Date post: | 24-May-2015 |
Category: |
Health & Medicine |
Upload: | wendy-thompson |
View: | 1,739 times |
Download: | 0 times |
NUTRITION CASE STUDY
WENDY THOMPSONWVU DIETETIC INTERN
DECEMBER 2N D , 2013
Bariatric Surgery Complications
Outline
Overview of the PatientSleeve Gastrectomy SurgeryMedical Nutrition Therapy for Bariatric
SurgeryNutrition Care Process of the Patient
Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring/Evaluation Follow-Ups
2
Patient Overview
58-year-old femaleCurrent Medical
History: s/p Gastric Sleeve
Surgery (July 2013) Persistent Leakage Gastric Stenting Left Upper Quadrant
Abscess Nausea and Vomiting Leukocytosis
Past Medical History: Morbid Obesity (BMI
45 pre-surgery) Hypertension Hyperlipidemia GERD Cholecystectomy Hysterectomy
3
What is a Laparoscopic Sleeve Gastrectomy?
Laparoscopic Sleeve Gastrectomy Overview
Removes 60-80% of the stomachShrinks stomach capacity to ≤300 mLWeight loss mechanism = gastric restriction
and possible decreased levels of ghrelin Ghrelin = appetite stimulating hormone primarily
produced in fundus and with small amounts produced in the pancreas
Potential nutritional risk factors = nutrient deficiencies due to: Decreased intake Removal of the majority of parietal cells
Decreased hydrochloric acid and intrinsic factor (B12)
5
Who is a Candidate for Bariatric Surgery?
BMI ≥ 40 or 35-39.9 with comorbidities: Type 2 diabetes Sleep apnea Hypertension Cardiovascular disease Osteoarthritis
Age 16-70 (some exceptions possible)Failed attempts at diet and exerciseHave been obese for at least 5 yearsFree of substantial psychological disease, drug or alcohol
dependencyCandidates must be able to understand surgery and post-
surgery lifestyle requirementsMotivated and well-informed
6
Outcomes of Sleeve Gastrectomy
Weight Loss Outcomes for average % of excess body weight: 1 month: 18-30% 3 months: 37-41% 6 months: 54-61% 1 year: 58-70% 2 years: 61.5% 5 years: no long-term
data
Potential Complications: Nausea/Vomiting GERD Anemia Leakage along the staple
line causing peritonitis or abscess
Sleeve Stricture Bowel Obstruction Pneumonia Deep Venous Thrombosis
(DVT) Acute Kidney Injury Liver Failure
7
Post-Bariatric Surgery Behavior
Eat slowly and chew thoroughly – at least 25 times!Avoid concentrated sugars, especially in liquid formLimit fats and fried foodsShrink your portions – do NOT overeat!Do not drink liquids with a meal – try not to drink
30 minutes before and after a meal or snackIf you can no longer tolerate diary – try a lactose-
free diary sourceExercise – after 2 months more strenuous exercise
can be tolerated
8
MNT for Sleeve Gastrectomy
Typical Diet Progression: Bariatric Phase I: Clear Liquids (begins post-op for 2-3 days) Bariatric Phase II: Full Liquid (advance as tolerated) Bariatric Phase III: Pureed/Home Soft Diet (progress as
tolerated, usually begins 1 week post-op) Bariatric Phase IV: Solids (progress as tolerated, usually
begins 1 month post-op)Protein Needs:
No set standard – typically 80-120g/day or 1-1.5 g/kg IBW CAMC Weight Loss Center = 1.5 g protein/kg of IBW
Adequate Hydration – goal 64 oz. day Rule of Thumb: Sip 1-2 ounces every 15 minutes
9
Sample Menu for 1 Month Post Op(Bariatric Home Soft Diet)
8:00AM Breakfast: ¼ - ½ cooked cereal ¼ - ½ cup skim plus milk
10:00AM Snack: ½ cup protein supplement
12:00PM Lunch: ¼ - ½ cup sugar free yogurt ¼ cup pureed fruit
2:00PM Snack: ¼ - ½ cup unsweetened applesauce 1 sugar free popsicle
6:00PM Dinner: ¼-1/2 cup blended soup with protein ¼ cup pureed fruit
10
MNT Life-Long Bariatric Diet
High proteinLow in refined carbohydratesIdeally, choose protein first, then fruits and
