MS. MGI/EN CASE

Y VO N N E Y I RU XUL E V E L 4 D I E T E T I C S S T U D E N T

M C G I L L U N I V E R S I T Y

D E C E M B E R 1 5 T H, 2 0 1 5

1. Initial Admission + 1st OR

2. 2nd OR + Dobhoffinsertion

3.Dobhoff failed &d/ced

4. PEG Insertion

5.Rate and Formula change

Poor PO

Weight lossLow K+, Mg+

EN Feed Tolerance

High PO4, CaRelated Nutritional Issues

Overview

[Oct. 10th] [Oct. 23rd] [Nov. 10th] [Nov. 27th]

1I N I TI AL

AD MI SSI ON+

1 S T OR ER àICU à6N

82 yo Ms. M:diarrhea x 3day+/- feverw/ abdominal pain general weakness + deterioration

[2015 Oct 10th]Admitted to ICUsocial hx: lives in daughter basement alone

independent for ADLs & IADLs, minimal help from daughter for mobility

OCT. 10

[Culture]C. diff. +

[C scope]Pseudo - membranous

colitis

[OR]total

colectomy +

ileostomy

C- Scope

0~25cm scope unable to advance further

• C. Difficile a bacteria in the colon, found widely in the environment

• A small population of healthy people naturally carry it without outbreaks of illness

• C.Diff spores can persist in a room for weeks or months

• Overgrowth in large intestine due to antibiotic-associated may occur

• Medication association risk factors: broad spectrum antibiotics, multiple antibiotics, length of time, medications to reduce stomach acids (including PPIs)

• Symptoms: Watery diarrhea, fever, loss of appetite, nausea, abdominal pain or tenderness à inflammation of the colon = Pseudomembranous C.Diff Colitis

PSEUDOMEMBRANOUS COLITIS [C.DIFF COLITIS]

C. Diff produces toxins that attack the lining of the intestine. The toxin destroy cells and plaques of inflammatory cells and decaying cellular debris inside the colon causing watery diarrhea

http://www.mayoclinic.org/diseases-conditions/c-difficile/basics/definition/CON-20029664?p=1

PMHX

COPD Chronic bronchitis Asthma

HTN Osteoporosis Hip replacement

GERD ex-smokerPnemonia

SMH x 2 days (d/c sept 30)

MEDS UPON INITIAL CONSULT

Nutrition Supplements

• Vit D 10,000 q week

• Oscal 500mg QD

• FeSo4 300mg QD Anti-

inflammatory

• Celebrex• Prednisone

Anti-osteoporosis

• Fosamax

Anti-depressant

• Celexa

Anti-biotic

• Flagyl• Vancomycin

Anti-coagulant

• Fragmin

Proton Pump Inhibitor

• Pantoloc

Anti-diarrhetic

• Metamucil (15g BID qd)

Laxative

• Colace

Analgesic

• Lyrica• Aspirin

22 ND OR

+ D OBHOFF

I N SE RTI ON6N

Ms. M:severe adbominal paininable to tolerate any foods/liquids

[2015 Oct 23rd]Back to OR + G-scope done

FASCIAL DEHISCENCE

• Fascia is a connective tissue made of collagen, that separates, organs, muscles and the skin• Fascial disruption is due to abdominal

wall tension overcoming tissue or suture strength. • It can occur early or late in the

postoperative period.• With early fascial dehiscence, the

skin closure may be intact depending upon the method of closure• the patient, nevertheless, is at risk for

evisceration.

[Oct 23rd] OR: Tx of Fascial dehiscence

http://www.uptodate.com/contents/complications-of-abdominal-surgical-incisions

• Esophagitis refers to any inflammation, irritation, or swelling of the esophagus.

• Causes• acid reflux, the following increase your risk of

esophagitis:• Alcohol use• Cigarette smoking• Surgery or radiation to the chest (for example,

treatment for lung cancer)• Taking certain medicines without drinking plenty of

water. These medicines include alendronate, doxycycline, ibandronate, risedronate, tetracycline, potassium tablets, and vitamin C

• Vomiting• weakened immune system may develop

infections that lead to esophagitis. Infection may be due to:

• Fungi or yeast (most often Candida)• Viruses, such as herpes or cytomegalovirus

[Oct 23rd] G-scope: Severe esophagitis along entire esophagus

https://www.nlm.nih.gov/medlineplus/ency/article/001153.htm

Received nutrition consultbefore going to OR on

Oct 23rd

Usual Intake

Prior to Admission

Always had good appetite and intake

Right before Admission Low Intake x 3days as felt unwell

Since Admission/Post OR

Barely taking in spoonfuls at mealsVery low intakec/o burning sensation mid-esophagus w/ solids >liquids

Seen by Speech Language Pathologist

• Previously known to SLP• Baseline mild pharyngreal dysphagia• Not at significant aspiration risk

• Ht: 155cm (estimated)

• UBW 54.5 kg (reported) stable weight before

• BMI 22.7

• IBW: 53~65 kg ( BMI 22~27)

