Small Bowel Obstruction after operation in a severely malnourished man. By: Ms Bounmark Phoumesy

Transcription

1 Small Bowel Obstruction after operation in a severely malnourished man By: Ms Bounmark Phoumesy

2 Normal length of GI tract Normal length(achieved by age 9) Small bowel 600cm (Men: 630 cm; Women: 592 cm) Jejunum 360 cm (3/5 length) Ileum 240 cm (2/5 of length) Colon 150 cm

3 Villi and Microvilli of Small Bowel

4 Small Bowel obstruction Blockage in the small intestine Gas produced by bacteria accumulates à intestinal distention Vessels become compromised à loss the ability to absorb nutrient Fluid moved into the intestinal lumen Reduced gut motility à bacterial overgrowth

5 Nausea Signs and symptoms Cramping abdominal pain Vomiting (loss of Na, K, H and Cl) Hypovolemia No bowel movement Risk factors Prior abdominal surgery(colorectal surgery, appendectomy) Intestinal inflammation NPO

6 Anatomical considerations: Adequate adsorption if >=60 cm jejunum to colon Malabsorption of bile salts & vitamin B12 Poor jejunal adaptation Rapid intestinal trantsit Small bowel bacterial overgrowth Reduced Peptide YY Ileal Resection

7 Refeeding syndrome Complications as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients. Potentially fatal. Electrolytes to monitor: Mg Phosphorus Potassium Give Thiamin before feeding

8 Post-operative ICU feeding Goal: provide nutrition within hours after surgery Avoid refeeding sydrome Avoid overfeeding Is the patient hemodynamically stable? If yes- then feeding is okay Oral or Tube feeding should begin as soon as possible to reduce gut atrophy and loss of mucosal barrier Trophic feeds of 0.5-1ml/kg/hours are beneficial

9 Patient admit Patient: Male 59 yrs old Admit: 02/11/2017 sent from Vientiane District Hospital Weight: 45 kg Height: 156 cm BMI: 18.5 kg/m2 Admitted with bloating, difficulty breathing Patient reports stomach pain for 4 days and cannot eat or drink Blood pressure : low (92/55)

10 History At home has been patient eating and drinking well Patient can not hear or speak from birth History of Hepatitis B Patient has has small bowel obstruction previously. Patient drinks alcohol and smokes

11 Surgical Ward History Admitted on 02/11/2017 time: 20:00-22:00 pm Underwent a ileocecal valve resection operation NPO Drainage tube have both side Difficult breathing Transferred to ICU on 05/11/2017 due to low blood pressure

12 D5 Sodium Choride Subtilis Multivitamin Capsules Ceftiaxone Oxygen Flagyl Omepraxol Lasix Notalgin Omepraxone Metronidazol Medication

13 Lab result No labs were available for review

14 Weight: ~45 kg Height: 156 cm Nutrition Intervention 06/11/2017 BMI: 18.5 kg/m2 UBW: 45 kg IBW: 49 KG

15 Nutrition Focused Physical Exam Severe wasting fat Severe wasting muscle No stool for 5 days Currently NPO x 8 days Pale Dry skin Poor dentition

16 Nutrition recommendation and intervention Nutrition recommendation Being feeding slowly with liquids- soup/ lactasoy- high calories and high protein Patient is at risk for re-feeding Patient will require B12 supplement due to removal of ilecocecal value. Also at risk for low Mg+ supplement needed for life Provide 220 mg Thiamin before feeding and continue x 10 days Nutrition intervention High energy and protein 28 kcal/kg/day(1255kcal/day) Protein: 2g/kg/day 90g/day

17 PPN PPN started at 11: 00 am on 06 October 482 kcal /720 ml (11 kcal/kg/day) Protein: 16.5g /720 ml (0.4g/kg/day)

18 07 October started tube feeding 100 ml x 4/day of Blendera-MF formula Total: 400 ml/day = 227 kcal/day Protein: 10.8g/day D5: 170 kcal/1000ml Plan: if patient does not have diarrhea will increase formula but if patient has diarrhea will decrease formula or continue same feed.

19 Follow-up Nutrition Intervention 08/11/2017 Patient has bowel movement - 4 time /day Stool is dark/black Patient still reports feeling tired Tolerating tube feeds No signs/symptoms of refeeding Unable to obtain labs to confirm

20 Follow-up Nutrition Intervention 9/11/17 Patient has less stool and it is now yellow colored Not as tired Patient complains of bloating/stomach discomfort with tube feeds

21 100 ml/feed; 4 times/day Energy: 369 kcal/day (8 kcal/kg/day) Protein: 8g/day (0.2g/kg/day) Change formula 09/11/2017 Blendera-MF to Similac Similac is not intended for adults but no other lactose free tube feeding formula was available

22 Follow-up Nutrition Intervention 10/11/17 On Similac formula 100ml/feed, 4 times/day Patient has no diarrhea and no bloating or discomfort He feels like he is getting better Not tired

23 Follow-up Nutrition Intervention 11/11/2017 In the morning patient doing well Still on formula No diarrhea No tired Blood pressure began to drop again Patient passed away at 13: 43pm

24 Reference Up-To-Date - Small Bowel Obstruction Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN), February 2016, JPEN Dr. Robert Martindale lecture on Post-surgical Nutrition, LANI

25 Khop Chai lai lai!