Transcript Slide 1

Cerebral Palsy and PEG
Olivia Cossari
ARAMARK Dietetic Internship
Southern Ocean Medical Center
December 22, 2013
Case Report Presentation
Contents
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Disease Description
Evidence-Based Nutrition Recommendations
Case Presentation
Nutrition Care Process (NCP): ADIME
Conclusion
Disease Description
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Cerebral Palsy
– A group of disorders caused by any insult or
damage to a premature brain
Rick Factors
– Maternal - Rubella, varicella, cytomegalovirus,
toxoplasmosis, syphilis, toxin exposure, and
thyroid problems
– Infant - bacterial meningitis, viral encephalitis, and
untreated jaundice
– Delivery - premature birth, low birth weight, breech
delivery, and multiple gestations.
Disease Description Continued
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Signs and Symptoms
– Inability to verbalize
– Delayed blinking
– Inability to turn head
– Seizures
– Difficulty holding objects
– Swallowing difficulties
– Lack of focus
– Deafness
Complications
– Poor muscle tone of body
and face
– Speech impairment
– Learning disabilities
– Feeding difficulties
– Sensory impairment
Disease Description continued…
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Management
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Develop a Care plan
 Diagnosis
 Assembly of a care team
 Assessment of abilities
 Determining goals
 Creating a care plan
 Maintaining records.
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The care plan may include
 Optimizing mobility
 Pain control
 Preventing compilations
 Maximizing dependence
 Enhancing social interaction
 Maximizing learning potential
 Enhancing the quality of life
Disease Description Continued
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Forms
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Spastic - stiffness and movement difficulties
 Hemiplegia
– affects half of the body
 Monoplagia
– affects only one limb
 Quadriplegia
– affects either both arms or both legs.
 Triplegia
– affects either both arms and one leg or both legs and one arm
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Non-spastic –muscle tone
 Dyskinetic
– uncontrolled movements of neck, face, hands, or limbs.
 Ataxic
– Uncontrolled movements of the entire body
– Disturbed sense of balance and depth perception
Percutaneous Endoscopic
Gastrostomy
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Percutaneous Endoscopic Gastrostomy (PEG tube)
tube placed through the skin into the stomach using an endoscope
Indications
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normal gastro-intestinal function
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need to bypass the upper gastro-intestinal tract
Advantages
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long term use
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reduced risk of tube displacement
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choice of continuous or bolus feeding
Disadvantages
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surgical procedure
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risk of irritation and infection at insertion site.
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http://www.gastrosanmarcos.com/peg.html
Evidence Based Nutrition
Recommendations
According to the American Society for
Parenteral and Enteral Nutrition (ASPEN)
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“Long-term access is dependent on the estimated length of therapy, the
patient’s disposition, and the special needs of the patient and caregivers.”
“Two studies of adult patients with persistent dysphagia due to
neurological diseases randomized patients to naso-gastric (NG) feedings
or percutaneous endoscopic gastrostomy (PEG) placement.”
“These studies found that the patients with PEGs had greater weight gain
and fewer missed feedings.”
“The patients fed by NG had a significant decrease in the amount of
formula they received because of tube difficulties compared to the PEG
patients who had no such difficulties.”
ASPEN. The science and practice of nutrition support. A case-based core
curriculum. 2001; 148.
Tube Feeding Formula
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Enteral formulas can be used in a PEG tube.
Polymeric– Whole protein sources
– Nutrients in whole form
– Useful for patients with normal functioning GI tract.
– Examples: Ensure, Glucerna, Jevity, Nepro,
Monomeric– hydrolyzed, or predigested, nutrients.
– Useful for patients with diminished digestive or absorptive
ability. Some enteral formulas contain fiber to support bowel
function
– Examples: Perative, Pivot 1.5, Peptamen
Evidence Based Nutrition
Recommendations
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Interventions for Feeding and Nutrition in Cerebral Palsy
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AHRQ (2013)
Systematic review of 1,055 citations and 553 articles.
Reviewed studies including classification and spectrum of disorder, feeding difficulties and interventions, clinical
uncertainties.
Results
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2.7 % (n= 15) met inclusion criteria
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40.0 % (n=6) of these studies included data about the effectiveness of tube feeding for feeding difficulties.
 One cohort study indicated data of overfeeding with gastrostomy.
 One case series indicated the potential for GERD with gastrostomy.
 Six case series indicated significant weight increase after gastrostomy in 6-20 months.
 One of these case series reported improvements on all weight and growth related outcomes.
 One case series assessed health care utilization for overall health and found the number of
hospitalizations significantly reduced over the year following gastrostomy.
