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Nutrition Therapy for Paralytic Ileus

Nutrition Therapy for Paralytic Ileus. Lara Snead Sodexo Dietetic Intern February 4, 2013. Objectives. Differentiate an ileus from a small bowel obstruction Identify indications for nutrition support Discuss medical and nutrition care throughout case study’s hospital course.

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Nutrition Therapy for Paralytic Ileus

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  1. Nutrition Therapy for Paralytic Ileus Lara Snead Sodexo Dietetic Intern February 4, 2013

  2. Objectives Differentiate an ileus from a small bowel obstruction Identify indications for nutrition support Discuss medical and nutrition care throughout case study’s hospital course

  3. General Information • GG is a 64 YO Male • Admitted on 11/12/2012 w/COPD • Initially seen as a Nursing Screen Referral on 11/13 by RD • Seen by dietetic intern 9 times • Remains an inpatient @ WAH

  4. Past Medical History COPD HTN Anemia Cellulitis of LEs Rashes PVD

  5. Social History Lives with parents Smokes about 1 pack/day Drinks alcohol almost qday

  6. Anthropometric Data Ht: 5’7” (67”) Admit Wt: 139# (63 kg) IBW: 148# (67 kg) BMI: 21.8 kg/m2 (Normal wt category)

  7. Hospital Course • 11/12: • Right femoral endarterectomy & embolectomy; fasciotomies • 11/13: • Seen by RD – intubated, sedated, on 2 pressors, nonresponsive to voice/questions • NPO; banana bag • Drsg to R shin & thigh • Kcal: 1134-1449 (18-23), Prot: 63-76 (1.0-1.2) • Lactate-4.5 H ↓, MAP-80’s • Rec. initiate EN w/Glucerna 1.2 @ 30 mL/hr, ↑ as tol. to 45 mL/hr (1296 kcal, 65 g prot)

  8. Hospital Course, Cont. • 11/15: • Tolerating Nepro @ 20 mL/hr • RLE w/inner & outer incisions w/staples OTA, leg is warm, ecchymotic • Rec. to Δ TF to Glucerna 1.2 @ 45 mL/hr (1296 kcal, 64 g prot) • ↑ BG (167, 235, 193 mg/dL) • 11/19: • Extubated, alert & responsive but delirious • Likely need amputation of R toes vs. foot • Kcal: 1575-1890 (25-30), Prot: 75-88 (1.2-1.4) • Tolerating feeds – rec. advance to Glucerna 1.2 @ 60 mL/hr (1728 kcal, 86 g prot)

  9. Hospital Course, Cont. • 11/27: • Reintubated – full vent • NPO – OGT on LCS (500 mL out in 4 hrs) • KUB: SBO, perforated viscus - no plan for surgery (allow to heal) • Rec. TPN – 2L (NS): 11% Dex, 4.2% AA, 175 mL Lipids (1434 kcal, 84 g prot) • 11/30: • KUB: C/w ileus vs. SBO • Gastrografin via NGT • Cont. TPN • If no extravasation, begin Osmolite 1.5 @ 20 and ↑ as tol. to 35 mL/hr + PS (1332 kcal, 68 g prot)

  10. SBO vs. Ileus • SBO – partial/complete blockage of small/large intestine • Tumor, adhesions, hernias, twisting/narrowing of intestines • Ileus – absence of intestinal peristalsis without mechanical obstruction • Normal times after surgery: • Small bowel – several hrs • Stomach – 24-48 hrs • Colon – 48-72 days • When postop ileus persists longer, considered pathologic and called a paralytic ileus

  11. Ileus • Causes: • Sympathetic-parasympathetic imbalance • Chemical mediators of bowel activity • Inflammation • Narcotic analgesics • S/S: N/V, moderate abd. distention • Dx: Abd. x-ray/CT, exclude SBO

