CENTRAL VERMONT MEDICAL CENTERClinical Case Study

Presented by: Tegan Bissell,

KSC Dietetic Intern 2012-13

Objectives

• Discuss the role of alcoholism in the deterioration of

essential organs

• Understand the physiology of the Pancreas

• Determine the differences between Acute and Chronic

Pancreatitis

• Determine the clinical manifestations of malnutrition

• Meet the case study patient and follow his plan of care

and treatment

Central Vermont Medical Center• Montpelier's Heaton Hospital and Barre City Hospital

merged in 1963 to form the Central Vermont Medical Center.

• 30 distinctive departments employing 1,400 full and part-time employees.

• Licensed for 122 inpatient beds

Role of Dietitians

Responsible for:• Performing nutrition screening• Assessments• Developing and implementing nutrition care plans• Providing nutrition education to patients, patients’ families,

CVMC Medical staff, employees, and outside groups and agencies as required.

• Participating on interdisciplinary healthcare teams, departmental and interdepartmental work teams.

Meet Mr. H• 56 year old Male admitted to IP on 7/11/13 with

depression, suicidal and EtOH detox

Alcohol Metabolism

pubs.niaaa.nih.gov

PMH• Alcohol dependency with alcoholic liver disease• Seizure disorder• HTN• HPLD• Chronic Hepatitis B• GERD• Alcohol induced Pancreatitis• Bipolar disorder• Depression• Anxiety• DJD• Hypothyroidism

The Pancreas

Anatomy of the Pancreas● Glandular tissue and system of ducts● Pancreatic duct merges with the bile duct to form

Ampulla of Vater● Leads to duodenum

Pancreatitis

Inflammation of the pancreas• Characterized by edema, cellular exudate, and fat necrosis.

Alcohol’s contribution• EtOH is responsible for 30% of AP cases in the US.• AP is common in men aged 35-45 years old from alcohol

abuse or gallstones.• Oxidative stress• Increased pressure within ducts• Auto-digestion

Acute Pancreatitis – (AP)• Hyper-metabolic and Catabolic State• Signs of malnutrition: Reduced serum albumin, transferrin,

lymphocytes, and serum calcium

• Symptoms:

• Abdominal pain

• Nausea/Vomiting

• Abdominal distention

• Steatorrhea

• Hypotension

• Oliguria

• Dyspnea

• Shock

• Coma

Chronic Pancreatitis – (CP)• Evolves slowly over time• Continual attacks of pain radiating into the back• Nausea, vomiting, diarrhea• Increased energy needs• Weight loss• Impaired immune function

Medical Nutrition TherapyAcute Chronic

Withhold oral and enteral feeding -If oral nutrition cannot be initiated in 5-7 days, start nutrition support

Provide oral diet as in acute phase

Support with IV fluids TF can be used when oral diet is inadequate

Once oral nutrition is started, provide:

Supplement pancreatic enzymes

-Easily digestible foods -Low-fat diet -6 small meals -Adequate protein intake -Increased calories

Supplement fat-soluble vitamins and vitamin B12

Medications• Antibiotics• Bile salts or fat-soluble vitamins• Diuretics• H2-receptor antagonists• Insulin• Octreotide• Opiates and other pain killers• Pancreatic enzymes• Vitamins and antioxidants

Day 3: 7/13/13Nutrition consult was received for pt with need for increased Mg and K in diet, as levels are affected by EtOH detox.

Social Hx• Pt is homeless and had been wandering between VT and

Maine.• Unable to access shelters while intoxicated and continues

to drink. • Has a tent and has been living in the woods at times.• Has been on a current binge for about 2 months.

Family hx:• Alcoholic father died at age 43 from suicide, stepfather who hung

himself and alcoholic paternal uncles. • Mother’s history unknown.

Diet/Wt Hx• Drinks about 24 beers per day• No special diet

• Ht: 5’ 11” Wt: 130# or 59 kg BMI: 17.6

• Sept 2011: 145#• Oct 2011: 175#• June 2013: 137#

• 5% wt loss in 1 mo.• Clinical indicators of muscle wasting

Malnutrition

ADA/ASPEN Clinical characteristics that the RD can obtain and document to support a diagnosis of malnutrition● Energy intake● Interpretation of weight loss● Physical findings

○ Body Fat○ Muscle Mass○ Fluid Accumulation

● Reduced grip strength

SOAP Notes

• Subjective: • No specific complaints, feels he’s eating well. Discussed high potassium

foods and pt likes potatoes.

