- The 77-year old female patient was admitted to the hospital for vomiting blood and abdominal pain. She suffered from multiple comorbidities and underwent several surgeries previously. - During her 13-day hospital stay, she developed several complications including ileus, sepsis, pneumonia, and small bowel obstruction. Her condition continued to decline despite treatment. - She passed away after being placed on comfort care measures only. Her complex medical history and multiple postoperative complications ultimately led to her death.

1. Case Ileus 1
Case Ileus
Allison Kliewer
Baptist Health System Dietetic Internship
March 28, 2013

2. Case Ileus 2
Case Ileus
Life expectancy in developed countries has almost doubled within the last 100 years and
now ranges from 76-80 years (Hiranyakas, 2011). The population aged over 65 years is
predicted to increase from 40 million in 2010, to 55 million in 2020 which is a 38 percent
increase since 2000 (Hiranyakas, 2011). This increase in the elder population will by necessity,
increase the number of surgical procedures and number of hospital stays. Elderly patients have
a higher complication of disease and have an increased need for more complicated and invasive
procedures which increase length of stay at the hospital and increase cost (Kuy, 2011). It is
important that these patients are properly cared for and given the best healthcare in order to
reduce hospital length of stay, costs to the patient, and related morbidity and mortality. The
following reading will discuss current literature and the clinical care of an elderly woman who
presented with ileus and associated complications.
Patient Profile
The 77 year old female was admit to North East Baptist Hospital on the twenty-fifth of
January, 2013. The patient stayed in the hospital for 13 days and was pronounced dead on the
sixth of February, 2013. She was brought to the hospital by her friend for vomiting blood. The
patient had been vomiting all night and felt weak. She complained of mid-epigastric abdominal
pain and generalized weakness. The patient had a remarkable past medical history of
cerebrovascular accident, sacral fracture, hypertension, dyslipidemia, coronary artery disease,
osteoporosis, and deconditioning. The patient had a past surgical history of hernia repair,
hysterectomy, diskectomy, exploratory surgery and pyloroplasty from duodenal ulcer in 2007, a

3. Case Ileus 3
cholecystectomy in 2007, and a recent sacroplasty in October of 2012. Family history includes
mother deceased at age 86 from a massive myocardial infarction, and father deceased from
metastatic prostate cancer. The patient experiences hallucinations when taking hydrocodone,
but is able to tolerate Tylenol with codeine, so it is not a true allergy, per se. Patient denies
history of melena, syncopal episodes, easy bruising or bleeding, chest pain, shortness of breath,
and history of bright red blood per rectum or hemorrhoids. The patient takes Ecotrin daily at
325 mg for her heart condition, codeine for body aches, and is a chronic aspirin user. She lives
in independent living and does not drink, smoke, or use drugs. She has two daughters and a
friend. The patient was underweight upon admittance with a body mass index of 16.8, at a
height of 66 in and 47.3 kg. Her ideal body weight (IBW) was 59 kg and she was at 80 percent of
IBW.
Course of Treatment
On day one of admission the impression of the patient’s condition was that of an acute
upper gastrointestinal tract bleed with associated hematemesis coffee ground in nature. The
bleed was considered to possibly be related to aspirin use. The patient was put on a nil by
mouth (NPO) status with IV fluids, proton pump inhibitors, and Protonix twice daily. The aspirin
regimen was discontinued as well as the Fosomax which the patient was taking for
osteoporosis. Fosomax was discontinued because it can cause additional gastrointestinal upset.
Other medications were continued for urinary retention, Baclofen, Claritin, and Codein for pain.
Within the next two days of stay the patient had an endoscopy and she was found to have an
upper gastrointestinal bleed secondary to erosive induced gastritis and esophagitis. The patient