• Energy Rqmts: 1635 kcal (30kcal/kg)

• Protein: 65 ~ 82 g (1.2 ~1.5 g/kg)

– Infection, wound healing, recovery from stress

Anthropometrics

LABS [ OCT 22]WBC 10.6

Hgb 99

Na 135

Mg 0.8 (border line low)

PO4 0.81 (border line low)

K 3.4ß 4.1ß4.2

BUN 4.6

Cr 79

Glu 4.1

Albumin [Oct 19th] 32ß37(Aug 15th)

Nutrition Therapy and Suggestions

1. Well nourished PTA w/ N BMI for age, stable weight and intake hx, however at increase nutritional risk since A with negligeable intake x ~2 weeks 2o to reflux with P.O ( solids > fluids)

2. Possible insert dobhoff in OR, therefore will prepare EN Protocol for weekend as pt would benefit from EN to prevent deterioration in H

Peptamen 1.5 @ 70cc/hr x 16 hr (20 à40à60à70) 65 cc H2O flushes q 2h [Nasoduodenal]

Actual Needs Total yield of feeds

Energy (kcal) 1635 1680

Protein (g) 65~82 76

Water (ml) 1635 1380

3D OBHOFF

& I N TAK E

HI ST ORY6N

Dobhoff EN rate EN time Beneprotein Supplement PO intake

Oct 26 inserted 20 ml/h

6 am – 10 pm [16h]

--- --- NPO

Oct 27 In place 40 ml/h --- --- NPO

Oct 28 In place 60 ml/h --- --- NPO

Oct 30 In place

70ml/h

--- --- Clear Fluids

Nov 2 Pulled-outover w/e +reinserted

--- ---

⬆Calorie⬆Protein

SoftDiet

Nov 3 In place 6 pm – 6 am [12h]2 scoops

Two Cal 60ml BID

Nov 6 In place 80 cc/h 6 am – 6 pm [12h]

Nov 10 Pulled out over w/e

--- --- ---

Nov 13Re-insertion

failed--- --- ---

Nov 16Re-insertion

Failed--- --- ---

4PE G

6N

October

1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

17 19 20 21 22 23 24

25 26 27 28 29 30 31

November

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30

• PEG was indicated at this point• Nov. 20th: D/c with family, obtained consent on PEG

insertion post-poned twice• Nov 25th: 1st trial of PEG insertion failed [adhesion/platelet]• Nov 27th: 2nd trial of PEG inserted• Nov 28th: EN Started

Is PEG indicated?

Before Starting feeds…is pt at risk for refeeding syndrome?

One or more of the following• BMI <16• Unintentional wt loss >15% in past

3~6 month• Little or no nutritional intake for >10

days• Low levels of K, PO4 or MG before

feeding

Two or more of the following• BMI <18.5• Unintentional wt loss >10% in

past 3~6 month• Little or no nutritional intake for

>5 days• Hx of alcohol misuse or drugs,

including insulin, chemotherapy, antacids or diuretics

àWt on 11/03 = 52kg ??? questionable accuracyàNegliglbe PO intake on/off for total of 6 weeksàAnd labs?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/

