Download Stenoses of the Mesenteric Arteries with TPN

Chronic Mesenteric
Ischemia: TPN and
Treating Severe Malnutrition
Gabriella Vetere
NUTN 515
Overview
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Introduction of Case Study
Diagnosis
Pathophysiology and Causes of Mesenteric
Ischemia
Medical Treatment
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Nutrition Assessment
Nutrition Related Problems
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Mesenteric Revascularization
Total Parenteral Nutrition
Severe Malnutrition and Risk of Re-feeding
Medical Nutrition Therapy
Discussion and Conclusion
Case Study: RW
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56 yr old Male, habitual cigarette and marijuana
smoker, veteran, lives in Coos Bay
Entered ED with abdominal pain and severe
malnutrition (40 lb wt. loss)
PMH: COPD, chronic multiple polyps, diverticulosis,
malnutrition, cachexia, diarrhea, gastritis
C/O significant diarrhea
Per MD note- Pt reports started to feel extreme pain
when he would eat, which caused him to have a
“fear of food”.
Diagnosis
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Diagnosis is suggested by clinical history and
confirmed by:
Duplex ultrasonography
 Magnetic Resonance Angiography (MRA)
 Biplane aortography
 CT angiography (CTA)
 CTA was used on
RW to diagnose
Chronic mesenteric ischemia
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Diagnosis: Chronic Mesenteric
Ischemia
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Pre-Procedure Dx: Weight loss, concern for
mesenteric atherosclerotic disease.
Results of CTA: High-grade proximal
stenoses of the celiac and superior
mesenteric arteries
causing chronic
mesenteric
ischemia
Chronic Mesenteric Artery
Ischemia
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Inflammation or injury of the small intestine due to
lack of blood supply.
Occurs when there is a narrowing or blockage
(stenosis) of one or more of the three mesenteric
arteries, the major arteries that supply the small and
large intestine.
These arteries run directly from the aorta, the main
artery from the heart.
Often seen in patients with hardening of other
arteries such as (coronary artery disease).
Incidence and Risk Factors
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Accounts for 0.1% of all hospital admissions.
Mesenteric stenosis is found in 17.5% of
independent elderly adults.
Risk Factors:
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Atherosclerosis caused by Smoking, Poor Dietary Habits,
Physical Inactivity, and Genetics.
High Blood Pressure
Heart problems: CHF or irregular heart beat
Medications
Blood-clotting problems
Illegal drug use: cocaine, methamphetamine
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Information from Mayo Clinic: mayoclinic.com
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Signs and Symptoms of
Chronic Mesenteric Ischemia
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Abdominal cramps or fullness, beginning within 30
minutes after eating and lasting one to 3 hours
Abdominal pain that gets progressively worse over
weeks or months
Fear of eating because of subsequent pain
Unintended wt. loss
Diarrhea
Nausea, vomiting
Bloating
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Information from Mayo Clinic: mayoclinic.com
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Medical Treatment
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Relieve symptoms
Restore normal weight
Prevent bowel infarction
Mesenteric Revascularization-only in presence of
symptoms
RW’s Treatment: Supraceliac aorta to celiac and
superior mesenteric artery (SMA) bypass to help
re-establish blood supply to gut.
Aorta-to-SMA Bypass
NCP: Nutrition Assessment
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Food and Nutrition Related History:
Energy intake: Pt reports significant decrease in
intake for past 3 months.
Food Intake
Meal Pattern: 1-2 meals/day of foods easy to digest.
Types of Foods: Past 4 months: Chicken broth,
eggs, cream of wheat, soup, and pudding.
Supplemented diet with Ensure when possible.