4. Case Ileus 4
tolerated the procedure well but after continued with nausea and vomiting while feeling weak
and dizzy. The patient was tolerating a clear liquid diet but did not have an appetite. The
patient developed fever and following fever workup was found to have left lobe pneumonia
and was started on Levequin. On the fourth day of stay the patient was advanced to a full liquid
diet while still experiencing nausea and vomiting.
The patient continued on the fifth day with loss of appetite and was evaluated for a
skilled nursing facility (SNF), but the patient refused to go to a SNF. It is important to note that
the patient had previously refused SNF placement following a cholestectomy. Kuy and colleges
(2011) found that following a cholecystectomy, a large portion of elderly patients required
home health care support, institutional short-term rehabilitation, and nursing home care
following discharge, which may increase the risk of post-discharge mortality. On the sixth day of
stay the patient was noted to need full assisted living and nutritional supplements. The patient
was not able to tolerate PO diet.
A dietary consult was received on the seventh day of the patients stay for nutritional
supplements. The patient continued with feculent vomiting and was nauseated. She was put on
Zofran for nausea and vomiting and Megace to increase her appetite. The patient had been
receiving medication for nausea but the medication was not working, so Zofran was added to
the medication list. The patient was given an enema for constipation.
Early in the morning on the eighth day of stay the patient developed respiratory distress
and was transferred to the intensive care unit (ICU) and put on BIPAP. She had been
experiencing an increased occurrence of vomiting. After assessment in the ICU the patient was

5. Case Ileus 5
diagnosed with erosive esophagitis and gastritis, aspiration pneumonia, ileus, sepsis secondary
to pneumonia, hypoxia, hypokalemia, hypophosphatemia, hypomagnesaemia, and leukopenia.
Her antibiotics were broadened to include Zosyn and Levaquin and the patient was also started
on pressors for hypertension. Sepsis was treated along with fluid replacement as hypertension
was likely related to volume depletion given the high amount of vomit. For hypoxia, the plan
was to begin her on a high flow system as opposed to BIPAP which she would possibly tolerate
better. The ileus is considered to be multifactorial and related to decreased mobility and low
electrolytes. The patient was given a PICC line and speech therapy was consulted for a swallow
evaluation.
The patient was seen by a gastrointestinal doctor when in the ICU, and dietary received
a consult for TPN. The patient’s primary diagnosis was ileus rule out obstruction and the patient
met the ASPEN guidelines for TPN with the following: patient does not have functioning bowel,
and patient has a nonfunctional gastrointestinal tract with expected need for parental nutrition
for at least seven days.
On the eighth day of stay, the patient passed her swallow evaluation and was okayed
for a regular diet with thin liquids. Although the swallow function was working properly, the pt
was still unable to tolerate oral feeds and was put on TPN. At this point the patient began to
experience altered blood glucose, and insulin was added to her medications. Over the next four
days the patient was increased from level I sliding scale insulin to level III and insulin was
increased in her TPN as well. Significant Lab values can be viewed in Table I. The patient’s
respiratory failure continued along with sepsis, ileus, and a new diagnosis of small bowel

6. Case Ileus 6
obstruction. On the eleventh day of stay the pt was intubated and sedated due to her
decreasing respiratory status.
The twelfth day of stay was remarkable to the beginning of trophic feeds while
continuing on TPN. On the final day of life the patient failed another trial to extibate on BIPAP,
and possibly developed acute respiratory failure. After discussion with the family, the patient
was put on supportive comfort care and declared do not resuscitate (DNR). The patient
deceased at 15:37 on February sixth, 2013.
Sepsis
The term sepsis is used when a patient has an infection and an identifiable organism
(Wilker and Malone, 2008). Sepsis leads to the release of cytokines, proteolytic enzymes, or
toxic oxygen species and activate the inflammatory cascade (Wilker and Malone, 2008). Sepsis
further complicates ileus by worsening gut dysfunction. The alterations in the intestinal gut
barrier function in association with malnutrition are thought to occur through weight loss and
villous atrophy (Wilker and Malone, 2008).
Intensive Care Unit
Patients enter the ICU due to cardiopulomonary diagnosis, intraoperative or
postoperative complication, multiple traumas, burn injury, or sepsis (Wilker and Malone, 2008).
Critical illness is associated with catabolic stress state most commonly demonstrated with
systemic inflammatory response and complicated with infectious morbidity, multi-organ
dysfunction, prolonged hospitalization, and disproportionate mortality (McClave, 2009). The

