Slowing the Flow: Dietary, Fluid & Medication Management of the Patient with a High Output Stoma

Transcription

1 Slowing the Flow: Dietary, Fluid & Medication Management of the Patient with a High Output Stoma Dr. Mary Arnold Long, DNP, APRN, CRRN, CWOCN-AP, ACNS-BC Birmingham, AL 2017

2 ANCC/AANP Conflict of Interest Disclosure I have the following relevant relationships to disclose: I am on the speakers bureau and am a clinical consultant for Molnlycke. I am on the speakers bureau and a PI for 3M. I am on the speakers bureau for ConvaTec.

3 ANCC/AANP Unapproved or Investigational Use Yes, the content of my material(s)/presentation(s) in the CE activity will include discussion of unapproved or investigational uses of products or devices. The dosages of some medications will exceed the RDA approved by the FDA.

4 Learning Outcomes The participant will be able to: Describe interventions, including fluids, foods, and medications, to decrease output from a high output stoma. Discuss a Six Step process to be used in collaboration with a physician partner to guide the patient with a high output stoma to less than 1200mL output per day.

5 Causes of a high output stoma Surgery or fistula resulting in <200cm residual small bowel & no colon Medicare states <150cm Residual colon in the anastomosis is like adding 50-60cm small bowel Intra-abdominal sepsis Intestinal stoma site or proximal Investigate with CT scan Enteric infection (c diff) Recurrent disease in remaining bowel Radiation enteritis Medication (laxatives, prokinetics, sudden withdrawal of steroids)

6 Consequences of a High Output Stoma Water and sodium depletion Thirst, postural hypotension, headaches, nausea Urine output <800mL/day, renal impairment, urinary Na+ <20mmol/liter. Na+ depletion; kidneys trying to conserve Na+ Urine Na+ concentration can be low before serum Na+ levels change. Hypomagnesia Malnutrition Malabsorption or food avoidance to decrease symptoms Frequent emptying of ostomy, leakages, peristomal irritant dermatitis

7 Contributors to Diarrhea/Malabsorption Loss of absorptive area Loss of feedback mechanism leading to: Upper gut dumping Increased intestinal transit time Poor mixing of pancreatico-biliary secretions w/ food Gastric hypersecretion Volume of secretions (Saliva = 1.5L/day, Gastric = 2.0L/day) ph entering gut deactivating pancreatico-biliary secretions Ongoing new/continuing medical issues Primary disease C diff associated diarrhea Small bowel bacterial overgrowth Netsch,2016;Parrish, 2016

8 Other Common Causes of Stool Output C. diff/other GI infection Initiation of new med Discontinuation of gut slowing med Patient runs out or forgets to renew Drinking too much fluid or poor fluid choices New hypothyroidism Recurrent/active disease Outflow diarrhea from stricture or obstructive process

9 Contributors to Adaptation & Absorption Length & quality of remaining bowel Which segment of small bowel remains Intact colonic segment Intact, luminal nutrients Age (?) of patient Integrity of other organs Time elapsed since original insult Depending on other interventions since Patient adherence to therapies Parrish, 2016

10 Small Small Bowel Anatomy & Physiology Stomach secretes 2-3L of gastric juices and secretions Lowest volume/rate in morning Highest volume/rate in afternoon & evening Gastric secretion stimulated by moderate amounts of alcohol, caffeine, anger & hostility Gastric secretion inhibited by unpleasant odors, tastes, fear & depression Duodenum 20-25cm long Neutralizes acid gastric contents Continues digestive process Absorption of CHO, Fe+, Ca+, Mg+ Netsch, 2016

11 Small Bowel Anatomy & Physiology Jejunum Separated from Duodenum by Ligament of Treitz (suspension ligament) 2.5 meters long (250 cm) = 8 feet Primary organ of absorption Most fats, proteins, vitamins & remaining CHOs Ileum No distinct separation from jejunum 3.5 meters (350 cm)= 11.5 feet Absorbs nutrients not absorbed by jejunum Slower transit than jejunum Only receptors to absorb intrinsic vitamin B12 & bile salts Britannica.com;Nightingale, 2001; Netsch, 2016

12 Small Bowel Anatomy & Physiology Britannica.com

13 Small Bowel Anatomy & Physiology Villi can elongate or hypertrophy Atrophy if food/fluids not ingested Increase risk of bacterial translocation & impaired immune function of GI system if atrophy Normal transit time mouth to colon = 4-9 hours Duodenum w/in first few minutes, secretes extensive amounts of mucus from Brunner glands Small bowel enterocytes secrete approx. 3L of extracellular fluid Digestion & absorption >90% complete w/in 1 st 100cm of small intestine 1-2L of fluid passes from small intestine through ileocecal valve into colon Netsch, 2016

14 Assessment for Dehydration Urine output <1000mL/24hours Stoma output > mL/24hours Rapid weight loss Dark urine Chronic fatigue Hypotension Dehydration admissions? Recurrent kidney stones Decline in kidney function Lightheadedness on standing Thirst, dry mouth, thick saliva Rees Parrish, 2016

