Transcript File - Hilary Smith

Mini-Case Study
Hilary Smith
Patient EH
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87 y/o female
Admitted from Levindale 12/11/14
PMH: CAD, HTN, CHF, COPD, atrial
fibrillation, pulmonary HTN, DM, h/o lung
cancer, hypothyroidism, SBO with
resection
Levindale
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Admitted 12/5/14 for rehab following
hospitalization for COPD exacerbation and
CHF
Positive for CDiff, was put on vancomycin
Intake <50% of meals since admission
Dobhoff NGT placed 1 day PTA to Sinai,
started enteral nutrition and developed
abdominal distention and vomiting
Admission to Sinai
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Admitted 12/11/14 for aggressive
resuscitation and observation, intubated
in the ED
Assessed on 12/12/14
CT Abd: colitis and ileus
ABD US: possible cholecystitis
NGT on LIS with coffee ground output
Stage II Sacral Pressure Ulcer
Medications
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NS@150 ml/hr
Propofol @ 4.3 ml/hr (114 kcal)
Aztreonam
SSI
Magnesium Sulfate
Flagyl
Protonix
Vancomycin
Norepinephrine
Relevant Labs
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BUN 57
Creatinine 1.76
Glucose 256
Phosphorus 1.4
Albumin 1.5
FS: 135, 127, 51, 138
Trop I .113
Lipase 56
GI/Physical
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BS +
Last BM: 12/12/14 day of assessment
12/11/14 I: 1486ml O: 105ml
Has NGT on LIS with coffee ground
output
Stage II sacral PU
Radiology
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CT abdomen/pelvis – non-specific
colitis, ileus
U/S abdomen – gallbladder wall edema
suggested, cannot exclude acute
cholecysitis, sludge seen in gallbladder
Anthropometrics
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Weight: 65.9 kg
Height: 162.5 cm
BMI: 25
IBW: 57.5 kg
%IBW: 114%
Weight at Levindale 12/10: 63.8 kg
Nutrition Needs
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Calories: Penn State Critical Non-Obese
Minute Ventilation: 7.56 L/min
Tmax: 37.1 degrees Celsius
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Protein: 1.2 – 1.5 g/kg (wound, ventilator
support)
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1313 kcal
79-99 g/day
Fluids: 25 ml/kg
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1648 ml/day
Goals and Progress
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Upon first assessment, pt to stay NPO,
unknown as to GI status or plan of
care
Pt started the next day (12/13) on
Glucerna 1.2 10 ml/hr but was changed
to Vital 1.2, goal of 50 ml/hr, due to
sepsis and vomiting.
Once sepsis and GI issues resolve,
change back to Glucerna 1.2
Progress
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12/13 – re-assessed patient
No surgical intervention planned due to
improved clinical status after antibiotics
and fluids, pt was transferred to MICU
service
Added Banatrol TID for liquid BMs
WBC increased, stay on Vital, culture of
picc line will be obtained
No growth picc line
Progress
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As of 12/17, pt remains in ICU on
ventilator support, was given Lasix due
to fluid retention and needed pressor
support due to decreased BP. Will now
be on Lasix drip.
Not ready to extubate since on
pressors.
Toxic Megacolon & CDiff
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The incidence of toxic megacolon associated C.
difficile colitis varies from 0.4%-3% of cases
Thought to develop from inflammatory changes
to the colon resulting in neural injury, altered
motility and dilation
Risk factors: concurrent malignancy, severe
chronic obstructive pulmonary disease,
organ transplantation, cardiothoracic
procedures, diabetes mellitus,
immunosuppression and renal failure
Diagnosis: Toxic Megacolon
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Radiographic evidence of colon distension, plus
One of at least 3 of the following:
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Fever>38C
HR>120bpm
Neutrophilic leukocytosis >10,500/microL
Anemia
Plus at least one of the following:
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Dehydration
Altered sensorium
Electrolyte disturbances
Hypotension
Treatment of Toxic Megacolon
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Pts placed at bowel rest and NGT inserted to
decompress stomach
Enteral feeding begins as soon as pt shows
signs of improvement to stimulate normal
motility and mucosal healing
TPN is of limited value in severe cases
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No proven benefit to avoid surgery or decrease
hospital stay
Treatment of Toxic Megacolon
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Due to CDiff –vancomycin 500mg 4x
daily orally or via NGT and IV
metronidazole 500mg every 8 hours.
IV vancomycin has no effect on C.Diff
since it is not excreted into the colon
Complete bowel rest and surgical
consultation
Questions?