 One study reported significant correlations between severity of motor impairment and feeding problems
including choking, underweight, prolonged feeding times, vomiting, and need for gastrostomy feeding (p
values typically <0.005).
 There is limited data on role of feeding interventions for adults with CP.
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AHRQ. Interventions for feeding and nutrition in cerebral palsy.
Comparative
Effectiveness Review. Number 94. March 2013. Accessed
Evidence Based Nutrition
Recommendations
Percutaneous Endoscopic Gastrostomy (peg):
Retrospective Analysis of a 7-year Clinical Experience
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Vanis N, Sara A, et al. (2012)
7 year Retrospective analysis of 359 patients receiving PEG tube placement.
Assessment of indications, success, and complications
Cerebral Palsy indication for PEG : 11% (n=38) patients
Success rate (n= 341, 95.0%)
Complications (n=30, 9.2%):
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Minor
 Wound infection (n=3, 0.8%),
 Tube leakage (n=4, 1.10%),
 Stoma leakage (n=2, 0.56%)
 Inadvertent PEG removal (n=9, 2.5%)
 Tube blockage (n=4, 1.1%).
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Major complications
 Hemorrhage (n=4,1.1%)
 Tube migration (n=3, 0.8%)
 Buried bumper syndrome (n=2,0.56%)
Conclusion
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PEG provides durable access for enteral nutrition
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prevents malnutrition
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reduces hospitalization
Thompson M, Prithviraj R. Percutaneous endoscopic gastrostomy and
Gastroesophageal reflux in neurologically impaired children. World J of
Gastroenterology. 2011 January 14; 17(2): 191-196.
Evidence Based Nutrition
Recommendations
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Growth and Nutrition Disorders in Children with Cerebral Palsy
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Kuperminc M, et al. 2008.
Multicenter study of 273 children with moderate to severe cerebral palsy.
Growth and development - key measures of determining health in children.
Patients who suffer from cerebral palsy often experience:
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Slower growth than children without health disorders
Diminished body fat composition
Adequate nutrition is important for motor functioning, neurological, and physiological functions.
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Malnutrition may lead to:
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Diminished muscle mass.
Weakened respiratory system
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Cardiac conditions
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Increasing the susceptibility of disease and impaired wound healing.
Neurological implications
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Contributing to heart failure.
Compromised immune system
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Increasing risk for pneumonia.
Diminished growth, delayed cognitive development, and abnormal behavior.
About 35% (n= 96) of patients with cerebral palsy are malnourished.
Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral
palsy. Dev Disabil Res Rev. 2008; 14(2): 137-146.
Evidence Based Nutrition
Recommendations
Continued….
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Growth and Nutrition Disorders in Children with Cerebral Palsy
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Kuperminc M, et al. 2008.
Intervention
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interpretation of nutritional status
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Deterimine target weight
Maximizing oral intake
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Past medical history
Physical examinations
Diet history
Anthropometry.
optimizing caloric intake
nutrition support
increasing feeding frequency
addition of supplements.
If unable to consume foods orally due to dysphagia or other swallowing difficulties
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Utilize tube feeding regimens
Nasogastric is recommended for short term supplementation.
PEG tube is optimal for long term supplementation.
Monitoring changes in weight gain is essential to ensure successful treatment
Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral
palsy. Dev Disabil Res Rev. 2008; 14(2): 137-146.
Case Presentation
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Mr. G is a 57 year old male that resides at a long care facility.
He was brought in to the hospital when his family and caregivers
noticed unusual behavior.
He was admitted with pneumonia with chief complaints of fever and
altered mental status.
Mr. G was started on the polymeric formula
Glucerna 1.0 at 75 ml/hr (5 cans/day)
providing 1800 calories, 1800 ml fluid,
and 75 grams protein via PEG per MD order
NCP:
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ADIME
Client History (CH-2.1)
– Mr. G has dysphagia and recurrent aspiration pneumonia
resulting in a previous PEG tube placement.
*The Academy of Nutrition and Dietetics recommends that
providers of medical nutrition therapy use the Nutrition
Care Process as a means of describing and providing
standardized care. The NCP was utilized for the case
subject, as well as, ARAMARK standards and the
International Dietetics and Nutrition Terminology
Reference Manual (IDNT).
NCP:
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ADIME
Food/Nutrition Related History (FH-1.1.1)
– At the long-term facility, Mr. G is on the
monomeric formula, Peptamen, at the rate of 60
ml/hr, or 6 cans per day. This would provide Mr. G
with 1850 calories, 1210 ml fluid, and 82 grams
protein.
