weebly clinical case study

8/10/2019 Weebly Clinical Case Study

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CLINICAL NUTRITION MANAGEMENT

OFSUPERIOR MESENTERIC ARTERY

THROMBOSIS

Dana Magee

ARAMARK Distance Dietetic Internship


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OVERVIEW

Disease Description

Evidenced Based Nutrition Recommendations

Case Presentation

Nutrition Care Process

Assessment

Nutrition Diagnosis

Interventions

Monitoring and Evaluation

Conclusion


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ACUTE MESENTERIC ISCHEMIA

(AMI)

Inadequate blood flow to the bowel caused by:

Non- occlusive Mesenteric Ischemia (NOMI)

Mesenteric Vein Thrombosis (MVT)

Acute Mesenteric Atrial (AMA) Embolus

Acute Mesenteric Atrial (AMA) Thrombosis

http://emedicine.medscape.com/article/191560

-overview#showall


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OCCLUSIVE MESENTERIC

ISCHEMIAEmbolus Thrombosis

50% of AMI cases 25% of AMI cases

Occurs in distal branches Occur at origin of SMA

Quick onset Gradual onset

Low collateral blood flow Larger portion of bowelaffected

Smaller portion of bowel

affected

Can affect multiple arteries

Associated with MI, mitral

stenosis, Afib, endocarditis,mycotic aneurysm,

dislodged plaque

Associated with CAD,

stroke, PAD, dehydration,MI, HF


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ACUTE MESENTERIC ISCHEMIA

Risks for AMI

Age over 50 years old

Atherosclerosis (African Americans as higher risk)

AFib

Hypercoaguable states (Critical Care)

Epidemiology

AMI accounts for .1% of hospital admissions in US

Mortality rate is 71% (AMA thrombosis is highest mortalityrate)


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SIGNS AND SYMPTOMS

Abdominal pain out of proportion to expectation

Benign abdominal exams

Fear of eating due to postprandial pain

N,V, D

GI bleed

Bad breath

AFib

Signs of sepsis


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SMA BLOCKAGE

Ischemia can lead to:

Vomiting and diarrhea

GI bleed

Necrotic bowel (8-12 hrs)

Bacterial overgrowth

Perforated bowel

Sepsis

HF

Multi- organ system failure

http://emedicine.medscape.com/article/191560-

overview#showall


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DIAGNOSIS

Aortography gold standard

Distinguish between SMA thrombosis and embolism

CT scan / ultrasound

Not as specific or sensitive Can see blockage of SMA

Can rule out other reasons for abdominal pain

Lab results helpful- not for diagnosis

CBC, PPT, acid base balance, lactate


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TREATMENT

Immediate exploratory surgery

Remove ischemic/ necrotic bowel

Embolectomy

In surgery: Peristalsis

Coloring

Doppler ultrasonography

IV fluorescent under Woodlamp

Second look surgery


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CASE PRESENTATION

Presented with abdominal pain out of proportion

Admitting diagnosis: SMA thrombosis

PMH: A-Fib, stroke, CAD, HTN, cardiomyopathy.


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http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-

%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm


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CASE PRESENTATION

CT scan showed SMA thrombosis

Started on TPN

Exploratory laparotomy

30 cm small bowel resected, NGT decompressionSecond look surgery

GI bleed

Pacemaker


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EVIDENCED BASED GUIDELINES

Early or late parenteral nutrition: ASPEN vs. ESPEN

Casaer MP, Mesotten D, Hermans G et al

Objective: Comparing the early initiation of PN (European)

vs. late initiation of PN (American and Canadian)

Prospective, randomized, controlled, parallel- group,

multicenter trial in Belgium

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517.

Doi: 10.1056/NEJMoa1102662.


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Protocol:

2312 patients receiving PN in 48 hours

2328 patients receiving PN after seven days

Patients must be at nutritional risk

Excluded patients with BMI


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PN 48 hours post admission ICU

1 day shorter LOS in ICU (p


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EVIDENCE BASED GUIDELINES

Conclusion: Late initiation better outcomes for patients.

Limitations:

No glutamine in PN or other modulators

Premixed PN

No indirect calorimetry

Not double blinded study

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517.

Doi: 10.1056/NEJMoa1102662.


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ASPEN: Adult Critical Care Guidelines:

Early PN feeding with protein calorie malnutrition

Indicated with recent weight loss of 10-15%

Studies show:

Lower risk for complications (p


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Efficacy of Parenteral Nutrition Supplemented with Glutamine

Dipeptide to decrease Hospital Infections in Critically Ill Surgical

Patients

Estivariz CF, Griffith DP, Luo M, et al

Double blind, randomized, controlled study Objective: Effect of glutamine PN (GLN-PN) vs. standard PN

(STD-PN) on infections in critically ill surgery patients

Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in

critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.


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Methods:

2 Cohorts: pancreatic necrosis surgery and

cardiac/vascular/colonic surgery

Ages 18-80

s/p one of five surgeries

Required PN for at least 7 days




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GLN- PN

30 subjects

0.5 g/kg/day glutamine

with 1 g/kg/day amino

acid solution

STD- PN

29 subjects

1.5 g/kg/day amino acid

solution



Limitations:

Availability of glutamine- two time periods of

research

Limited number of postoperative PN


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No significant changes in infection in the pancreatic cohort

In non- pancreatic cohort GLN- PN

Decrease in total infections (p


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Critical Illness Nutrition Practice Guidelines 2012

Recommend glutamine considered in treatment for critically ill

Associated with decreased risk of infection

Not sufficient evidence for decreased LOS, intubation

period, medical cost, or mortality

Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine. Evidence Analysis Library.

http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. Accessed March 22, 2013.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201


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Aspen Adult Critical Care Guidelines

Recommend 0.5 g/kg/day glutamine in PN

Associated with decreased risk of infection, LOS, and mortality

McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically

Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.


