Clinical Nutrition Management of

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Clinical Nutrition Management of Superior Mesenteric Artery Thrombosis

Dana Magee

ARAMARK

Distance Dietetic Internship

Overview

Disease Description

Evidenced Based Nutrition Recommendations

Case Presentation

Nutrition Care Process

Assessment

Nutrition Diagnosis

Interventions

Monitoring and Evaluation

Conclusion

Acute 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

Occlusive 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

Acute 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)

Signs 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

SMA 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

Diagnosis

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

Treatment

Immediate exploratory surgery

Remove ischemic/ necrotic bowel

Embolectomy

In surgery:

Peristalsis

Coloring

Doppler ultrasonography

IV fluorescent under Woodlamp

Second look surgery

Case Presentation

Presented

with

abdominal

pain out of proportion

Admitting diagnosis: SMA thrombosis

PMH:

A-Fib, stroke,

CAD, HTN, cardiomyopathy.

http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm

Case Presentation

CT scan showed SMA thrombosis

Started

on TPN

Exploratory laparotomy

30 cm small bowel resected, NGT decompression

Second look surgery

GI bleed

Pacemaker

Evidenced 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.

Evidenced 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.

Evidenced 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.

Evidence 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.

Evidence 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.

Evidence 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.

Evidence 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.

Evidence 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

Evidence 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.

Evidence 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.

Evidence 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.

Nutrition Care Process

Assessment: Client History

A-Fib uncontrolled

Does

not

work

Lives

at home with

a caregiver

Nutrition 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

Nutrition Care Process

Assessment: Anthropometric Measurements

Height discrepancies 62-71 inches

Weight 145 pounds

BMI 22.79

Usual weight 156 pounds

Nutrition 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

)

Nutrition 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

Nutrition Care Process

DRG Coding

Weight loss of 5-10% of usual body weight

Albumin 3.5-5

Mild Protein calorie malnutrition

Nutrition 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.

Nutrition 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

.

Nutrition 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

Monitoring 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.

Conclusion

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

Conclusions

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

References

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.

References

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.