case study - ms m
TRANSCRIPT
MS. MGI/EN CASE
Y VO N N E Y I RU XUL E V E L 4 D I E T E T I C S S T U D E N T
M C G I L L U N I V E R S I T Y
D E C E M B E R 1 5 T H, 2 0 1 5
1. Initial Admission + 1st OR
2. 2nd OR + Dobhoffinsertion
3.Dobhoff failed &d/ced
4. PEG Insertion
5.Rate and Formula change
Poor PO
Weight lossLow K+, Mg+
EN Feed Tolerance
High PO4, CaRelated Nutritional Issues
Overview
[Oct. 10th] [Oct. 23rd] [Nov. 10th] [Nov. 27th]
1I N I TI AL
AD MI SSI ON+
1 S T OR ER àICU à6N
82 yo Ms. M:diarrhea x 3day+/- feverw/ abdominal pain general weakness + deterioration
[2015 Oct 10th]Admitted to ICUsocial hx: lives in daughter basement alone
independent for ADLs & IADLs, minimal help from daughter for mobility
OCT. 10
[Culture]C. diff. +
[C scope]Pseudo - membranous
colitis
[OR]total
colectomy +
ileostomy
C- Scope
0~25cm scope unable to advance further
• C. Difficile a bacteria in the colon, found widely in the environment
• A small population of healthy people naturally carry it without outbreaks of illness
• C.Diff spores can persist in a room for weeks or months
• Overgrowth in large intestine due to antibiotic-associated may occur
• Medication association risk factors: broad spectrum antibiotics, multiple antibiotics, length of time, medications to reduce stomach acids (including PPIs)
• Symptoms: Watery diarrhea, fever, loss of appetite, nausea, abdominal pain or tenderness à inflammation of the colon = Pseudomembranous C.Diff Colitis
PSEUDOMEMBRANOUS COLITIS [C.DIFF COLITIS]
C. Diff produces toxins that attack the lining of the intestine. The toxin destroy cells and plaques of inflammatory cells and decaying cellular debris inside the colon causing watery diarrhea
http://www.mayoclinic.org/diseases-conditions/c-difficile/basics/definition/CON-20029664?p=1
PMHX
COPD Chronic bronchitis Asthma
HTN Osteoporosis Hip replacement
GERD ex-smokerPnemonia
SMH x 2 days (d/c sept 30)
MEDS UPON INITIAL CONSULT
Nutrition Supplements
• Vit D 10,000 q week
• Oscal 500mg QD
• FeSo4 300mg QD Anti-
inflammatory
• Celebrex• Prednisone
Anti-osteoporosis
• Fosamax
Anti-depressant
• Celexa
Anti-biotic
• Flagyl• Vancomycin
Anti-coagulant
• Fragmin
Proton Pump Inhibitor
• Pantoloc
Anti-diarrhetic
• Metamucil (15g BID qd)
Laxative
• Colace
Analgesic
• Lyrica• Aspirin
22 ND OR
+ D OBHOFF
I N SE RTI ON6N
Ms. M:severe adbominal paininable to tolerate any foods/liquids
[2015 Oct 23rd]Back to OR + G-scope done
FASCIAL DEHISCENCE
• Fascia is a connective tissue made of collagen, that separates, organs, muscles and the skin• Fascial disruption is due to abdominal
wall tension overcoming tissue or suture strength. • It can occur early or late in the
postoperative period.• With early fascial dehiscence, the
skin closure may be intact depending upon the method of closure• the patient, nevertheless, is at risk for
evisceration.
[Oct 23rd] OR: Tx of Fascial dehiscence
http://www.uptodate.com/contents/complications-of-abdominal-surgical-incisions
• Esophagitis refers to any inflammation, irritation, or swelling of the esophagus.