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NUTRITION CARE PROCESS

Assessment: Client History

A-Fib uncontrolled

Does not work

Lives at home with a caregiver


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Assessment: Food/Nutrition-Related History:

Poor appetite after stroke, 40 pound weight loss

Patient reported 11 pound weight loss in one week

PTA following a low fat diet

Assessment: Nutrition-Focused Physical Findings:

Nausea and vomiting X two days

Abdominal pain out of proportion to expectation


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Assessment: Anthropometric Measurements

Height discrepancies 62-71 inches

Weight 145 pounds

BMI 22.79

Usual weight 156 pounds


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Assessment: Nutrient Needs

Energy: 1650-1848 kcal

(25-28 kcal/kg actual body weight)

Protein 79-99g protein

(1.2-1.5g/kg actual body weight)

Fluid needs: 1680-1890 ml

(25-30 ml/kg actual body weight)


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Assessment: ARAMARK Nutrition Status Classification

Nutrition Care Indicator Category

Highest Points Assigned

Nutrition History 3 (poor appetite and vomiting)

Feeding Modality/Nutrition Care Order

4 (anticipated TPN)

Unintentional Weight Loss 4 (greater than 2% weight loss in one

week)

Weight Status 0

*Serum Albumin or Pre-albumin

0

Dx/Condition 3 (anticipated GI surgery)

TOTAL POINTS 14 Nutritionally severely compromised


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DRG Coding

Weight loss of 5-10% of usual body weight

Albumin 3.5-5

Mild Protein calorie malnutrition


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Nutrition Diagnosis

Inadequate oral intake related to GI distress as evidenced by

NPO diet order, 0% intake and not meeting estimated kcal or

protein needs.

Inadequate parenteral infusion related to parenteral prescriptiondoes not meet estimated nutritional needs as evidenced by

parenteral regimen providing 67% of estimated caloric needs.


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Interventions

Once PICC is functional initiate day one TPN. 1700 ml volume:

70g protein, 150g CHO, 15g lipid.

Day two recommend 1700 ml volume: 80g protein, 255g CHO,

and 15g lipids to provide 1337 kcal, 80g protein, GIR 2.68 (81% ofnutritional needs)

Increase CHO in TPN to 255g.


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Monitoring and evaluation

Food and nutrient intake: Parenteral nutrition administration

Monitor parenteral access

Food and nutrient administration: Parenteral nutrition intake

formula/ solutionAnthropometric Measurements: Body weight


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MONITORING AND EVALUATION

Biochemical data, medical tests, and procedures: Electrolytes

and renal profile potassium, magnesium, and phosphorus

Biochemical data, medical tests, and procedures: glucose

endocrine profile, glucose casual

Nutrition- focused physical findings: Digestive system: returnof GI function.


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CONCLUSION

SMA thrombosis, NPO

Patient reported recent significant weight loss, TPN initiated

Small bowel resection

NGT suctioning, GI bleed, low hemoglobin, multiple transfusions

Pacemaker, NPO

Aspiration, Chopped, nectar thickened liquids

Weaning off TPN with cardiac diet


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CONCLUSIONS

Late initiation of PN linked to decreased LOS, time on dialysis,

time on ventilator, ad risk for infections

Early PN support in patients that are admitted to the ICU

malnourished for less complications

Consideration of adding glutamine to PN for patients in the ICU,especially surgical patients

Decrease infections

More research on LOS and mortality


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REFERENCES

Dang CD. Acute Mesenteric Ischemia. Medscape.http://emedicine.medscape.com/article/189146-overview. Updated February 22, 2013.Accessed March 22, 2013.

Tessier DJ. Mesenteric Artery Thrombosis. Medscape.http://emedicine.medscape.com/article/191560-overview. Updated January 6, 2012.Accessed March 22, 2013.

American Heart Association. What is Atrial Fibrillation (AFib or AF)?. American HeartAssociation. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-

is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp. Updated October 18, 2012.Accessed March 22, 2012.

American Heart Association. Coronary Artery Disease- Coronary Heart Disease. AmericanHeart Association.http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsp. Updated February 27, 2013.Accessed March 22, 2013.

American Heart Association. Prevention and treatment of High Blood Pressure. American

Heart Association.http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsp.Updated June 6, 2012. Accessed March 22, 2012.
http://emedicine.medscape.com/article/189146-overviewhttp://emedicine.medscape.com/article/191560-overviewhttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsphttp://emedicine.medscape.com/article/191560-overviewhttp://emedicine.medscape.com/article/191560-overviewhttp://emedicine.medscape.com/article/191560-overviewhttp://emedicine.medscape.com/article/189146-overviewhttp://emedicine.medscape.com/article/189146-overviewhttp://emedicine.medscape.com/article/189146-overview


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REFERENCES

McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessmentof Nutrition Therapy in Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition.2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically illadults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi:10.1056/NEJMoa1102662.

Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented withglutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal ofParenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.

Academy of Nutrition and Dietetics. Recommendations Summary CIU: SupplementalGlutamine. Evidence Analysis Library.http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. AccessedMarch 22, 2013.

International Dietetics & Nutrition Terminology (IDNT) Reference Manual Third Edition.Chicago, IL: American Dietetic Association; 2011.

ARAMARK. Patient Food Services Policies & Procedures Volume IV. Updated March 10,

2010. ARAMARK. Malnutrition Assessment & Diagnosis (DRG coding form).

Pronsky ZM, Crowe JP. Food Medication Interactions 16thEdition. Birchrunville, PA: Food-Medication Interactions; 2010.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201

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