CLINICAL CASE STUDY

HILLARY SULLI VANWELLNESS W ORKDAYS DIETETIC INTERN

APRIL 20 , 2016

Nutrition Complications of Necrotizing Pancreatitis

Agenda

Introduction to the PatientOverview of Necrotizing PancreatitisMedical Nutrition Therapy for Necrotizing

PancreatitisNutrition Care Process of the Patient

Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring/Evaluation Follow -Ups

Meet the Patient

Mr. Z is a 53 y/o Caucasian malePresented to Lakewood Ranch Medical Center on

February 25 with necrotizing pancreatitis from Shands Hospital at University of Florida

Discharged on March 17 to Kindred HospitalReadmitted to LWR on March 25Discharged on April 1 to Shands HospitalLength of stay: 28 days

Social Hx: Denies tobacco, alcohol, or substance abuse Hospitalized >6 months Girlfriend constantly at bedside

Meet the Patient

Current medical conditions: Necrotizing pancreatitis Stage II decubitus pressure ulcer of sacral coccyx Respiratory failure Sepsis Metabolic acidosis Atrial Fibrillation Deep Vein Thrombosis End Stage Renal Disease (hemodialysis dependent) Leukocytosis Klebsiella pneumoniae carbapenemase (KPC)

What is Necrotizing Pancreatitis?

Pancreatic necrosis is the death of pancreatic tissue and fatty tissue in the abdomen

Acute complication due to exocrine dysfunction

Digestive enzymes become trapped inside the pancreas and begin to auto-digest the pancreas (killing it)

Etiology Signs and symptoms

Gallstones and alcohol account for more than 80% of severe pancreatitis cases

Mortality rate is >36% in patients with multisystem organ failure with NP

High likelihood of medical complications and long-term hospital stay

Nausea Vomiting Fever Rapid pulse Pain in the abdomen and back Abdomen tender to the touch Distended abdomen Cullen’s sign

Discoloration around the navel Turner’s sign

Discoloration of flank

Necrotizing Pancreatitis

Diagnosis Medical Treatment

Blood tests Elevated white blood cells Abnormal levels of pancreatic and

liver enzymes (ALT, AST, T-bilirubin) Elevated amylase and lipase

Abdominal and Endoscopic ultrasound

Abdominal CT scan with IV contrast

MRI with contrast Necrosis is suspected when the

contrast material is not "taken up" by the pancreatic tissue and is not viewable on a monitor

Drainage of the infected area

Percutaneous drainage catheter

Electrolyte balanceAntibiotics

Necrotizing Pancreatitis

MNT for Necrotizing Pancreatitis

Dietary Recommendations Prevent malabsorption and undernutrition

Weight loss is often seen, due to a reduced calorie intake and malabsorption of macronutrients

Initiate nutrition support (EN, PN) Improve immune function, wound healing, ventilation,

strength, mobility, psychology

Energy requirements Sepsis or multi-organ failure significantly increase the

patients resting energy expenditure (REE), increasing nutrient requirements

Nutrition Support

Enteral Nutrition (EN) is associated with reduction in infectious morbidity, length of hospital stay, the need for surgical intervention, multi-organ failure, and mortality as compared with PN use in these patients

-The Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition guidelines for adult patients who are critically ill state

EN tolerance may be improved by feeding more distally in the GI tract, and using an elemental formula rather than standard polymeric formula

Parenteral Nutrition (PN) should be used if EN is not possible

Mr. Z’s Secondary Conditions

Pressure Ulcers Increased calorie/protein needs Unintentional weight loss, malnutrition are risk factors for

worseningKPC

Cause infections associated with significant morbidity and mortality

Limit antibiotic optionsESRD

Hemodialysis 3 x week Complicated tunnel catheter placement IV contrast induced nephropathy

Nutrition Care Process

Nutrition Assessment

Anthropometric MeasurementsFood & Nutrition Related History

Nutritional needs Diet order

Biomedical Data Nutrition Related Physical FindingsClient History

Medications Medical history

Anthropometric Measurements

Height 68 in. (5’8”) Weight 79.5 kg (175#) IBW 70 kg (154#) BMI 26.65 (overweight)Weight Hx 25# weight loss (13%,

severe) in past 6 months

Nutrient Needs Current Diet order

Estimated Needs

Per Kg of CBW

Per Day

Energy (calories)

30-35 kcal 2400-2800 kcal

Protein 1.2-1.5 grams

96-120 grams

Fluids 25 mL 2000 mL

Enteral nutrition d/t dysphagia and nutrient malabsorption

Food /Nutrition Related History

Mr. Z has increased nutrient needs d/t pressure ulcers

Dialysis treatments allow for liberalized protein

Biomedical DataLabs 2/26 3/4 3/11 3/17 3/25 4/1 Potential for

AbnormalityWBC(4,500-10,000 mcl)

18,000 H

19,000 H

19,000 H

17,00o H

28,000 H

18,000 H

Infection/ Inflammation

Hgb (13.5-17.5 gm/dl)

8.2 L 7.9 L 8.3 L 7.1 L 8.1 L 8.8 L Potential for anemia, low RBC

Hct (48.8-50%)

25 L 25 L 26 L 24 L 25 L 27 L Potential for anemia, low RBC

BUN(7-20 mg/dl)

43 H 38 H 19 37 H 50 H 26 H Decrease in kidney function

Creatinine (0.6-1.2 mg/dl)

2.7 H 3.8 H 2.4 H 3.4 H 2.9 H 2.0 H Decrease in kidney function

Albumin (3.5-5 gm/dl)

