Clinical Experience

Presented by Maxine Rostolder

KSC Dietetic Intern 2013July 19th, 2013

Concord Hospital Charitable organization Quality is a top priority 295 licensed beds 238 staffed beds In 2012, total of 17,593 admissions 40 medical specialties & subspecialties

6,325 patients received diabetes self management education

Mission StatementConcord Hospital is a

charitableorganization which exists to

meet the health needs of individuals

within the communities it serves.

It is the established policy ofConcord Hospital to provideservices on the sole basis of

the medical necessity of such services

as determined by the medical staff

without reference to race, color,

ethnicity, national origin, sexual

orientation, marital status, religion, age, gender,disability or inability to pay for such services.

Nutrition Services 8 registered dietitians 3 registered dietetic technician All patients are screened by the DTRs within 24 hours of admission

All high risk patients are assessed by the RDs within 24 hours of admission

Offer nutrition education/counseling as well as outpatient services

Clinical Case Study - Mr. B

Admission - 5/30 - Day 0 Pt presented with Epigastric abdominal pain

Nausea and vomiting

Blood alcohol level of 337

Complaints of SOB on exertion

Lipase = 962 U/L

Medical Dx: Acute pancreatitis likely 2º to chronic alcohol abuse

Diet: NPO Thiamine, MVI, and Folate ordered daily

Substance abuse consult requested

Etiology Chronic alcoholism Gallstones Biliary tract disease Hypertriglyceridemia Hypercalcemia Trauma Certain drugs Some viral infections

Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen, H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201.

Pathophysiology Premature or inappropriate activation of digestive enzymes

Results in autodigestion of the pancreas

Signs of inflammation are found in surrounding tissue

Image Retrieved from http://www.marric.us/images/digestive_diagram.jpg

5/31 - Day 1 5/31 - Day 1

Tx to ICU CT scan showed evidence of necrotizing pancreatitis•Complicated by splenic vein thrombosis

Lipase = 3380 U/L, Amylase = 272 U/L

Screened as moderate risk, level 2

Patient History Social

Unemployed Uninsured Drinks 7-8 beers per night

Smokes 1 pack per day

Uses marijuana

Medical Alcoholism COPD Anxiety Recent pneumonia with alcohol withdrawals (3/20/13)• No sign of acute hepatitis

Over the Weekend 6/1 - Day 2

Corpak feeding tube placed

Started on Jevity 1.2 at 40ml/hr with a goal rate of 50ml/hr

6/2 - Day 3 Pt placed on ventilator

Lipase = 204 U/L Propofol started

EN is preferred over PN

Benefits of early EN for pts with severe acute pancreatitis Lower incidence of infections

Less surgical interventions

Shorter hospital stay Should be started within 24-48 hours of admission

Information retrieved from: Hegazi, R.A., Cockram, M.A. and Luo, M. (2012). Misconceptions and truths for feeding patients in the intensive care unit: case studies with practical nursing solutions. Open Journal of Nursing, 2, 327-331.

RD Assessment 6/3 - Day 4

Learned of this pt Feeding tube was placed in duodenal bulb

Jevity 1.2 formula Started capsticks and SSI CF30

Thiamine, MVI, and Folate given via EN feeding

49 year old male Ht: 73” Wt: 117.7kg BMI: 34.2 kg/m2

IBW: 92 kg Estimate of pt needs

2000-2300kcals (22-25kcal/kg IBW)

110-130g Pro (1.2-1.4g/kg IBW)

2760-3220ml fluids (30ml/kg IBW)

Nutrition Diagnosis Inadequate protein and energy intake r/t altered GI function as evidenced by poor intake and necrotizing pancreatitis

RD Questions Propofol amount

Placement of feeding tube

Type of formula

Pt was receiving 746kcals from propofol

MD was fine with feeding tube placement

MD agreed with changing formula to Vital 1.2

Pancreatitis Research Two RCTs compared NGT vs NJT1

Showed no significant differences between• Recurrence or worsening of pain• Hospital stay• Complications• Mortality

A systematic review of NGT feeding included 4 studies2

73% achieved full tolerance of feeding Tube feeding into the duodenum, mid jejunum, and distal

jejunum were compared for pancreatic secretory response2

Pts with acute pancreatitis have significantly lower secretion rates into the duodenum compared to healthy subjects

Another study showed 86% rate of pancreatic exocrine insufficiency in pts recovering from severe acute pancreatitis2

1Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen, H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201.2 Petrov, M.S., Correia, M.I.T.D. and Windsor, J.A. (2008). Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. Journal of the Pancreas, 9(4), 440-448.

