Case Report: Nutritional Management of Small Bowel Obstruction - PowerPoint Presentation

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Case Report: Nutritional Management of Small Bowel Obstruction

By Christine Bannon

ARAMARK Dietetic Internships

December 14, 2014

Slide2

Abstract

Purpose: Follow the Nutrition Care Process

Case: 82

yr

old female with small bowel obstruction (SBO) who required total parental nutrition (TPN)

Previous hospital visit for SBO – noninvasive treatment and low fiber

Hospitalized again for SBO secondary to adhesions

PMH: Uterine cancer requiring hysterectomy

TPN, lysis of adhesions, and right partial colectomy

Discharged after 15 days on oral low fiber

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Disease Description – Small Bowel Obstruction

The small intestine is a complex organ that plays a major role in the absorption of nutrients

When contents of the intestine are blocked and unable to pass freely, this is considered a small bowel obstructions (SBO).

Signs & Symptoms

Abdominal distention

ConstipationVomitingAbdominal pain and crampsNauseaDiarrhea

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Disease Description – Causes

Mechanical

- characterized by the narrowing of the intestinal

lumen

Inflammation

or trauma to the bowelNeoplasmsAdhesions (Most common)HerniasVolvulus (twisted bowel)

Compression

from outside the intestinal

tract

Nonmechanical

- factors that interfere with the muscle action or innervation of the

bowel

Paralytic ileus

Mesenteric

embolus

or thrombus

Hypokalemia

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Evidence-Based Nutrition Recommendations

Title: Reoperation on the Abdomen Encased in Adhesions

Purpose: To determine the short and long-term outcomes after lysis of adhesions

Method: 40 patients who had recently undergone lysis of adhesions were contacted to evaluate the outcome

Results: 1 postoperative death, 24 early complications. 28 out of 31 had resolved SBO from the surgery

Long-term outcomes: all subjects able to tolerate oral feedings

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Evidence-Based Nutrition Recommendations

Title: Burden of Adhesions in Abdominal & Pelvic Surgery: A Systematic Review and

Metanalysis

Purpose: To estimate the burden of complications associated with abdominal adhesions

Method: Analysis of 196 papers from PubMed,

Embase, and Central which reported incidences of adhesion related complicationsResults: Increase risk of developing a SBO in open abdominal/pelvic surgery. Adhesive SBO associated with longer hospital stays.

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Case Presentation

An 82 year old woman is admitted to the hospital after a night of worsening abdominal pain, nausea and vomiting.

Patient was recently admitted one month prior for a SBO which was treated conservatively with no invasive processors. Since then, patient has followed a low-fiber diet.

Once admitted, patient underwent a series of radiographs to diagnose her with another SBO and renal failure secondary to dehydration

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Nutrition Case Process (NPC): Assessment

Past Medical History

Hypertension

High cholesterol

Type 2 diabetes mellitus

HypothyroidismArthritisFractured spine and coccyxOsteoporosisMissing right kidney from birthReflux

Constipation

Hysterectomy from uterine cancer which was last treated with radiation in 2005

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Food/Nutrition Related History

Lack of appetite for one week prior to admission

Follows a low-fiber diet which was prescribed to her since her last hospitalization for SBO

Lactose – intolerant

Home medications can be found in Table 1

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Nutrition-Focused Physical Findings

No appetite at admission

No identified chewing/swallowing issues with good oral health

Trace bilateral edema in lower extremities

Appeared well nourished

No bowel movement for 2 days prior to admission

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Anthropometric Measurements

4’ 9” (57”)

121 pounds (55kg)

BMI of 26.6 = overweight

IBW: 100 pounds

121% of IBW

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Biochemical Data, Medical Test, and Procedures

Went through a series of x-rays and radiographs to confirm SBO diagnosis.

