Clinical Case Study

Sarah Jacobson, Keene Dietetic Intern 2013-2014

Catholic Medical Center

!! West !! 330

Manchester, NH

bed, not-for-profit acute care

!! New England Heart Institute !! Diabetes Resource Institute !! The Obesity Treatment Center !! Moms Place !! Surgical & Acute Care

Catholic Medical Center

Clinical Dietetic Team:
!! Inpatient RDs !! Full time/part time !! Dietary Department/ !! Outpatient/Bariatric

Food Service

Case Study: Mr. M

!!

66 yo Male, married, retired

Jan 2011 Roux-en-Y GBP Oct 2011 CABG x3, AVR, ICD placed July 2012 Bentall procedure (replace aortic valve) w/ sternal plating. Pace Maker removed d/t endocarditis
!! MTE !! Chronic Kidney Insufficiency

August 2012 EGD/Enteroscopy: Upper GI bleed Oct 2013 Laparotomy/ surgical repair anastomotic ulcer w/perforation at GJ junction with PEG placed in remnant stomach

Gastric Bypass
Goal: Significant Long-term Weight Loss (60-80%) !! Weight loss: Malabsorption, volume restriction (15-30 ml), change in hormone-controlled metabolism, including reduction of appetite/ enhanced satiety !! Pros: maintain > 50% excess weight loss !! Cons: More possible complications, vitamin/mineral deficiencies, life-long adherence to diet/ supplementation !! Nutrients of Concern: B12, Iron, Calcium, Folate and zinc, copper, vitamin D

Gastric Bypass
!! Research

on metabolic changes after Roux en Y

!! Reverses one primary mechanism in which obesity promotes Type 2 diabetes

!! Changes

!! Theory that changes in microbes after GBP may aid in weight loss !! Changes in microbes by 1 week post-op

In Microbes

CABG/AVR
Coronary Artery Bypass Graft x3 w/ Aortic Valve Replacement
!!

Nutrition Concerns: Increased needs for healing, diet low in saturated fat/cholesterol/trans fats and sodium. Increase beneficial nutrients such as unsaturated & omega-3 fatty acids. Initial restriction on fluid. Post surgical patients are in catabolic state Goal: prevent further atherosclerosis and vessel stenosis.

!! !!

GI Bleed/Ulcer
GI bleed/ ulcer w/perforation at anastomosis site
!!

Nutrition Concerns: anemia, infection/sepsis, decreased nutrient assimilation, fluid/electrolyte imbalance Most surgeons suggest use of PPIs and eradicated H. Pylori to prevent ulcers. Hemoglobin & Hematocrit are decreased, decreased oxygen carrying capacity

!!

!!

PEG/ TF
PEG into gastric remnant
!! Goal: To

therapy

provide long-term enteral nutrition

!! Nutrition

Concerns: tolerance to TF, assimilation of nutrients, adequate nutrition, prevention of further weight loss risk:Valvular disease/ coronary stents/ low BMI/ hypoalbunemia

!! High

PEG Placement into Remnant

Overview: Mr. M
Current Admission: malnutrition d/t intolerance to TF (cyclic and bolus), inability to take PO

!!

BMI 20.1, 58.1kg/128lbs, 170.1cm/57

!!

Weight hx: 224lbs (before GBP) 145 lbs (CABG) 128 lbs (2013, ~100lbs lost)

!! !!

Diet: 4-5 cans Nepro w/variable PO Pmhx: CKD, Type 2 DM, CAD, HTN

Assessment
!!

malnutrition d/t intolerance to TF, inability to take PO, Chronic Kidney Disease 128 lbs, 57 86% IBW 87% UBW (loss of 16.5 lbs in 5 weeks) Edentulous, non-distended abdomen, N d/t TF, weakness, generalized muscle/fat wasting Alert & oriented, very talkative! Meds: MVI liquid, IV fluids, Xanax, Adderall, Lopressor, protonix, Odansetron and Oxycodone and Ambien(prn) Allergies: Pine pitch, Kiwi

!! !! !!

!!

!! !!

!!

Assessment
!!

Diet: Bariatric Phase 2

!! Full Liquids !! Increase nutrient density !! Minimum of 60 grams protein daily

!! !! !!

Unjury TID (4 oz) Gentle IV hydration Osmolite 1 Cal @ 50 ml/hr (1272 kcal, 53 pro)
!! RD & ARPN in agreement
"! Evaluate tolerance and monitor CKD

Assessment
Laboratory values Mr. M Date RBC hemoglobin hematocrit WBC Creatinine BUN Glucose Albumin Calcium Sodium Potassium CKD/GFR Alk Phosphate 11/14/13 2.92 8.9 26.8 13.86 4.6 116 123 3.0 11.2 131 4.7 Stage 4 153 10.1 135 4.3 Stage 4 This Adm 11/15/13 2.51 7.7 23.2 12.35 4.2 89 106

Diagnosis of this admission

!! Nutrition

Diagnosis: Protein Energy Malnutrition

!! PES

statement: Severe protein calorie malnutrition related to medical/physical condition and chronic illness as evidenced by inadequate oral intake ! 75% x 1 month, 13% wt. loss x 5 wks, and severe depletion of muscle/fat mass.

Diagnosis of this admission

!!

Other Potential Diagnoses:

!! Inadequate energy intake !! Inadequate oral intake !! Inadequate enteral nutrition infusion

!!

Etiology:
!! Physiological causes increasing nutrient needs due to illness, acute or chronic or injury/trauma

!!