Tube Feeding Recommendations Vital 1.2

60ml/hr 2330 kcals

• Includes 746kcals from propofol

146g CHO 99g Pro 1070 free H2O Meets RDI

6/4 - Day 5 Pt reaches goal rate

Still receiving same amounts of propofol

Triglycerides = 169 mg/dL

Days 6 - 8 6/5

Start to wean pt off propofol

Question tube feed placement again• MD agrees to check amylase and lipase

• If values were trending upward, we will reposition feeding tube into the jejunum

6/6 Propofol continues to decrease

Discontinue caps and SSI

Amylase = 46 U/L; Lipase = 267 U/L

6/7 Propofol discontinued Extubated in the AM EN discontinued Diet: Clear liquids Pt agitated and confused

1:1

Over the Weekend 6/8 - Day 9

Intermittently confused

Delusional with occasional visual hallucinations

6/9 - Day 10 Confused Hallucinating Anxious Agitated

Day 11 - 6/10 Tx to 5E Impulsive at times Continued with hallucinations and delusions

? Wernicke’s encephalopathy Started on thiamine therapy

•500 mg IV TID for 3 days•250 mg IV or oral TID until pt no longer requires

Wernicke’s Encephalopathy A result of a thiamine deficiency with continued carbohydrate ingestion

Common among alcoholics Pathology is restricted to the CNS Symptoms include:

Loss of immediate memory Disorientation Nystagmus Ataxia

Patient Interview Diet hx:

Typically eats once a day

Doesn’t feel hungry Binges on fast food

Pt feels as if he has gained some weight and requests weight loss information

Change Nutrition Dx Excessive alcohol intake r/t knowledge deficit as evidenced by acute pancreatitis, hx of 30+ years of excessive drinking, confused, and delusional with occasional visual hallucinations

Ready for Discharge Day 12

Psych consult Pt was offered inpatient psychiatric hospitalization, which he deferred

Has an outpatient follow-up plan

Fresh Start recommended

Day 13 Gave pt weight management/loss info and healthy eating info

Discharged in the afternoon

Any Questions…

References Abou-Assi, S. and O’Keefe, S.J.D. (2002). Nutrition support during acute pancreatitis.

Nutrition, 18(11/12), 938-943. Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen,

H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201.

Hegazi, R.A., Cockram, M.A. and Luo, M. (2012). Misconceptions and truths for feeding patients in the intensive care unit: case studies with practical nursing solutions. Open Journal of Nursing, 2, 327-331.

Wu, B.U. and Banks, P.A. (2013). Clinical management of patients with acute pancreatitis. Gastroenterology, 144(6), 1272-1281.

Remig, V.M. (2008). Medical nutrition therapy for neurological disorders. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 1067-1101). St. Louis, MI: Saunders

Gallagher, M.L. (2008). The nutrients and their metabolism. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 39-143). St. Louis, MI: Saunders

Hasse, J.M. & Matarese, L.E. (2008). Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 707-738). St. Louis, MI: Saunders

Mirtallo, J.M., Forbes, A., McClave, S.A., Jenson, G.L., Waitzberg, D.L. and Davis, A.R. (2012). International consensus guidelines for nutrition therapy in pancreatitis. Journal of Parenteral and Enteral Nutrition, 36(3), 284-291.

Arana-Guajardo, A.C., Cámara-Lemarroy, C.R., Rendón-Ramírez, E.J., Jáquez-Quintana, J.O., Góngora-Rivera, J.F. and Galarza-Delgado, D.Á. (2012). Wernicke encephalopathy presenting in a patient with severe acute pancreatitis. Journal of the Pancreas, 13(1), 104-107.

Petrov, M.S., Correia, M.I.T.D. and Windsor, J.A. (2008). Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. Journal of the Pancreas, 9(4), 440-448.