Bioactive substance intake
History of Alcohol Abuse-sober for 6 months
Cigarettes-1.0 pack/day for 45 years
Marijuana Use-5 times/week
NCP: Nutrition Assessment
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Anthropometric Measurements:
HT: 5’11 (71”)
WT: 96 lbs (44 kg) UBW: 165 lbs (75 kg, 4 months
ago)
BMI: 13.50 kg/m^2
IBW: 160 lbs (73 kg) %IBW: 60%
Medications
(During course of stay): Metaprolol for mild HTN,
Simvastin (statin), Prilosec then changed to
Ranitidine (for GI prophylaxis), Zofran, Vanco and
Zosyn
NCP: Nutrition Assessment
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Biochemical Data/Labs:
Na
2/8
139
2/11
136
2/13
135
2/15
137
2/16
137
2/17
139
K
3.9
3.6
4.7
3.9
3.6
4.2
CL
100
102
111 108
109 110
CO2 34
29
21
22  25
Gluc 85
96
134 107
102
114
Mg
na
2.0
1.9
2.1
2.0
1.8
Phos na
3.6
2.8
4.3
3.9
4.0
Alb
2.7
na
na
na
na
2.9
24
NCP: Nutrition Assessment
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Nutrition-Focused Physical Findings:
General Appearance: very thin, cachetic
male
Body Language: pleasant attitude, but
lethargic and weak
Muscles and bones: diminished fat stores,
and visible loss of muscle tone
Head and eyes: sunken eyelids
Skin: thin skin
NCP: Nutrition Assessment
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Comparative Standards
Estimated Energy Needs:1,320-1,540 kcal
(30-35 kcal/kg)
Estimated Protein Needs: 66-88 gm (1.52.0 gm/kg)
Estimated Fluid Needs(rounded for TPN):
1,560 ml (~1 ml/kcal)
NCP: Nutrition Assessment
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Patient/Family Medical Health History
Medical Hx
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Pt with h/o of diagnoses related to smoking and
GI problems: COPD, Diarrhea, Gastritis, and
Diverticulosis
Personal Data/Social Hx
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56 yr old Caucasian male, married, everyday
smoker for 45 years, and habitual marijuana user
NCP: Nutrition Diagnosis
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Primary Diagnosis: Pt with malnutrition and
inadequate protein and energy intake r/t
altered GI function AEB 40 lb wt loss in 4
months, and chronic abdominal
pain/diarrhea.
RW’s Clinical Course Timeline
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Admit: 2/8/2011
2/10/11- Diagnosed with Mesenteric Ischemia
and stenoses of the mesenteric arteries
2/10/11- TPN Consult received and initiated
2/11/11-Pt to OR for celiac and SMA bypass
2/11/11-TPN resumed
2/14/11-Clear Liquid diet ordered, SLP eval,
and TPN
Timeline cont.
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2/15/11-Full Liquid diet ordered, TPN, and on
Vanco and Zosyn due to pneumonia
diagnosis
2/17/2011-Regular diet, 1/2 TPN goal,
starting to have regular bowel movements
2/18/2011-Calorie Count started
2/19/2011-TPN D/C
2/21/2011-Pt discharged
Needs Related to Diagnosis
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Pre-Op TPN (Total Parenteral Nutrition)
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Improve nutrition
Nutrition to Treat Severe Malnutrition
Restore Weight After Surgical Treatment
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High calorie foods
Small frequent meals
Nutritional supplements
Issues Relating to TPN and
Severe Malnutrition
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“Re-feeding Syndrome”
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Need to monitor with patients who present with
severe malnutrition.
Characterized by an abrupt decrease in serum
potassium, magnesium and/or phosphorus driven
from pancreatic stimulation and insulin secretion
after introduction of carbohydrate.
Need to draw labs frequently to adjust
micronutrients in TPN, nurses/doctors replete prn.
Medical Nutrition Therapy
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Determine Estimated Needs via OHSU
Guidelines for TPN
Estimated Energy Requirements:
1,320-1,540 kcal (30-35 kcal/kg)
Estimated Protein Requirements:
66-88 gm pro (1.5-2.0 gm pro/kg)
Fluid: 1 ml/kcal or 25-30 ml/kg
1,560 ml/day (calculated to make a round number
for TPN)
Medical Nutrition Therapy:
Food and Nutrient Delivery
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TPN Consult: Parenteral Nutrition is indicated
when there is a documented inability to absorb
nutrients via the GI tract (OHSU Guidelines for
TPN)
Indication for TPN: Stenoses of the celiac and
superior mesenteric arteries
Recommended:
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TPN to provide 15 kcal/kg, 2.0 gm protein/kg,
20% lipids in vol of 1,560 ml/day (dosing wt: 44
kg) then increased to 30 kcal/kg.
TPN Calculation
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TPN to provide 15 kcals/kg, 2.0 gm protein/kg, and
20% kcals/lipids in a vol of 1,560 ml (dosing weight
44 kg) then increased to 30 kcals/kg.
