Nutrition case study

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Nutrition case study

  1. 1. Bariatric Surgery Complications NUTRITION CASE STUDY WENDY THOMPSON WVU DIETETIC INTERN D E C E M B E R 2 ND, 2 0 1 3
  2. 2. Outline 2  Overview of the Patient  Sleeve Gastrectomy Surgery  Medical Nutrition Therapy for Bariatric Surgery  Nutrition Care Process of the Patient  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Monitoring/Evaluation  Follow-Ups
  3. 3. Patient Overview 3  58-year-old female  Past Medical History:  Current Medical History:  s/p Gastric Sleeve Surgery (July 2013)   Persistent Leakage  Gastric Stenting  Left Upper Quadrant Abscess    Nausea and Vomiting Leukocytosis     Morbid Obesity (BMI 45 pre-surgery) Hypertension Hyperlipidemia GERD Cholecystectomy Hysterectomy
  4. 4. What is a Laparoscopic Sleeve Gastrectomy?
  5. 5. Laparoscopic Sleeve Gastrectomy Overview 5  Removes 60-80% of the stomach  Shrinks stomach capacity to ≤300 mL  Weight loss mechanism = gastric restriction and possible decreased levels of ghrelin  Ghrelin = appetite stimulating hormone primarily produced in fundus and with small amounts produced in the pancreas  Potential nutritional risk factors = nutrient deficiencies due to:   Decreased intake Removal of the majority of parietal cells  Decreased hydrochloric acid and intrinsic factor (B12)
  6. 6. Who is a Candidate for Bariatric Surgery? 6  BMI ≥ 40 or 35-39.9 with comorbidities:  Type 2 diabetes  Sleep apnea  Hypertension  Cardiovascular disease  Osteoarthritis  Age 16-70 (some exceptions possible)  Failed attempts at diet and exercise  Have been obese for at least 5 years  Free of substantial psychological disease, drug or alcohol dependency  Candidates must be able to understand surgery and postsurgery lifestyle requirements  Motivated and well-informed
  7. 7. Outcomes of Sleeve Gastrectomy 7  Weight Loss Outcomes for average % of excess body weight:       1 month: 18-30% 3 months: 37-41% 6 months: 54-61% 1 year: 58-70% 2 years: 61.5% 5 years: no long-term data  Potential Complications:  Nausea/Vomiting  GERD  Anemia  Leakage along the staple line causing peritonitis or abscess  Sleeve Stricture  Bowel Obstruction  Pneumonia  Deep Venous Thrombosis (DVT)  Acute Kidney Injury  Liver Failure
  8. 8. Post-Bariatric Surgery Behavior 8  Eat slowly and chew thoroughly – at least 25 times!  Avoid concentrated sugars, especially in liquid form  Limit fats and fried foods  Shrink your portions – do NOT overeat!  Do not drink liquids with a meal – try not to drink 30 minutes before and after a meal or snack  If you can no longer tolerate diary – try a lactose-free diary source  Exercise – after 2 months more strenuous exercise can be tolerated
  9. 9. MNT for Sleeve Gastrectomy 9  Typical Diet Progression:  Bariatric Phase I: Clear Liquids (begins post-op for 2-3 days)  Bariatric Phase II: Full Liquid (advance as tolerated)  Bariatric Phase III: Pureed/Home Soft Diet (progress as tolerated, usually begins 1 week post-op)  Bariatric Phase IV: Solids (progress as tolerated, usually begins 1 month post-op)  Protein Needs:  No set standard – typically 80-120g/day or 1-1.5 g/kg IBW  CAMC Weight Loss Center = 1.5 g protein/kg of IBW  Adequate Hydration – goal 64 oz. day  Rule of Thumb: Sip 1-2 ounces every 15 minutes
