Allison KliewerBaptist Dietetic InternshipApril 10, 2013
Outline Introduction Patient Profile Disease background of Ileus Trophic feeds in the Critically Ill Admission Nutri...
Patient Profile Stay: 1/25 – 2/06 77 year old white female Lives independently Two daughters and friend Does not drin...
Pt Profile Allergy to hydrocodone PMH: CVA, sacral fracture, HTN,dyslipidemia, CAD, osteoporosis,deconditioning Past su...
Pt Profile Chief complaint: coffee ground emesis Vomited for 24 hrs before admission Midepigastric pain and weakness C...
Impression Acute upper gastrointestinal tract bleed With hematemesis, coffee ground innature NPO IV fluids Proton pum...
Ileus Refers to the partial or completeblockage of the small and/or largeintestine due to either impairedperistalsis or a...
Symptoms Nausea Vomiting Constipation Gastric Pain Discomfort Characterized by abdominal distention,lack of bowel so...
Etiology Blockage of small or large intestine Mechanical and paralytic bowelobstruction outside or within the gut wall,o...
Etiology Intraperitonial or retroperitoneal infection Edema 2/2 to massive fluid resuscitation Bacterial or parasitic i...
Pathophysiology Loss of synchronization resulting inimpaired peristalsis GI dysmotility = luminal pressure andintestinal...
Pathophysiology Dilatation and pressure = Gut wallischemia = system uptake of cytokinesand other inflammatory mediators ...
Aspiration Impaired motility promotes reflux ofintestinal juices back into stomach = gastric residuals = gastric coloni...
Hypovolemia distention and intra-luminal pressure =compromises intestinal profusion,impairs microcirculation, and ultimat...
Bacterial Overgrowth Ileus associated with alterations inintestinal flora and overgrowth ofbacteria Microorgansisms and/...
Bacterial Translocation Intestinal wall impaired or systemicimmunocompetence is compromised =spillover of microorganisms ...
Impaired Cardiac Output intraluminal pressure and intrathoracicpressure affects venous return, cardiacfilling, ventricula...
Decreased RespiratoryFunction Compressed pulmonary parenchyma Drop in functional residual capacity Negative affect on l...
Nutrition Considerations EN for restoration and maintenance ofintestinal function, perfusion, motility,and barrier functi...
Prognosis Outcome depends on the cause of theblockage Consequences and recovery time vary Underlying cause, time taken ...
Feeds in Critically Ill Associating between inadequate feedingand poor clinically outcome in critically illpatients EN h...
Enteral Nutrition Stimulates epithelial cell growth andproliferation Maintains mucosal mass and microvilliheight Preser...
Trophic Feeds Trophic feeds appropriate for patientsdeemed unsuitable for high volumeintragastric feeds Feeding small vo...
Trophic Feeds ARF affects more than 3 million pts inUS and is the single most commonreason ICU pts cannot eat Conclusive...
Trophic vs. ENStudy Design Subjects Purpose Intervention ResultsRice andcolleagues2011’03-’09Randomopen-labelstudy200 pts ...
Progression of Disease Acute Upper GI bleed with coffeeground emesis Ileus with gastritis and esophagitis Fever and lef...
Progression of Disease Ileus Erosive esophagitis and gastritis Aspiration pneumonia Hypoxia Hypokalemia, hypophosphat...
Progression of Disease Metabolic disorder Small bowel obstruction Intubated and sedated with mechanicalvent Decreasing...
Nutrition Care Process BMI: 16.8 80 % IBW N/V/C and loss of appetite Wt gain (30-35 kcal/kg actual wt) 1420-1700 kcal...
NCP Severely compromised nutrition status PES: Inadequate oral food intake relatedto her current condition as evidence b...
NCP TPN assessment Pt met ASPEN criteria for TPN withnonfunctional GI tract (ileus) Rec feeds of 85 g amino acids, 275 ...
NCP TPN + insulin + EN trophic feeds of Pulmocare @ 20ml/hr Hold for NG residuals >200 cc Adjust ENN for IBW 1300- 16...
NCP PES: Altered GI function related to ileusas evidence by PN and EN Rec continue trophic feeds with Vital AF1.2 at 20 ...
Reflection Effective nutritional support for criticallyill patients represents a difficult aspect ofoverall management of...
References Allen, A. M., Antosh, D. D., Grimes, C. L., Crisp, C. C., Smith, A. L.,Friedman, S., Mcfadden, B. L., Gutman, ...