0.550.650.750.850.951.05

27-O

ct-1

5

28-O

ct-1

5

29-O

ct-1

5

30-O

ct-1

5

31-O

ct-1

5

1-N

ov-1

5

2-N

ov-1

5

3-N

ov-1

5

4-N

ov-1

5

5-N

ov-1

5

6-N

ov-1

5

7-N

ov-1

5

8-N

ov-1

5

9-N

ov-1

5

10-N

ov-1

5

11-N

ov-1

5

12-N

ov-1

5

13-N

ov-1

5

14-N

ov-1

5

15-N

ov-1

5

16-N

ov-1

5

17-N

ov-1

5

18-N

ov-1

5

19-N

ov-1

5

20-N

ov-1

5

21-N

ov-1

5

22-N

ov-1

5

23-N

ov-1

5

24-N

ov-1

5

25-N

ov-1

5

26-N

ov-1

5

27-N

ov-1

5

28-N

ov-1

5

Mg

0.50.70.91.11.31.51.7

27-O

ct-1

5

28-O

ct-1

5

29-O

ct-1

5

30-O

ct-1

5

31-O

ct-1

5

1-N

ov-1

5

2-N

ov-1

5

3-N

ov-1

5

4-N

ov-1

5

5-N

ov-1

5

6-N

ov-1

5

7-N

ov-1

5

8-N

ov-1

5

9-N

ov-1

5

10-N

ov-1

5

11-N

ov-1

5

12-N

ov-1

5

13-N

ov-1

5

14-N

ov-1

5

15-N

ov-1

5

16-N

ov-1

5

17-N

ov-1

5

18-N

ov-1

5

19-N

ov-1

5

20-N

ov-1

5

21-N

ov-1

5

22-N

ov-1

5

23-N

ov-1

5

24-N

ov-1

5

25-N

ov-1

5

26-N

ov-1

5

27-N

ov-1

5

28-N

ov-1

5

PO4

2345

27-O

ct-1

5

28-O

ct-1

5

29-O

ct-1

5

30-O

ct-1

5

31-O

ct-1

5

1-N

ov-1

5

2-N

ov-1

5

3-N

ov-1

5

4-N

ov-1

5

5-N

ov-1

5

6-N

ov-1

5

7-N

ov-1

5

8-N

ov-1

5

9-N

ov-1

5

10-N

ov-1

5

11-N

ov-1

5

12-N

ov-1

5

13-N

ov-1

5

14-N

ov-1

5

15-N

ov-1

5

16-N

ov-1

5

17-N

ov-1

5

18-N

ov-1

5

19-N

ov-1

5

20-N

ov-1

5

21-N

ov-1

5

22-N

ov-1

5

23-N

ov-1

5

24-N

ov-1

5

25-N

ov-1

5

26-N

ov-1

5

27-N

ov-1

5

28-N

ov-1

5

K

Dobhoff EN Feeds

Refeeding Syndrome

Feeding Insulin

Response

HypoK

HypoPO4

Thiamin Deficiency

HypoMg

• Protein and glycogen synthesis

• electrochemical membrane potentialàarrhythmias and cardiac arrest.

• important cofactor in most enzyme systems, including oxidative phosphorylation and ATP production.

• structural integrity of DNA, RNA, and ribosomes.

• membrane potential àlead to cardiac dysfunction and neuromuscular complications

• coenzyme in carbohydrate metabolism.

• Wernicke’s encephalopathy (ocular abnormalities, ataxia, confusionalstate, hypothermia, coma)

• Korsakoff ’s syndrome (retro- grade and anterograde amnesia, confabulation).

• Neurological (ataxia, confusion, or paresthesias)

• neuromuscular (weakness, myalgia, or rhabdomyolysis)

• cardiopulmonary (cardiac and ventilatory failure), or hematologic.

YES! Pt at risk for RS! Start feeding with NICE guidelines

• Consider Thiamine supplement and Vit B and multivitamins/trace elements

• Start with 10 kcal/kg/day• Slowly increase to meet

needs in 4-7 days• Monitor cardiace rhythm,

fluid status• Replace electrolytes• do not need to wait

until electrolytes are N to start

Vital 1.5 @ 85ml/hr x 12 hr (35à65à85 q2d) H2O flushes 30ml q 2h [PEG]1 scoop of beneprotein qd

Actual Needs Total yield of feeds

Energy (kcal) 1635 1555

Protein (g) 65~82 75

Water (ml) 1635 790 (just formula)

Start EN Feeding1. Suggested Thiamin IV 100mg x 3 days2. Pt already on Multivitamin3. Replace all eletrolytes before feeds start and replace

PRN once EN feeds initiate

EN Formula EN rate EN time Bene

protein Tolerance

Nov 28

Vital 1.5

35 ml/h

6 am – 6 pm [12h]

1 scoop

well

Nov 29 well

Nov 3065 ml/h

well

Dec 1 well

Dec 2 85 ml/h2 episodes

of Vo

Dec 3 70 ml/h 3 scoops well

PEG Feeds History

0.50.60.70.80.9

11.1

Mg

0.60.8

11.21.41.61.8

2

PO4

2.53

3.54

4.55

K

PEG EN Feeds started @ goal rate

Electrolyte Repletion

• Mg• IV:3,4,5 g with in 3~5 h• PO: 3000mg PO

• K & PO4 • KPO4 IV:30mmol• PO: KCl 20~40mEq

Updated practice recommendation for Mg Repletion (Karosanidize, 2014):• Increase Mg reabsorption up to 95% max in the kidney, when low Mg

detected• However there is a renal thereshold• When rapid IV pushed over 1-4 h, Mg levels will rise above physiological

levels exceeding renal thereshold à 50% of infused Mg would be excreted in the urine.

• SUGGEST:• 8~24h infusion• Adding Mg to IV or PN solution

54 kg UBW

52 kg 11/24

43.8 kg 12/04

Weight & Albumin18% wt loss x 2 months

Baseline

37

29

1415

1715

22

2729

23

2019

1716

151516

17

2220 20

1920

2120

23 23 2324 24

2624

2223

22

25 2527

28

3231

0

5

10

15

20

25

30

35

40

Albumin

OR 1+2

Dobhoff Minimal intake

PEG

NEW UPDATES

Change of Formula? Why?

Isosource 1.5 @ 70ml/hr x 12 hrH2O flushes 30ml q 2h [PEG]

1 scoop of beneprotein qd

Actual NeedsR/A Actual Needs

According to 43.8kgTotal yield of

feeds

Energy (kcal) 1635 1315 (30kcal/kg) 1285

Protein (g) 65~82 52~65 (1.2~1.5g/kg) 63

Water (ml)1635 1315 ml

790 (just formula)

• Complete formula• Long term• Fiber containing• Cost-effective

New Issue – Ca, PO4, PTHàMalignancy?

0.60.8

11.21.41.61.8

2

PO4

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

2.9

Ca- corrected

PTH 0.3 (Dec 10th) LOW

Questions?