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Clinical Experience

Clinical Experience. Presented by Maxine Rostolder KSC Dietetic Intern 2013 July 19th, 2013. Concord Hospital. Charitable organization Quality is a top priority 295 licensed beds 238 staffed beds In 2012, total of 17,593 admissions 40 medical specialties & subspecialties

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Clinical Experience

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  1. Clinical Experience Presented by Maxine Rostolder KSC Dietetic Intern 2013 July 19th, 2013

  2. Concord Hospital • Charitable organization • Quality is a top priority • 295 licensed beds • 238 staffed beds • In 2012, total of 17,593 admissions • 40 medical specialties & subspecialties • 6,325 patients received diabetes self management education

  3. Mission Statement Concord Hospital is a charitable organization which exists to meet the health needs of individuals within the communities it serves. It is the established policy of Concord Hospital to provide services on the sole basis of the medical necessity of such services as determined by the medical staff without reference to race, color, ethnicity, national origin, sexual orientation, marital status, religion, age, gender, disability or inability to pay for such services.

  4. Nutrition Services • 8 registered dietitians • 3 registered dietetic technician • All patients are screened by the DTRs within 24 hours of admission • All high risk patients are assessed by the RDs within 24 hours of admission • Offer nutrition education/counseling as well as outpatient services

  5. Clinical Case Study - Mr. B

  6. Pt presented with Epigastric abdominal pain Nausea and vomiting Blood alcohol level of 337 Complaints of SOB on exertion Lipase = 962 U/L Medical Dx: Acute pancreatitis likely 2º to chronic alcohol abuse Diet: NPO Thiamine, MVI, and Folate ordered daily Substance abuse consult requested Admission - 5/30 - Day 0

  7. Etiology • Chronic alcoholism • Gallstones • Biliary tract disease • Hypertriglyceridemia • Hypercalcemia • Trauma • Certain drugs • Some viral infections Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen, H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201.

  8. Pathophysiology • Premature or inappropriate activation of digestive enzymes • Results in autodigestion of the pancreas • Signs of inflammation are found in surrounding tissue Image Retrieved from http://www.marric.us/images/digestive_diagram.jpg

  9. 5/31 - Day 1 • 5/31 - Day 1 • Tx to ICU • CT scan showed evidence of necrotizing pancreatitis • Complicated by splenic vein thrombosis • Lipase = 3380 U/L, Amylase = 272 U/L • Screened as moderate risk, level 2

  10. Social Unemployed Uninsured Drinks 7-8 beers per night Smokes 1 pack per day Uses marijuana Medical Alcoholism COPD Anxiety Recent pneumonia with alcohol withdrawals (3/20/13) No sign of acute hepatitis Patient History

  11. 6/1 - Day 2 Corpak feeding tube placed Started on Jevity 1.2 at 40ml/hr with a goal rate of 50ml/hr 6/2 - Day 3 Pt placed on ventilator Lipase = 204 U/L Propofol started EN is preferred over PN Benefits of early EN for pts with severe acute pancreatitis Lower incidence of infections Less surgical interventions Shorter hospital stay Should be started within 24-48 hours of admission Over the Weekend Information retrieved from: Hegazi, R.A., Cockram, M.A. and Luo, M. (2012). Misconceptions and truths for feeding patients in the intensive care unit: case studies with practical nursing solutions. Open Journal of Nursing, 2, 327-331.

  12. 6/3 - Day 4 Learned of this pt Feeding tube was placed in duodenal bulb Jevity 1.2 formula Started capsticks and SSI CF30 Thiamine, MVI, and Folate given via EN feeding 49 year old male Ht: 73” Wt: 117.7kg BMI: 34.2 kg/m2 IBW: 92 kg Estimate of pt needs 2000-2300kcals (22-25kcal/kg IBW) 110-130g Pro (1.2-1.4g/kg IBW) 2760-3220ml fluids (30ml/kg IBW) RD Assessment

  13. Nutrition Diagnosis • Inadequate protein and energy intake r/t altered GI function as evidenced by poor intake and necrotizing pancreatitis

  14. RD Questions • Propofol amount • Placement of feeding tube • Type of formula Pt was receiving 746kcals from propofol MD was fine with feeding tube placement MD agreed with changing formula to Vital 1.2

  15. Pancreatitis Research • Two RCTs compared NGT vs NJT1 • Showed no significant differences between • Recurrence or worsening of pain • Hospital stay • Complications • Mortality • A systematic review of NGT feeding included 4 studies2 • 73% achieved full tolerance of feeding • Tube feeding into the duodenum, mid jejunum, and distal jejunum were compared for pancreatic secretory response2 • Pts with acute pancreatitis have significantly lower secretion rates into the duodenum compared to healthy subjects • Another study showed 86% rate of pancreatic exocrine insufficiency in pts recovering from severe acute pancreatitis2 1Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen, H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201. 2 Petrov, M.S., Correia, M.I.T.D. and Windsor, J.A. (2008). Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. Journal of the Pancreas, 9(4), 440-448.