Labs were taken as followed:

Lab

Normal

Patient’s

Rationale

Sodium

136-144

133

(L)

Acute Renal Failure (AFR), dehydration

Potassium

3.6-5.1

3.4 (L)

Obstruction

Glucose

234 (H)

Acute inflammation

BUN

8-20

21

(H)

Dehydration, hypovolemia

Creatinine

0.6-1.1

2.1

(H)

ARF, dehydration,

inadeq

.

dietary protein, reduced muscle mass

Magnesium

1.9

Indicates

wnl

Phosphorous

Not tested

Albumin

1.9 (L)

Acute inflammation

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Nutrient Needs

1138-1365 calories

55-69gm of protein

1138-1369ml of fluid

Protein needs are elevated due to:

Moderate protein depletion (Albumin 2.1 -2.7)Mildly metabolically stressed Nutritional needs are summarized in Table 2.

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ARAMARK Nutrition Status Classification

M

oderate nutritional risk (status 3)

4

points: GI obstructions

3 points: Vomiting 3 points: Poor appetiteTotal of 10 pointsFollow up in 3-5 days

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Malnutrition Identification

Malnutrition diagnosed with 2 out of the 6 Characteristics

Intake (fair to poor longer than 1 week)

Weight loss

Loss of muscle mass

Loss of subcutaneous fatFluid accumulationFunctional status

Chronic vs. Acute Etiology

Inflammation is chronic and mild-moderate degree vs. inflammation is acute and severe degree

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Malnutrition Identification (cont.)

Malnutrition diagnosed with 2 out of the 6

Characteristics

Intake –

Patient reported consuming <75% of her estimated energy needs for longer than a week

Weight loss Loss of muscle massLoss of subcutaneous fat

Fluid accumulation –

edema noted in lower extremities

Functional

status

Chronic vs Acute Etiology

Acute due to

hypoalbuminemia

(1.9)

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NCP: Diagnoses

Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by abdominal distention, vomiting and lack of bowel movement.

Malnutrition (NI-5.2) related to small bowel obstruction as evidenced by fluid retention and oral energy intake < 50%-75% for one week.

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NCP: Interventions

Medical Interventions

Nasogastric tube was place for suction to prevent further nausea and vomiting

Right Partial Colectomy

Lysis of adhesions

Medications and their rationale the patient was placed on can be found on Table 3.

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NCP: Interventions

Nutrition Interventions

Parental Nutrition (ND 2.2)

Day

1 standard formula: 70gm amino acids, 150gm dextrose, 20gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg

seleniumProvides: 990kcal (22kcal/kg ideal wt), 70gm protein (1.5gm/kg ideal wt

)

Justification:

Malnourished

Enteral feeding can not be safely attempted

Nonfunctional gut

TPN expected to be needed for at least 7 days

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NCP: Interventions

Additional consults were needed from nephrology due to patient’s acute renal failure(ARF)diagnosis

Nephrology findings:

ARF was secondary to

dehydration

Intervention: Intravenous fluid needed

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NCP: Monitoring and Evaluation

Parenteral nutrition

formula (FH-1.3.2.1)

Domain: FOOD/NUTRITION-RELATED HISTORY (FH

)Weight (AD-1.1.2)Domain: ANTHROPOMETRIC MEASUREMENTS (AD) Digestive system (mouth to rectum) (bowel function, bowel sounds) (PD-1.1.5)

Domain: NUTRITION-FOCUS PHYSICAL FINDINGS (PD)

Potassium (BD-1.2.7), Magnesium

(BD-1.2.8), Phosphorus(BD-1.2.11), Glucose,

casual(BD-1.5.2)

Domain

: BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)

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Follow-Ups (F/U)

F/U #1 (11/14)

PES

: Inadequate energy

intake(NI-1.2) related to small bowel obstruction as evidenced by poor appetite.

Intervention: Parenteral Nutrition/IV Fluids (2.2) when ableGoal: Initiate PN when ableAchievement: PN was started F/U #2 (11/15)

PES:

Inadequate

parenteral

nutrition

infusion (NI-2.7)

related

to

day 1 standard

TPN

formula as evidenced by 72.5% of energy needs being met

.