• Causes• acid reflux, the following increase your risk of
esophagitis:• Alcohol use• Cigarette smoking• Surgery or radiation to the chest (for example,
treatment for lung cancer)• Taking certain medicines without drinking plenty of
water. These medicines include alendronate, doxycycline, ibandronate, risedronate, tetracycline, potassium tablets, and vitamin C
• Vomiting• weakened immune system may develop
infections that lead to esophagitis. Infection may be due to:
• Fungi or yeast (most often Candida)• Viruses, such as herpes or cytomegalovirus
[Oct 23rd] G-scope: Severe esophagitis along entire esophagus
https://www.nlm.nih.gov/medlineplus/ency/article/001153.htm
Received nutrition consultbefore going to OR on
Oct 23rd
Usual Intake
Prior to Admission
Always had good appetite and intake
Right before Admission Low Intake x 3days as felt unwell
Since Admission/Post OR
Barely taking in spoonfuls at mealsVery low intakec/o burning sensation mid-esophagus w/ solids >liquids
Seen by Speech Language Pathologist
• Previously known to SLP• Baseline mild pharyngreal dysphagia• Not at significant aspiration risk
• Ht: 155cm (estimated)
• UBW 54.5 kg (reported) stable weight before
• BMI 22.7
• IBW: 53~65 kg ( BMI 22~27)
• Energy Rqmts: 1635 kcal (30kcal/kg)
• Protein: 65 ~ 82 g (1.2 ~1.5 g/kg)
– Infection, wound healing, recovery from stress
Anthropometrics
LABS [ OCT 22]WBC 10.6
Hgb 99
Na 135
Mg 0.8 (border line low)
PO4 0.81 (border line low)
K 3.4ß 4.1ß4.2
BUN 4.6
Cr 79
Glu 4.1
Albumin [Oct 19th] 32ß37(Aug 15th)
Nutrition Therapy and Suggestions
1. Well nourished PTA w/ N BMI for age, stable weight and intake hx, however at increase nutritional risk since A with negligeable intake x ~2 weeks 2o to reflux with P.O ( solids > fluids)
2. Possible insert dobhoff in OR, therefore will prepare EN Protocol for weekend as pt would benefit from EN to prevent deterioration in H
Peptamen 1.5 @ 70cc/hr x 16 hr (20 à40à60à70) 65 cc H2O flushes q 2h [Nasoduodenal]
Actual Needs Total yield of feeds
Energy (kcal) 1635 1680
Protein (g) 65~82 76
Water (ml) 1635 1380
3D OBHOFF
& I N TAK E
HI ST ORY6N
Dobhoff EN rate EN time Beneprotein Supplement PO intake
Oct 26 inserted 20 ml/h
6 am – 10 pm [16h]
--- --- NPO
Oct 27 In place 40 ml/h --- --- NPO
Oct 28 In place 60 ml/h --- --- NPO
Oct 30 In place
70ml/h
--- --- Clear Fluids
Nov 2 Pulled-outover w/e +reinserted
--- ---
⬆Calorie⬆Protein
SoftDiet
Nov 3 In place 6 pm – 6 am [12h]2 scoops
Two Cal 60ml BID
Nov 6 In place 80 cc/h 6 am – 6 pm [12h]
Nov 10 Pulled out over w/e
--- --- ---
Nov 13Re-insertion
failed--- --- ---
Nov 16Re-insertion
Failed--- --- ---
4PE G
6N
October
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
17 19 20 21 22 23 24
25 26 27 28 29 30 31
November
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
• PEG was indicated at this point• Nov. 20th: D/c with family, obtained consent on PEG
insertion post-poned twice• Nov 25th: 1st trial of PEG insertion failed [adhesion/platelet]• Nov 27th: 2nd trial of PEG inserted• Nov 28th: EN Started
Is PEG indicated?
Before Starting feeds…is pt at risk for refeeding syndrome?
One or more of the following• BMI <16• Unintentional wt loss >15% in past
3~6 month• Little or no nutritional intake for >10
days• Low levels of K, PO4 or MG before
feeding
Two or more of the following• BMI <18.5• Unintentional wt loss >10% in
past 3~6 month• Little or no nutritional intake for
>5 days• Hx of alcohol misuse or drugs,
including insulin, chemotherapy, antacids or diuretics
àWt on 11/03 = 52kg ??? questionable accuracyàNegliglbe PO intake on/off for total of 6 weeksàAnd labs?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
0.550.650.750.850.951.05
27-O
ct-1
5
28-O
ct-1
5
29-O
ct-1
5
30-O
ct-1
5
31-O
ct-1
5
1-N
ov-1
5
2-N
ov-1
5
3-N
ov-1
5
4-N
ov-1
5
5-N
ov-1
5
6-N
ov-1
5
7-N
ov-1
5
8-N
ov-1
5
9-N
ov-1
5
10-N
ov-1
5
11-N
ov-1
5
12-N
ov-1
5
13-N
ov-1
5
14-N
ov-1
5
15-N
ov-1
5
16-N
ov-1
5
17-N
ov-1
5
18-N
ov-1
5
19-N
ov-1
5
20-N
ov-1
5
21-N
ov-1
5
22-N
ov-1
5
23-N
ov-1
5
24-N
ov-1
5
25-N
ov-1
5
26-N
ov-1
5
27-N
ov-1
5
28-N
ov-1
5
Mg
0.50.70.91.11.31.51.7
27-O
ct-1
5
28-O
ct-1
5
29-O
ct-1
5
30-O
ct-1
5
31-O
ct-1
5
1-N
ov-1
5
2-N
ov-1
5
3-N
ov-1
5
4-N
ov-1
5
5-N
ov-1
5
6-N
ov-1
5
7-N
ov-1
5
8-N
ov-1
5
9-N
ov-1
5
10-N
ov-1
5
11-N
ov-1
5
12-N
ov-1
5
13-N
ov-1
5
14-N
ov-1
5
15-N
ov-1
5
16-N
ov-1
5
17-N
ov-1
5
18-N
ov-1
5
19-N
ov-1
5
20-N
ov-1
5
21-N
ov-1
5
22-N
ov-1
5
23-N
ov-1
5
24-N
ov-1
5
25-N
ov-1
5
26-N
ov-1
5
27-N
ov-1
5
28-N
ov-1
5
PO4
2345
27-O
ct-1
5
28-O
ct-1
5
29-O
ct-1
5
30-O
ct-1
5
31-O
ct-1
5
1-N
ov-1
5
2-N
ov-1
5
3-N
ov-1
5
4-N
ov-1
5
5-N
ov-1
5
6-N
ov-1
5
7-N
ov-1
5
8-N
ov-1
5
9-N
ov-1
5
10-N
ov-1
5
11-N
ov-1
5
12-N
ov-1
5
13-N
ov-1
5
14-N
ov-1
5
15-N
ov-1
5
16-N
ov-1
5
17-N
ov-1
5
18-N
ov-1
5
19-N
ov-1
5
20-N
ov-1
5
21-N
ov-1
5
22-N
ov-1
5
23-N
ov-1
5
24-N
ov-1
5
25-N
ov-1
5
26-N
ov-1
5
27-N
ov-1
5
28-N
ov-1
5
K
Dobhoff EN Feeds
Refeeding Syndrome
Feeding Insulin
Response
HypoK
HypoPO4
Thiamin Deficiency
HypoMg
• Protein and glycogen synthesis
• electrochemical membrane potentialàarrhythmias and cardiac arrest.