  12. Ileus Management • Nasogastric tube for decompression • Early postop enteral feeding • Gum-chewing • Meds: • Limit narcotics • Erythromycin – antibiotics, motilin receptor antagonist • Metoclopramide (Reglan) – antiemetic, prokinetic

  13. Hospital Course, Cont. • 12/4: • TF w/Jevity 1.2 @ 10 off d/t ↑ residuals of 1.2L; ↑ NGT output • Vomited & asp. • Skin: Necrotic feet, Stage 2 sacral (not seen) • Alb-0.9 L, plan to check prealbumin • Cont. TPN • Rec. 24 hr metabolic cart

  14. Hospital Course, Cont. • 12/7: • CT on 12/5 showed↑ dilated SB c/w high-grade SBO • Tracheostomy on 12/6 • Indirect Calorimetry – avg. 2200 kcal, RQ <0.8 • NGT on LCS w/100 mL out overnight • Δ TPN to 2L (NS): 19% Dex, 4.5% AA, 275 mL Lipids (2206 kcal, 90 g prot) • Trial Jevity 1.2 @ 10 mL/hr if NGT output remains <400 mL/next 24 hrs

  15. Indirect Calorimetry • “Gold standard” • Resting Energy Expenditure (REE) • Respiratory quotient (RQ) • CO2 production : O2 consumption • < 0.82 – underfeeding, predominant lipid catabolism • > 1 w/excessive CO2 production – overfeeding, lipogenesis, ↑ resp. demand • GG: • REE: Avg. 2200 kcal • RQ: < 0.8 – indicated underfeeding • TPN – 2L (NS): 1434 kcal, 84 g prot (65% of needs) • TPN Δ’d to 2L (NS): 2206 kcal, 90 g prot

  16. Hospital Course, Cont. • 12/10: ↑ Na+/Cl- likely r/t ↑ kcal in same volume • RD Δ’d TPN to 2.5L (NS) – 15% Dextrose, 3.6% AA, 275 mL Lipids (2185 kcal, 90 g prot)

  17. Hospital Course, Cont. • 12/11: • Alert, more responsive, tolerating T-piece • Did not tolerate EN on 12/9 • SBFT: Not SBO, normal transit times; SB & LB dilation c/w ileus • ↓ abd. distention, NGT clamped but had 800 mL out overnight • Flexiseal w/600 mL out overnight • Skin: Unchanged • Na+-148 H, Cl--111 H, BUN-21 H, Prealbumin-4.4 L • Cont. TPN, add ½NS IVF’s until stooling improves, trial Reglan, check prealbumin • If NG output <500 mL in next 24 hrs, trial Jevity 1.2 @ 10 mL/hr

  18. Follow Up - 12/14 • TPN: 2.5L (NS) – 15% Dextrose, 3.6% AA, 275 mL Lipids (2185 kcal, 90 g prot) • TF: Jevity 1.2 @ 20 mL/hr (576 kcal, 27 g prot) • General: Alert, responds w/nods, nonverbal, full vent w/trach • GI: Abd. distended, denies abd. pain, ↑ BS, no residuals • Flexiseal w/500 mL liquid brown stool out/3.5 hours • Neg. for C. diff (12/11) • Skin: R toes necrotic, inner/outer R calf w/staples

  19. Follow Up - 12/14 Meds: Pepcid, Reglan Labs: Pending blood transfusion

  20. Nutrition Care Plan • Dx: Altered GI function R/T ?malabsorption vs. hypermotility side effect of Reglan AEB 500 mL liquid stool out in 3.5 hours. • Goal: Stool output <400 mL/day • Plan: • Cont. TPN • Δ TF to Vivonex @ 20 mL/hr (480 kcal, 24 g prot) • Rec. d/c Reglan • Check CRP • Add 25 mg Zn to TPN x 10 days • Rec. SLP consult for swallow eval (had been tol. T-piece) • Monitor: TF tolerance, stool output, labs