– No known food allergies
– No supplement prior to admission
Prescribed Medications
Medication
Rationale
Side-Effects
Enoxaparin (Lovenox)
Anti-Coagulant
Diarrhea
Clonazepam (Klonopin)
Treats seizure disorders
Diarrhea and Nausea
Lactobacillus Acidophilus
Maintain normal flora
Flatulence
Vancomycin
Anti-biotic
Nausea, Vomiting, Flatulence
Midodrine (Proamatine)
Increase blood pressure
Dizziness
Naproxen (Naprosyn)
Reduce inflammation
Nausea and Vomiting
Albuterol
Bronchodilator
Shakiness
NCP:
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ADIME
Nutrition-Focused Physical Findings (PD-1.1.5)
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Significant weight loss of 30# since previous hospitalization noted
Prior to admission – mal-nourished
Dysphagia
NCP:
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ADIME
Anthropometric Measurements (AD-1.1)
– 73 inches
– Admission body weight (10/15) : 140 #, BMI 18.4,
Underweight
– Current body weight (11/15) : 121 # , BMI 15.9,
Underweight
– Ideal body weight (IBW) 184#
– Current weight is 65.8% of IBW
Height
6’ 1”
73 inches
185 cm
Weight
1st : 140 # /64 kg
2nd: 121# /55kg
IBW
184 +- 18.4 lbs
166 to 202 lbs
75 to 92 kg
BMI
1st: 18.4 (underweight)
2nd: 15.5 (underweight)
NCP:
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ADIME
Biochemical Data, Medical Tests and Procedures
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Glucose profile (BD-1.5)
Gastrointestinal profile (BD-1.4)
Acid-base balance (BD-1.1)
Protein panel (BD-1.11)
Electrolyte and renal profile (BD-1.2)
NCP:
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ADIME
Nutrient Needs during Initial Assessment
– Energy requirements (CS-1.1.1)
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Protein requirements (CS-2.2.1)
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Admission weight of 140# / 64 kg
1600 to 1900 calories (25-30cal/kg),
64-76 grams protein (1-1.2g/kg).
Since the patient was under stress his nutrient requirements for
protein were elevated.
Fluid requirements (CS-3.1.1)
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1900 ml fluid (30ml/kg),
Lab Values
Lab
Measurement
Value
Normal
Value
Rationale
WBC
25.6 H
4.1-10.9 K/uL
Infection /stress
Glucose
109 H
65-99 mg/dL
Stress
BUN
20 H
7-8 mg/dL
Dehydration, excessive protein catabolism,
renal disease
Albumin
3.0 L
3.4-5.0 G/ dL
Malnutrition, short-term protein and energy
deficiency, acute inflammation, fluid
retention
Creatinine
0.44 L
0.8-1.3 mg/dL
Effective kidney function
NCP:
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ADIME
ARAMARK Nutrition Status Classification
– 20 nutrition care points = Status 4 -Severely compromised
 3 points for nutrition history (Swallowing problems )
 4 points for feeding modality (TPN/PPN and NPO >4 days)
 4 priority points for unintentional wt loss ( >10% in 6 months)
 3 points for weight status (BMI 16.0-16.9)
 2 points for serum albumin (3.0-3.4 g/dL)
 4 points for diagnosis/condition (malnutrition)
– Follow up should be scheduled in 1-4 days
NCP: A
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DIME
NCP: Nutrition Diagnosis
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Upon reassessment the patient….
Nutrition Diagnosis
/ PES
Statements
Domain
Problem/Nutrition
Diagnosis
r/t
Etiology
aeb
Signs/Symptom
s
Intake
(NI-2.3)
Less than optimal enteral
nutrition
composition
related to
Adjusted
calculated
needs
as evidenced
by
20 lb weight loss
Clinical
(NC-2.1)
Impaired nutrients
utilization
related to
Polymeric tube
feeding
formula
as evidenced
by
20 lb weight loss
Clinical
(NC-3.4)
Unintended weight loss
related to
Insufficient
energy
intake
as evidenced
by
Calculated needs
NCP: ADIME
NCP: Interventions
Mr. G’s energy requirements were recalculated, accounting for his physical activity:
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Energy requirements (CS-1.1.1)
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Harris-Benedict equation
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An activity factor of 1.3 (active),
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Ideal body weight of 75 kg
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~2100 calories per day.
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Protein (CS-2.2.1)
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IBW of 75kg was multiplied by 1.5 (for stress)
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~105 grams protein per day
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Monomeric formula
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Perative @ 70 ml/hr to provide 1680 ml, 2100 calories, and 112 grams amino acid.