Intervention: Modify volume of parenteral

nutrition (ND-2.2.4), Modify

composition of parenteral

nutrition(ND-2.2.1)

Modified TPN order

: 70gm amino acids, 235gm dextrose, 30gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg selenium

Provides:

1380kcal (30kca/kg ideal

wt

), 70gm protein (1.5gm/ideal

wt

)

Goal: Meet 50-75% of nutritional needs

Achievement: PN order was modified and 100% of nutritional needs were reached

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Follow-Ups (cont.)

F/U #3 (11/16

)

PES: Altered nutrition-related laboratory

values (phosphorous) (NC-2.2) related to SBO as evidenced by phosphorus levels of 1.4.

Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1). Recommend mineral supplement therapy (phosphorous) (ND-3.2.4.6)

Goal

: Meet 50-75% of nutritional needs

Achievement: Phosphorus was

repleted

. Dextrose was unchanged and serum glucose remained elevated

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Follow-Up (cont.)

F/U #4 (11/17

)

PES

: Parenteral Nutrition Administration Inconsistent with Needs (NI-2.10) related to SBO as evidenced by elevated glucose in the 200’s.

Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1) (decreased dextrose, increased lipid). Nutrition-Related Medication Management (ND-6) to add 0.15units of insulin/gm of dextrose.Modified TPN order: 1800mls total volume, 75ml/

hr

X 24 hrs. 70gm protein, 200gm dextrose, and 42gm lipid. Provides: 1380kcal (30kcal/kg ideal

wt

) and 70gm protein (1.5gm/kg ideal

wt

)

Goal: Blood Glucose >200

Achievement: PN modified. Additional insulin was added. Blood glucose improving in upper 100’s but remains elevated.

F/U #5 (11/18)

PES: Impaired nutrient

utilization (NC-2.1)

related

to ileus as evidenced by no bowel movement

Intervention

: Continue Parenteral Nutrition/IV Fluids (

2.2)

Achievement: PN was continued at recommended rate

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Follow-Up (cont.)

F/U #6 (11/20)

PES

: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by

lack of bowel movement/sound.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)Goal: Meet 50-75% of nutritional needsAchievement: PN was continued at recommended rate. (+) Hypoactive bowel.F/U #7 (11/21)PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by lack of bowel movement/sound.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)

Goal: Meet 50-75% of nutritional needs

Achievement: PN was continued at recommended

rate

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Follow-Up (cont.)

F/U #8 (11/22)

PES:

Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by

nausea and lack of bowel movement.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)Goal: Meet 50-75% of nutritional needsAchievement: PN was continued at recommended rate. Hypoactive bowel sounds heard. Patient begins to have flatus.F/U #9 (11/23)

PES

: Inadequate oral

intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.

Intervention:

Begin Clear

liquid

diet(ND-1.2.8.3) while continuing

Parenteral Nutrition/IV Fluids (2.2

) at goal rate.

Achievement: Patient tolerating clear liquids well

. Small bowel movement is noted.

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Follow-Up (cont.)

F/U #10 (11/24)

PES:

Inadequate oral intake (NI-2.1) related to TPN order as evidenced

by clear liquid diet.

Intervention: Advance to Full liquid diet (ND-1.2.8.4) when able. Modify rate of parenteral nutrition (ND-2.2.3) to 40ml/hr.Goal: Meet 50-75% of nutritional needs.Achievement: Diet advanced to full liquid diet. TPN rate was reduced.

F/U #11 (11/25)

PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by full liquid diet

.

Intervention: Advance

to General/healthful

diet (ND-1.1) when able

. Modify rate of parenteral

nutrition (ND-2.2.3) to be discontinued completely.

Goal: Meet 50-75% of nutritional needs.

Achievement: Diet advanced to regular for lunch. TPN order was discontinued.

