CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…
-
Upload
doreen-jennings -
Category
Documents
-
view
215 -
download
0
description
Transcript of CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…
![Page 1: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/1.jpg)
CASE STUDY: ESLD WITH DIPS
Melanie Boney
![Page 2: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/2.jpg)
Patient 61 year old man with multiple chronic
diseases Anthropometrics
Height 75” / 190.5 cm
BMI: 34.75
Pounds KilogramsAdmit Body Weight 277.6 126.2Usual Body Weight 300 136.4Ideal Body Weight 184 83.6
![Page 3: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/3.jpg)
Patient Medical History
IDDM Peripheral Vascular Disease
Left BKA (2008) ESLD/Cirrhosis (2008)
Secondary to Hepatitis C (1996) and Alcoholism Cholecystectomy (1989) Transient Ischemic Attack (2006) Hypothyroidism Hypertension Microcytic Anemia
![Page 4: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/4.jpg)
Patient Medical History2/5/2010 Admitted to SNF for
Right lower extremity wound care
New prosthesis fitting with occupational therapy for left BKA (2008)
Monitoring of ascites
![Page 5: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/5.jpg)
Medical Discoveries Ascites
Serial Large Paracentesis from 1/15 – 3/22 4.5 – 10 L removed
Hepatohydrothorax Repeat Therapeutic Thoracentesis 2/21 – 3
/18 1.5 – 2.0 L removed
Mild Encephalopathy Worsening Major Depressive Disorder &
Generalized Anxiety Disorder
![Page 6: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/6.jpg)
Active Medications Acyclovir Clobetasol Digoxin Diphenhydramine Ergocalciferol Ferrous Sulfate Furosemide Gabapentin Insulin Aspart Insulin Glargine Lactulose
Levothyroxine Morphine Multivitamin Omeprazole Oxycodone Polyethylene Glycol Powder Propranolol Quetiapine Sprironolactone Trazadone Venlafaxine
![Page 7: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/7.jpg)
Functions of the Liver Metabolism of Macronutrients & Steroids Storage / Activation of Vitamins &
Minerals Formation / Excretion of Bile Filters & Detoxifies Blood
Converts Ammonia to Urea
![Page 8: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/8.jpg)
Functions of the Liver
![Page 9: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/9.jpg)
Cirrhosis 5 – 10% of
Population Severe
Damage to Hepatic Cells
Inhibited Blood Flow
Portal HTN & Ascites
![Page 10: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/10.jpg)
Portal Hypertension
![Page 11: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/11.jpg)
Metabolic and Nutrition Complications
Hypoalbuminemia Ascites
Poor appetite/early satiety Hypoglycemia or Hyperglycemia Vitamin & Mineral Deficiencies Abnormal Electrolyte & Fluid Retention
Intravascular depletion of blood volume
![Page 12: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/12.jpg)
Hepatic Encephalopathy Endogenous and exogenous ammonia Ammonia and metabolites easily cross
BBB Irreparable neural cell damage Waste products result in cerebral edemaStage Symptoms
I Mild confusion, agitation, irritability, sleep disturbance, decreased attention
II Lethargy, disorientation, inappropriate behavior, drowsiness
III Somnolent but arousable, incomprehensible speech, confused, aggressive
IV Coma
![Page 13: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/13.jpg)
Nutritional Strategies to Lower Ammonia
Protein Restricted Diet 20-40g / day ↑ 10g q3-5 days UL of 0.8-1.0 g/kg
Severe Protein Restriction 0-40g / day
Not Evidence Based
![Page 14: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/14.jpg)
Normal Protein Diet 10 patients fed 1.2 g protein/kg/day 10 patients fed 0.5 g protein/kg/day Protein catabolism ↑ in protein-
restricted patients No significant difference in
development of HE
![Page 15: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/15.jpg)
ASPEN Guidelines on Nutrition for LD
“EN is the preferred route of nutrition therapy in ICU patients with acute and/or chronic liver disease. Nutrition regimens should avoid restricting protein in patients with liver failure.”
![Page 16: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/16.jpg)
ESPEN Guidelines on Nutrition for LD
“An energy intake of 35 – 40 kcal/kg/day and a protein intake of 1.2 – 1.5 g/kg/day are recommended.”
“Initiate normal food/EN within12–24 hours postoperatively.”
“Initiate early normal food or EN after other surgical procedures.”
![Page 17: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/17.jpg)
MNT in ESLD Protein-Energy Malnutrition
High protein catabolism High protein snacks 1.0 – 1.5 g/kg/day
Poor Dietary Intake Poor appetite/early satiety due to ascites
Small frequent meals Sodium restriction
Abnormal Glucose Metabolism Hypoglycemia or hyperglycemia
Nutrient Malabsorption / Deficiencies MVM supplements
![Page 18: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/18.jpg)
Medical Strategies to Lower Ammonia
Medications to Decrease Ammonia Laxatives – remove GI ammonia Antibiotics – decrease colonic ammonia
production Devices to Compensate for Liver
Dysfunction Variceal ligation, or banding DIPS / TIPS
![Page 19: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/19.jpg)
Direct Intrahepatic Portocaval Shunt A Transjugular Intrahepatic Portosystemic
Shunt (TIPS) is a stent that is placed in veins in the middle of the liver which connects the portal vein to one of the hepatic veins. This procedure is performed without imaging
guidance. The Direct Intrahepatic Portacaval Shunt
(DIPS) is a modification of the TIPS procedure, using intravascular ultrasound-guidance, combined with fluoroscopy.
![Page 20: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/20.jpg)
DIPS
![Page 21: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/21.jpg)
Fig. 1 Transfemoral placement of IVUS probe and puncture of portal vein with modified Rosch-Uchida Portal Access set which has been placed into IVC from a transjugular route.