7. Case Ileus 7
Table I
SignificantLabValues
25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb
Glucose 140 H 141 H 173 H 261 H 357 H 177 H 133 H 122 H
WBC 13.47 H 22.89 H 28.60 H 15.33 H 16.01 H
Lipase 16 L
Potassium 3.3 L 3.0 L 3.2 L 3.1 L 2.8 L 2.9 L 5.2 H 3.1 L
RedBloodCells 3.73 L 3.48 L 2.82 L 2.87 L 2.50 L 3.33 L
Hemoglobin 11.2 L 10.5 L 8.5 L 8.6 L 10.4 L 9.8 L
Hematocrit 33.1 L 26.1 L 26.8 L 31.4 L 29.9 L
Chloride 111 H 112 H 114 H
CarbonDioxide 23 L 19 L 21 L 22 L 19 L 32 H
Calcium 7.3 L 7.6 L 7.7 L 7.0 L 7.0 L 8.3 L 7.8 L
Albumin 2.5 L 2.6 L 2.5 L 1.9 L 1.7 L 1.4 L 1.5 L 1.3 L 1.5 L
Phosphorus 1.3 L 1.9 L 2.1 L 1.1 L 7.5 H 4.6 H
BloodUrea Nitrogen 8 L 7 L 34 H 42 H
Magnesium 1.7 L 1.5 L
Creatine 0.46 L
Note: Valuesare displayedasthe actual value withan H for highvaluesandL for lowvalues.All cells
that are blankindicate missingvaluesorvalueswithinnormal limits.

8. Case Ileus 8
ICU patients often have numerous catheters for intravenous fluids and invasive hemodynamic
monitoring, as well as tubes for drainage of body fluids (Wilker and Malone, 2008). Nutritional
assessments in the ICU do not follow traditional methods and require more time and attention,
mostly due to the patient’s condition and inability to provide dietary history. Weight values may
be erroneous after fluid resuscitation, and anthropometric measurements are not easily
attainable, nor are they sensitive to acute changes (Wilker and Malone, 2008). Serum albumin
may be altered as a result from the effects of undernutrition and the severity of illness or the
underlying disease and other plasma proteins can be altered due to the inflammatory response
and shifts in body fluid (Wilker and Malone, 2008). The difficulty in conducting a nutrition
assessment requires clinical judgment when deciding on nutrition support. The ICU nutrition
assessment focuses on the preadmission, preoperative, or preinjury nutrition status, the need
presence of any organ dysfunction, the need for early nutrition support, and options for enteral
or parenteral access (Wilker and Malone, 2008). Laboratory data is used in the critically ill
patient to design the nutrition prescription, rather than define or determine nutrition status
(Wilker and Malone, 2008).
Practice in ICU patients worldwide shows a significant underfeeding with hospital
nutrition protocol despite observational research shows that the amount of energy and protein
received during the early stages of ICU admission impacts patient mortality (Heyland et al,
2010). The goals for nutrition support in the ICU is to minimize starvation, prevent or correct
specific nutrient deficiencies, provide adequate calories to meet energy needs while minimizing
metabolic complications, and manage fluid and electrolytes for adequate urine output and
homeostasis (Wilker and Malone, 2008). Nutrition support should begin as soon as the patient

9. Case Ileus 9
is hemodynamically stable, which includes; stabilized vital functions, balanced fluid,
electrolytes, and acid-base, and adequate tissue perfusion to allow transport of oxygen and fuel
(Wilker and Malone, 2008).
Small Bowel Obstruction
Scarring from GI surgeries may partially or completely obstruct the GI tract of result in
dysfunctional segments (Beyer, 2008). When sections of the GI tract are partially obstructed or
are not moving appropriately, obstructions from food may occur causing prolonged bloating,
abdominal distention, pain, nausea and vomiting (Beyer, 2008). Some intestinal obstruction
may require clear liquids or total restriction of food an parenteral nutrition with fluid may be
needed (Beyer, 2008).
Coffee Ground Emesis
In the United States there are over 300,000 cases of hospital admissions for upper
gastrointestinal bleeds (Bou-Abdallah, 2012). Blood loss from the GI tract is manifested as
hematemesis or bloody coffee grounds (Bou-Abdallah, 2012). The treatment and initial
management of acute upper GI bleed is identical regardless of the mode of presentation and
usually involves stabilization of hemodynamic status (Bou-Abdallah, 2012). A recent case report
by Bou-Abdallah and colleagues (2012) found six patients admit for coffee ground emesis led to
other more severe complications including new-onset atrial fibrillation, ICU admits, pulmonary
emboli, ileus, and small bowel obstruction. The study showed that diagnosis and management
of the other complications were delayed due to the standard management given to patients
diagnosed with acute upper GI bleed (2012). Despite early endoscopy that has shown to have

