Initiation of Peripheral Parenteral Nutrition with Appendicitis and Small Bowel Obstruction

Transcription

1 Initiation of Peripheral Parenteral Nutrition with Appendicitis and Small Bowel Obstruction Tiffany Peters Andrews University Dietetic Intern September 2015-April 2016

2 Outline Introduction Social History Past Medical History Normal Anatomy and Physiology of Appendix and Bowel Hospital Stay Labs Medications Treatment Medical Nutrition Therapy Prognosis Conclusion

3 Introduction of K.C. 12 year old Caucasian female Weight: 73.9 kg (162.5 lbs.) Height: 64 inches BMI: th percentile BMI for age and 151% IBW Obese Less active in winter months Case Study: March 28 April 5, 2016 Body mass index-for-age percentiles. (2000). Retrieved April 17, 2016, from

4 Social History 6 th grade Active during the summer Likes to play outdoors Lives at home with father, mother, and two brothers No preferred religion

5 Past Medical History No significant history Lip laceration - stitches First admission to St. Francis Hospital

6 Normal Anatomy and Physiology of the Appendix No major function we can live without it Descends from the lower cecum Bound to the abdominal wall, anterior loops of ileum, and the omentum Average length is 9 cm but ranges from 2-20 cm End artery Nundy, S. (Ed.). (2014). The Appendix-ECAB. Elsevier Health Sciences.

7 Normal Anatomy and Physiology of the Small Bowel Imperative to nutrient absorption Duodenum, Jejunum, and Ileum Finger-like projections villi Hair-like projections microvilli Complete bowel obstruction Inability for nutrients to be absorbed and waste to be excreted properly Another source of nutrition is indicated parenteral nutrition Nelms, M. Sucher, K., Lacey, K., and Roth, S.L. Nutrition Therapy & Pathophysiology. 2 nd ed. Brooks/Cole Cengage Learning, Belmont, CA; 2011

8 Hospital Stay Admission on March 28, 2016 Complaints of abdominal pain, nausea, loss of appetite, previous fever CT scan confirmed acute appendicitis Inflammation and free fluid in the pelvis area indicated perforation Laparoscopic appendectomy Found adhesions to the retroperitoneum Appendix was cut out and removed Drain placed for intra-abdominal abscess

9 Hospital Stay March 29, 2016 Postop day #1 Diarrhea Abdominal pain Vomiting Thought to be caused by medications

10 Hospital Stay March 30, 2016 Postop day #2 Nausea/vomiting especially after eating Diarrhea had stopped Generalized ileus and lack of bowel function IV fluids were increased Potassium chloride hypokalemia NPO

11 Hospital Stay March 31, 2016 Postop Day #3 Continued vomiting bilious Allergic reaction to Zosyn, switched to Meropenem Abdominal scan small bowel obstruction vs. postop ileus CT scan ordered for confirmation NG tube placed for suction Started PPN

12 Hospital Stay April 1, 2016 second surgery CT scan confirmed 4 cm intraloop abscess in the central abdomen Small bowel obstruction secondary to adhesions due to the abscess Adhesion severed Abscess drained and irrigated

13 Hospital Stay April 1, 2016 Postop day #1 K.C. feeling much better No pain or vomiting NG tube returned light green bile April 3, 2016 Postop day #3 NG tube removed Clear liquid diet April 4, 2016 Postop day #4 GI soft diet PPN discontinued Discharged on April 5, 2016

14 Labs Admit labs 3/28/16 Post-op 1 3/30/16 Post-op 2 3/31/16 Post-op 1 4/2/16 Post-op 3 4/4/16 Final labs 4/5/16 Normal lab values Sodium 134 L L mmoll Potassium L 3.5 L mmoll Chloride mmoll TCO2 20 L mmoll Glucose 125 H 126 H 115 H mg/dl BUN mg/dl Creatinine mg/dl Calcium mg/dl Hemoglobin L g/dl Hematocrit L % Total Protein L gm/dl Total Bili L mg/dl ALT/SGOT IU/L AST/SGPT IU/L Albumin L L gm/dl Alk Phos IU/L CRP < 0.1 mg/dl Magnesium mg/dl Phosphorus mg/dl Prealbumin mg/dl Triglycerides <200 mg/dl

15 PRN Medications Medication Purpose Drug/Nutrient Interaction Possible Side Effects Normal Saline Flush Morphine Hydrocodone Zofran To clear medications from the port to make sure the drug was delivered fully. Narcotic; pain reliever Narcotic; pain reliever Antiemetic, antinauseant May alter how other medications work Avoid alcohol Take with food or milk to decrease GI distress; avoid alcohol. May cause delayed digestion. N/A Possible allergic reaction. Symptoms include rash, itching/swelling, severe dizziness, and trouble breathing. May cause dry mouth, taste changes, anorexia, weight loss, decreased gastric motility, constipation, nausea, vomiting. May cause dry mouth, constipation, nausea, or vomiting. May cause dry mouth, abdominal pain, constipation, or diarrhea Promethazine Antiemetic, sedative Take with meals to decrease GI distress; increased need for riboflavin; avoid alcohol May cause dry mouth, constipation, nausea, or vomiting. Phenol- Phenolate Sodium 1.4% Oral anesthetic for sore mouth or throat N/A Possible allergic reaction. Symptoms include nausea, vomiting, rash, difficulty breathing. Ativan Antianxiety Limit caffeine. Caution with grapefruit/citrus. Chamomile may increase sedative effect. Echinacea may decrease drug levels. May cause weight loss or weight gain, increased thirst, constipation, diarrhea, nausea or vomiting. Dextrose 50% Used for dehydration or to control blood sugars May lower serum sodium and increase serum potassium Hyperglycemia, edema Humulin Insulin; to lower blood glucose levels Diabetic meal plan to balance carbohydrate with insulin; alcohol may increase effect of insulin causing hypoglycemia May cause weight gain or hypoglycemia