  21. Follow Up 12/18 • TPN: 2.5L Non-Standard (2185 kcal, 90 g prot) • TF on hold since 12/16 d/t vomiting • 12/17 CT: C/w paralytic ileus • General: Nonverbal, eyes closed, agitated, full vent • No NGT output, clamped during visit (1.3L on 12/17) • GI: Abd. less distended, NT, soft, ↑ BS • Flexiseal w/500 mL liquid brown stool out/8 hrs • Skin: Unchanged

  22. Follow Up 12/18 • Meds: Pepcid, Ativan, KCl • *Reglan d/c’d – no Δ’s in stool output; ↑ vomiting • Labs: • Pending blood transfusion • Low K+ r/t ↑ vomiting & NGT output • High Cl- and low CO2 r/t diarrhea

  23. Nutrition Care Plan • Dx: Altered GI function R/T ?malabsorption AEB >500 mL stool output/8 hours. • Goal: Stool output <400 mL/day • Plan: • Cont. TPN • Rec. restarting Reglan • Rec. Imodium • Rec. GI consult • Monitor: Stool output, labs, ileus status

  24. Follow Up - 12/21 • TPN: 2.5L Non-Standard (2185 kcal, 90 g prot) • TF not resumed despite order for Vivonex @ 20 mL/hr 48 hrs prior + issue w/feeding pump & bottle • General: Nonverbal, nods responses; full vent • NGT clamped, no output recorded • GI: No N/V; abd. soft, ND/NT, + BS *Reglan restarted (10 mg BID) • Flexiseal Δ’dw/200 mL out/~1 hour; 800 mL out/previous 24 hrs • Neg. for C. diff (12/19) • Skin: BUE anasarca (R>L), rash all over body, Stage 1 sacral (not seen) • Bedscale wt: 184# ← 139# (11/13) *45# wt gain since admit likely r/t edema – no reliable I/O recorded, no wts recorded

  25. Follow Up - 12/21 • Meds: Benadryl, Fluconazole, MgSO4 (12/20) • Labs: • *Na+ was high previous day d/t pt receiving D5/NS + NaHCO3 for low CO2 • D/w ACNP to check Prealbumin and C-Reactive Protein (CRP)

  26. C-Reactive Protein Indicator of inflammation Prealbumin not appropriate for evaluating adequacy of nutrition support in critically ill pts w/inflammation Prealbumin & albumin likely low 2° inflammation (↑CRP & ↑WBC)

  27. Nutrition Care Plan • Dx: Altered GI function R/T ?zinc deficiency vs. unknown etiology AEB stool output of 800 mL/24 hrs. • Goal: Decrease stool output to <600 mL/24 hrs • Plan: • Rec. Octreotide & Cholestyramine • Rec. Lactinex • Add 25 mg Zn to TPN x 10 days • Remove Ca from TPN • Decrease Reglan to 5 mg BID • Rec. GI consult • Trial trophic feeds of Vivonex @ 20 mL/hr – do not advance • Strict I/O’s • Monitor: Stool output, labs, wt, GI input, TF tolerance, I/O’s

  28. Hospital Course • 12/24: • TPN: 2.5L Non-Standard (2185 kcal, 90 g prot) • TF: Vivonex @ 20 mL/hr (480 kcal, 24 g prot) • R subclavian central line infection – plan for new line on L • GI consulted – did not see pt, rec. d/c Reglan • W/Reglan, no significant residuals, no vomiting • Flexiseal: 1.2 L out on 12/23, 770 mL out on 12/22 (Neg. for C. diff) • Cont. TPN • Rec. Imodium & Cholestyramine • Trial increase Vivonex to 40 mL/hr if stool decreases