10. Case Ileus 10
an impact on hospital admission, length of hospital stay, and transfusion requirements, in
patients presenting with coffee ground emesis endoscopy does not predict further
complications (Bou-Abdallah, 2012).
Ileus
Ileus refers to the partial or complete blockage of the small and/or large
intestine due to impaired peristalsis or because of a mechanical obstruction (Madl and Druml,
2003). There is no standardized definition of ileus for diagnosis and is often difficult to
distinguish between a small-bowel obstruction (SBO) radiologically (Allen et al, 2012).
Diagnostic imaging studies and abdominal X-rays are most commonly used to diagnose and
help differentiate ileus from bowel obstruction (Allen et al, 2012). Symptoms, caused by altered
bowel function are characterized by lack of bowel sounds, abdominal distention, accumulation
of gas and fluids in the bowel, decreased or absent defecation, nausea, vomiting, decreased GI
passage, and discomfort (Allen et al, 2012; Madl and Druml, 2003). Ileus is multifactorial in
origin and causative factors include neurogenic, inflammatory, hormonal, and pharmacologic
influences (Senagore, 2010). The neurogenic component relates to pain induced neural reflexes
which result in sympathetic hyperactivity and inhibition of gastrointestinal activity (Sengagore,
2010). Surgical manipulation can cause ileus by activating a number of inflammatory cascades,
which further exacerbate the effects of exogenous opiod analgesics given for analgesia, and
inhibit bowel function (Sengagore, 2010). Hormonal influence on ileus is mediated as a
response to trauma and pain medication may further impair GI motility (Sengagore, 2010).

11. Case Ileus 11
Ileus itself is not life-threatening but can lead to other complications, increased hospital
length of stay and healthcare resource utilization cost (Sengagore, 2010). Treatment usually
includes nasogastric decompression, diet reversal for symptom relief, hydration, antiemetics,
and restoring electrolyte balance (Allen et al, 2012). The abdominal distention increases the risk
of hernia formation and wound dehiscence, and nausea and vomiting impacts the possibility of
feeds and increases the risk for malnutrition and impaired wound healing (Sengagore, 2010).
Prolonged venous access and the need for nasogastric decompression inhibit ambulation and
can increase rates of pulmonary complications and thromboembolus (Sengagore, 2010).
Increased lengths of stays at hospitals also places a burden economically and raise issues with
hospitals of limited beds and high inpatient demand (Sengagore, 2010).
Gastric motility impaired by ileus can last over five days, and may required total
parenteral nutrition or TPN (Wilker and Malone, 2008). However, because of the demonstrated
benefits of enteral nutrition (EN), tube feeds can often be administered simultaneously with
TPN at low rates to maintain gut intergrity and preserve intestinal mucosa while providing
adequate nutrition (Wilker and Malone, 2008).
Pathophysiology
Ileus has been described as a chaotic activity of individual cells with a loss of
synchronization and impaired peristalsis (Madl and Druml, 2003). The associated increased in
luminal pressure can lead to gut wall ischemia and cause increased intra-abdominal pressure
(Madl and Druml, 2003). Intra-abdominal hypertension has been found in up to 20 percent of
critically ill patients and may lead to multiple complications including cardiovascular, hepatic,

