RESEARCHPractical SolutionsAcute Bariatric Surgery Complications: ManagingParenteral Nutrition in the Morbidly ObeseYIMIN ...
Table. Nutrition prescriptions, laboratory results, resting energy expenditure, and clinical status of a patient with morb...
succus from her abdominal wound. In the operating room,        charge, no plans for enteral nutrition were in place be-she...
and/or evaluate protein losses of body fluids, especially in   Referencesindividuals with morbid obesity.                  ...
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Acute bariatric surgery_complications__managing_parenteral_nutrition_in_the_morbidly_obese

  1. 1. RESEARCHPractical SolutionsAcute Bariatric Surgery Complications: ManagingParenteral Nutrition in the Morbidly ObeseYIMIN CHEN, MS, RDA fter years of failure achieving and/or maintaining sium, and zinc should be supplemented because the du- weight loss with diet and exercise alone, many indi- odenum is bypassed. Use of high-potency multivitamins viduals with obesity turn to surgical treatment. In can help individuals meet the needs of most micronutri-1991, the National Institutes of Health established guide- ents. An additional 18 to 27 mg elemental iron and 1,500lines for selecting individuals considered appropriate for to 2,000 mg elemental calcium have been recommendedbariatric surgery in the treatment of morbid obesity as to avoid deficiencies (3). B vitamins can become depletedthose with a body mass index (BMI; calculated as kg/m2) as normal absorption of these vitamins takes place in the 40 or a BMI 35 with substantial comorbidities who have proximal jejunum, which is also bypassed. The followingfailed supervised diet and exercise programs. The most com- case highlights the importance and challenges of special-mon bariatric surgery procedures include the Roux-en-Y ized nutrition support in a critically ill individual withgastric bypass (RYGB), gastric banding (adjustable and complications after the RYGB procedure.nonadjustable bands), vertical banded gastroplasty, andbiliopancreatic diversion (duodenal switch). RYGB ac-counts for the majority of bariatric surgery performed in PATIENT PROFILEthe United States and includes both restrictive and mal- RT is a 59-year-old African-American female with a med-absorptive techniques (1). In RYGB, a small (1 to 2 oz) ical history of asthma, hypertension, type 2 diabetes,gastric pouch is created as the new gastric reservoir and congestive heart failure, arthritis, obstructive dyspnea,is directly connected to a distal portion of the small bowel, and a surgical history of cholecystectomy. RT is 64 inchesbypassing the remainder of the stomach as well as the and weighs 273 kg, with a BMI of 103. After failingproximal portion of the small bowel. Weight loss after multiple attempts at supervised weight loss and after aRYGB has been reported to reach up to 28.6% after 1 comprehensive multidisciplinary workup, RT was clearedyear, with some individuals showing maintenance of for an elective RYGB surgery for weight loss.long-term weight loss for 10 to 15 years (1). As with any surgical procedures, bariatric surgery is CLINICAL COURSEnot without known complications. During the immediatepostoperative period, the most commonly observed com- The elective procedure started initially as a laparoscopicplications include anastomotic leak and anastomotic RYGB surgery, which was converted to an open proce-stricture. These have obvious nutritional implications be- dure because of difficulties with manipulation of the lap-cause the surgical reconnections of the gastrointestinal aroscope secondary to an enlarged fatty liver. The re-tract make it difficult to place conventional temporary mainder of the surgical procedure was noted to beenteral feeding access and often require use of specialized unremarkable. RT was extubated on postoperative day 2,nutrition support (2). Anastomotic leak has a reported but was emergently reintubated within 24 hours afterprevalence of 5% with the RYGB procedure and often extubation secondary to respiratory failure. She was un-requires the use of parenteral nutrition (PN) if the leak able to be weaned from mechanical ventilation for thecannot be surgically corrected (3). Because of the malab- next 5 days because of poor respiratory efforts. In addi-sorptive nature of RYGB, risk of micronutrient deficien- tion, RT developed hypotension on postoperative day 6cies requires close monitoring and observation as well. and responded minimally to fluid resuscitation. She re-Vitamin B-12 deficiency can develop because of the lack of quired the initiation of norepinephrine administration forintrinsic factor from the stomach. Nutrients typically ab- blood pressure support. During the next 24 hours, RT’s abdomen became distended and she developed acute re-sorbed in the duodenum such as iron, calcium, magne- nal failure with minimal urine output (320 mL during 24 hours). RT was taken back to the operating room on postoperative day 8 when she had increased serosanguin-Y. Chen is an advanced level dietitian, Rush University eous drainage from her abdominal wound. In the opera-Medical Center, Chicago, IL. tive room, RT was found to have a strangulated, necrotic Address correspondence to: Yimin Chen, MS, RD, Rush bowel with a small anastomotic leak at the distal anas-University Medical Center, 1700 W. Van Buren, Suite 425, tomosis connecting the Y limb of the jejunum to theChicago, IL 60612. E-mail: yimin_chen@rush.edu remaining small bowel. The necrotic bowel was resected, Manuscript accepted: April 7, 2010. the wound was debrided, a gastrostomy tube was placed Copyright © 2010 by the American Dietetic for gastric decompression, and the anastomotic leak wasAssociation. repaired. Because the entirety of the small intestine 0002-8223/$36.00 was extremely edematous, a polyglycolic acid mesh was doi: 10.1016/j.jada.2010.08.010 placed over RT’s open abdomen and sutured in place to1734 Journal of the AMERICAN DIETETIC ASSOCIATION © 2010 by the American Dietetic Association
