conditioning of the surgical schumann risk patient - case ... · 10 days after surgery fistula...

ESPEN Congress Leipzig 2013

Conditioning of the surgical Schumann risk patient - Case discussion

Case presentation

M. Panisic (RS)

Case disscusion

Marina Panisic – Belgrade - Serbia

MILITARY MEDICAL ACADEMY

Leipzig, August Leipzig, August 2013.

2013.

Old Testament’s Book of Judges

Eglon

sustained an

acute posttraumatic

enterocutaneous fistula

„...and Ehud

put forth his hand,

and took the dagger

and thrust it into his belly...

And the dirt came out.“

Celsus Aulus Cornelius

“ Cicero medicorum ”

25y b.c. – 50y a.c.

“...when the colon has been penetrated,

it can be sutured,

not with any certain assurance,

but because this doubtful hope

is preferable to certain despair;

for occasionally it heals up.”

John Hunter

first recorded

conservative approach !!!

...fistulas occasionally close spontaneously ...

“ In such cases nothing is to be done but dressing the

wound superficially, and when the contents of the

wounded viscus become less, we may hope for cure.”

1728 - 1793

Surgical catastrophes

C A S E

19 years-old female

Hospitalized in another center for abdominal pain and

necrosis of abdominal wall, one month after incision in

the right inguinal region according to acute lymphangitis

Hemicolectomia lat. dex. was performed

PH: Ileitis terminalis et colitis regionalis – Mb Crohn

10 days after surgery fistula enterocutanea appeared,

patient’s general condition rapidly decreased

No nutritional support instituted – only I.V. fluid therapy

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For further treatment

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30.000 pts/y

30% operated

H Y S T O R Y

Abdominal pain

Necrosis of abdominal wall

No nausea, no vomiting

No allergic reactions

No previous diseases

Negative family history

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PHYSICAL EXAMINATION

Tachycardia

No fever

Signs of severe malnutrition

H = 165 cm W = 28 kg

BMI = 10.28 Tenderness in all abdominal regions

Drains on both sides of the abdomen, with purulent

secretion

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weight and height on admission

W-28 kg H-165 cm

BMI = 10.28

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Fistula output – 850 ml/day

LABORATORY FINDINGS on admission

CRP 102 mg/l

KKS:

WBC 3,5x10^9, Hgb 11.4 gr/dL, MCV 84 fl, Plt 56x10^9

Coagulation status: INR 1.35, APTT 41 s

II 0.46, VII 0.28, IX 0.65, X 0.54,

Antitrombin III 0.39

D-dimmer 1522 μg/l

Mg: 0.65 mmol/l

Ca: 1.45 mmol/l

Fe: 3 umol/l

Feritin: 1084 μg/l

Albumin: 22 g/l

AST: 57 U/L, ALT: 60 U/L, GGT: 234 U/L, ALP: 1009 U/L

Urino-culture: Klebsiella sp.

Haemmo-culture: Fungal sepsis

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laboratory on admission

• Na 130 mmol/L

• K 2,5 mmol/L

• Cl 98 mmol/L

• GLU 4.6 mmol/L

• BUN 2.5 mmol/L

• CREA 50 µmol/L

• TP 42 g/L

• Alb 22 g/L

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INITIAL NUTRITION THERAPY

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initial nutritional therapy

Maybe we need some extra information

before starting nutritional support?

ENERGY

20-30 kCal/kg per day

A Actual body weight (28 kg)

B Ideal body weight (57 kg)

C Adjusted body weight (46 kg)

Ideal weight + 0.25x(actual weight-ideal weight)

1050 – 1750 kCal/day (1400 kCal/day)

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PROTEINS AND AMINO ACIDS

C 1.5 - 2 g/kg ideal body weight / day

85.5 - 114 g proteins

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DETERMINATE

glucose : fat RATIO?

G 50 - 70%

F 30 - 50%

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initial nutritional therapy

it has been started

immediately, but how?

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?

?

?

a) Enteral

b) Parenteral

c) Combination

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Immediately on receipt,

beside all symptomatic conservative therapy,

applied is TPN – system “all in one”

CVC placed in v. subclavia l. sin….

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TPN

Composition of nutrients:

Proteins&AA – Glamin, Vamin 18,…….500-1000g

Carbon-hydrates – Glucosa, ………….100-150g

Fat emulsions 10% - ………………...250-750ml

+ electrolytes, vitamins, trace elements, heparin and

insulin crystal………………………………...on going

• Volume…………………………...1050 – 2000 ml

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20 days after admission

in severe currently condition

unconscious

psycho-motoric agitated

without peripheral pulsations

with peripheral cyanosis

three grand mal seizures

patient transferred to ICU…

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IMAGING STUDIES

ECG: sinus tachycardia Fr 135/min

DOPPLER showed thrombosis of v.

jugularis l. sin.

CT of ABDOMEN: hepato-splenomegalia

and colonic dilatation.

CT of BRAIN: without any signs of

pathological alteration of the tissue.

EEG: normal

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Thrombosis of v. jugularis l.sin

↓

CVC was removed from v. subclavia l.sin

↓

Another one was placed on the opposite

side of the body

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THERAPY STRATEGIES

Antibiotics

TPN

Anticoagulant therapy

Immunosuppressive (KS, azatioprim)

Mesalazine tabl.

Blood transfusions

Albumin, immunoglobulin, cгуоprecipitate

+ I.V. fluid therapy

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Fistula output: ▼ 850 ml/day

▼ 470 ml/day

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Bowel in continuity / complitely disrupted ???

Fistula arrising from the lateral wall / end fistula

– no communication with bowel distally ???

Associated abscess cavity / drain into the cavity ???

Condition of adjacent bowel:

damaged, strictured, inflamed ???

Distal obstruction ???

Arrising in what part of GIT ???

Ethiologic disease process ???

Lenght of the tract << / >> 2cm ???

Bowel wall defect greater 1 cm² ???

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Fistula output: ▼ 470 ml/day

▼ 220 ml/day

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How long parenteral nutrition

should be given?

Our TPN lasted for 35 days

Treatment gave a positive result and

fistula enterocutanea was closed

We started with enteral nutrition

two days before TPN stopped

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ENTERAL NUTRITION

Our choice was

Sip feeding

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Enteral nutrition

Sip feeding

1st and 2nd day - EN + TPN

3rd and 4th day - EN only

The rest of the treatment –

EN + special diet

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laboratory findings on departure

• Na 139 mmol/L

• K 3.9 mmol/L

• Cl 98 mmol/L

• GLU 5.7 mmol/L

• BUN 4.2 mmol/L

• CREA 68 µmol/L

• TP 65 g/L

• Alb 31 g/L

• Ca 2.24µmol/L

• WBC 6.1x10^9

• RBC 3.40x10^12

• Hgb 97g/L

• Hct 0.31

• Plt 189x10^9

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weight and height on departure

W-39.5kg H-165 cm

• BMI = 14.5

RESULTS

Oral feeding re-established on

the 56th postoperative day

Discharged on the 45th day

of admission from our hospital

Weight 39.5 kg

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