16 Routine Medications Medication Purpose Drug/Nutrient Interaction Flagyl Antibiotic Food may decrease drug bioavailability Zosyn Antibiotic Food may decrease absorption of drug Meropenem injection Omnipaque 240 Potassium chloride Possible Side Effects May cause anorexia, metallic taste, nausea, vomiting, epigastric distress, or diarrhea May cause anorexia, oral candidiasis, nausea, vomiting, epigastric distress, or diarrhea Antibiotic N/A May cause oral candidiasis, glossitis, nausea, vomiting, diarrhea, GI bleeding, or colitis Iodinated contrast agent given to diagnose problems. Used during CT scans to pinpoint problem areas to prevent or to treat low blood levels of K+ Do not take with Amiodarone or Metformin Not to be taken while using salt substitutes. May cause nausea May cause GI irritation, nausea, vomiting, abdominal pain, diarrhea, or flatulence.

17 Treatment Diagnosis traditionally using a CT scan Exposure to radiation increased risk for developing cancer 1 Study in Cleveland, OH 2 Iterative reconstruction technique reduces background noise and uses a lower dose of radiation Tested specifically on diagnosing children with acute appendicitis Found to be just as successful as regular CT scans 1 Miglioretti, D. L., Johnson, E., Williams, A., Greenlee, R. T., Weinmann, S., Solberg, L. I.,... & Smith-Bindman, R. (2013). The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA pediatrics, 167(8), Didier, R. A., Vajtai, P. L., & Hopkins, K. L. (2015). Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatric radiology, 45(2),

18 Treatment Removal Laparoscopic vs. open surgery Most physician and patients prefer laparoscopic 1 Three small incisions 1 Less recovery time, decreased risk for formation of adhesions, and faster return of bowel function 2 K.C. had laparoscopic surgeries Perez, E. A., Piper, H., Burkhalter, L. S., & Fischer, A. C. (2013). Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surgical endoscopy, 27(4), Di Saverio, S., Coccolini, F., Galati, M., Smerieri, N., Biffl, W. L., Ansaloni, L.,... & Fraga, G. P. (2013). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg, 8(1), 42.

19 Medical Nutrition Therapy Typical eating pattern Skips breakfast Lunch at 12:00pm school cafeteria food After school snack crackers & fruit Dinner is prepared by K.C. mom Dislikes mushrooms and cabbage Breakfast Carbs (g) Protein (g) Fat (g) Sodium (mg) Calories N/A Lunch 1 slice pepperoni pizza ½ cup carrots oz raspberry lemonade smoothie Snack cup goldfish crackers banana Dinner 1 cup Lasagna ½ cup corn ¾ cup applesauce cookie crumble ice cream cone TOTAL 260g 51g 39g 1634mg 1572 kcal

20 Medical Nutrition Therapy K.C. s Energy Needs Kcal: 2049 (Schofield Equation with 1.3 stress factor for surgery) Protein: grams (1-1.2 g/kg for draining abscess) Fluid: 2578 ml (according to body surface area) Pediatric Multivitamin Electrolytes to replete as needed Corkins, M., Balint, J., Seebeck, N. & American Society for Parenteral and Enteral Nutrition. (2010). The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.

21 Medical Nutrition Therapy Prescribed Diets Clear liquid Regular NPO + TPN Clear liquid GI soft Initiation of PPN According to American & European Guidelines on Parenteral Nutrition PN is NOT beneficial for postoperative complications if the child was well nourished AND will be NPO for less than 7 days The risk of infection is more of a concern than the lack of nutrition Lack of sufficient energy intake does not prove to have any deleterious effect on growth status as long as the child was well nourished prior to surgery Mueller, C., McClave, S., Kuhn, J. M., & American Society for Parenteral and Enteral Nutrition. (2012). The A.S.P.E.N. adult nutrition support core curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition. Mantegazza, C., Landy, N., Hill, S. M., Zuccotti, G. V., & Koglmeier, J. (2016). Parenteral Nutrition in Hospitalized Children. Medical & Clinical Reviews.

22 Medical Nutrition Therapy Peripheral Parenteral Nutrition 3/31/16 4/1/16-4/2/16 Total fluid 2400 ml 3000 ml Total kcals 990 kcal 1448 kcal Non-protein calories 750 kcal 1160 kcal Amino acids 60 g 72 g Dextrose 150 g 200 g Lipids 24 g 48 g Kcal from dextrose 52% 47% Kcal from protein 24% 20% Kcal from lipids 32% 33% GIR (mg/kg/min) Kcal needs: 2049 Protein needs: At goal rate, the PPN meets 71% kcal needs and 65% protein needs.

23 Prognosis K.C. comprehended and cooperated Strong family support Complete healing with no other complications Return in one week to have drains removed

24 Thank you for listening!