  2. 2. Table. Nutrition prescriptions, laboratory results, resting energy expenditure, and clinical status of a patient with morbid obesity after complications after Roux-en-Y gastric bypass PNa day 1 PN day 5 PN day 11 PN day 16 PN day 18 PN day 25 PN day 41 Weight (kg) 279 NAb NA 293 NA NA 295 kcal/day 2,050 2,050 2,050 2,050 2,050 2,050 2,050 kcal/kg actual 7.5 7.5 7.5 7.5 7.5 7.5 7.5 body weight Protein (g/day) 155 155 105 155 155 125 125 IBWc (g/kg) 2.8 2.8 1.9 2.8 2.8 2.3 2.3 Albumin (g/dL) 1.6 1.8 1.5 1.5 1.7 2 Prealbumin (g/dL) 15 7 9 N-balanced Unsuccessful; continuous Positive 0.6 g furosemide infusion initiated Indirect calorimetry 3,480 (kcal) e f Clinical course POD 10 initial surgery Tracheostomy Increased BUN Substantial improvement Oxygen requirement Increasing BUN Stable clinical POD 1 wound placed and in renal function with on ventilator and status, dehiscence, bowel creatinine decreased BUN and decreased below creatinine. granulating resection, creatinine 60% Suspected tissues anastomotic leak sepsis repair, open abdomen a PN parenteral nutrition. b NA not available. c IBW ideal body weight. d N-balance nitrogen balance. e POD postoperative day. f BUN blood urea nitrogen.the fascia. RT returned to the surgical intensive care unit tomotic leak and compromised gastrointestinal tractfor postoperative care and remained on mechanical ven- function, as evidenced by multiple draining fistulas.tilation. NUTRITION INTERVENTIONNUTRITION ASSESSMENT Although guidelines are available to facilitate clinicalOn postoperative day 9, PN was initiated by the physi- decisions on feeding morbidly obese individuals, actualcian and the nutrition support service was consulted to clinical situations might not always fit within the frame-evaluate RT for management of PN. Upon initial nutri- work provided by these guidelines. Because of RT’s classtion assessment, it was noted that RT had been consum- III obesity, it was difficult to use traditional predictiveing a very-low-calorie liquid diet for 2 weeks in prepara- equations to determine caloric and protein requirements.tion for surgery (approximately 800 calories per day). In However, indirect calorimetry, the “gold standard,” wasaddition, she had received only maintenance intravenous unable to be performed at this time because of her highfluid support for 10 days since surgery secondary to her oxygen requirements through mechanical ventilationclinical status. Based on the nutritional history collected, (fraction of inspired oxygen 60%). The nutrition supportit was determined that vitamin/mineral intake had also service decided to adjust RT’s PN prescription to providebeen suboptimal. It was evident that RT had inadequate hypocaloric feeding with additional amino acids to pro-oral food/beverage intake (Nutrition Diagnostic Term In- mote wound healing and preservation of lean body masstake Domain 2.1) related to preoperative liquid diet con- (Table) (4). PN was initiated on postoperative day 10 andsumption, as evidenced by reported insufficient intake of provided 7.5 kcal/kg of actual body weight obtained beforeenergy (approximately 800 calories per day). On physical hospitalization, and 2.8 g/kg protein of ideal body weight.examination, RT was found to have low muscle tone in Although RT was in acute renal failure, she started toboth upper and lower extremities secondary to her pre- produce urine and it was determined that the benefits ofsurgical physical inactivity, and her family reported that meeting her increased protein needs for healing out-she had not been able to walk for many years because of weighed the need for protein restriction for her acuteher morbid obesity and worsening arthritis. Applying renal failure at this time. RT received a tracheostomy onSubjective Global Assessment, RT’s nutritional status postoperative day 15 because of prolonged intubation.was categorized as normal at admission; however, she After 11 days of PN, RT’s renal function continued towas deemed at high nutrition risk because of the com- decline and she became azotemic; her blood urea nitrogenplexities of providing adequate nutrients, her increased increased to 105 mg/dL (37.5 mmol/L). As a result, thepostoperative energy and protein needs, and her altered amount of protein in her PN prescription was decreasedgastrointestinal anatomy (4). It was evident that RT had to 1.9 g/kg of ideal body weight.altered gastrointestinal function (Nutrition Diagnostic On postoperative day 23, RT returned to the operatingTerm Clinical Domain 1.4) related to postoperative anas- room because of increased output that appeared to be November 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1735