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Discharge Care

No driving X 6 weeks

No lifting/baths

Outpatient F/U in 2 weeks

Wear abdominal binder when out of bed X 2 months

Ice for discomfortLow-fiber diet

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Conclusion

SBO is a serious medical and nutritional concern that can lead to lengthy hospital stays. Clinicians needs to monitor GI function daily in order to prevent GI atrophy

TPN plays an essential role in the management of electrolytes and can supply adequate nutrients when enteral feedings can not be done

Patients should be routinely cautioned on the risk and complications associated with adhesions before undergoing any abdominal or pelvic surgery

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Appendix

Table 1

Medication

Rationale

Tylenol extra

strength, 500mg

Pain

Calcium Carbonate, 500mg

Calcium supplement,

antacid

Coreg,

6.25mg BID

Beta-blocker

for hypertension and heart health

Vitamin D3, 1000units

For osteoporosis

Plavix, 75mg

Blood thinner

Levofloxacin, 250mg

Antibiotic

Levothyroxine,

75mg

Synthetic thyroid hormone for hypothyroidism

Lisinopril, 20mg

ACE inhibitor

Flagyl,

500mg q 8hrs

Antibiotic

Omeprazole, 40mg

Proton

pump inhibitor for GI ulcers, heart burn, GERD

Zofran, 4mg q 6hrs

Nausea,

Vomiting

Florastor

Probiotic

Simvastatin, 40mg

Statin

Ambien, 5mg

Gamma-

aminobutyric

acid for insomnia

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Appendix

Table 2

Anthropometric Data

Height

Weight

IBW

IBW%

BMI

57”

121#

100#

121%

24.95

Nutrient Needs

REE

 

Protein

45.45

kg x 25 kcal/kg =

1138

kcal

45.45

kg x 30 kcal/kg =

1365kcal

 

1138-1365 kcal/day

45.45kg

x

1.2

g/kg =

55

g

45.45

kg x 1.5 g/kg =

69

g

 

55 – 69 g/day

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Appendix

Table 3

Medication

Rationale

Vitamin

D3

Bone health

Heparin

Anticoagulant

Sliding

Scale Insulin

Control serum glucose

Levothyroxine

Synthetic thyroid hormone for hypothyroidism

Lopressor

Control high

blood

pressor

Protonix

Proton-pump inhibitor

to manage reflux

Sodium

Chloride flush

Provides additional fluid and electrolyte

balance

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Appendix

Table 4

Domain

Problem/Nutrition Diagnosis

Etiology

Signs/Symptoms

Clinical

(NC-1.4)

Altered Gastrointestinal Function

Related to

small bowel obstruction

As evidenced

by

abdominal distention, vomiting and lack of bowel movement.

Intake (NI-5.2)

Malnutrition

Related to

small bowel obstruction

As evidenced

by

fluid retention and oral energy intake < 50%-75% for one week.

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References

1. Mahan LK,

Escott

-Stump S. Krause’s Food & Nutrition Therapy. 13th ed. St. Louis, MO: Saunders Elsevier; 2011:9-10/306-309.

2.

Kulaylat MN, Doerr RJ. Small Bowel Obstruction – Surgical Treatment. National Library of Medicine. 2001. http://www.ncbi.nlm.nih.gov/books/NBK6873/ . Accessed December 14, 2014. 3. Lucey J. Small Bowel Obstruction. NYU Langone Medical Center. http://www.med.nyu.edu/content?ChunkIID=96913 . Accessed December 12, 2014.

4. Harris EA, Kelly AW,

Pockaj

BA et al. Reoperation on the Abdomen Encased in Adhesion. The American Journal of Surgery. 2002:184 (6): 499-504.

dio

: 12488146.

5. Ten

Broek

RPG,

Issa

Y, van

Santbrink

EJP, et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ : British Medical Journal 2013;347:f5588. doi:10.1136/bmj.f5588.

6. Width M,

Reinhard

T. The Clinical Dietitian’s Essential Pocket Guide. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

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References

7. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2007.

8. White JV,

Guenter

P, Jensen G et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (

Undernutrition). Journal of Parenteral and Enteral Nutrition. 2012: 36(3): 275-283. DOI: 10.1177/01486071124402859. American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL. 2011.10. Bordeianou L,

Yeh

D. Overview of management of mechanical small bowel obstruction in adults.

UpToDate

. http://www.uptodate.com/contents/overview-of-management-of-mechanical-small-bowel-obstruction-in-adults . Accessed December 7, 2014.