DIPS
![Page 22: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/22.jpg)
DIPS Using the IVUS
probe to guide the needle of a slightly modified Rosch-Uchida set, the needle is thrust directly from the IVC, through the caudate lobe of the liver and into the portal vein.
![Page 23: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/23.jpg)
DIPS Then using conventional catheter
and guidewire techniques, a shunt is constructed from the IVC to the portal vein using a Viatorr endoprosthesis self expandable stent-graft.
![Page 24: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/24.jpg)
DIPS
![Page 25: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/25.jpg)
Nutrition Assessment Estimated energy needs: 2300 kcal/day
(28 g/kg for IBW)
Estimated protein needs: 100 g/day (1.2 g/kg for IBW)
PES: Excessive carbohydrate, fat and sodium
intake related to limited adherence to nutrition related recommendations as evidenced by elevated CBGs, ascites and obesity.
![Page 26: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/26.jpg)
Physical Assessment Overall Appearance
Middle aged male, pale gray skin Pulmonary: Shortness of Breath Digestive system
Persistent diarrhea, protuberant, abdominal pain
![Page 27: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/27.jpg)
Biochemical Data: 2/8/10Albumin 2.6Prealbumin 11.3Potassium 4.7 Sodium 136Chloride 98Phosphorous 4.4Magnesium 2.0Calcium 8.0CBG’s 213-308Hemoglobin A1C 7.2
![Page 28: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/28.jpg)
Nutrition Intervention: 2/11/10 Diet: Regular Nutrition
Education Low Sodium High Protein Diabetes
Education Patient declined
Weight Loss Patient
requested Goal wt. 225 lbs
![Page 29: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/29.jpg)
Biochemical Data: 2/22/10Albumin 2.4Potassium 3.9 Sodium 132Chloride 93Phosphorous 4.4Magnesium 1.7CBG’s 183-287
![Page 30: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/30.jpg)
Nutrition Intervention: 2/23/10 Diet: Mild Sodium Nutrition Education
Low Sodium High Protein
![Page 31: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/31.jpg)
Nutrition Intervention: 3/3/10 Diet: Mild Sodium Nutrition Counseling
Patient discussed his strategies for weight loss Wt. 255 lbs Excessive fluid restriction Ice cream or pudding 2 – 3 x’s /day
![Page 32: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/32.jpg)
DIPS Surgery: 3/22/10
![Page 33: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/33.jpg)
Nutrition Intervention: 3/24/10 Diet: Mild Sodium Juven BID Nutrition Education
High Protein Low Sodium Low Carbohydrate Fluid Restriction
![Page 34: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/34.jpg)
Admitted to PVAMC Diet: Diabetic Discharged home 4/2/10 Admitted for worsening hepatic
encephalopathy Treated from 4/7/10 to 4/14/10 at PVAMC Transferred back to SNF
![Page 35: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/35.jpg)
Nutrition Intervention: 4/15/10 Diet: Mild Sodium, Diabetic Nutrition Counseling
High protein Small frequent meals
![Page 36: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/36.jpg)
Surgery: 4/23/10 Modifications to
Existing DIPS
![Page 37: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/37.jpg)
Outcome Renal function remains
Normal BUN & Creatinine Patient’s mental status continues to
decline His nutrition status continues to decline
Currently on a 1800-2000 kcal restriction Awaiting approval for DIPS reversal
![Page 38: CASE STUDY: ESLD WITH DIPS Melanie Boney. Patient 61 year old man with multiple chronic diseases…](https://reader035.fdocuments.us/reader035/viewer/2022070616/5a4d1c0f7f8b9ab0599f5cee/html5/thumbnails/38.jpg)
References Image http://www.360oandp.com/is-a-c-leg-right-for-you.aspx Davis GL. Thoughts on Nutrition and Liver Disease. NCP. 2006;21:243-244. Summar ML. Urea Cycle Disorders Overview. Gene Reviews. 2005; Retrieved from
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ucd-overview Image http://www.beliefnet.com/healthandhealing/getcontent.aspx?cid=11959 Image
http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=BB532D8A-43CB-416C-9FD2-A07AC6426961&GDL_Disease_ID=C8BD9205-E51B-4186-B4E4-B5087B21F9EA
Khanna S, Gopalan S. Role of Branched-chain Amino Acids in Liver Disease: the Evidence For and Against. Current Opinion in Clinical Nutrition and Metabolic Care. 2007;10297-102303.
Shenkin A. Serum Prealbumin: Is It a Marker of Nutritional Status or of Risk of Malnutrition? Clinical Chemistry. 2006;52:2177-2179.
McClave SA, Martindale RG, Vanek WV, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. 2009; 33:277-316. doi:10.1177/0148607109335234
Plauth M, Cabre E, Riggio O, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr.2006; 25:285 -294.
Córdoba J, López-Hellın J, Planas M, Sabın P, Sanpedro F, Castro F, et al. Normal Protein Diet for Episodic Hepatic Encephalopathy: Results of a Randomized Study. J Hepatol. 2004;41:38–43.
DiCecco SR, Fracisco-Ziller N. Nutrition in Alcoholic Liver Disease. NCP. 2006;21:245-254. Intravascular US-guided Direct Intrahepatic Portocaval Shunt with an Expanded Polytetrafluoroethylene-covered
Stent-Graft. Radiology. 2008;246:306-314. Rose JDG, Pimpalwar S, Jackson RW. A New Stent-graft for Transjugular Intrahepatic Portosystemic Shunts. British
Journal of Radiology. 2001;74:908-912.