Transcript A Case Study - Erin Huckle`s Professional Portfolio

Short Bowel Syndrome
Secondary to Ischemic
Bowel Resulting in a
Duodenal Stump
A Case Study Presentation
By: Erin Huckle
The Patient
60 y/o white male with short bowel syndrome secondary to
bowel ischemia, hospitalized for evaluation and treatment of
ischemic bowel
The patient was admitted with:
 Septic shock
 GI bleed
Past Medical History
The patient presented with a complex medical history
significant for…
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Short bowel syndrome
Ischemia, bowel
Bacteremia
Septic embolism
Atrial fibrillation
CAD s/p stent placement x 3
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Ischemic cardiomyopathy
Anemia, unspecified
Hypertension
Acute kidney injury
Severe malnutrition
History of Illness
 July 2011: patient developed bowel ischemia, underwent a
colectomy and partial small bowel resection with
jejunostomy
 Central line was placed,
TPN started
 Line became infected, patient
developed septic emboli
 Lengthy hospital stay, patient
discharged to SNF
History of Illness
 At SNF, patient c/o abdominal pain, sent to local emergency
department
 Patient hospitalized, bloody output
from jejunostomy
 A CT demonstrated pneumotosis
throughout the small bowel from
ligament of Treitz to jejunostomy
 Patient transferred for further evaluation and treatment
Surgery
Once transferred, the patient underwent numerous procedures
including:
 Exploratory laparotomy, lysis of adhesions, and
ileocolostomy takedown
 Resection of ischemic small bowel (the entirety of his
remaining small bowel – duodenal stump)
 Wound vac placement
Surgeries
Before surgeries
(normal bowel)
After last surgery –
remainder of bowel
removed to ligament of
Treitz
After colectomy &
partial bowel resection
Issues to be Addressed
 Life-long Issues
 Short & Long Term Goals
 Nutritional Assessment
 Long-term risks of TPN
 Medical Diagnosis
 Outcomes
 Nutrition Diagnosis
 Nutritional Interventions
Life-Long Issues
1. The patient will require life-long TPN. No solid foods. Only
limited clears.
2. The patient will have a life-long gastrostomy tube to drain
the contents of the stomach
3. The patient will have a life-long gastroduodenostomy tube
to drain the contents of the duodenal stump
Food/Nutrition-Related
History
Diet: NPO for most of hospital stay, advanced to limited clears,
no jello, no concentrated sweets
Total energy intake: 1750 kcal/day and 126 gm protein/day
from TPN
Emotions:
• Unhappy with inability to eat
• Asked anyone who entered his room for food/beverages
• Frustrated with further diet modifications – avoidance of
concentrated sweets, jello, etc.
Hospital Medications
The patient can take NO MEDICATIONS BY MOUTH – They WILL
NOT be absorbed
Nexium – decrease stomach acid production
Glucagen, prn – control CBGs
Humulin R, prn – control CBGs
Vancomycin – antibiotic
Zosyn – antibiotic
Anthropometric Measurements
Height: 68 inches
Weight: 100.3 kg (admission), 105.2 kg (discharge)
- 10.7# weight gain
BMI: 33.5
Ideal Body Weight/Dosing Weight: 70 kg
%IBW: 143%
Biochemical Assessment
Lab Values
Reference Range
5-Feb
6-Feb
7-Feb
8-Feb
9-Feb
13-Feb
Na
134 - 143
137
141
147
145
150
145
K
3.4 - 5.0
4.8
4.3
3.6
2.9
3.8
3.4
Cl
97 - 108
107
115
114
113
119
115
BUN
6 20
55
46
34
33
30
32
Cr
0.7 - 1.3
4.85
3.75
2.87
2.21
1.79
1.24
Gluc
60 - 99
153
111
158
163
116
113
Corrected Ca
8.6 - 10.2
8.7
9
8.9
9
9.2
9.2
Mg
1.8 - 2.5
-
1.2
1.6
1.9
1.5
1.6
Phos
2.4 - 4.7
-
7.4
5.9
3.3