  3. 3. succus from her abdominal wound. In the operating room, charge, no plans for enteral nutrition were in place be-she was found to have multiple small bowel fistulae and cause she had evidence of multiple small bowel and co-one colonic fistula. Because of the friable nature of the lonic fistulae. Upon discharge, it was determined that thebowel walls at the time, repairs of the fistulae were not surgeon would continue to care for RT at the long-termperformed. Instead, small surgical drains were placed acute care facility for continuity of care; the cliniciannear the fistulae for decompression and monitoring pur- communicated with the surgeon to ensure that RT wouldposes. On postoperative day 26, in light of an improve- transition to enteral nutrition as soon as medically feasi-ment in RT’s renal function, with blood urea nitrogen of ble pending closure of the multiple small bowel and co-39 mg/dL (13.9 mmol/L) and serum creatinine down to 1.7 lonic fistulae. The clinician also communicated with themg/dL (150.3 mol/L), the protein content of her PN nutrition support clinician at the long-term acute careprescription was increased back to 2.8 g/kg to facilitate facility to continue monitoring for weight loss of 1 to 2 lbhealing of her multiple intestinal fistulas. On postopera- per week with routine nitrogen balance studies to assuretive day 28, indirect calorimetry was conducted, revealing adequate protein provision to promote wound healing.her resting energy expenditure to be 3,480 kcal/day, witha respiratory quotient of 0.81 and a coefficient of varianceof 10%, indicating a good measurement. Because the DISCUSSIONPN was providing only 2,050 kcal/day with 155 g protein Nutrition support in the critically ill patient can be chal-per day, this created a 1,430 caloric deficit per day. On lenging; however, nutrition support in the critically illpostoperative day 29, a 24-hour urine collection for urine patient who is morbidly obese is even more difficult. Thisurea nitrogen was initiated; however, because of changes case report highlights the complexities in determiningin her intravenous medications, erroneous nitrogen bal- appropriate nutrition support for an individual with classance results were obtained, which were deemed unusable III obesity (BMI of 103 at admission) who developed mul-for clinical application. On postoperative day 35, RT’s tiple surgical complications of the gastrointestinal tract,blood urea nitrogen level again had been rising; therefore, with a prolonged intensive care unit stay for respiratorythe protein in her PN was decreased to 2.3 g/kg to prevent failure, sepsis, and acute renal failure. It has been shownazotemia. Her prealbumin level had also decreased from that positive nitrogen can be achieved in the obese during15 to 7 mg/dL (150 to 70 mg/L), which was thought to be critical illness when fed hypocalorically (13 to 21 kcal/kgcaused by a new infection secondary to her low-grade of actual body weight) with adequate provision of proteintemperatures, slowly increasing white blood cell count, (1.9 to 2.1 g/kg of ideal body weight) (5-7). Although theand intermittent hypotension. Blood cultures and abdom- existing literature provides some level of guidance forinal wound cultures were obtained on the same day with caloric and protein provision in the morbidly obese, therepositive infectious bacterial growth from both blood and is a paucity of research on how to optimally feed thewound cultures. In patients undergoing hemodialysis, ni- critically ill obese. The existing literature is limited bytrogen balance can be assessed by collecting and analyz- small sample sizes and the combination of differenting nitrogen losses through dialysate to calculate total classes of obesity (BMI range 33 to 51). Collectively, thisnitrogen appearance. However, during RT’s acute renal makes extrapolation to patient care difficult, especially infailure, dialysis was not initiated; therefore, total nitro- individuals who have a higher BMI than those includedgen appearance could not be assessed. During the next 2 in these studies (5-7). A clinical decision was made toweeks, RT’s clinical condition stabilized, infections were provide a lower-caloric prescription than used in the stud-treated with antibiotics, her abdominal wound started to ies (7.5 kcal/kg) because RT’s BMI was essentially twicedevelop granulating tissue, and her renal function con- that of the highest BMI included in these studies; addi-tinued to improve. A second 24-hour urine for urine urea tional protein was also prescribed (2.8 g/kg) as a highernitrogen was successfully completed to assess nitrogen caloric deficit was created for RT.balance. RT was found to be in even nitrogen balance, When providing nutrition support to the morbidlywith net balance of positive 0.6 g; it was decided at that obese individual in the intensive care unit with calorictime that the current PN prescription was appropriate deficit and additional protein, it is often difficult to bal-and no changes were necessary. Serum