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A kliewer case_2_presentation

  1. 1. Allison KliewerBaptist Dietetic InternshipApril 10, 2013
  2. 2. Outline Introduction Patient Profile Disease background of Ileus Trophic feeds in the Critically Ill Admission Nutrition Care Process Summary and Reflection
  3. 3. Patient Profile Stay: 1/25 – 2/06 77 year old white female Lives independently Two daughters and friend Does not drink, smoke or use drugs Family Hx: mother passed away at 86from MI; father passed away fromprostate cancer
  4. 4. Pt Profile Allergy to hydrocodone PMH: CVA, sacral fracture, HTN,dyslipidemia, CAD, osteoporosis,deconditioning Past surgical Hx: hernia repair,hysterectomy, diskectomy, exploratorysurgery and pyloroplasty form perforatedduodenal ulcer, cholestectomy andsacroplasty
  5. 5. Pt Profile Chief complaint: coffee ground emesis Vomited for 24 hrs before admission Midepigastric pain and weakness Chronic aspirin use Lungs are clear Good bowel sounds
  6. 6. Impression Acute upper gastrointestinal tract bleed With hematemesis, coffee ground innature NPO IV fluids Proton pump inhibitors d/c aspirin and Fosamax Plan endoscopy GI consult
  7. 7. Ileus Refers to the partial or completeblockage of the small and/or largeintestine due to either impairedperistalsis or a mechanical obstruction Most common complication in critically ill May affect all parts of the GI tract Degree of impairment of intestinalmotility is correlated to the severity ofillness and mortality(Madl and Druml, 2003)
  8. 8. Symptoms Nausea Vomiting Constipation Gastric Pain Discomfort Characterized by abdominal distention,lack of bowel sounds, accumulation ofgas and fluids in the bowel anddecreased GI passage with delayed orabsent defecation(Allen et al, 2012)
  9. 9. Etiology Blockage of small or large intestine Mechanical and paralytic bowelobstruction outside or within the gut wall,or intraluminal Surgical procedures(Madl and Druml, 2003)
  10. 10. Etiology Intraperitonial or retroperitoneal infection Edema 2/2 to massive fluid resuscitation Bacterial or parasitic infection Toxic megacolon Abdominal arterial injury Venous injury Retroperitoneal or intra-abdominalhematomas Metabolic disturbances(Madl and Druml, 2003)
  11. 11. Pathophysiology Loss of synchronization resulting inimpaired peristalsis GI dysmotility = luminal pressure andintestinal dilatation Intestinal dilatation leads to neutrophilsinvading and damaging muscle layer = release of nitric oxide = paralysesmuscle cells(Madl and Druml, 2003)
  12. 12. Pathophysiology Dilatation and pressure = Gut wallischemia = system uptake of cytokinesand other inflammatory mediators Inflammatory response contributes tothe systemic symptoms of ileus andcorrelates with severity of ileus(Madl and Druml, 2003)
  13. 13. Aspiration Impaired motility promotes reflux ofintestinal juices back into stomach = gastric residuals = gastric colonization with intestinalbacteria Ascension of microorganisms into theesophagus, into the pharynx, into thetrachiobranchial tree risk of pneumonia(Madl and Druml, 2003)
  14. 14. Hypovolemia distention and intra-luminal pressure =compromises intestinal profusion,impairs microcirculation, and ultimatelyresults in fluid sequestration into theintestinal wall and lumen Inflammation promotes fluid loss intoluminal space = hypovolemia and circulationimpairment(Madl and Druml, 2003)
  15. 15. Bacterial Overgrowth Ileus associated with alterations inintestinal flora and overgrowth ofbacteria Microorgansisms and/orendotoxins/exotoxins may invademucosa = mucosal inflammation, mucosalperfusion and hypersectrection(Madl and Druml, 2003)
  16. 16. Bacterial Translocation Intestinal wall impaired or systemicimmunocompetence is compromised =spillover of microorganisms into thelymphatic system and/or portalcirculation = systemic infections or septicemia Bacterial overgrowth, inflammation andimpairment of barrier function of theintestinal wall, impairedimmunocompetence(Madl and Druml, 2003)
  17. 17. Impaired Cardiac Output intraluminal pressure and intrathoracicpressure affects venous return, cardiacfilling, ventricular compliance, andcontractility cardiac output mean arterial pressure(Madl and Druml, 2003)
  18. 18. Decreased RespiratoryFunction Compressed pulmonary parenchyma Drop in functional residual capacity Negative affect on lung mechanics andchest wall ↓ lung compliance = atelectasis alveolar pressure Negative influences gas exchange(Madl and Druml, 2003)
  19. 19. Nutrition Considerations EN for restoration and maintenance ofintestinal function, perfusion, motility,and barrier function Minimal EN can help support intestinalfunction in pts whom sufficient EN isimpossible(Madl and Druml, 2003)
  20. 20. Prognosis Outcome depends on the cause of theblockage Consequences and recovery time vary Underlying cause, time taken todiagnose, and treatment Margin of complications and mortalityrange from 12 to 27% Mean length of stay is 15 days(Rojas, 2012)