12. Case Ileus 12
pulmonary, renal, and neurological dysfunction (Madl and Druml, 2003). Gastrointestinal
dysmotility may result in increased luminal pressure with intestinal dilatation, releasing nitric
oxide which is a known inhibitor of smooth-muscle tone (Madl and Druml, 2003). During
inflammation neutrophils invade the muscle layer of the gut wall and damage the muscle by
releasing proteolytic enzymes and cytokines (Madl and Druml, 2003). The inflammatory
response leads to the release of nitric oxide in the intestinal muscle layer, paralyzing the muscle
cells and aggravation the intestinal dilatation (Madl and Druml, 2003). The amount and activity
of nitric oxide synthase directly correlates to the severity of intestinal dilatation, and
consequently the severity of gut ischemia (Madl and Druml, 2003). Gut ischemia leads to an
uptake of cytokines and other inflammatory mediators which contribute to the systemic
symptoms of ileus and correlate with the severity of ileus (Madl and Druml, 2003).
Etiology
There is not one known cause of ileus and can be due to a blockage in the small or large
intestine as well as a mechanical or paralytic bowel obstruction (Madl and Druml, 2003).
Disorders associated with a mechanical bowel obstruction can be located outside the gut wall,
within the gut wall, or intraluminal (Madl and Druml, 2003). A paralytic ileus may affect all parts
of the GI tract and is one of the most common complications in critically ill patients (Madl and
Druml, 2003). The cause of a paralytic ileus may be an adverse consequence of a surgical
procedure, use of opiods or catecholaminces, intraperitoneal of retroperitoneal infection,
edema or ascites secondary to massive fluid resuscitation during septic shock, or toxic shock
with capillary leakage, acute bacterial or parasitic intestinal infection, toxic megacolon, arterial

13. Case Ileus 13
or venous injury, intra-abdominal hematomas, or metabolic disturbances (Madl and Druml,
2003). In the critically ill, the degree of impairment of intestinal motility is tightly correlated to
the severity of illness and mortality (Madl and Druml, 2003).
Systemic Consequences
Aspiration
Impaired motility of intestinal contents promotes reflux of intestinal juice of the small
intestine back into the stomach and increases gastric residuals (Madl and Druml, 2003). This
allows for colonization of intestinal bacteria and ascension of microorganisms into the
esophagus, pharynx, and tracheobronchial tree (Madl and Druml, 2003). This along with
vomiting and aspiration increases the risk of evolution of pneumonia (Madl and Druml, 2003).
Hypovolemia
Distention, increased intraluminal pressure, and increased intra-abdominal pressure
impair microcirculation and ultimately result in fluid sequestration into the intestinal wall and
intestinal lumen (Madl and Druml, 2003). The fluid sequestration into the third space can result
in hypovolemia and circulatory impairment and can further aggravate various systemic
consequences of ileus (Madl and Druml, 2003).
Bacterial Overgrowth and Translocation
Ileus is associated with alterations in intestinal flora with an overgrowth of bacteria
(Madl and Druml, 2003). The impaired protective mucosal layer may allow microorganisms and
or endotoxins/exotoxins to invade the mucosa, cause mucosal inflammation, and increase

14. Case Ileus 14
mucosal perfusion and hypersecretion (Madl and Druml, 2003). Medication has an impact on
bacterium and can promote bacterial selection and overgrowth resulting in antibiotic-induced
diarrhea or colitis, and can promote bacterial translocation (Madl and Druml, 2003).
Bacterial translocation refers to the permeation of viable microorganisms, fragments of
microorganisms, or macromolecules through an intact or injured intestinal wall into the
lymphatic systemand/or intestinal venous circulation, such as the liver, spleen, kidney and
bloodstream (Madl and Druml, 2003). Intestinal bacteria is important to mature the immune
system and prompt the proper inflammatory responses but can become compromised when
there is an overgrowth of abnormal bacteria and/or the barrier function of the intestinal wall is
impaired (Madl and Druml, 2003). Bacterial overgrowth, increased permeability in the
intestinal mucosal barrier, and deficiencies in host immune defenses synergistically promote
the spread of indigenous translocation bacteria to cause lethal sepsis (Madl and Druml, 2003).
When the mucosal epithelium is damaged, indigenous bacteria translocate intercellularly
between the epithelial cells to directly access the blood. Sepsis can result with a spillover of
microorganisms into the lymphatic systemvia the vena cava superior into the circulation and
the lung, and/or spillover into the portal circulation promoting evolution of systemic infections
and septicemia (Madl and Druml, 2003).
Bacterial overgrowth, inflammation and impairment of barrier function of the intestinal
wall, and impairment of systemic immunocompetence are the three determinants of
translocation involved with ileus (Madl and Druml, 2003). Mucosal functions are further
compromised with a reduced mesenteric blood flow and increased intra-abdominal pressure