levels of trace ance the increased protein needs for the promotion ofelements were also studied as RT had been on PN for wound healing and decreased protein tolerance second-more than 1 month with additional succus output, and all ary to acute renal failure. It is also difficult to determinevalues were found to be within normal limits. Plasma the appropriate amount of caloric deficit without increas-zinc was found to be 1,030 g/L (157.6 mol/L) (normal ing the likelihood of protein catabolism and resultantrange 600 to 1,300 g/L [91.8 to 198.9 mol/L]); whole lean body wasting. In this case report, RT did not haveblood selenium was 131 g/L (1.66 mol/L) (normal excessive gastrointestinal output causing additional pro-range 120 to 200 g/L [1.52 to 2.54 mol/L]); whole tein losses; however, an astute clinician should alwaysblood manganese was 13 g/L (237 nmol/L) (normal monitor for all possible excessive body fluid losses thatrange 7 to 16 g/L [127 to 291 nmol/L]). Throughout can lead to additional protein depletion. These lossesRT’s hospitalization, blood glucose was controlled with a must be accounted for in the total nitrogen balance cal-continuous insulin infusion to maintain glucose levels at culation and the nutrition support prescription. It hasthe institution’s goal glucose levels (80 to 120 mg/dL [4.44 been found by Cheatham and colleagues that a substan-to 6.66 mmol/L]). tial amount of protein (2 g/L) can be lost through abdom- On postoperative day 56, RT was discharged to a long- inal fluids, which further validates the need to quantifyterm acute care facility for continued ventilator support, additional protein losses of body fluids (8). However, nopotential weaning, and rehabilitation. At the time of dis- other studies have been conducted to further validate1736 November 2010 Volume 110 Number 11
  4. 4. and/or evaluate protein losses of body fluids, especially in Referencesindividuals with morbid obesity. 1. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Co- chrane Database Syst Rev. 2009 Apr 15;(2):CD003641. Review. 2. Kumpf VJ, Slocum K, Binkley J, Jensen G. Complications after bari-CONCLUSIONS atric surgery: Survey evaluating impact on the practice of specializedRYGB is typically a safe procedure with low complication nutrition support. Nutr Clin Pract. 2007;22:673-678.rates; however, when complications occur, nutrition sup- 3. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Col- lazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R,port is often necessary because rapid declines in nutri- Sarwer DB, Anderson WA, Dixon J, Guven S; American Association oftional status can occur. It is the nutrition support clini- Clinical Endocrinologists; Obesity Society; American Society for Met-cian’s obligation to recognize and communicate this acute abolic and Bariatric Surgery. American Association of Clinical Endo-change in nutritional status and to provide adequate crinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery Medical guidelines or clinical practice for thenutrition as soon as medically feasible using evidence- perioperative nutritional, metabolic, and nonsurgical support of thebased guidelines. Malnutrition in the morbidly obese is bariatric surgery patient. Obesity (Silver Spring). 2009;17(suppl 1):S1-commonly underappreciated because of the obvious large S70.body habitus, resulting in a false representation of the 4. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; A.S.P.E.N. Board ofindividual’s metabolically active lean body mass stores. Directors; American College of Critical Care Medicine; Society of Crit-Despite multiple postoperative complications from her ical Care Medicine. Guidelines for the provision and assessment ofRYGB procedure, the nutrition support provided to RT nutrition support therapy in the adult critically ill patient: Society offacilitated wound healing and eventual progression to Critical Care Medicine and American Society for Parenteral and En- teral Nutrition. J Parenter Enteral Nutr. 2009;33:277-316.rehabilitation. This case highlights the need for addi- 5. Dickerson RN, Rosato EF, Mullen JL. Net protein anabolism withtional research efforts to elucidate appropriate caloric hypocaloric parenteral nutrition in obese stressed patients. Am J Clindeficit, protein provision, and micronutrient supplemen- Nutr. 1986;44:747-755.tation in the morbidly obese who experience postopera- 6. Burge JC, Goon A, Choban PS, Flancbaum L. Efficacy of hypocaloric total parenteral nutrition in hospitalized obese patients: A prospective,tive complications and require specialized nutrition sup- double-blind randomized trial. J Parenter Enteral Nutr. 1994;18:203-port to maximize the recovery process. 207. 7. Choban PS, Burge JC, Flancbaum L. Hypoenergetic nutrition supportSTATEMENT OF POTENTIAL CONFLICT OF INTEREST: in hospitalized obese patients: A simplified method for clinical appli-No potential conflict of interest was reported by the cation. Am J Clin Nutr. 1997;66:546-550. 8. Cheatham ML, Safcsak K, Brezinski SJ, Lube MW. Nitrogen balance,author. protein loss, and open abdomen. Crit Care Med. 2007;35:127-131. November 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1737

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