  29. Hospital Course • 12/26: • No new line placed – TPN stopped • Tolerating Vivonex @ 40 mL/hr • Flexiseal: 250 mL on 12/25, 550 mL out on 12/24 • Imodium & Cholestyramine added • Rec. increasing TF to 60 mL/hr • If no significant Δ’s in stooling, Δ TF to Impact 1.5 @ 60 mL/hr (2160 kcal, 135 g prot) • D/w ACNP to check Zn level – if still low, add ZnSO4 x 10 days

  30. Follow Up – 1/2 • TF: Impact 1.5 @ 60 mL/hr (2160 kcal, 135 g prot) + autoflushes • General: Alert, nods to questions, TC during day, vent @ night as tolerated • SLP swallow eval: NPO except ice chips • GI: Abd. soft, ND/NT, +BS • Flexiseal w/400 mL liquid brown stool during shift • Skin: R shin staples removed, incisions healed • Bedscale wt: 157#

  31. Follow Up – 1/2 Meds: Cholestyramine, Imodium, Pepcid, ABO, Lactinex, ZnSO4, Benadryl, Methylprednisolone Labs:

  32. Nutrition Care Plan • Dx: Inadequate fluid intake R/T diarrhea AEB Na+-146 H, Cl-116 H, BUN-36 H. • Goal: Normal lab values • Plan: • Cont. Impact @ 60 mL/hr + autoflushes • Add 210 mL H2O flushes q6hrs (total 2549 mL free H20) • Monitor: Stool output, TF tolerance, labs, hydration

  33. Follow Up – 1/8 • 1/4: • Off vent – pt “coughed” out trach • NGT removed • MBS : Mild-mod pharyngeal dysphagia w/delayed swallow & silent asp. • Diet: Mechanical Soft, Nectar Thick Liquids • General: Alert & oriented, able to converse • Drinking liquids, not eating a lot of solid foods; willing to try Resource Shake Thickened • GI: Flexiseal w/350 mL liquid green stool during shift; abd. ND/NT +BS • Skin: Less anasarcic in BUE, bandage over throat stoma • Bedscale wt: 138# ← 157# (1/2) *Wt loss likely r/t less edema

  34. Follow Up – 1/8 • Meds: Cholesyramine, Benadryl, Haldol • Labs: BMP WNL, except Cl--110 H ↓; WBC – 12.2 H ↓ • D/w ACPA d/c of Cholestyramine d/t high eosinophils • Eosinophils – WBC that become active during allergic diseases, infections • Cholestyramine added around time when eosinophils started to ↑ • Possible reaction? • Or r/t rash?

  35. Nutrition Care Plan • Dx: Inadequate protein-energy intake R/T pt choosing to drink liquids and not eat solid foods AEB meeting ~30% of est. needs. • Goal: ≥50% PO intake + supplements • Plan: • Cont. current diet • Add Resource Shake Thickened TID • Add appetite stimulant • Monitor: PO intake, stooling

  36. Follow Up - 1/10 • Diet: Mech. Soft, Nectar Thick, Resource Shake TID • General: A & O, reports good appetite (on Marinol) • PO Intake: 50% of meal, all liquids and supplements • GI: No abd. pain, ND/NT +BS, no N/V/C • Flexiseal w/50 mL of light brown stool output during shift • 840 mL out on 1/9 – *needed Cholestyramine • Bedscale wt: 137# ← 138# (1/8) • Labs:

  37. Nutrition Care Plan • Dx: No acute nutrition problems @ this time. • Goal: ≥75% PO intake • Plan: • Cont. current diet & supplements • Add Imodium – d/w ACPA • Monitor: PO intake, stooling GG LIVED HAPPILY EVER AFTER…

  38. Patient Update • 1/14: • CT: High-grade mechanical SBO • NPO, NGT on LCS • Restarted Reglan • 1/21: • NGT removed • PO diet resumed: Mech. soft, thin liquids (per SLP rec’s), Ensure TID • Reports good appetite, >75% PO intake • Cont. on Reglan • Still @ WAH. To be continued…

  39. Questions?

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