15. Case Ileus 15
(Madl and Druml, 2003). Therefore, treatment should be aimed particularly at preserving
intestinal functions in intensive care patients (Madl and Druml, 2003).
Pulmonary
Raised intra-abdominal pressure results in increased intrathoracic pressure and affects a
broad pattern of respiratory functions (Madl and Druml, 2003). Increased intra-abdominal
pressure can drop pulmonary residual capacity and may affect lung mechanics and decrease
lung compliance which promotes development of atelectasis and increased intrapulmonary
shunt (Madl and Druml, 2003). Increased pressure can negatively affect breathing and
significantly increased alveolar pressure and influence gas exchange (Madl and Druml, 2003).
Nutrition Therapy
Adequate hydration status is important to support cardiovascular function with ileus
(Madl and Druml, 2003). Maintenance of intestinal motility is a goal for a critically ill patient
with ileus and can be managed by prophylactic measures, motility medications, and early EN
(Madl and Druml, 2003). Early EN, even low in low or minimal amounts has been shown to
maintain intestinal functions, perfusions, motility, and barrier functions (Madl and Druml,
2003). Enteral diets containing dietary fiber can promote motlility, formation of short-chain
fatty acids through fermentation by bacteria, and reduce translocation (Madl and Druml, 2003).
Enteral diets including prebiotics has been shown to support intestinal barrier functions, to
reduce mucosal inflammation by inhibiting the adherence of pathological microorganisms to
the mucosal surface, and to prevent antibiotic-induced intestinal complications (Madl and
Druml, 2003).

16. Case Ileus 16
Feedings
After being NPO for a period of time, many patients do not have an appetite, suffer
from dry mouth, experience taste alterations, are too tired or weak to eat, are in an
uncomfortable position in bed, are in pain, and may require EN to meet their nutritional needs
(Klos). Psychological factors may influence a patient’s willingness to eat, such as stress caused
by being in a hospital and the fear of returned intestinal pain that might occur after the
reintroduction of oral food (Klos). Medications are also the cause of additional nausea,
diarrhea, constipation, dry mouth, and altered appetite that can influence a patients will to eat
(Klos).
Enteral nutrition is the preferred route of nutrition support, with PN reserved for
patients whom adequate EN is not possible (Sriram, 2009). Enteral nutrition has been shown to
decrease infectious complications and is more cost effective when compared to PN (Sriram,
2009). Parenteral nutrition should be used only when the GI tract is not anatomically adequate
or not functional, the GI tract cannot be accessed, or when nutritional requirements cannot be
completely met with EN (Sriram, 2009).
When a patient receives parenteral nutrition (PN), the ultimate goal is to transition back
to enteral nutrition (EN) or oral feeds (Klos). Parenteral nutrition is used when the
gastrointestinal tract is nonfunctional or cannot be accessed, such as small bowel resection,
radiation enteritis, high output enterocutaneous fistula, and paralytic ileus (Klos). Mucosal mass
and function of the ileum and jejunum significantly decrease, as well as intestinal digestive
enzyme activity and exocrine pancreatic function during total PN (Klos). After a period of time

17. Case Ileus 17
on NPO, the return of the GI function is slow and requires time and effort to resume tolerance
to a normal diet (Klos).
Enteral nutrition has been shown to support intestinal structure and function, prevent
increased permeability, bacterial translocation, and systemic inflammation (Rice et al, 2011).
Enteral nutrition has also been shown to attenuate hypermetabolism of critical illness, decrease
infectious complications, and shorten ICU stays compared to PN, and reduce mortality (Rice et
al, 2011). Overall, EN stimulates epithelial cell growth and proliferation, maintains mucosal
mass and microvilli height, preserves tight junctions between epithelial cells, and promotes
blood flow; all of which are absent with ileus (Rice et al, 2011).
Trpohic feeds refers to small volume enteral feeds in order to stimulate the GI tract by
improving gastrointestinal enzyme activity, hormone release, blood flow, motility, and
microbial flora (Mishra et al, 2007).
Literature
Rice and colleagues (2011) conducted a randomized, open-label study to test the hypothesis
that initial trophic feeds would decrease episodes of gastrointestinal intolerance/complications
and improve outcomes as compared to initial full-energy EN in patients with acute respiratory
failure. The study included 200 patients with acute respiratory failure expected to require
mechanical ventilation for at least 72 hours who randomly received either trophic feeds at 10
ml an hour, or full energy EN for the initial six days of ventilation. Primary outcome measures
included; ventilator-free days to day 28, ICU-free days, mortality, episodes of diarrhea, and
episodes of elevated gastric residual volumes. Rice found that initial trophic EN resulted in