Malnourished patients are two times more likely to develop a pressure ulcer, and three times more likely to develop an infection Alliance to Advance Patient Nutrition

Disease: Malnutrition
!! Malnutrition

Defined: Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting including starvation-related malnutrition, chronic disease-related malnutrition and acute disease or injury-related malnutrition. - The International Dietetics and Nutrition Terminology

Disease: Malnutrition
!! Protein-Calorie !! Primary

Malnutrition at CMC

!! % Weight loss !! Energy Intake !! Body Fat and/or Muscle Mass !! Fluid Accumulation !! Grip Strength !! Labs: Alb, PAB

Indicators Must have 3

!! ASPEN

Recommendations
!! High

!! Current nutrition Rx does not meet nutrient/fluid needs

Risk

!! Based

!! 1525- 1830 kcals/day !! 40-50 grams Pro/day (given stg 4/5 CKD) !! 1 ml/kcal/day

on LEIBW 61 kg (starting point)

Patient Progression
Transitioned to
!! Diet: Bariatric

!! Chopped/moist foods (no dentures) !! Low sugar, avoid fluid w/meals

Phase 5

!! Nephrologist

changed TF to Nepro @ 40ml/hr continuous sips 100%, Ave 25-50%

!! PO

Monitoring
!! TF

tolerance/PO intake: PO Tube Feedings

210ml residuals, TF on hold Increase IV fluids restart TF 15 ml/hr 30ml residuals no residual

!! 11/13 none !! 11/14 25% !! 11/14 75% !! 11/14 50% !! 11/15 25% !! 11/15 10%

Plan of Care
!!

1/19/13 Follow-up: Received nutrition consult for TF management and recommendations for cyclic TF at home.Visited w/pt who is now on TF Nepro @ 40ml/hr and has been progressed to stage 5 bariatric diet. ARF/Renal labs improving.Via TF: total vol 960 mls, 1728 kcals, 78 grams Protein. PO intake has been poor/variable and pt explained that the phase 2 bariatric was unappealing. Pt would like to try more PO options and states he has had no recent issues w/dumping syndrome, or taking fluids w/meals. Pt now has dentures and states that he has no problems chewing. Ordered dinner tonight: tuna & cheese, 4 oz Reg Root Beer, and tapioca, Per conversation with RD/NP, plan will be for pt for go home on 4 cans Nepro continuous (pt on 4 cans PTA). Pt would like to run the TF continuously and adjust the rate and time of infusion as tolerated (has backpack pump at home). Goal is for adequate nutrition to promote wgt gain and repletion. Monitor tolerance to TF, PO intake, and labs; intervene and provide recommendations as appropriate.

Plan of Care
!!

1/19/13 Nutrition Recommendations:

Recommendations for tube feeding for home: hold on cyclic feedings per pt preference. Continue Nepro formula at 40 mls/hr continuous, (~4 cans/day). Eventual plan will be to continue the 4 cans/day while adjusting the rate of infusion upward to allow pt more time off the pump. Pt confident in his ability to adjust feeding as tolerated and will keep up with the 4 can/day recommendation. Will also take po feedings as tolerated.

Patients Progression
!! On Discharge: Renal labs improving !! Pt tolerating TF/ Increasing PO intake !! Pt returned home with TF regimen w/

pump

!! Goal

for weight gain and increased TF tolerance and PO intake possible exacerbation of comorbidities as

!! Reduce

Conclusion
!! Pt

was not readmitted as of 1/2/2013

!! Outpatient

follow-up: weight, PO/TF tolerance, nutrient deficiencies, compliance with supplements/medications cases need to consider pmhx, but treatment/goals must reflect current situation

!! Complicated

References
Reprogramming of intestinal glucose metabolism and glycemic control in rats after gastric bypass. Saeidi N, Meoli L, Nestoridi E, Gupta NK, Kvas S, Kucharczyk J, Bonab AA, Fischman AJ,Yarmush ML, Stylopoulos N.Science. 2013 Jul 26;341(6144):406-10. http://directorsblog.nih.gov/2013/07/30/new-take-on-how-gastric-bypass-cures-diabetes/ http://medicalxpress.com/news/2013-12-weight-loss-surgery-safe-effective.html http://asmbs.org/membership/helping-my-patients/the-surgical-procedures http://www.jaoa.org/content/109/11/601.full http://medicalxpress.com/news/2013-12-weight-loss-surgery-safe-effective.html NIH Gut Microbes Affect Weight After Gastric Bypass, April 15, 2013 http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/ nutritionarticles/ODonnell_November2011.pdf http://www.ncbi.nlm.nih.gov/pubmed/24347350 http://bariatrictimes.com/access-to-the-bypassed-stomach-after-rygb/ http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutritionarticles/Vance%20PG%20May%202012.pdf http://www.researchgate.net/publication/ 6739816_Use_of_doubleballoon_enteroscopy_to_perform_PEG_in_the_excluded_stomach_after_Roux-enY_gastric_bypass https://www.nutritioncaremanual.org/topic.cfm? ncm_category_id=1&lv1=5545&lv2=16758&ncm_toc_id=16758&ncm_heading=Nutrition%20Care http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIResourceRooms2/ MalnutritionResourceCenter/home.htm?gclid=CImf3ry25bsCFe3m7AodjBkAEw http://malnutrition.com/getinformed/evidencelibrary/recognizing https://www.nutritioncaremanual.org/content.cfm?ncm_content_id=111002 http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines/2009_ENPR__Section_VI_Enteral_Nutrition_Administration/