15 Data Baseline 24 hours I&O: Urine: Goal = 1200mL Stone formers = > 1500 ml Stool: <1500 ml Rees Parrish, 2016

16 Goals of Therapy Slow motility nutrient contact time absorption stool/ostomy output urine output Then everything else falls in line once motility slowed Rees Parrish, 2016

17 Diet Guidelines General Tips: 6-8 meals/day start w/ 2-3; diet record; Tailor diet to individual, tell them what they CAN eat; chew well; Written diet materials for SBS Fluids: oral rehydration fluids; oral fluids may need limited in some & IV fluids given (dextrose/saline solution) CHOS: Generous complex CHO intake (pasta, rice, potatoes, breads, etc.); limit simple sugars & sugar alcohols (food & fluids); limit lactose & lactaid milks Fats: limit fat to <30% in those w/ a colon segment; May need to limit in those without. Ensure oils w/ essential fatty acids included (sunflower, soybean, corn, walnut) Proteins: High quality protein at each meal & snack Fiber: Encourage some fiber (in food) in those with a colon segment Oxalate: Limit in those w/ a colon. Ensure adequate urine output first. Salt: Usual intake in those w/ a colon. INCREASE salt intake in those without a colon. Rees Parrish, 2016

18 Fluids/Hydration Hypertonic Pull water into the small bowel lumen to dilute the higher osmotic fluid, increasing stool volume Fruit juices & drinks Sodas Sweetened liquid nutritional supplements Sweet tea Ice cream Sherbet Hypotonic Pull sodium into the small bowel lumen to increase the osmolarily of the fluid &, along with it, pull water, increasing stool volume Water Tea Coffee Alcohol Diet drinks Rees Parrish, 2016

19 Fluids/hydration Small sips of fluids w/ meals only Sip more BETWEEN meals Demonstrate to the patient the effect of oral fluids to stool/ostomy output by severely limiting/decreasing oral fluid intake for 24 hours ADD IV FLUIDS if needed to keep urinary output >1200mL/24hours Rees Parrish, 2016

20 Magnesium Depletion Partly occurs b/c main absorptive sites (distal small bowel & colon) removed Degree of malabsorption does not correlate w/ residual jejunal length Salt & H2O depletion leads to 2⁰ hyperaldosteronism, leading to increased renal Mg+ excretion Syndrome: fatigue, jerky/weak muscles, depression, ataxia, cardiac arrhythmia & seizures Most Mg+ salts poorly absorbed & may increase output. Mg+ acetate better absorbed than Mg+ gluconate. Often Mg+ supplemented IV or SQ. Nightingale, 2001

21 Oral Rehydration Solutions (ORS) Mechanisms of Water Movement Passive absorption Active absorption (via Na+/K+/ATP pump) Glucose-coupled transport Coupling is obligatory Permits 1 Na+ molecule w/ each glucose molecule Coupled transport is uni-directional Rees Parrish, 2016

22 ORS Are not for everyone Start w/ 500mL daily Sipping is better than drinking/gulping Try ice cubes/popsicles Nocturnal feeding tubes Commercial and recipes available A Patient s Guide to Managing a Short Bowel Rees Parrish, 2016

23 Vitamins/Minerals Minimal Dosing Evidence Considerations: Osmotic drag from multiple medications & fluid to administer Expense Burden of administration Add therapeutic vitamin/mineral supplement Chewable or liquid (avoid elixir/alcohol) Dosing frequency to improve uptake BID vs. daily? B12/methylmalonic acid PO vs. SQ vs. IM Thiamine deficiency can cause Wernicke/Korsikoff psychosis Rees Parrish, 2016; Nightingale, 2001

24 Vitamin D/Bone Health Baseline DXA Scan Baseline 25-OH-vitamin D Sunlight/UV light Vitamin D dosing Avoid 50,000 u weekly Higher daily dose, twice daily, crushed tabs, liquid Calcium Dietary contribution & supplements Rees Parrish, 2016

25 Anti-motility Drugs Loperamide Take every ½ hour before food, even in high doses (up to 100mg daily*), NOT prn. Reduces diarrhea by slowing forward propulsion of intestinal contents Clinical improvement usually seen in 48 hours Non-addictive, non-sedative Reduces Na+ content of output CHECK FOR C DIFF FIRST!! FDA approved 1976 *Dosing: adults & children >12: 4mg with 2 mg after each stool to 16 mg daily Allan, nd; Fellows, 2014; FDA.gov; Rees Parrish, 2016

26 Other Anti-motility Drugs Tincture of Opium 50mg/5mL Dosing 6mg (0.6mL) PO every 6 hours not to exceed 6mL/day 25x as strong as paregoric $800/118mL bottle FDA-approved only for diarrhea Consensus it does not need to be stocked in hospital pharmacies. Camphorated Tincture of Opium (paregoric) 2mg/5mL Dosing 2-4mg (5-10mL) PO daily every 6 hours $300/473mL bottle FDA.gov; Medscape.com