18. Case Ileus 18
similar clinical outcomes in mechanically ventilated patients with acute respiratory failure as
early full-energy EN but with significantly fewer episodes of gastrointestinal intolerance (2011).
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome
Clinical Trials Network (2012) conducted a very similar randomized open-label design study
with 1000 adults across 44 hospitals that within 48 hours of developing acute lung injury
required mechanical ventilation. The purpose was to determine if initial trophic feedings would
increase ventilator-free days and decrease gastrointestinal intolerances compared with initial
full EN. Outcomes measures included; ventilator-free days to day 28, 60-day mortality,
infectious complications, vomiting, gastric residual volumes, constipation, plasma glucose
values and insulin administration. It was concluded that trophic feeds did not improve
ventilator-free days, 60-day mortality, or infectious complications but was associated with less
gastrointestinal intolerance (2012).
There is a lack of conclusive evidence regarding the caloric dose required for the critically ill.
The two studies show that more research is needed to determine the role of trophic feeds in
ventilated patients and possibly challenge hospital nutritional standards for the critically ill
patient.
Nutrition Care Process
The patient was consulted on January, 31, 2013 after a referral from a nurse because the
patient was not eating. The patient was found with limited appetite because she could not keep
her food down. At that time the patient only had an appetite for a milkshake. That day the
patient was given different medications for nausea and vomiting because the other medications

19. Case Ileus 19
seemed to be ineffective. The patient was at 80 percent IBW had a BMI of 16.8, and met
guidelines to be clinically underweight. The patient was receiving adequate fluids with normal
saline at 75 ml per hour. She was assessed for weight gain and her calculated needs were 1420
to 1655 calories per day at 30 to 35 calories per kilogram actual body weight, and 56-71 grams
protein per day at 1.2 to 1.5 gram per kilogram actual body weight. Her nutrition status was
severely compromised with inadequate oral food intake related to her current condition as
evidence by intake record, BMI, and albumin lab values. Dietary intervention was to send
meals, snacks and supplements, and Mighty Shake was recommended twice daily to
supplement oral intake. The outcome set for the patient was to meet over 95 percent of
estimated nutritional needs (ENN), maintain lean body mass, protein profile to trend towards
normal, and to maintain skin integrity.
On the first of February the patient was referred from a physician for TPN assessment.
The patient met ASPEN criteria for TPN with a nonfunctional GI tract (ileus). It was
recommended the patient begin feeds at 85 grams protein, 275 grams dextrose, and 40 grams
of lipids to provide a total of 1675 calories, 85 grams of protein with a 2.3 glucose infusion rate
(GIR). The GI doctor was to write daily TPN orders.
The final nutrition assessment was made on the fifth of February for a follow up
evaluation. The patient had been receiving TPN of 100 grams protein, 300 grams dextrose, and
40 grams of lipids. As discussed previously with the GI doctor on the case, the patient was to
begin trophic feeds. The doctor ordered Pulmocare at 20 ml an hour in addition to the TPN
feeds and would hold for nasogastric residuals over 200 ml. Calculated needs were adjusted

20. Case Ileus 20
and needs were set at 1298 to 1593 calories at 22 to 27 calories per kilogram IBW and 88 to 118
grams protein at 1.5 to 2.0 grams per kilogram IBW. The nutrition status of the patient
remained severe due to an altered GI function related to ileus as evidence by PN and EN. The
nutrition intervention was requesting prealbumin and recommending trophic feeds with Vital
AF 1.2 at 20 ml an hour to help manage inflammation and promote GI tolerance. Outcomes
were that all forms of nutrition will meet over 95 percent of ENN, and that the patient would
tolerate EN feeds.
Reflection
As the patient was ultimately ventilated, it was appropriate in her case to begin trophic
feeds in hope to improve gut integrity, and to improve ileus status. Despite an unfortunate
outcome, the patient’s case provided means for an edifying research of the literature and
prevalent research questions. Effective nutritional support for critically ill patients represents a
difficult aspect of care with the complexity of the clinical status. With new research published
daily, there is a need to challenge commonly used nutritional support practices and to
individualize patient care with an evidence-based approach to achieve optimal nutrition
therapy.

21. Case Ileus 21
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