• important cofactor in most enzyme systems, including oxidative phosphorylation and ATP production.
• structural integrity of DNA, RNA, and ribosomes.
• membrane potential àlead to cardiac dysfunction and neuromuscular complications
• coenzyme in carbohydrate metabolism.
• Wernicke’s encephalopathy (ocular abnormalities, ataxia, confusionalstate, hypothermia, coma)
• Korsakoff ’s syndrome (retro- grade and anterograde amnesia, confabulation).
• Neurological (ataxia, confusion, or paresthesias)
• neuromuscular (weakness, myalgia, or rhabdomyolysis)
• cardiopulmonary (cardiac and ventilatory failure), or hematologic.
YES! Pt at risk for RS! Start feeding with NICE guidelines
• Consider Thiamine supplement and Vit B and multivitamins/trace elements
• Start with 10 kcal/kg/day• Slowly increase to meet
needs in 4-7 days• Monitor cardiace rhythm,
fluid status• Replace electrolytes• do not need to wait
until electrolytes are N to start
Vital 1.5 @ 85ml/hr x 12 hr (35à65à85 q2d) H2O flushes 30ml q 2h [PEG]1 scoop of beneprotein qd
Actual Needs Total yield of feeds
Energy (kcal) 1635 1555
Protein (g) 65~82 75
Water (ml) 1635 790 (just formula)
Start EN Feeding1. Suggested Thiamin IV 100mg x 3 days2. Pt already on Multivitamin3. Replace all eletrolytes before feeds start and replace
PRN once EN feeds initiate
EN Formula EN rate EN time Bene
protein Tolerance
Nov 28
Vital 1.5
35 ml/h
6 am – 6 pm [12h]
1 scoop
well
Nov 29 well
Nov 3065 ml/h
well
Dec 1 well
Dec 2 85 ml/h2 episodes
of Vo
Dec 3 70 ml/h 3 scoops well
PEG Feeds History
0.50.60.70.80.9
11.1
Mg
0.60.8
11.21.41.61.8
2
PO4
2.53
3.54
4.55
K
PEG EN Feeds started @ goal rate
Electrolyte Repletion
• Mg• IV:3,4,5 g with in 3~5 h• PO: 3000mg PO
• K & PO4 • KPO4 IV:30mmol• PO: KCl 20~40mEq
Updated practice recommendation for Mg Repletion (Karosanidize, 2014):• Increase Mg reabsorption up to 95% max in the kidney, when low Mg
detected• However there is a renal thereshold• When rapid IV pushed over 1-4 h, Mg levels will rise above physiological
levels exceeding renal thereshold à 50% of infused Mg would be excreted in the urine.
• SUGGEST:• 8~24h infusion• Adding Mg to IV or PN solution
54 kg UBW
52 kg 11/24
43.8 kg 12/04
Weight & Albumin18% wt loss x 2 months
Baseline
37
29
1415
1715
22
2729
23
2019
1716
151516
17
2220 20
1920
2120
23 23 2324 24
2624
2223
22
25 2527
28
3231
0
5
10
15
20
25
30
35
40
Albumin
OR 1+2
Dobhoff Minimal intake
PEG
NEW UPDATES
Change of Formula? Why?
Isosource 1.5 @ 70ml/hr x 12 hrH2O flushes 30ml q 2h [PEG]
1 scoop of beneprotein qd
Actual NeedsR/A Actual Needs
According to 43.8kgTotal yield of
feeds
Energy (kcal) 1635 1315 (30kcal/kg) 1285
Protein (g) 65~82 52~65 (1.2~1.5g/kg) 63
Water (ml)1635 1315 ml
790 (just formula)
• Complete formula• Long term• Fiber containing• Cost-effective
New Issue – Ca, PO4, PTHàMalignancy?
0.60.8
11.21.41.61.8
2
PO4
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
Ca- corrected
PTH 0.3 (Dec 10th) LOW
Questions?