27 Anti-Secretory Drugs Omeprazole (PPI) 40mg daily FDA-approved dose Can cause 0.5-2L reduction in gastric secretions/day Does not change absorption DOES NOT reduce jejunostomy output enough to prevent need for parental fluid/electrolyte replacement Nightingale reported as effective as IV octreotide BID so long as patient has at least 50 cm of jejunum If less than 50cm jejunum,, may need to be given IV Aslam, et al; Nightingale, 1991; Nightingale, 2001

28 Other Anti-secretory Drugs Cholestyramine May be effective if excess bile salts in small intestine are causative factor. May be considered if fistula in duodenum or proximal jejunum. Somatostatin analogues Increase odds of spontaneous fistula closure (if not stomatized) Reduce time to fistula closure (if not stomatized) Did not reduce fistula-associated mortality 68.4% in a randomized double blind placebo controlled trial of lanreotide 30 mg in TX of pancreatic & ECF had 45% mean reduction in fistula output. Fellows, 2014; Gayral et al, 2009

29 High Output Stoma Management 6 Steps Must be done in collaboration with physician, dietitian and patient Adapted from the Manchester Method

30 Output Management Step 1 Isotonic Fluids up to 500 ml daily only Omeprazole up to 80 mg daily* Consider impact for c diff add Flagyl MEGADOSE Loperamide 16mg, 40 mg up to 100mg* total daily before meals and at hs (not prn, scheduled) Antibiotic trial (Flagyl) for bacterial overgrowth Strict stoma/fistula & urinary I&O

31 Output Management Step 2 If stoma/fistula output still more than 1500mL/daily: NPO 48 hours with IV solutions to assess baseline output Review all investigations and management Has small bowel follow through been done? Monitor electrolytes (including magnesium) daily If baseline output less than 1200mL daily, consider need for IV fluids longterm If stoma/fistula output less than 1200mL/daily: Go to step 3

32 Output Management Step 3 Commence Oral Rehydration Trial 48 hours If can t tolerate taste, try freezing into pops or ice cubes Use PEG tube, if patient has one.

33 Output Management Step 4 <1500mL in 24 hours Go to step 5 >1500mL in 24 hours Omneprazol 80mg*/day +Loperamide 8mg 4-5x/day (can increase up to 100mg*/day) +Codeine 60mg 4x/day (no acetaminophen) +Octreotide 3x/day STOP Octreotide after 72 hrs if impact less than 300mL/day Output <1500mL daily Go to step 5 Output >1500ml daily Plan longterm TPN/IVs

34 Output Management Step 5 Commence Liquid Food (Nutritional Supplements) Measure Effect on Output < 1500 ml go to Step 6 >1500mL plan for TPN/IVs

35 Output Management Step 6 Start Food and Monitor Effect on Output Dry Diet Bananas Creamy peanut butter Saltine Crackers White Breads Cheese Plain Pasta Boiled White Rice Mashed or Boiled Potatoes Baked Chicken or Turkey Baked Fish Add salt Oils to include: Sunflower, corn, soybean, walnut As tolerated add: Eggs Plain hamburger Grits Oatmeal Cream of wheat Fellows, 2014; Rees Parrish, 2016

36 References and Resources Allen, P (nd) Medical Management of High Output Fistulae and Stoma. Oxford Inflammatory Bowel Disease Master Class. Fellows, J (6/21/2014) Fistula Management Across the Continuum: Finding a Harmonious Plan of Care: Medication & Nutrition in the Management of Enterocutaneous Fistulae. WOCN 2014 Conference. Gayral, F Campion, J Regimbeau, J. (2009). Randomized placebo-controlled, double-blind study of the efficacy of lanreotide 30mg PR in the treatment of pancreatic and enterocutaneous fistulae. Annals of Surgery, 250(6):

37 Netsch, D S (2016). Anatomy and physiology of the gastrointestinal tract,p1-15. WOCN Core Curriculum: Ostomy Management. Philadelphia; Wolters Kluwer. Nightingale, J & Woodward, JM (2006) Guidelines for management of patients with a short bowel, Gut, 55(S4):iv1-iv12. Nightingale, J (2001) Management of patients with a short bowel, World Journal of Gastroenterology 7(6): Nightingale, JM, et al. (1991) Effect of omeprazole on intestinal output in the short-bowel syndrome, Aliment Pharmacol Ther 5: Parrish, CR (2016) Management of the High Output Stoma & Short Bowel Syndrome. WOCN/CAET 2016 Conference.

38 Patient Handouts content/uploads/sites/199/2014/04/sbs-diet-revision pdf Diet for Small Bowel Patients content/uploads/sites/199/2014/04/sbs-snack-ideas pdf Snacks for Small Bowel Patients content/uploads/sites/199/2014/04/homemade-oral- Rehydration-Solutions pdf Home made Oral Rehydration Solutions (ORS)

39 THE END "Nursing encompasses an art, a humanistic orientation, a feeling for the value of the individual, and an intuitive sense of ethics, and of the appropriateness of action taken." -- Myrtle Aydelotte Mary Arnold Long WOConsultation, LLC skinhorse2011@hotmail.com