  10. 10. Sample Menu for 1 Month Post Op (Bariatric Home Soft Diet) 10  8:00AM Breakfast:  ¼ - ½ cooked cereal  ¼ - ½ cup skim plus milk  10:00AM Snack:  ½ cup protein supplement  12:00PM Lunch:  ¼ - ½ cup sugar free yogurt  ¼ cup pureed fruit  2:00PM Snack:  ¼ - ½ cup unsweetened applesauce  1 sugar free popsicle  6:00PM Dinner:  ¼-1/2 cup blended soup with protein  ¼ cup pureed fruit
  11. 11. MNT Life-Long Bariatric Diet 11  High protein  Low in refined carbohydrates  Ideally, choose protein first, then fruits and vegetables, and then whole grains  Maintain adequate hydration
  12. 12. Vitamin and Supplement Rx 12  First 3 Weeks Post-Op:  Chewable multi-vitamin  Chewable calcium  Vitamin D – only if levels are low  Vitamin B12 – if needed  Protein supplements  Must be high in protein (15-25g/serving) and low in sugar (less than 10g/serving)  After 3 Weeks Post-Op:  Multi-vitamin  Calcium Citrate (1200 mg)  Vitamin B12- if needed  Vitamin D – only if levels are low  Iron – only if prescribed by MD  Protein Supplements – if unable to consume 50-70g protein/day  Ursodiol – “Gall Bladder Pills” only for the first 6 months  Helps prevent gallstones due to rapid weight loss
  13. 13. Nutrition Care Process
  14. 14. Nutrition Assessment (11/12) 14  Secondary To: TPN protocol consult  Current Medical History:  s/p sleeve gastrectomy, persistent gastric leak, morbid obesity, HTN, hypokalemia, tachycardia  Past Medical History:  HTN, hyperlipidemia, GERD, cholecystectomy, partial hysterectomy 
  15. 15. Bariatric Past Medical History 15  7/8/2013: Laparoscopic Sleeve Gastrectomy  N/V started 2 weeks post-op  8/9/2013: Upper GI Endoscopy – found mild stricture in the        opening of the gastroplasty (between esophagus and stomach), performed balloon dilation 8/15/2013: Admitted to ER with N/V, HTN, leukocytosis, lactic acidosis – conducted CT scan to find left upper quadrant abscess and left pleural effusion 8/16/2013: Transferred to Cleveland Clinic and had abscess drained 8/19/2013: Re-drained abscess 8/23/2013: Re-drained abscess, placed gastric sleeve stent, resealed the leak at the staple line 8/29/2013: Endoscopic exploration found stent partially collapsed so it was adjusted 9/2/2013: Double stenting placed to correct the collapse stent 11/02/2013: Transferred from Cleveland Clinic to CAMC
  16. 16. Patient Medications and Supplements 16 Medication Name Reason Protonix PPI to decrease stomach acid to treat GERD Mylanta Neutralizes existing stomach acid to treat GERD Reglan Reduces nausea, vomiting, and GERD Phenergan Helps treat existing nausea and vomiting Zofran Helps prevent nausea and vomiting Metoprolol Beta-blocker to lower blood pressure Lasix Loop diuretic to lower blood pressure Dilaudid Treats pain Folic Acid Individuals post bariatric surgery are at an increased risk for deficiency – used to prevent deficiency Vitamin B6 Vitamin B12 Thiamine
  17. 17. Anthropometric Measurements 17 Height 165.1 cm (5’5”) Weight 112 kg (10/30 – Bed Scale) IBW 57 kg % IBW 196% Adjusted/Feeding Weight 71 kg BMI 41.1 (Class III Obesity)
  18. 18. Nutrient Needs 18  Current Diet Order (11/12):  Vivonex RTF @ goal rate of 60ml/hr to provide 1440kcal, 72g protein, and 1224ml free H2O   NG tube Bariatric Phase I - Clear Liquids Estimated Needs Per Kg of IBW Per Day Energy (kcal) 18 – 22 kcal 1278 – 1562 kcal Protein 1 – 1.5 grams 71 – 106 grams Fluid Per MD Per MD