Objective:• Dx: Depression, EtOH detox• 7# loss noted in last month per Meditech

• Calories needed: 25-35 cal/kg 1470-1770 cal/day• Protein needed: 1-1.2g/kg 59-71 g/day• Alternate Equation: Mifflin x 1.2

• Diet: Low Fat, Low Cholesterol Intake: 90% meals • Rx: Folic Acid, Thiamine, KCL, Pantoprozole, Mg, Multivitamins

Date Wt Alb Glu BUN CR K CL CA Phos Mg WBC HGB HCT

7/11 3.1

7/12 161 5 8.4 1.3

7/13 137 6 0.8 3.4 2.7 1.4

• Assessment: • Unintentional wt loss 2’ mental health issues affecting self care,

appetite, and access to calories as evidenced by wt changes, underwt status, and H&P.

• Plan: • Provide 1-2 high K foods each meal per pt preferences, Mg not

readily repleted by diet – Rec supplement as needed• Not appropriate for diet ed at this time.• RD to follow

Day 5: 7/15/13• Pt transferred to DSCU this AM with Chest Pain

• Put on telemetry monitoring, cardiac enzymes

• Nutrition follow up:• S: “I ate all my meals when on IP. I love fish, chicken, potatoes..”• O: Diet NPO this AM, advance to NAS, Low Fat Low Chol

• A: Tolerating PO diet with excellent intake, expecting transfer back to IP today.

• P: Continue current diet• To follow when admitted back to IP

Date Wt Alb Glu BUN CR K CL CA Phos Mg WBC HGB HCT

7/12 161 5 8.4 1.3

7/13 137 6 0.8 3.4 2.7 1.4

7/15 134 2.8 108 12 0.6 8.4 4.0 1.7 13.4

Day 6: 7/16/13• New admission back to IP, requires new RD Assessment

• Wt: 135#• New PES: Underweight related to poor PO intake prior to

admission and EtOH intake as evidenced by BMI, Alb levels, and cachectic appearance.

• Current Plan:• Added NAS to current diet order of Low Fat, Low Chol • Nighttime nourishment of PB&J• Calorie count start x3 days

Day 9: 7/19/13 • Nutrition Follow Up: Pt presenting with signs of refeeding

syndrome as evidenced by Phos and Mg labs.

Date Wt Alb Glu BUN CR K CL CA Phos Mg WBC HGB HCT

7/15 134 2.8 108 12 0.6 8.4 4.0 1.7 13.4

7/16 182 14 3.6 8.6 3.1 1.6

7/19 141 132 19 1.0 3.7 96 1.6 1.3

Correcting Refeeding Syndrome

• Put on QID phos and IV mg• Wt: 141#• Results of Calorie count: 7/17- 2000cal

7/18- 2300cal

7/19- 2537cal ● 8% wt gain in 8 days

Day 11: 7/21/13• Pt positive for pneumonia and emphysema changes.• Vomiting episode this AM• Tired and depressed.

Day 14: 7/24/13• Improved lung sounds, pneumonia resolving.• Intake has been 100% at all meals.• Pt states the food here is great!• Wt: 142#

Date Wt Alb Glu BUN CR K CL CA Phos Mg WBC HGB HCT

7/19 141 132 19 1.0 3.7 96 1.6 1.3

7/22 2.9 130 11 0.9 4.4 3.8 1.4 12.4

7/23 141 145 13 0.9 4.5 99 9.3 1.6 11.7

Day 16: 7/26/13• Unable to interview pt• Intake 100%

Date Wt Alb Glu BUN CR K CL CA Phos Mg WBC HGB HCT

7/23 141 145 13 0.9 4.5 99 9.3 1.6 11.7

7/26 2.5 123 25 0.9 4.4 104 9.0 3.4 1.7 12.0

Day 20: 7/30/13• Discharge Plans

• Electrolytes within normal limits• To go to an assisted living facility in VT• Wt gain 10# over 2 weeks, BMI now 18.99• Discussed plan to maintain wt and pt confident with strategies to

prevent wt loss in the future.• Scheduled for mental health follow up within the next week.

Questions?

Thank you!!

Tegan Bissell, KSC Dietetic Intern, 2012-2013

References•Escott-Stump, S. Nutrition and diagnosis-related care. 7� th ed.

Lippincott Williams & Wilkin; 2012.

•Whitcomb DC. Clinical practice. Acute Pancreatitis. N Engl J Med 2006; 354:2142

•Mahan, K. Krause’s Food and Nutrition Therapy. 12th edition. Saunders Elsevier; 2008.

•Steer ML, Waxman 1, Freedman S. Chronic Pancreatitis.

•N Engl J Med 1995; 332: 1482.

•Anand P, Park JH, Wu BU. Modern management of acute pancreatitis. Gastroenterol Clin North America. 2012; 41:1-8.

•Gropper, S. Advanced Nutrition and Human Metabolism. 5th ed. Wadsworth, Cengage Learning; 2009.