CASE STUDY:GI Surgery Cristel Moubarak – Dietetic Intern – 2014 Candidate

Elena Tejedor – GI/ENT Surgery RD – Preceptor

March 2014

OUTLINE

Introduction Patient Case Initial Screening Nutrition Diagnosis Nutrition Needs Interventions Complications Follow-ups

Ms. C

66 year old female Admitted with Peritoneal

Mesothelioma on Dec 10 PMHx: Hypercholesterolemia and

depression Baseline Diet: Good appetite and

intake No recent significant weight loss ETOH Hx (2-3 glasses of wine/day)

INITIAL NUTRITION ASSESSMENT

Usual Weight = 61.4 kg Current Weight = 60 kg Height = 165 cm

BMI = 22 kg/m2

Nutritional Status Risk Factors: Nausea, NPO x4 days, hypercatabolism, substance abuse (ETOH Hx), fatigue, decreased mobility

SGA: Mildly malnourished, at moderate risk

PROCEDURES

Lysis of Adhesions Right Hemicolectomy Omentectomy Cholecystectomy Partial Vaginectomy Bilateral Salpingo-

oophorectomy HIPEC

BASIC DEFINITIONS

Peritoneal Mesothelioma: Rare cancer that develops in the mesothelium cells (usually due to exposure to asbestos) in the peritoneum (abdomen cavity lining).

Cytoreductive Surgery: Removing all visible tumors that can be removed throughout the peritoneal cavity.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC): It is designed to kill any remaining cancer cells by circulating a sterile solution--containing a chemotherapeutic agent--throughout the peritoneal cavity, for a maximum of two hours.

NUTRITION DIAGNOSIS

P: Malnutrition E: related to altered GI function/predicted ileus

and increased needs with stress of OR S: as evidenced by cytoreductive surgery and

HIPEC treatment (x5d), post-operative nausea, ETOH Hx (2-3 glasses/d), and NPO x 5d to date and expected to be NPO for ≥ 5d.

NUTRITION NEEDS

Goal of Nutrition Care:

PREVENT REFEEDING SYNDROME

HBE = 1218 kcal REE x 1.2 – 1.4 = 1460 kcal – 1705 kcal [24-28

kcal/kg] Protein [1.2 – 1.5 g/kg/day] = 72 – 90 g/d CHO [ 2 – 3 g/kg/day] = 120 – 180 g/d

INTERVENTION #1: Day 2 Post-Op TPN ORDER Calculated

Requirements 1st: Dec 12 – Refeeding

Total Calories 1460 kcal – 1705 kcal

1290 kcal (20 kcal/kg)

Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg)

CHO 120 – 180 g/d (refeeding)

150 g/d (39% - 2.5 g/kg)

Fat U/L 90 g/d 50 g/d (39% - 0.8g/kg)

Phosphate 30 mmol 30 mmol

Potassium 60 mmol 55.2 mmol

Magnesium 5 mmol 7.5 mmol

Folic Acid 5 mg

Zinc 2.5 mg

Vitamin C 200 mg

Thiamine 100 mg

COMPLICATIONS

Ileus Nausea Abdominal Fluid and high NG drainage

Magnesium, potassium and phosphate depletion

Day 2 Day 3

Magnesium (0.8 – 1.45)

0.63 0.60

Potassium (3.5 – 5) 3.5 3.4

Phosphate (0.7 – 1.10)

0.71 0.65

INTERVENTION #2: Day 4 Post-Op

Continue to replete Mg (5g via IV), PO4 (15 mmol x 3) and K-lyte (40 mEq)

TPN ORDER

Calculated Requirements

1st: Refeeding 2nd: Goal

Total Calories

1460 kcal – 1705 kcal

1290 kcal (20 kcal/kg)

1565 (26 kcal/kg)

Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg)

75 g/d (19% - 1.25 g/kg)

CHO 120 – 180 g/d (refeeding)

150 g/d (39% - 2.5 g/kg)

225 g/d (49% - 3.75 g/kg)

Fat 50 g/d (39% - 0.8g/kg)

50 g/d (32% - 0.83 g/kg)

Ranitidine

150 mg

INTERVENTION #3: Day 8 Post-Op

TPN ORDER

Calculated Requirements

2nd: Goal 3rd: Goal

Total Calories

1460 kcal – 1705 kcal

1565 (26 kcal/kg)

1565 (26 kcal/kg)

Protein 72 – 90 g/d 75 g/d (19%) 75 g/d (19%)

CHO 120 – 180 g/d (refeeding)

225 g/d (49%) 225 g/d (49%)

Fat 50 g/d (32%) 50 g/d (32%)

Magnesium

10 mmol

Sodium 40 mmol

PROGRESSION

Diet progression: Day 8 Post-Op: advance to CF Day 14: advance to FF Day 15: provide low residue diet education Day 16: dental soft; hold TPN Day 20: D/C on dental soft; low residue diet education

Dec 8 Day 16

Magnesium (0.8 – 1.45)

0.60 0.56

Potassium (3.5 – 5) 3.6 3.6

Phosphate (0.7 – 1.10)

1.08 1.2

FOLLOW-UP: Day 36 Post Op Re-Admission

Ms C was readmitted on January 16 for a Partial Obstruction

Weight loss of 10% over 2 months Loss of appetite, suboptimal intake Unresolved nausea and increased vomiting prior

re-admission and during Hypomagnesemia, Hypophosphatemia.

FOLLOW-UP: Day 78 Post-Op Post-Discharge

Controlled nausea with medications Regular bowel movements with medications Following a low residue diet Appetite is back! Eating 3 meals a day and 2 snacks Gaining lost weight (Currently at 124 lbs, aiming to

get back to 132 lbs)

REFERENCES

HIPEC Treatment. (2014). The hipec procedure; what is hipec and how does it work?. Retrieved from http://www.hipectreatment.com/about-the-hipec-procedure/

BC Cancer Agency. (2013, October). Mesothelioma. Retrieved from http://www.bccancer.bc.ca/PPI/TypesofCancer/Mesothelioma/default.htm

BC Cancer Agency. (2013, March). Hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Gastrointestinal/13-appendix/13.5+Hyperthermic+Intraperitoneal+Chemotherapy+(HIPEC).htm

Mulier, S. (n.d.). Hipec for peritoneal cancer; patient information. Retrieved from http://www.drmulier.com/3 en pat info hipec.html

Ceelen, W. P. (2013). Treatment of peritoneal carcinomatosis using surgery combined with hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.surgery.ugent.be/pages/hipec_eng.htm

Ceelen, W. P., & Flessner, M. F. (2010). Intraperitoneal therapy for peritoneal tumors: Biophysics and clinical evidence. Nat. Rev. Clin. Oncol., 7, 108-115. doi: 10.1038/nrclinonc.2009.217

Tan, G. H., Cheung , M., Chanyaputhipong, J., Soo , K. C., & Teo , M. C. (2013). Cytoreductive surgery (crs) and hyperthermic intraperitoneal chemotherapy (hipec) for peritoneal mesothelioma. Ann Acad Med Singapore, 42(6), 291-6. Retrieved from http://www.annals.edu.sg/pdf/42VolNo6Jun2013/V42N6p291.pdf