TPN Discontinuation Post Bowel Resection. Clinical Case Study by: Cody Steiner MSU Dietetic Intern

Transcription

1 TPN Discontinuation Post Bowel Resection Clinical Case Study by: Cody Steiner MSU Dietetic Intern

2 Overview Examine patient post reconstructive surgery Review patients outcome Determine best practice for TPN discontinuation

3 The Patient 52 year old female patient admitted for pelvic sarcoma Resection of recurrent pelvic sarcoma, en bloc ileocecal region, sigmoid colon and dome of the bladder, extensive lysis of adhesion for reestablishment of gastrointestinal continuity, and a cystoscopy with ureteral stent placement

4 ADIME Charting: Assessment Anthropometric Ht: 60 Weights: 54.4kg - at admission 45.1kg - 15 days post admission Ideal Body Weight: 49kg % Ideal Body Weight: 110% - at admission 92% - 15 days post admission BMI: 22.7 at admission

5 ADIME Charting: Assessment Past Medical History Metastatic pelvic cancer TPN dependence since % TPN for > 3 years Venting gastric tube in place Chronic anemia Recurrent bacteremia and line sepsis Benign meningioma in 1990 Invasive breast cancer of right breast Surgical Procedures Pelvic Sarcoma resection followed by abdominal/pelvic radiation in 2010 Small bowel to transverse colon anastomosis in 2013 Risk for malabsorption of fat soluble vitamins, B12, and fluids/electrolytes

6 ADIME Charting: Assessment Nutrition Focused Information Poor appetite and fear of eating Related to numerous years of TPN Surgeon note reports adequate intake with some emesis on prior to discharge Weight loss of 9.3kg between admission and discharge 17% decrease - considered significant in 30 day period

7 ADIME Charting: Assessment Estimated Nutritional Needs: Calories: 1640kcals (30kcals/kg) Admission weight used Based on Harris-Benedict with x1.5 stress factor for current cancer Protein: 65-81g ( g/kg) Related to current cancer and post resection

8 ADIME Charting: Diagnosis PES 1: Altered gastrointestinal function related to decreased functional intestine length as evidenced by two resections of small bowel sarcoma and 5 years of partial parenteral nutrition dependence including 3 years of no enteral nutrition. PES 2: Inadequate caloric intake related to abrupt discontinuation of TPN as evidenced by a > 5% weight loss in less than 1 month post discontinuation.

9 ADIME Charting: Case Study Intervention TPN was abruptly discontinued upon discharge No outpatient follow up or RD referral for diet counseling scheduled Inpatient RD gave as much information/support as possible Signs of dehydration/malabsorption Moderate fat intake, increasing soluble fiber, frequent small meals, decreasing fluid intake during meals Vitamins, minerals, and supplementation

10 Abrupt vs. Stepwise TPN Discontinuation Abrupt vs. Stepwise discontinuation: Abrupt discontinuation Quickens increases of enteral intake Risk of weight loss Stepwise discontinuation Combines TPN and oral intake Adjusts as oral intake increases Delays adequate oral nutrition

11 Abrupt vs. Stepwise TPN Discontinuation Current research on gut atrophy after TPN dependence: Journal of Digestive Disease and Sciences Rat model - 8 days 100% TPN Significant (p<0.01) decreases in intestinal circumference, villi diameter in the jejunum and ileum Nutrition Issues in Gastroenterology Great risk of malabsorption during adaptation phase Can last 2-3 years post resection

12 Abrupt vs. Stepwise TPN Discontinuation Three case studies by the International Life Sciences Institute Patient #1 adapted to abrupt discontinuation Required nocturnal enteral hydration Patient #2 discontinuation with nightly TPN Extremely short functioning length ~100cm Nocturnal TPN only to promote oral intake Patient #3 Stepwise TPN tapering planned 3 meals/day provided ~55% calories, TPN ~45%

13 ADIME Charting: Intervention & Monitoring Patient needs diet counseling and weight monitoring in relation to reinitiating of oral intake Stepwise TPN discontinuation should be utilized Begin with nightly TPN meeting 75% needs and decrease in relation to oral intake There should be little to no unintentional weight loss Weight and oral intake should be self monitored by patient at least x2 weekly and changes reported to dietitian Any weight loss would trigger a reevaluation of diet and nutritional support

14 Conclusions Unfortunately unable to personally follow up with patient after discharge Outpatient RD reported weight stabilized at 41kg (83.5% IBW) with supplemental TPN reinitiated

15 Conclusions Best evidence-based research shows: Gut adaptation with abrupt discontinuation is possible Dependent on many factors Functional intestine length Other SBS treatments (medications, EN, etc.) Ability for oral intake Most effective treatment plan: A patient centered approach! TPN discontinuation dependent on not only functional length, but also patient s readiness for oral intake Diet adaptation, with education and monitoring, should also be based on individual needs

16 Q & A

17 References Barrett, M., Demehri, F. R., Ives, G. C., Schaedig, K., Arnold, M. A., & Teitelbaum, D. H. (2017). Taking a STEP back: Assessing the outcomes of multiple STEP procedures. Journal of Pediatric Surgery, 52(1), doi: /j.jpedsurg Bodoky, Gyorgy, Antonio C. Campos, Zhong-Jin Yang, David C. Hitch, and Michael M. Meguid. "The comparative effects of abrupt vs. stepwise discontinuation of TPN in rats." Physiology & Behavior 52.3 (1992): Web. 15 Nov Carroll, Robert E., Enrico Benedetti, Joseph P. Schowalter, and Alan L. Buchman. "Management and Complications of Short Bowel Syndrome: An Updated Review." Current Gastroenterology Reports (2016): Web. Ekelund, Mikael, Elin Kristensson, Mats Ekelund, and Eva Ekblad. "Total Parenteral Nutrition Causes Circumferential Intestinal Atrophy, Remodeling of the Intestinal Wall, and Redistribution of Eosinophils in the Rat Gastrointestinal Tract." SpringerLink. Kluwer Academic Publishers-Plenum Publishers, 28 Mar Web. 03 Apr Nauth, Justin, Chih Wen Chang, Sohrab Mobarhan, Sherri Sparks, Margaret Borton, and Sheryl Svoboda. "A Therapeutic Approach to Wean Total Parenteral Nutrition in the Management of Short Bowel Syndrome: Three Cases Using Nocturnal Enteral Rehydration." Nutrition Reviews 62.5 (2004): Web. 3 Apr Parrish, C. R., & DiBaise, J. K. (2015). Short Bowel Syndrome in Adults Part 5 Trophic Agents in the Treatment of Short Bowel Syndrome. Nutrition Issues in Gastroenterology, 141st ser., Retrieved March 28, Seguy, D., et al. Growth Hormone Enhances Fat-Free Mass and Glutamine Availability in Patients with Short-Bowel Syndrome: An Ancillary Double- Blind, Randomized Crossover Study. American Journal of Clinical Nutrition (2014): Web. SUDAN, D, et al. A Multidisciplinary Approach to the Treatment of Intestinal Failure. Journal of Gastrointestinal Surgery 9.2 (2005): Web. Wu, Guo-Hao, Zhao-Han Wu, and Zhao-Guang Wu. Effects of Bowel Rehabilitation and Combined Trophic Therapy on Intestinal Adaptation in Short Bowel Patients. World Journal of Gastroenterology 9.11 (2003): Print.