vegetables, and then whole grainsMaintain adequate hydration
11
Vitamin and Supplement Rx
First 3 Weeks Post-Op: Chewable multi-vitamin Chewable calcium Vitamin D – only if levels are low Vitamin B12 – if needed Protein supplements
Must be high in protein (15-25g/serving) and low in sugar (less than 10g/serving)
After 3 Weeks Post-Op: Multi-vitamin Calcium Citrate (1200 mg) Vitamin B12- if needed Vitamin D – only if levels are low Iron – only if prescribed by MD Protein Supplements – if unable to consume 50-70g protein/day Ursodiol – “Gall Bladder Pills” only for the first 6 months
Helps prevent gallstones due to rapid weight loss
12
Nutrition Care Process
Nutrition Assessment (11/12)
Secondary To: TPN protocol consult
Current Medical History: s/p sleeve gastrectomy, persistent gastric leak, morbid
obesity, HTN, hypokalemia, tachycardiaPast Medical History:
HTN, hyperlipidemia, GERD, cholecystectomy, partial hysterectomy
14
Bariatric Past Medical History
7/8/2013: Laparoscopic Sleeve Gastrectomy N/V started 2 weeks post-op
8/9/2013: Upper GI Endoscopy – found mild stricture in the opening of the gastroplasty (between esophagus and stomach), performed balloon dilation
8/15/2013: Admitted to ER with N/V, HTN, leukocytosis, lactic acidosis – conducted CT scan to find left upper quadrant abscess and left pleural effusion
8/16/2013: Transferred to Cleveland Clinic and had abscess drained 8/19/2013: Re-drained abscess 8/23/2013: Re-drained abscess, placed gastric sleeve stent, re-sealed
the leak at the staple line 8/29/2013: Endoscopic exploration found stent partially collapsed so it
was adjusted 9/2/2013: Double stenting placed to correct the collapse stent 11/02/2013: Transferred from Cleveland Clinic to CAMC
15
Patient Medications and Supplements16
Medication Name
Reason
Protonix PPI to decrease stomach acid to treat GERD
Mylanta Neutralizes existing stomach acid to treat GERD
Reglan Reduces nausea, vomiting, and GERD
Phenergan Helps treat existing nausea and vomiting
Zofran Helps prevent nausea and vomiting
Metoprolol Beta-blocker to lower blood pressure
Lasix Loop diuretic to lower blood pressure
Dilaudid Treats pain
Folic Acid Individuals post bariatric surgery are at an increased risk for deficiency – used to prevent deficiency
Vitamin B6
Vitamin B12
Thiamine
Anthropometric Measurements
Height 165.1 cm (5’5”)
Weight 112 kg (10/30 – Bed Scale)
IBW 57 kg
% IBW 196%
Adjusted/Feeding Weight 71 kg
BMI 41.1 (Class III Obesity)
17
Nutrient Needs18
Current Diet Order (11/12): Vivonex RTF @ goal rate of 60ml/hr to provide
1440kcal, 72g protein, and 1224ml free H2O NG tube
Bariatric Phase I - Clear Liquids
Estimated Needs
Per Kg of IBW Per Day
Energy (kcal) 18 – 22 kcal 1278 – 1562 kcal
Protein 1 – 1.5 grams 71 – 106 grams
Fluid Per MD Per MD
Subjective Information (11/12)
Patient was consuming ~50% of clear liquid diet and tube feeding was up to 40ml/hour
Very nauseousVomits multiple times a day and has since 2
weeks post-surgery in JulyPatient has had nothing but clear liquids and
tube feedings since surgery
19
Patient Labs
11/11 Potential Reasons for Abnormalities
Glucose (74-106) 127 Stress, insulin resistance
Na (136-145) 135 Occurs with prolonged vomiting
K (3.5-5.1) 3.4
BUN (7-18) 21 Potential decrease in kidney function or dehydrationCreatinine (0.6-
1.3)1.4
eGFR (>60) 47 Based on creatinine levels – potential decrease in kidney function
Albumin (3.4-5) 1.6 Sign of inflammation with potential protein/energy deficiency
20
Nutrition Diagnosis21
Altered GI function related to persistent gastric leak and stent placement as evidenced by intolerance to tube feed
