrose
• Total a.a + dextrose= 1689.6 kCal
• To complete nut requirements, would be beneficial to add lipid solution @ 5 cc/hr (240 kcal). However, Dr Moussa decided 15 cc/hr (720 kcal).
• Total E from TPN solution: 2410 kcal

Summary

QUESTIONS?

Medications + PRN

Meds in CCH:

• IV Gravol q 4 hrs (PRN) for N/V
• IV Morphine 5-10 mg (PRN) for pain
• Cipro 500 mg BID x 28 days for infection
• Flagyl 500 mg TID x 28 days for infection
• Lactulose 60 cc daily, reduced to 30 cc @ Day 14 as laxative
• Vit K 10 cc weekly for affected distal ileum
• IV Mg SO4 BID @ Day 9 for LYTES
• Ferrous gluconate 300 mg daily for anemia
• TPN via PICC for feeds

At home:

• Usually fair appetite
• Because of night time job, P.M.D. eats foods/meals requiring less preparation
• Eats processed food more often such as chocolate cookies, processed cheese and frozen meals elevated in fat (sat/trans)
• No fruits/vegetables
• No fried food in general
• Not lactose intolerant (1 glass of chocolate milk daily)
• No fiber (*Insoluble), spices and soft drinks
• No fish (*Inflammation)
• No supplements (*Diarrhea)
• No probiotic (*Intestinal flora)

Image 5

• Understand the correlation between Crohn's disease and obstruction
• Follow Crohn's diet guidelines to help meet nutritional requirements and regulate symptoms
• Risk of other obstructions when resections are done
• Very painful and unpleasant for Pt
• Reduce use of TPN as much as possible to help reduce risk of health complications
• Pt is afraid to eat food that is beneficial to improve BM due to previous symptoms

Conclusion

After understanding the relationship between Crohn's disease and obstructions, it is important to understand the purpose of the provided ostomy: temporary vs permenant (14).

P.M.D. used to have a colostomy before having large bowel removed. Today, Pt has a permanent ileostomy and preferes to keep it. Anastamosis ileorectal!!! (2)

It is important that Pt knows what type of food aggravate diarrhea and choose the ones that are more beneficial to help meet nutritional requirements and help BM. Signs/Symptoms

Pt should be aware that diarrhea irritates the epithlium of the bowel by causing inflammation and higher risk of obstruction (2,3,8).