  16. Vital 1.2 60ml/hr 2330 kcals Includes 746kcals from propofol 146g CHO 99g Pro 1070 free H2O Meets RDI 6/4 - Day 5 Pt reaches goal rate Still receiving same amounts of propofol Triglycerides = 169 mg/dL Tube Feeding Recommendations

  17. 6/5 Start to wean pt off propofol Question tube feed placement again MD agrees to check amylase and lipase If values were trending upward, we will reposition feeding tube into the jejunum 6/6 Propofol continues to decrease Discontinue caps and SSI Amylase = 46 U/L; Lipase = 267 U/L 6/7 Propofol discontinued Extubated in the AM EN discontinued Diet: Clear liquids Pt agitated and confused 1:1 Days 6 - 8

  18. 6/8 - Day 9 Intermittently confused Delusional with occasional visual hallucinations 6/9 - Day 10 Confused Hallucinating Anxious Agitated Over the Weekend

  19. Day 11 - 6/10 • Tx to 5E • Impulsive at times • Continued with hallucinations and delusions • ? Wernicke’s encephalopathy • Started on thiamine therapy • 500 mg IV TID for 3 days • 250 mg IV or oral TID until pt no longer requires

  20. Wernicke’s Encephalopathy • A result of a thiamine deficiency with continued carbohydrate ingestion • Common among alcoholics • Pathology is restricted to the CNS • Symptoms include: • Loss of immediate memory • Disorientation • Nystagmus • Ataxia

  21. Diet hx: Typically eats once a day Doesn’t feel hungry Binges on fast food Pt feels as if he has gained some weight and requests weight loss information Change Nutrition Dx Excessive alcohol intake r/t knowledge deficit as evidenced by acute pancreatitis, hx of 30+ years of excessive drinking, confused, and delusional with occasional visual hallucinations Patient Interview

  22. Day 12 Psych consult Pt was offered inpatient psychiatric hospitalization, which he deferred Has an outpatient follow-up plan Fresh Start recommended Day 13 Gave pt weight management/loss info and healthy eating info Discharged in the afternoon Ready for Discharge

  23. Any Questions…

  24. References • Abou-Assi, S. and O’Keefe, S.J.D. (2002). Nutrition support during acute pancreatitis. Nutrition, 18(11/12), 938-943. • Van Brunschot, S., Bakker, O.J., Besselink, M.G., Bollen, T.L., Fockens, P., Gooszen, H.G., and Van Santvoort, H.C. (2012). Treatment of necrotizing pancreatitis. Perspectives in Clinical Gastroenterology and Hepatology, 10(11), 1190-1201. • Hegazi, R.A., Cockram, M.A. and Luo, M. (2012). Misconceptions and truths for feeding patients in the intensive care unit: case studies with practical nursing solutions. Open Journal of Nursing, 2, 327-331. • Wu, B.U. and Banks, P.A. (2013). Clinical management of patients with acute pancreatitis. Gastroenterology, 144(6), 1272-1281. • Remig, V.M. (2008). Medical nutrition therapy for neurological disorders. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 1067-1101). St. Louis, MI: Saunders • Gallagher, M.L. (2008). The nutrients and their metabolism. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 39-143). St. Louis, MI: Saunders • Hasse, J.M. & Matarese, L.E. (2008). Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders. In L.K. Mahan & S. Escott-Stump (12th Ed.), Krause’s food and nutrition therapy (pp. 707-738). St. Louis, MI: Saunders • Mirtallo, J.M., Forbes, A., McClave, S.A., Jenson, G.L., Waitzberg, D.L. and Davis, A.R. (2012). International consensus guidelines for nutrition therapy in pancreatitis. Journal of Parenteral and Enteral Nutrition, 36(3), 284-291. • Arana-Guajardo, A.C., Cámara-Lemarroy, C.R., Rendón-Ramírez, E.J., Jáquez-Quintana, J.O., Góngora-Rivera, J.F. and Galarza-Delgado, D.Á. (2012). Wernicke encephalopathy presenting in a patient with severe acute pancreatitis. Journal of the Pancreas, 13(1), 104-107. • Petrov, M.S., Correia, M.I.T.D. and Windsor, J.A. (2008). Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. Journal of the Pancreas, 9(4), 440-448.

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