Notes: High risk for refeeding syndrome
due to minimal intake: Advance feedings slowly Monitor electrolyte values closely
Watch for low potassium, phosphate, magnesium levels
Nutrition Intervention (11/12)22
d/c tube feeding and bariatric clear liquid diet Due to persistent N/V
PICC line placement was ordered by MD and x-ray was used to verify correct placement
Initiate TPN @ 8:00PM (11/12) per CAMC protocol TPN was discussed with Physician, who determined
the initial rate to be 75 ml/hour Nursing staff was notified
IPOC
Parenteral Nutrition Invention
PICC Line Start: subclavian vein End: superior vena cava
23
Parenteral Nutrition Intervention24
Initial TPN Order - 11/12 Rate: 75ml/hour Macronutrients:
Amino Acids: 50g of 15%
Dextrose: 75g of 70% Lipids (M/W/F only) =
0g Total Calories: 455
kcal
Electrolytes: Sodium: 140 mEq Potassium: 30 mEq Calcium: 10 mEq Magnesium: 8 mEq Phosphate: 6 mEq
MVI: StandardAscorbic Acid: 125mgThiamine: 50mgTrace Elements: NoneInsulin: NonePepcid: None (on
Protonix)
Monitoring and Evaluation
Goals: Improve protein status Provision of adequate nutrition via nutrition support Stabilize blood glucose levels
Monitoring: High Risk – F/U in 5 days Will follow daily Will monitor weight, labs, and TPN/PPN tolerance
25
TPN Monitoring and Evaluation26
Check labs per TPN protocol:Every 6 hours:
GlucoseDaily:
Basic Metabolic Panel (BMP)
Sodium Potassium Calcium Chloride
Weekly (unless abnormal): Complete Metabolic
Panel (CMP) Triglyceride Magnesium Phosphorus Ionized Calcium Pre-albumin Liver panel
Follow-Up Assessment (11/14)
Subjective Information: Patient was tolerating full liquid diet and a Boost Glucose
Control with lunch and dinner Patient was still nauseated but had only vomited once today Patient preferences of cream of chicken, tomato, chicken
noodle soup were recorded
Plan for Patient: Spoke with social worker and determined that the patient
must be on 12-hour cyclic TPN prior to discharge in order to be accepted into a skilled nursing facility Plan to start cycling on Monday (11/18)
Patient will require an stent placement – per MD notes, date planned for 11/20
27
Follow-Up Assessment (11/19)28
Nutrition Orders: 11/17: TPN d/c due to lost access secondary to
multiple blood clots Bariatric Phase II – Full Liquid with Boost Glucose
Control w/ lunch and dinnerSubjective:
Patient was tolerating full liquid diet and consuming the majority of the supplement
Vomiting frequency has decreased but nausea still persist
Follow-Up Assessment (11/19) Cont.29
Significant Lab Changes: Alkphos (39-117): 306 ALT (17-67): 127 AST (15-65): 181
Suggestive of potential hepatic dysfunction and common with TPN
Updates30
11/20: Gastric stent placed11/22: Restarted TPN11/24: Started to cycle TPN – due to SNF
requirements11/27: Reached cyclic goal of 12 hours11/28: Switched TPN back to continuous due
to acute renal failure TPN providing an average of 1,314 kcal
12/2: Bariatric Phase III – Pureed/Soft with Boost Glucose Control and continuous TPN
Questions?31
References
Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
CAMC Standards of Practicehttp://www.cornellweightlosssurgery.org/pdf/
dietary_guidelines_sleeve_gastrectomy.pdf http://www.camc.org/surgicalweightloss
32
Appendix: Patient Labs
11/11 11/13 11/14 11/15 11/16 11/17 11/18
Glucose (74-106)
127 120 140 112 106 135 117
Na (136-145) 135 137 139 139 143 140 139
K (3.5-5.1) 3.4 3.3 3.3 3.7 3.5 3.4 3.5
BUN (7-18) 21 27 31 37 44 50 60
Creat (0.6-1.3)
1.4 2.0 2.0 1.9 1.6 1.6 1.7
GFR (>60) 47 31 31 33 40 40 37
Phosphorus (2.5-4.9)
3.4 2.5 2.3 3.1 3.6
Albumin (3.4-5)
1.6 1.7 1.6 1.8
Pre-Alb. (20-40)
15.5
Triglycerides (50-200)
224
33