Neglected deficiencies in severe malnutrition: phosphate and thiamine Case-based introduction A-M. Liberati-Cizmek (Croatia)

Transcription

1 ESPEN Congress Vienna 2009 Neglected deficiencies in severe malnutrition: phosphate and thiamine Case-based introduction A-M. Liberati-Cizmek (Croatia)

2 Neglected deficiencies in severe malnutrition: thiamine Case-based introduction Ana-Marija Liberati Čizmek M.D. UHC Zagreb Dpt. of Gastroenterology & Center of Clinical Nutrition

3 Critical illness Trauma/Infection Acute Stress Response Iatrogenic Factors Immunological Response Neuroendocrine Response Metabolic Response

4 Introduction Spring years old girl, few months before the onset of symptoms

5 Introduction Spring 2005 Height: 160 cm Weight: 70 kg BMI 27.5

6 History born in smoker during 2005 she lost her appetite developped diarrhea abdominal pain weight loss

7 History County Hospital (60 km from University Hospital Center) Treated as anorexia nervosa, because of the appetite loss and decreased food intake as leading signs After therapeutic failure, transfer from a County Hospital to the University Hospital Center 38 kg weight loss/ 6 months!

8 History hospitalised at Department of Endocrinology, UHC Weight: 32 kg BMI: 12.5! IBD suspected IBD complications detected Biochemistry ESR 30 CRP 150 L 15,7 Hg 85 platelets 625 albumin 24,9 g/l

9 History Department of Gastroenterology Dg: Crohn s disease (terminal ileitis) CD complications: Stenosis of ileum, Rectosigmoid fistula, Presacral abscess

10 History Department of abdominal surgery

11 History 2006: Department of abdominal surgery Right hemicolectomy resection of terminal ileum and ascendent colon with ileotransversal anastomosis Bipolar sigmoidostomy

12 History Department of of abdominal surgery Resection of transversal colon Fistulectomy Bipolar sigmoidostomy Weight: 33 kg BMI: 12.89

13 Recent History Department Department of of Gastroenterology gastroenterology - Intraabdominal abscess Abdominal MSCT Weight: 34kg BMI:13.28

14 Recent History January Department of abdominal Abdominal surgery Surgery Left hemicolectomy- proctocolectomy Abscess evacuation Fistula occlusion Terminal ileostomy

15 Recent History Postoperative period - 2 weeks after the surgery in surgical ICU and on the surgical ward

16 Recent History Nutritional support (surgical ICU+ ward): AIO- Three chamber bags- TPN- olive oil based formula >40 kcal/kg/d! Glucose 235 g/day! Polymeric enteral formula-up to 500 ml/d No MV

17 Recent History transfer to the Depatment of Gastroenterology and Clinical Nutrition Center

18 Recent History Nutritional support: Day 1. AIO- Three chamber bags- olive oil based formula Decrease energy intake to 30 kcal/kg/d Glucose 128, Lipids 32, AA 32 g/d MV added Polymeric enteral formula- 250 ml/d

19 Recent History Day 2. Onset of symptoms

20 Recent History Day 2. acute confusion, decreased consciousness level dizziness, dyplopia, nistagmus weakness palpitations, hypotension nausea

21 Thiamine deficiency suspected

22 Workup Laboratory Studies NO significant electrolyte disbalance CBC-normal Slight metabolic acidosis (ph 7,3) Moderate hyperlactatemia (3,75 mmol/l) Glucose levels- normal *Serum thiamine levels are not routinely measured in our hospital

23 Imaging Studies Workup Head CT- no intracerebral hemorrhage or other abnormalities Cerebral MR- bilateral and symmetrical hyperintensities in the subthalamus, the floors of the third and fourth ventricles

24 Thiamine deficiency suspected We accepted a motto: If in doubt, treat

25 Empiric therapy applied: 100 mg of thiamine parenterally

26 Recent History Within a week neurologic symptoms vanished Improved mental state

27 Nutrition plan Name Body weight/height/age BMI /description Diet type Daily energy requirements Average daily energy value of diet Recommended weekly weight gain Recommended dietary supplement K.R. 35 kg/1.60 m/22 y 13,7 / severe malnutrition Crohn s disease ~ 1703 kcal ~ 2300 kcal 0,5 kg Modulen IBD x 500 ml (500 kcal) or Ensure plus 2x220 ml (660 kcal)

28 Today Year 2009, seven months later: Remission of CD Weight: 48 kg (+13 kg) BMI: Good mental and physical state Ordinary food and additional enteral nutrition (sip feeding)

29 Take home message In severe malnurished patient on TPN presented with neurologic symptomatology: Always Keep In Mind Thiamine Deficiency

30 Credits to: Prof. Zeljko Krznaric, M.D., Ph.D. Darija Vranesic Bender, Ph.D., nutritionist Dina Ljubas Kelecic, pharmacist

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