tpn discontinuation post bowel resection · bodoky, gyorgy, antonio c. campos, zhong-jin yang,...
TRANSCRIPT
TPN Discontinuation
Post Bowel Resection Clinical Case Study by:
Cody Steiner MSU Dietetic Intern
Overview
• Examine patient post reconstructive surgery
• Review patients outcome
• Determine best practice for TPN discontinuation
The Patient
• 52 year old female patient admitted for pelvic
sarcoma
• Resection of recurrent pelvic sarcoma, en bloc
ileocecal region, sigmoid colon and dome of the
bladder, extensive lysis of adhesion for
reestablishment of gastrointestinal continuity, and a
cystoscopy with ureteral stent placement
ADIME Charting: Assessment
• Ht: 60”
• Weights:
• 54.4kg - at admission
• 45.1kg - 15 days post admission
• Ideal Body Weight: 49kg
• % Ideal Body Weight:
• 110% - at admission
• 92% - 15 days post admission
• BMI: 22.7 at admission
Anthropometric
ADIME Charting: Assessment
• Metastatic pelvic cancer
• TPN dependence since 2011
• 100% TPN for > 3 years
• Venting gastric tube in place
• Chronic anemia
• Recurrent bacteremia and line sepsis
• Benign meningioma in 1990
• Invasive breast cancer of right breast
Past Medical History
Surgical Procedures
• Pelvic Sarcoma resection followed by
abdominal/pelvic radiation in 2010
• Small bowel to transverse colon
anastomosis in 2013
• Risk for malabsorption of fat
soluble vitamins, B12, and
fluids/electrolytes
ADIME Charting: Assessment
• Poor appetite and fear of eating
• Related to numerous years of TPN
• Surgeon note reports “adequate intake with some emesis” on prior to
discharge
• Weight loss of 9.3kg between admission and discharge
• 17% decrease - considered significant in 30 day period
Nutrition Focused Information
ADIME Charting: Assessment
• Estimated Nutritional Needs:
• Calories: 1640kcals (30kcals/kg)
• Admission weight used
• Based on Harris-Benedict with x1.5 stress factor for current cancer
• Protein: 65-81g (1.2-1.5g/kg)
• Related to current cancer and post resection
ADIME Charting: Diagnosis
PES 1: Altered gastrointestinal function related to
decreased functional intestine length as evidenced by
two resections of small bowel sarcoma and 5 years of
partial parenteral nutrition dependence including 3 years
of no enteral nutrition.
PES 2: Inadequate caloric intake related to abrupt
discontinuation of TPN as evidenced by a > 5%
weight loss in less than 1 month post
discontinuation.
ADIME Charting: Case Study
Intervention
• TPN was abruptly discontinued upon discharge
• No outpatient follow up or RD referral for diet counseling
scheduled
• Inpatient RD gave as much information/support as possible
• Signs of dehydration/malabsorption
• Moderate fat intake, increasing soluble fiber, frequent small
meals, decreasing fluid intake during meals
• Vitamins, minerals, and supplementation
Abrupt vs. Stepwise TPN
Discontinuation
• Abrupt vs. Stepwise discontinuation:
• Abrupt discontinuation
• Quickens increases of enteral intake
• Risk of weight loss
• Stepwise discontinuation
• Combines TPN and oral intake
• Adjusts as oral intake increases
• Delays adequate oral nutrition
Abrupt vs. Stepwise TPN
Discontinuation• Current research on gut atrophy after TPN dependence:
• Journal of Digestive Disease and Sciences
• Rat model - 8 days 100% TPN
• Significant (p<0.01) decreases in intestinal circumference,
villi diameter in the jejunum and ileum
• Nutrition Issues in Gastroenterology
• Great risk of malabsorption during adaptation phase
• Can last 2-3 years post resection
Abrupt vs. Stepwise TPN
Discontinuation• Three case studies by the International Life Sciences Institute
• Patient #1 adapted to abrupt discontinuation
• Required nocturnal enteral hydration
• Patient #2 discontinuation with nightly TPN
• Extremely short functioning length ~100cm
• Nocturnal TPN only to promote oral intake
• Patient #3 Stepwise TPN tapering planned
• 3 meals/day provided ~55% calories, TPN ~45%
ADIME Charting: Intervention
& Monitoring
• Patient needs diet counseling and weight monitoring in relation to reinitiating of oral
intake
• Stepwise TPN discontinuation should be utilized
• Begin with nightly TPN meeting 75% needs and decrease in relation to oral intake
• There should be little to no unintentional weight loss
• Weight and oral intake should be self monitored by patient at least x2 weekly and
changes reported to dietitian
• Any weight loss would trigger a reevaluation of diet and nutritional support
Conclusions
• Unfortunately unable to personally follow up with patient after
discharge
• Outpatient RD reported weight stabilized at 41kg (83.5%
IBW) with supplemental TPN reinitiated
Conclusions• Best evidence-based
research shows:
• Gut adaptation with abrupt discontinuation is possible
• Dependent on many factors
• Functional intestine length
• Other SBS treatments (medications, EN, etc.)
• Ability for oral intake
• Most effective treatment plan:
• A patient centered
approach!
• TPN discontinuation
dependent on not only
functional length, but
also patient’s readiness
for oral intake
• Diet adaptation, with
education and
monitoring, should also
be based on individual
needs
Q & A
Barrett, M., Demehri, F. R., Ives, G. C., Schaedig, K., Arnold, M. A., & Teitelbaum, D. H. (2017). Taking a STEP back: Assessing the outcomes of
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Bodoky, Gyorgy, Antonio C. Campos, Zhong-Jin Yang, David C. Hitch, and Michael M. Meguid. "The comparative effects of abrupt vs. stepwise
discontinuation of TPN in rats." Physiology & Behavior 52.3 (1992): 591-95. Web. 15 Nov. 2016.
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References