Transcript File - Hilary Smith

Mini Case Study Presesntation
Hilary Smith
November 18, 2014
Patient BC
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76 y/o female, lives with husband
Admitted 11/11/14
CC: lethargy, falling at home, decreased
appetite, anorexia, and drainage from
her abdomen
Has enterocutaneous fistula
Prior Medical History
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SBO
Chronic diarrhea
Pancreatitis
Hepatitis C
Endometriosis
Arthritis
HTN
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Recent history of:
CDiff
Bowel Resection
Cholecystectomy
Liver biopsy
Partial small bowel
resection x 2
Past NWH Consults
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Admitted 1/2/12
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Admitted 12/13/13
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SBO, D/C with high fiber diet and follow-up outpatient
colonoscopy, 1/6/12
SBO, D/C with regular diet 12/16/13
Admitted 7/30/14
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Recurrent SBO. Had surgery 8/1 – small bowel resection
CT scan of her abdomen and pelvis revealed small
bowel enterocutaneous fistula, 8 days post-op
MD ordered NPO and TPN
Past NWH Consults Continued
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MD wanted to attempt conservative management to close
the fistula since she was so close to her actual operative
date
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Plan: placement in rehabilitation. Rehabilitation accepted and D/C
NWH 8/19/14.
8/16/14 NWH Surgical consult – Plan: Continue on TPN
until fistula closes
9/11/14: Rehabilitation facility thought a new hole was in
her incision
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NWH Surgeon: Tracking of fluid up through subcutaneous tissue,
did not believe there was a second fistula
Past NWH Consults Continued
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9/25/14 NWH Surgeon thought the fistula may have
closed. No ostomy bag discharge.
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Surgeon wanted her on clear liquids x 1 week. If she tolerated
and no drainage from fistula site, wanted to try and wean her
off TPN and get her out of the rehab facility.
10/2/14 developed PICC line infection at rehab
NWH Surgeon wanted clear liquids x 1 more week and
Ensure TID, still wants rehab to wean pt off TPN
10/23/14 tolerating diet at rehab. Surgeon
recommended increase po intake and protein
supplements, if tolerating, wean off TPN and D/C rehab.
Admitted 11/11/14 to NWH
Anthropometrics
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Height: 154 cm
Weight: 55kg (11/12)
BMI: 23.2 Normal
%IBW: 104%
IBW: 52.5 kg
UBW: 55kg (per pt)
Labs
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Mg 1.6 low
Phos 1.2 low
Glucose 134 high
Albumin 2.9 low
Vitamin D 18.9 low
TSH3 0.240 low
C difficile: +antigen, -toxin, +amplified
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11/12/14
Pertinent Medications
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D5NS + KCl @120 ml/hr
Vancomycin
Flagyl
Magnesium sulfate
Zofran PRN
Nutrition/Fluid Needs
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Calorie needs – Mifflin St. Jeor
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Protein Needs
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Weight used: 55kg (admit wt)
Activity factor: 1.4 to 1.5
1368-1466 kcal/day
1.3-1.5 g/kg
72-83g/day
Fluid Needs
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30 ml/kg
1650 ml/day
Can She Meet Her Needs?
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Clear liquid diet
Vital AF 1.2 TID
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850 kcal, 53g protein
Ensure Clear BID
400 kcal, 14g protein
Total: 1250 kcal, 67g protein
89% of calorie needs, 86% protein
needs offered from supplements
RD/Intern Visit
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11/13/14, Consult for nutrition assessment
Pt says poor appetite since last surgery in
August
Was D/C from rehab 10 days PTA
Pt says she may have gained weight on TPN
On clears diet and PO Vital AF 1.2 TID, pt
making good attempt at intake
PES Statement
Altered GI function as related to
abdominal wall fistula as evidenced by
limitation to clear liquid diet and
supplements
Assessment and Plan
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Status: Severe Level 4
Monitor supplement and diet tolerance
Add Ensure clear apple BID to increase
calorie and protein intake
Pt may need TPN if fistula output is
high
Current Status
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PPN ordered 11/15/14
Started TPN 11/17/14 @ 2100 via PICC
Clinimix E 5/15 @ 53 ml/hr
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63g protein, 188g CHO
Lipid frequency: 5x/weekly; serum
triglycerides mildly elevated @ 177.
Care manager: cycle TPN for D/C,
fistula is draining less.
Literature Support –
Enterocutaneous Fistulas
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Treatment should concentrate initially on correction of
fluid and electrolyte imbalances, drainage of collections,
treatment of sepsis and control of fistula output
No evidence that bowel rest results in increased rates of
fistula closure
Enteral should be used if possible, but high-output small
bowel fistulas usually require PN due to feeding
intolerance, lack of access to the GI tract, or increased
fistula output
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BC has High output: drains more than 500 ml/day
Operative repair should be performed when spontaneous
closure does not occur
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Should be delayed for at least 3 months
Literature Support – How to
Diagnose C. diff
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Stool culture in symptomatic patient
Use a 2-step strategy
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Use enzyme immunoassay to detect glutamate
dehydrogenase (GDH) as initial screening
Use the cell cytotoxicity assay or toxigenic culture as
the confirmatory test for GDH-positive stool specimens
only
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Alternative: use polymerase chain reaction test
BC’s Results
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Positive: C Diff Antigen
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Negative: C Diff Toxin
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Indicates presence of C Diff
C diff toxin absent, or specimen is below the
detection limit of the test
Positive: C Diff Amplified
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Indicates presence of C Diff toxin B gene
Uses polymerase chain reaction to detect
Sensitivity: 98.79%; specificity: 90.82%
Questions?????
References
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3.
Overview of Enteric Fistulas, UpToDate
Nutrition and Management of
Enterocutaneous Fistula, British Journal of
Surgery
Clinical Practice Guidelines for Clostridium
difficile infection in Adults: 2010 Update by
the Society for Healthcare Epidemiology of
America (SHEA) and the Infectious Diseases
Society of America (IDSA)