  21. 21. Feeds in Critically Ill Associating between inadequate feedingand poor clinically outcome in critically illpatients EN has been shown to attenuatehypermetabolism of critical illness,decrease infectious complications, andshorten ICU stays compared to PN, andreduce mortality EN supports intestinal structure andfunction, prevents increased permeability,bacterial translocation, systemicinflammation(Heyland et al, 2010)
  22. 22. Enteral Nutrition Stimulates epithelial cell growth andproliferation Maintains mucosal mass and microvilliheight Preserves tight junctions betweenepithelial cells Promotes blood flow Enhances brush-border enzyme activity(Rice et al, 2011)
  23. 23. Trophic Feeds Trophic feeds appropriate for patientsdeemed unsuitable for high volumeintragastric feeds Feeding small volume of enteral feeds inorder to stimulate the GI tract Improves GI enzyme activity, hormonerelease, blood flow, motility, andmicrobial flora(Rice et al, 2011)
  24. 24. Trophic Feeds ARF affects more than 3 million pts inUS and is the single most commonreason ICU pts cannot eat Conclusive evidence supports earlyfeeds in the ICU Lack of conclusive evidence regardingthe caloric intake dose required for theICU pt(Rice et al, 2011)
  25. 25. Trophic vs. ENStudy Design Subjects Purpose Intervention ResultsRice andcolleagues2011’03-’09Randomopen-labelstudy200 pts withacuterespiratoryfailureexpected torequireventilation forover 72 hrsCompareclinicaloutcomes andGIcomplicationswith trophicfeeds and full-energy ENRandomlyreceivedtrophic feeds(10 ml/hr) orfull energyEN for theinitial 6 daysof ventilationTrophic feedsresulted insimilar clinicaloutcomeswith fewerepisodes ofGI intoleranceARDSclinicaltrials‘08-’11RandomOpen-labelstudy1000 pts44 hospitalsWith acutelung injuryRequiringventillationDetermine iftrophic feedswouldincreaseventillator-free days anddecrease GIintoleranceRandomlyreceivedtrophic or fullEN for first 6daysTrophic feedsdid notimprove VFD,60-daymortality, orinfectiouscomplicationsTrophic feedshad less GIintolerance
  26. 26. Progression of Disease Acute Upper GI bleed with coffeeground emesis Ileus with gastritis and esophagitis Fever and left lobe pneumonia Acute respiratory distress andtransferred to the ICU NPO Clear liquid Full
  27. 27. Progression of Disease Ileus Erosive esophagitis and gastritis Aspiration pneumonia Hypoxia Hypokalemia, hypophosphatemia,hypomagnesemia Leukopenia Sepsis Began TPN
  28. 28. Progression of Disease Metabolic disorder Small bowel obstruction Intubated and sedated with mechanicalvent Decreasing respiratory status Failed extibation to BIPAP TPN + Trophic Feeds Comfort Care
  29. 29. Nutrition Care Process BMI: 16.8 80 % IBW N/V/C and loss of appetite Wt gain (30-35 kcal/kg actual wt) 1420-1700 kcals/day 56-71 g protein (1.2-1.5 g/kg actual wt) 1420-1700 ml/day (1ml/kcal/kg actualwt)
  30. 30. NCP Severely compromised nutrition status PES: Inadequate oral food intake relatedto her current condition as evidence byintake record, BMI, and albumin labvalues Rec Mighty Shake BID
  31. 31. NCP TPN assessment Pt met ASPEN criteria for TPN withnonfunctional GI tract (ileus) Rec feeds of 85 g amino acids, 275 gdextrose, 40 g lipids Provide 1675 kcals with 2.3 glucoseinfusion rate
  32. 32. NCP TPN + insulin + EN trophic feeds of Pulmocare @ 20ml/hr Hold for NG residuals >200 cc Adjust ENN for IBW 1300- 1600 kcals (22-27 kcal/kg IBW) 88-118 g protein (1.2- 2.0 g/kg IBW)
  33. 33. NCP PES: Altered GI function related to ileusas evidence by PN and EN Rec continue trophic feeds with Vital AF1.2 at 20 ml/hr to help manageinflammation and promote GI tolerance
  34. 34. Reflection Effective nutritional support for criticallyill patients represents a difficult aspect ofoverall management of complex patients The is a need to challenge commonlyused nutritional support practices and toachieve an individualized, evidence-based approach for optimal nutritionaltherapy
  35. 35. References Allen, A. M., Antosh, D. D., Grimes, C. L., Crisp, C. C., Smith, A. L.,Friedman, S., Mcfadden, B. L., Gutman, R. E., & Rogers, R. G. (2012).Management of ileus and small-bowel obstruction following benigngynecologic surgery. International Journal of Gynecology andObstetrics.121: 56-59. Heyland, D. K., Cahill, N. E., Dhaliwal, R., Wang, M., Day, A. G.,Alenzi, A., Aris, F., Muscedere, J., Drover, J. W., & McClave, S. A.(2010). Enhanced protein-energy provision via the enteral route incritically ill patients: A single center feasibility of the PEP uPprotocol. Critical Care. 14: R78. Madl, C., & Druml, W. (2003). Systemic consequences of ileus. BestPractice & Research Clinical Gastroenterology. 17(3): 445-456. Rice, T. W., Mogan, S., Hays, M. A., Bernard, G. R., Jensen, G., L., &Wheeler, A. P. (2011) A randomized trial of initial trophic versus full-energyenteral nutrition in mechanically ventilated patients with acute respiratoryfailure. Critical Care Medicine. 39(5): 967-974. Rojas, D. J., Martinez-Ordaz, J. L., & Romero- Hernandez, T. (2012). Biliaryileus: 10-years experience. Case Series. Cirugia y Cirujanos. 80(3): 228-232.

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