2.3 L 2.0 L 1.8 L 1.4 L 1.2 L 1.5 L Associated with morbidity

GFR (90-120 mL/min)

17 L 17 L 30 L 19 L 27 L 36 L Decrease in kidney function

ALT)(<40 U/L

63 H 66 H 73 H 58 H 25 22 Decrease in liver function

AST(<40 U/L)

93 H 107 H 120 H 110 H 35 59 H Decrease in liver function

T Bilirubin(0.3-1.9 mg/dl)

9.8 H 9.9 H 8.4 H 7.6 H 6.7 H 7.2 H Decrease in liver function, jaundice skin, low RBC

Glucose(74-110 mg/dl)

89 93 93 92 85 81 Diabetes Mellitus

Nutrition Related Physical Findings

Stage II decubitus pressure ulcer of sacral coccyx

Severe jaundice skinOverweight sarcopenia: “fat frail”

Medical History Surgical History

2013 motorcycle accident Necrotizing pancreatitis Multi-organ failure Respiratory failure Electrolyte imbalance Multiple retroperitoneal

bleeds GDA bleed ESRD (hemodialysis

dependent) Pulmonary embolism

G/J tube Tracheostomy collar JP drains, draining intra-

abdominal fluids Pancreatic necrosectomy Cholecystectomy Wound VAC placement Rectal tube Tunneled hemodialysis

catheter

Medical History

Scheduled Meds PRN Meds

Aspirin Chlorhexidine Colistimethate* Epoetin alfa Erythromycin* Heparin Insulin Micafungin* Midrodrine Multivitamin Nystatin Pantoprazole Sertraline Sodium chloride flush Tigecycline* Trazodone Ursodiol

Acetaminophen Albuterol-ipratropium Alprazolam Chloropromazine Dextrose 50% Glucagon Glucose 40% Hydromorphone Loperamide Metoclopramide Ondansetron Oxycodone Promethazine Sodium citrate 4%

Current Medications

Nutrition Diagnosis

PES statement: Chronic disease related malnutrition (NI-5.2) related

to chronic necrotizing pancreatitis as evidenced by severe unintentional weight loss of 25# (13%) in 6 months

Mr. Z is assessed at high nutrition risk

Nutrition Intervention

Initiate EN Vital AF 1.2 @ 80 mL/hr +100 mL free water via G/J

tube to provide 2304 calories, 144 g protein, 2155 mL total fluid To establish tolerance start feeding at 20 mL/hr then

advance by 10 mL/hr every 4 hours until goal rate is achieved

Nutrition goals Tolerate tube feeding at goal rate Improve skin integrity Improve immune function

Nutrition Monitoring & Evaluation

Follow up with patient in 3-5 days for nutrition reassessment, per LWR protocol

Monitor Mr. Z’s progress at ICU roundingEvaluate:

Toleration of tube feeding Residual volume Weight change Critical lab values Skin integrity N/V/D/C

Nutrition Reassessments

Follow Up 1 Diarrhea, G/J tube clogged; later unclogged and TF resumed at goal rate

Follow Up 2 Diarrhea, RN reduced TF to 40 ml/hr d/t residuals of 50-70 ml/hr, patient not meeting

estimated nutrition needs, skin integrity improving Recommend resuming Vital AF 1.2 @ 80 mL/hr

Follow Up 3 Diarrhea, intermittent hiccups, vomiting when residuals reach 150 ml/hr, tolerating TF at 50

ml/hr, patient not meeting estimated nutrition needs Recommend changing TF formula to Nepro, which is a more caloric dense formula requiring

less volume to meet patient’s nutritional needs Start Nepro @ 60 ml/hr +100 mL free water every 4 hours to provide 2590 calories, 116 g

protein, 1696 ml Follow Up 4

Patient readmitted to LWR, tolerated Peptamin AF at Kindred Hospital Recommend Restarting Nepro @ 60 ml/hr+100 mL free water every 4 hours

Follow Up 5 Unable to tolerate TF at high volumes, reached residuals of 300 ml/hr, TF d/c’d for procedure Recommend restarting Nepro after procedure, consider TPN if not tolerating TF

Clinical Updates

Mr. Z developed AMSMD discussed code status with familyIntubated and sedatedTransferred back to Shands hospitalCondition remains critical with poor

prognosis

Questions

References

Surgery for Acute Pancreatitis. University of Southern California Center for Pancreatic and Biliary Disease. 2002. Web. 3 Apr. 2016.

Banks, Peter A., Martin L. Freeman, and Darren S. Baroni. "Practice Guidelines in Acute Pancreatitis.” American Journal of Gastroenterology, Oct. 2006. Web. 16 Apr. 2016.

Pancreatic Necrosis. Virginia Mason Hospital & Medical Center, Seattle. Web. 11 Apr. 2016.

Rice, Niamh. "Malnutrition: What Is It and Why Does It Matter?" Irish Society for Enteral and Parenteral Nutrition. Royal College of Physicians of Ireland. Web. 12 Apr. 2016.

O'keefe, Stephen J. D., Timothy Broderick, Maryann Turner, Stacie Stevens, and J. Sebastian O'keefe. "Nutrition in the Management of Necrotizing Pancreatitis." Clinical Gastroenterology and Hepatology 1.4 (2003): 315-21. Web. 3 Apr. 2016.

Dorner, Becky, Mary Ellen Posthauer, and David Thomas. "The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper." National Pressure Ulcer Advisory Pannel (2009). Web. 12 Apr. 2016.