Calculate grams protein, lipids, and dextrose as well
as total calories.
Ex:
15 kcals x 44 kg=660 kcals total
2.0 gm protein x 44 kg= 88 gm protein x 4 kcals/gm=
352 kcals
20%kcals lipids (660 x .20)= 132 kcals / 10
kcals/gm= 13.2 gm
660 kcals-440 kcals= 176 kcals left/ 3.4 kcals/gm
dextrose= 51.7 gm dextrose
TPN Calculation #2 Answers
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30 kcals/kg, 2.0 gm protein/kg, and 20%
lipids in vol 1,560 ml.
1, 320 kcals, 88 gm protein (352 kcals), 26.4
gm lipids (264 kcals), and 207 gm dextrose
(704 kcals)
Medical Nutrition Therapy:
Monitor and Evaluate
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Monitor Re-feeding Syndrome: When initiating
nutrition support, it is important to monitor
closely to avoid re-feeding.
Recommended:
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Monitoring for re-feeding syndrome and
aggressively replete K, Mg, Phos via IV
 Start TPN only when Phos is >2.0 and Mg
level is >1.5
 Advance kcals to 30 kcal/kg when no longer at
risk
Medical Nutrition Therapy:
Monitor and Evaluate
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Monitoring of Labs: Labs were assessed to
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determine if changes to TPN were warranted.
2/16/2011- Pt became acidotic
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Recommended:
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Omit NaCl-70 mEq/L and added NaOAc-70
mEq/L, and omitted KCl-20 mEq/L and added
KOAc-25 mEq/L
Medical Nutrition Supplement:
Food and Nutrient Delivery
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Diet Advancement and Calorie Count: TPN
should be d/c with transition to PO or enteral
nutrition as soon as feasible
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Recommended:
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Pt advance from CL -> FL-> Regular diet
Tapered TPN to half once patient was
beginning to eat greater than 75% of meals
Ordered Calorie Count to assess d/c of TPN
Medical Nutrition Therapy:
Food and Nutrient Delivery
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Oral Nutrition Supplements: Probiotics as a
supplement can be used to help maintain
adequate gut flora when pt is on antibiotics.
Pt on vanco and zosyn d/t pneumonia
Ordered:
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Nancy’s Fruited Yogurt to be sent TID w/
meals
Medical Nutrition Therapy:
Nutrition Education
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Education on Nutrient Dense Foods and
Oral Nutrition Supplements
Prior to discharge, RD discussed nutrientdense foods and oral supplements.
Pt states he has a case of Ensure at home
and will try to have 2 drinks/day.
RD provided written recommendations for
high protein/calorie foods
Medical and Nutritional
Outcome: How’d We Do?
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Pt was discharged within 10 days, and eating a
regular diet.
Pt was consuming up to 1,300 kcals prior to
discharge based on Calorie Count.
Pt showed very minimal signs of re-feeding
syndrome, and was successfully tapered off TPN.
3/14/2011 Vascular F/U in Outpatient Clinic:
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“Eating more, and no pain with eating”
“Slowly gaining weight”
Pt gained 7.2 kg in ~24 days
Pt is still smoking
Discussion and Conclusion
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Summary of Events:
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Pt was admitted with CMI and severe malnutrition
Pt was put on pre and post-operation TPN
Quickly recovered and advanced to regular diet
within 5-6 days after bypass
Regained energy and is slowing starting to regain
weight
Now audience....
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How can a person prevent themselves
from getting any kind of atherosclerotic
disease? (coronary artery disease or CMI for
example)
References
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Oderich, G. Current Concepts in the Management of Chronic Mesenteric
Ischemia. Current Treatment Options in Cardiovascular Medicine. 2010;
12:117-130.
Parrish, CR. The Hitchhiker Guide to Parenteral Nutrition Management for
Adult Patients. Practical Gastroenterology: Nutrition. Issues in
Gatroenterology, Series #40. July 2006
McClave, S, Martindale, R et al. Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Critically Ill Patient: Society
of Critical Care Medicine (SCCM) and American Society for Parenteral and
Enteral Nutrition (ASPEN). JPEN. 2009. 33(3): 277-316
Mayo Clinic Staff. Intestinal Ischemia. Retrieved: April 8 2011.
www.mayoclinic.com/health/intestinal-ischemia/
OHSU Guidelines
ADA Nutrition Care Manual