Neglected deficiencies in severe malnutrition: phosphate ... · ESPEN Congress Vienna 2009...
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ESPEN Congress Vienna 2009 Neglected deficiencies in severe malnutrition: phosphate and thiamine Case-based introduction A-M. Liberati-Cizmek (Croatia)
Transcript of Neglected deficiencies in severe malnutrition: phosphate ... · ESPEN Congress Vienna 2009...
ESPEN Congress Vienna 2009
Neglected deficiencies in severe malnutrition: phosphate and thiamine
Case-based introduction
A-M. Liberati-Cizmek (Croatia)
Neglected deficiencies in severe malnutrition:
thiamineCase-based introduction
Ana-Marija Liberati Čizmek M.D.UHC Zagreb
Dpt. of Gastroenterology & Center of Clinical Nutrition
„Critical illness“
Acute Stress Response
Trauma/Infection
Immunological
Response
Neuroendocrine Response
Metabolic Response
Iatrogenic Factors
Introduction
• Spring 2005
• 18-years old girl, few months before the onset of symptoms
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Introduction
• Spring 2005
• Height: 160 cm• Weight: 70 kg• BMI 27.5
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History
• ♀ born in 1987.
• smoker
• during 2005 she lost her appetite
• developped diarrhea
• abdominal pain
• weight loss
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History• County Hospital (60 km from University Hospital Center)
• Treated as anorexia nervosa, because of the appetite loss and decreased food intake as leading signs
• After therapeutic failure, transfer from a County Hospital to the University Hospital Center
• 38 kg weight loss/ 6 months!
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History• 2006.- hospitalised at
Department of Endocrinology, UHC
• Weight: 32 kg• BMI: 12.5 !
• IBD suspected• IBD complications
detected
• Biochemistry
– ESR 30
– CRP 150
– L 15,7
– Hg 85
– platelets 625
– albumin 24,9 g/L
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History• 2006.- Department of
Gastroenterology
• Dg: Crohn’s disease(terminal ileitis)
• CD complications:Stenosis of ileum, Rectosigmoid fistula, Presacral abscess
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History
2006. Department of abdominal surgery
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History
2006: Department of abdominal surgery
Right hemicolectomy – resection of terminal ileum and ascendent colon with ileotransversal anastomosis
Bipolar sigmoidostomy
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
2006. Department of abdominal surgery
2007. Department of abdominal surgery
Resection of transversal colon
Fistulectomy
Bipolar sigmoidostomy
Weight: 33 kgBMI: 12.89
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
History
2007. Department of abdominal surgery
Recent History
2009. Department of Gastroenterology
Abdominal MSCT
Weight: 34kgBMI:13.28
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
2009. Department of gastroenterology
- Intraabdominal abscess
Recent History
January 2009. Department of Abdominal Surgery
Left hemicolectomy- proctocolectomy
Abscess evacuation
Fistula occlusion
Terminal ileostomy
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
January 2009. Department of abdominal surgery
Postoperative period - 2 weeks after the surgery in surgical ICU
and on the surgical ward
Recent HistoryAM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Nutritional support (surgical ICU+ ward):
• AIO- Three chamber bags- TPN- olive oil based formula
• >40 kcal/kg/d !• Glucose 235 g/day !• Polymeric enteral formula-up to 500 ml/d • No MV
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• transfer to the Depatment of Gastroenterology and Clinical Nutrition Center
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Nutritional support:• Day 1.• AIO- Three chamber bags- olive oil based
formula• Decrease energy intake to 30 kcal/kg/d• Glucose 128, Lipids 32, AA 32 g/d • MV added• Polymeric enteral formula- 250 ml/d
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Day 2.
• Onset of symptoms
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Day 2.• acute confusion, decreased
consciousness level• dizziness, dyplopia, nistagmus• weakness • palpitations, hypotension• nausea
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Thiamine deficiency suspected
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Laboratory Studies
• NO significant electrolyte disbalance• CBC-normal • Slight metabolic acidosis (pH 7,3)• Moderate hyperlactatemia (3,75 mmol/L)• Glucose levels- normal
*Serum thiamine levels are not routinely measured in our hospital
Workup
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Imaging Studies
• Head CT- no intracerebral hemorrhage or other abnormalities
• Cerebral MR- bilateral and symmetrical hyperintensities in the subthalamus, the floors of the third and fourth ventricles
Workup
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Thiamine deficiency suspected
We accepted a motto:“If in doubt, treat”
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Empiric therapy applied:
100 mg of thiamine parenterally
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
• Within a week neurologic symptoms vanished
• Improved mental state
Recent History
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Nutrition planName K.R.
Body weight/Height/Age 35 kg/1.60 m/22 y
BMI /description 13,7 / severe malnutrition
Diet type Crohn’s disease
Daily energy requirements ~ 1703 kcal
Average daily energy value of diet ~ 2300 kcal
Recommended weekly weight gain 0,5 kg
Recommended dietary supplement
Modulen IBD x 500 mL (500 kcal)or Ensure plus 2x220 mL (660 kcal)
Today
• Year 2009, seven months later:
• Remission of CD
• Weight: 48 kg (+13 kg)• BMI: 18.75
• Good mental and physical state• Ordinary food and additional
enteral nutrition (sip feeding)
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Take home message
• In severe malnurished patient on TPN presented with neurologic symptomatology:
“Always Keep In Mind Thiamine Deficiency”
AM Liberati Čizmek. Thiamine deficiency- Case-based introduction
Credits to:
• Prof. Zeljko Krznaric, M.D., Ph.D.
• Darija Vranesic Bender, Ph.D., nutritionist• Dina Ljubas Kelecic, pharmacist
