Slide 1

Lara SneadSodexo Dietetic InternFebruary 4, 2013

Nutrition Therapy for Paralytic Ileus

1Differentiate an ileus from a small bowel obstructionIdentify indications for nutrition supportDiscuss medical and nutrition care throughout case studys hospital courseObjectivesGG is a 64 YO Male

Admitted on 11/12/2012 w/COPD

Initially seen as a Nursing Screen Referral on 11/13 by RDSeen by dietetic intern 9 times

Remains an inpatient @ WAH

General InformationCOPDHTNAnemiaCellulitis of LEsRashesPVDPast Medical HistoryLives with parents

Smokes about 1 pack/day

Drinks alcohol almost qday

Social HistoryHt: 57 (67)

Admit Wt: 139# (63 kg)

IBW: 148# (67 kg)

BMI: 21.8 kg/m2 (Normal wt category)Anthropometric Data11/12:Right femoral endarterectomy & embolectomy; fasciotomies11/13:Seen by RD intubated, sedated, on 2 pressors, nonresponsive to voice/questionsNPO; banana bagDrsg to R shin & thighKcal: 1134-1449 (18-23), Prot: 63-76 (1.0-1.2)Lactate-4.5 H , MAP-80sRec. initiate EN w/Glucerna 1.2 @ 30 mL/hr, as tol. to 45 mL/hr (1296 kcal, 65 g prot)Hospital Course11/15:Tolerating Nepro @ 20 mL/hrRLE w/inner & outer incisions w/staples OTA, leg is warm, ecchymoticRec. to TF to Glucerna 1.2 @ 45 mL/hr (1296 kcal, 64 g prot) BG (167, 235, 193 mg/dL)11/19:Extubated, alert & responsive but deliriousLikely need amputation of R toes vs. foot Kcal: 1575-1890 (25-30), Prot: 75-88 (1.2-1.4)Tolerating feeds rec. advance to Glucerna 1.2 @ 60 mL/hr (1728 kcal, 86 g prot)

Hospital Course, Cont.11/27:Reintubated full ventNPO OGT on LCS (500 mL out in 4 hrs)KUB: SBO, perforated viscus - no plan for surgery (allow to heal)Rec. TPN 2L (NS): 11% Dex, 4.2% AA, 175 mL Lipids (1434 kcal, 84 g prot)11/30: KUB: C/w ileus vs. SBOGastrografin via NGTCont. TPNIf no extravasation, begin Osmolite 1.5 @ 20 and as tol. to 35 mL/hr + PS (1332 kcal, 68 g prot)

Hospital Course, Cont.SBO partial/complete blockage of small/large intestineTumor, adhesions, hernias, twisting/narrowing of intestines

Ileus absence of intestinal peristalsis without mechanical obstructionNormal times after surgery:Small bowel several hrsStomach 24-48 hrsColon 48-72 days

When postop ileus persists longer, considered pathologic and called a paralytic ileus SBO vs. Ileus

Causes:Sympathetic-parasympathetic imbalanceChemical mediators of bowel activityInflammationNarcotic analgesics

S/S: N/V, moderate abd. distention

Dx: Abd. x-ray/CT, exclude SBO

IleusNasogastric tube for decompressionEarly postop enteral feedingGum-chewingMeds:Limit narcoticsErythromycin antibiotics, motilin receptor antagonistMetoclopramide (Reglan) antiemetic, prokineticIleus Management12/4:TF w/Jevity 1.2 @ 10 off d/t residuals of 1.2L; NGT outputVomited & asp.Skin: Necrotic feet, Stage 2 sacral (not seen)Alb-0.9 L, plan to check prealbuminCont. TPNRec. 24 hr metabolic cartHospital Course, Cont.12/7:CT on 12/5 showed dilated SB c/w high-grade SBOTracheostomy on 12/6 Indirect Calorimetry avg. 2200 kcal, RQ