2.8
3
CBGs
60 - 99
-
111-153
89-185 129-256 117-166
88-121
Nutrition-Focused Physical
Findings
Mouth: Lips dry, tongue slightly red, teeth in poor condition
Hair: appeared brittle and dry, balding
Nails: dry, white, chalky appearance
Skin: soft and warm, skin on lower extremities appeared tight
and shiny, no pitting
No observable physical findings of muscle wasting or depletion
of fat stores
Client History
Occupation: Previously managed an RV park, lost job in 2006
Social history: Never married, no children
Living/housing situation: Desires to go home and live in doublewide mobile home with his brother and elderly mother
Tobacco use: 1 pack/day for 48 years – Quit in July 2011
Alcohol use: 2-3 drinks per day
Drug use: Current THC use, history of cocaine and meth use
Estimated Needs
Total Estimated Energy Needs: 1540-1750 kcal/day
(22-25 kcal/kg IBW – patient with a BMI > 30)
Total Protein Estimated Needs: 105-140 gm protein/day
(1.5-2.0 gm protein/kg IBW – patient with a BMI > 30-40)
Total Fluid Estimated Needs: 1750 ml/day
(1 ml/kcal/day)
Diagnosis – Bowel Ischemia
Definition:
Damage to or death of part of
the intestine due to a decrease in
blood supply
Symptoms include:
• Abdominal pain
- most common
- pt’s chief complaint
• Diarrhea
• Vomiting
• Fever
Diagnosis – Bowel Ischemia
Common causes include:
Usual medical treatment:
• Hernia
Surgery is usually necessary.
The sections of dead bowel are
removed and healthy ends of
the bowel are reconnected.
• Bowel adhesions
• Embolus
• Arterial thrombosis
• Venous thrombosis
• Low blood pressure
Diagnosis – Short Bowel
Syndrome (SBS)
Definition:
Inadequate absorptive capacity due to decreased length and/or
decreased functional bowel. Typically occurs with 70-75% loss
of small bowel.
Symptoms can include:
• Diarrhea
• Steatorrhea
• Edema (especially of the legs)
• Very foul-smelling stools
• Weight loss
Diagnosis – Short Bowel
Syndrome (SBS)
Goals of Treatment for SBS:
 Provide the patient with adequate nutrients, water, and
electrolytes to maintain health.
 Facilitate the use of total parenteral nutrition (TPN) when
necessary
 Maximize the potential of the remaining bowel in order to
reduce or eliminate the use of TPN
Short Bowel Syndrome
Nutrition concerns related to SBS:
• Nutrient deficiencies
• Hydrations status
• Avoidance of concentrated sweets and caffeine
Absorption
Nutrition Diagnosis
Impaired nutrient utilization related to malabsorption
as evidenced by need for parenteral nutrition
Intervention/MNT
Parenteral Nutrition Interventions:
Placed TPN orders, modified on a daily basis if needed.
Example of TPN order placed for this patient:
Cyclic TPN x 18 hrs: 60 ml x 1 hr; increase to 105 ml/hr x 16 hrs;
decrease to 60 ml x 1 hr to provide 25 kcal/kg, 1.8 gm
protein/kg, with 20% lipids (39 g lipid/day) in a volume of 1800
ml/day
Interventions/MNT
Parenteral Nutrition Interventions (continued):
• Make changes to rate and volume of TPN as needed
• Monitor CBGs and recommend adjustments in insulin drip
accordingly
• Monitor lab values and make adjustments to TPN substrates
accordingly
Shortages
Due to national shortages the patient’s TPN did not contain
magnesium sulfate or additional selenium.
If needed, the patient would have to receive Mg SO4 or
additional selenium via IV or PO medication.
Intervention/MNT
Nutrition Education
 Provided pt with written and verbal SBS education
 Emphasis placed on avoidance of concentrated, sweetened
beverages & caffeine-containing beverages.