NCP: ADIME
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Nutrition Care Process: Monitoring and Evaluation
– High nutritional risk follow-up 3 to 5 days.
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Food and Nutrition-Related History
– Food and Nutrient Intake
 Energy intake - Total energy intake (FH-1.1.1.1) Meet needs
 Protein intake - Total protein (FH-1.5.2.1) Meet needs
– Food and Nutrient Administration Enteral nutrition intake – Formula/solution (FH- 2.1.4.1). Evaluated for total
energy and protein intake.
NCP: ADIME
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Anthropometric Measurements
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Body composition – Weight (AD-1.1.2) monitored daily via bed scale.
Biochemical Data, Medical Tests and Procedures
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Protein profile- Albumin (BD-1.11.1). Monitored daily to evaluate effectiveness of nutritional
therapy and state of malnutrition.
Recommendations for discharge
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Monitor weight
Continue to follow up 3-5 days or as needed per MD or RN request.
Conclusion
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Cerebral palsy and PEG tube formula introduced many barriers and complications for calculating his energy,
protein, and nutrient needs.
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Mr. G lost over thirty pounds due to these complications.
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After trial and error, Mr. G’s caloric needs where able to be recalculated to meet his actual needs.
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Mr. G’s activity factor greatly implemented his needs. This activity factor was misleading due to his immobility.
Also, Mr. G’s tube feeding was overlooked.
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Mr. G tolerated the polymeric formula well when considering residual, despite this, he was unable to absorb the
nutrients at an optimal rate.
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Changing Mr. G’s formula to a Monomeric formula greatly enhanced absorption.
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Mr. G was shortly discharge as his symptoms resided, it is unclear whether nutrition ultimately resolved these
symptoms but it is clear that his weight loss was attributed to the incorrect formula at an incorrect rate.
References
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1. Percutaneous Endoscopic Gastrostomy. my.clevelandclinic.org/services/
percutaneous_endoscopic_gastrostomy_peg/hic_percutaneous_endoscopic_
gastrostmy_peg.aspx.Cleveland Clinic. Updated January 1, 2013. Accessed
December 2013.
2. Kim S, Pellegrino L. Types of cerebral palsy causes symptoms and treatment.
everydayhealth.com/health-center/types-of-cerebral-palsy.aspx. Everyday
Health. Updated September 30, 2010. Accessed December 2013.
3. Cerebral palsy. cdc.gov/ncbddd/cp/index.html. Centers for Disease Control and
Prevention. Updated October 17, 2013. Accessed December 2013.
4. Kuperminc M, Stevenson R. Growth and nutrition disorders in children with cerebral
palsy. Dev Disabil Res Rev. 2008; 14(2): 137-146.
5. Thompson M, Prithviraj R. Percutaneous endoscopic gastrostomy and
Gastroesophageal reflux in neurologically impaired children. World J of
Gastroenterology. 2011 January 14; 17(2): 191-196.
6. Holliday MA and Segar WE. The Maintenance Need for Water in Parenteral Fluid
Therapy. Pediatrics 1957; 19; pg 823-832.
7. Theberge C, Illing A. Nutrition in cerebral palsy. nafwa.org/cp1.ph. Nutrition and Food
Web Archive. Updated 2005. Accessed December 2010.
8. Charney P, Malone AM. ADA pocket guide to nutrition assessment. American
Dietetic Association. 2009; 2nd ed: 167-191.
9. Perative®. Abbott Nutrition. http://abbottnutrition.com/brands/products/perative.
10. Journal of Parenteral and Enteral Nutrition, Vol. 33, No. 2, 122-16753 (2009)
11. Nelms M, Sucher KP, Lacey K, Roth SL . Nutrition Therapy & Pathophysiology.
Belmont, CA. Cengage Learning. 2011.
12. ASPEN. The science and practice of nutrition support. A case-based core
curriculum. 2001; 148.
13. Academy of Nutrition and Dietetics . Pocket Guide for International Dietetics &
Nutrition Terminology Reference Manual. 4th ed. Chicago, Il: Academy of
Nutrition and Dietetics ; 2013.
14. AHRQ. Interventions for feeding and nutrition in cerebral palsy. Comparative
Effectiveness Review. Number 94. March 2013. Accessed December 2013.
15. Vanis N, Saray A, et al. Percutaneous Endoscopic Gastrostomy (peg):
Retrospective Analysis of a 7-year Clinical Experience. ACTA INFORM MED.
2012 Dec; 20(4): 235-237. Accessed December 2013.
Questions?