Superior Mesenteric Artery Thrombosis Dana Magee ARAMARK Distance Dietetic Internship Overview Disease Description Evidenced Based Nutrition Recommendations Case Presentation Nutrition Care Process ID: 775408
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Slide1
Clinical Nutrition Management of Superior Mesenteric Artery Thrombosis
Dana Magee
ARAMARK
Distance Dietetic Internship
Slide2Overview
Disease Description
Evidenced Based Nutrition Recommendations
Case Presentation
Nutrition Care Process
Assessment
Nutrition Diagnosis
Interventions
Monitoring and Evaluation
Conclusion
Slide3Acute 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
Slide4Occlusive Mesenteric Ischemia
Embolus
Thrombosis
50% of AMI cases
25% of AMI
cases
Occurs
i
n distal
branches
Occur
at origin of SMA
Quick onset
Gradual onset
Low collateral blood flow
Larger portion of bowel affected
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
Slide5Acute 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 mortality rate)
Slide6Signs 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
Slide7SMA Blockage
Ischemia can lead to:Vomiting and diarrheaGI bleedNecrotic bowel (8-12 hrs)Bacterial overgrowthPerforated bowelSepsisHFMulti- organ system failure
http://emedicine.medscape.com/article/191560-overview#showall
Slide8Diagnosis
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
Slide9Treatment
Immediate exploratory surgery
Remove ischemic/ necrotic bowel
Embolectomy
In surgery:
Peristalsis
Coloring
Doppler ultrasonography
IV fluorescent under Woodlamp
Second look surgery
Slide10Case Presentation
Presented
with
abdominal
pain out of proportion
Admitting diagnosis: SMA thrombosis
PMH:
A-Fib, stroke,
CAD, HTN, cardiomyopathy.
Slide11http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm
Slide12Case Presentation
CT scan showed SMA thrombosis
Started
on TPN
Exploratory laparotomy
30 cm small bowel resected, NGT decompression
Second look surgery
GI bleed
Pacemaker
Slide13Evidenced Based Guidelines
Early or late parenteral nutrition: ASPEN vs. ESPENCasaer MP, Mesotten D, Hermans G et alObjective: 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.
Slide14Evidenced Based Guidelines
Protocol:2312 patients receiving PN in 48 hours 2328 patients receiving PN after seven daysPatients must be at nutritional riskExcluded patients with BMI<17To keep fluid intake the same received dextrose at the same rate at PN
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.
Slide15Evidenced Based Guidelines
PN 48 hours post admission ICU1 day shorter LOS in ICU (p<0.04)2 days shorter LOS in hospital (p<0.04)Fewer infections 22.8% vs. 26.2% (p<0.0008)Less days on dialysis 7 days vs. 10 days (p<0.008)10% less patients needing >2 days on vent (p<0.006)
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.
Slide16Evidence Based Guidelines
Conclusion: Late initiation better outcomes for patients. Limitations:No glutamine in PN or other modulatorsPremixed PNNo indirect calorimetryNot 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.
Slide17Evidence Based Guidelines
ASPEN: Adult Critical Care Guidelines:Early PN feeding with protein calorie malnutritionIndicated with recent weight loss of 10-15% Studies show: Lower risk for complications (p<0.05)No nutrition support higher mortality risk ((p<0.05)
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.
Slide18Evidence Based Guidelines
Efficacy of Parenteral Nutrition Supplemented with Glutamine Dipeptide to decrease Hospital Infections in Critically Ill Surgical PatientsEstivariz CF, Griffith DP, Luo M, et alDouble blind, randomized, controlled studyObjective: 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.
Slide19Evidence Based Guidelines
Methods: 2 Cohorts: pancreatic necrosis surgery and cardiac/vascular/colonic surgeryAges 18-80s/p one of five surgeriesRequired PN for at least 7 days
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.
Slide20Evidence Based Guidelines
GLN- PN30 subjects0.5 g/kg/day glutamine with 1 g/kg/day amino acid solution
STD- PN29 subjects1.5 g/kg/day amino acid solution
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.
Limitations:
Availability of glutamine- two time periods of research
Limited number of postoperative PN
Slide21Evidence Based Guidelines
No significant changes in infection in the pancreatic cohortIn non- pancreatic cohort GLN- PNDecrease in total infections (p<0.03)Decrease bloodstream infections (p<0.01)GLN- PN had 5x less chance of Staph infectionNo significant difference in mortality
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.
Slide22Evidence Based Guidelines
Critical Illness Nutrition Practice Guidelines 2012Recommend glutamine considered in treatment for critically illAssociated with decreased risk of infectionNot 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.
Slide23Evidence Based Guidelines
Aspen Adult Critical Care GuidelinesRecommend 0.5 g/kg/day glutamine in PNAssociated 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.
Slide24Nutrition Care Process
Assessment: Client History
A-Fib uncontrolled
Does
not
work
Lives
at home with
a caregiver
Slide25Nutrition Care Process
Assessment: Food/Nutrition-Related
History:
P
oor
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
Slide26Nutrition Care Process
Assessment: Anthropometric Measurements
Height discrepancies 62-71 inches
Weight 145 pounds
BMI 22.79
Usual weight 156 pounds
Slide27Nutrition Care Process
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
)
Slide28Nutrition Care Process
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
Slide29Nutrition Care Process
DRG Coding
Weight loss of 5-10% of usual body weight
Albumin 3.5-5
Mild Protein calorie malnutrition
Slide30Nutrition Care Process
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 prescription does not meet estimated nutritional needs as evidenced
by
parenteral regimen providing 67% of estimated caloric needs.
Slide31Nutrition Care Process
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% of nutritional needs)
Increase
CHO in TPN to
255g
.
Slide32Nutrition Care Process
Monitoring and evaluation
Food and nutrient intake: Parenteral nutrition administration
Monitor
parenteral access
Food
and nutrient administration: Parenteral nutrition
intake
formula/ solution
Anthropometric
Measurements: Body weight
Slide33Monitoring 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: return
of GI function.
Slide34Conclusion
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
Slide35Conclusions
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
Slide36References
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 Heart Association.
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. American Heart 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.
Slide37References
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.
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.
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.
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.
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 16
th
Edition. Birchrunville, PA: Food-Medication Interactions; 2010.