 Pt expressed frustration to further diet restrictions, but
verbalized understanding.
Intervention/MNT
Oral Nutrition Supplements
 Provided nurses and pt with oral rehydration therapy (ORT)
formulas for SBS
 ORT can help the pt to meet fluid needs by increasing fluid
absorption
 Goal: Sip 1 L ORT over the course of the day
ORT Recipe
Gatorade Formula
1 cup Gatorade
1 cup water
¼ teaspoon salt
Mix together & drink.
ORT Recipe
Grape or Cranberry Juice Formula
1/8 cup grape/cranberry juice
7/8 cup water
1/8 teaspoon salt
Mix together & drink.
Short-Term Goals
 Provide the patient with adequate nutrients, water, and
electrolytes to maintain health
 Goal CBGs of ~110-150 mg/dl, d/t improved pt outcomes
associated with better glycemic control
 Avoid any food intake
 Avoid concentrated sweetened beverages, caffeine
 Trial oral rehydration therapy
Long-Term Goals
 Provide patient’s medical team with discharge TPN orders
 Maintain health as best as possible by obtaining adequate
nutrients and electrolytes from TPN until no longer a
desirable option
Long-Term Complications of
TPN
Common complications of long-term TPN use include:
 Hepatic dysfunction
 Cholelithiasis
 Metabolic acidosis
Outcome
 11 day hospital stay
 Discharged on home TPN, home health nurse will follow
 “Not if, but when…”
 Quality of Life
 Option for Hospice care
Discharge Medications
 Clonidine patch – control high BP
 TPN
 Fat Emulsion – 20%
All other IV meds were stopped
Discussion & Summary
 Patient will face life-long issues
 What if the patient takes food by mouth?
 Living environment at home
 Patient & family will need to make decisions about the
future
References
Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at: http://nutritioncaremanual.org. Accessed March 27, 2012.
Biomedical Central Nursing. “Gastroenterology Grand Rounds: Persistent metabolic acidosis in a patient with short bowel syndrome on long term TPN.” Accessed 25 March 2012 from
http://www.bcm.edu/gastro/VGICC/GI-M0054/09-DISC.HTM
Children’s Hospital of Pittsburgh. “Total Parenteral Nutrition (TPN)” Children’s Hospital of Pittsburgh. Accessed 25 March 2012 from http://www.chp.edu/CHP/tpn+intestine
Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrup J, Labadarios D, Nyulasi I, Castillo-Pineda JC, Waitzberg D. Adult Starvation and Disease-Related Malnutrition: A
Proposal for Etiology-Based Diagnosis in the Clinical Practice Setting From the International Consensus Guideline Committee. Journal of Parenteral and Enteral Nutrition March 2010; 34 (2): 156-9.
McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Naolitano L, Cresci G, A.S.P.E.N. Board of Directors, American College of Critical Care Medicine. Guidelines for the
Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition May/June 2009; 33 (3): 277-316.
Oregon Health & Science University. Suggested Guidelines for Nutrition Care: Adult TPN Guidelines. Revised Oct 2011. Available at:
https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adulttpn.pdf
Oregon Healthy & Science University. Suggested Guidelines for Nutrition Care: Adult Short Bowel Syndrome Guidelines. Revised Dec 2011. Available at
https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adultshortbowelsyndrome.pdf:
Parrish CR. The Clinician’s Guide to Short Bowel Syndrome. Practical Gastroenterology: Nutrition. Issues in Gastroenterology, Series #31. September 2005.
Parrish, CR. The Hitchhiker’s Guide to Parenteral Nutrition Management for Adult Patients. Practical Gastroenterology: Nutrition. Issues in Gastroenterology, Series #40. July 2006.
U.S. National Library of Medicine: PubMed Health. “Intestinal Ischemia and Infarction” PubMed Health, Accessed 25 March 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002136/
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