  19. 19. Subjective Information (11/12) 19  Patient was consuming ~50% of clear liquid diet and tube feeding was up to 40ml/hour  Very nauseous  Vomits multiple times a day and has since 2 weeks post-surgery in July  Patient has had nothing but clear liquids and tube feedings since surgery
  20. 20. Patient Labs 20 11/11 Potential Reasons for Abnormalities Glucose (74-106) 127  Stress, insulin resistance Na (136-145) 135  K (3.5-5.1) 3.4  BUN (7-18) 21  Creatinine (0.6-1.3) 1.4  eGFR (>60) 47  Based on creatinine levels – potential decrease in kidney function Albumin (3.4-5) 1.6  Sign of inflammation with potential protein/energy deficiency Occurs with prolonged vomiting Potential decrease in kidney function or dehydration
  21. 21. Nutrition Diagnosis 21  Altered GI function related to persistent gastric leak and stent placement as evidenced by intolerance to tube feed  Notes:  High risk for refeeding syndrome due to minimal intake: Advance feedings slowly  Monitor electrolyte values closely  Watch for low potassium, phosphate, magnesium levels 
  22. 22. Nutrition Intervention (11/12) 22  d/c tube feeding and bariatric clear liquid diet  Due to persistent N/V  PICC line placement was ordered by MD and x-ray was used to verify correct placement  Initiate TPN @ 8:00PM (11/12) per CAMC protocol   TPN was discussed with Physician, who determined the initial rate to be 75 ml/hour Nursing staff was notified  IPOC
  23. 23. Parenteral Nutrition Invention 23  PICC Line  Start: subclavian vein  End: superior vena cava
  24. 24. Parenteral Nutrition Intervention 24  Initial TPN Order - 11/12  Rate: 75ml/hour  Macronutrients:  Amino Acids: 50g of 15%  Dextrose: 75g of 70%  Lipids (M/W/F only) = 0g  Total Calories: 455 kcal  Electrolytes:  Sodium: 140 mEq  Potassium: 30 mEq  Calcium: 10 mEq  Magnesium: 8 mEq  Phosphate: 6 mEq  MVI: Standard  Ascorbic Acid: 125mg  Thiamine: 50mg  Trace Elements: None  Insulin: None  Pepcid: None (on Protonix)
  25. 25. Monitoring and Evaluation 25  Goals: Improve protein status  Provision of adequate nutrition via nutrition support  Stabilize blood glucose levels  Monitoring:  High Risk – F/U in 5 days  Will follow daily  Will monitor weight, labs, and TPN/PPN tolerance 
  26. 26. TPN Monitoring and Evaluation 26 Check labs per TPN protocol:  Every 6 hours:       Glucose  Daily:   Weekly (unless abnormal): Basic Metabolic Panel (BMP) Sodium Potassium Calcium Chloride       Complete Metabolic Panel (CMP) Triglyceride Magnesium Phosphorus Ionized Calcium Pre-albumin Liver panel
  27. 27. Follow-Up Assessment (11/14) 27  Subjective Information:    Patient was tolerating full liquid diet and a Boost Glucose Control with lunch and dinner Patient was still nauseated but had only vomited once today Patient preferences of cream of chicken, tomato, chicken noodle soup were recorded  Plan for Patient:  Spoke with social worker and determined that the patient must be on 12-hour cyclic TPN prior to discharge in order to be accepted into a skilled nursing facility   Plan to start cycling on Monday (11/18) Patient will require an stent placement – per MD notes, date planned for 11/20
  28. 28. Follow-Up Assessment (11/19) 28  Nutrition Orders:  11/17: TPN d/c due to lost access secondary to multiple blood clots  Bariatric Phase II – Full Liquid with Boost Glucose Control w/ lunch and dinner  Subjective:  Patient was tolerating full liquid diet and consuming the majority of the supplement  Vomiting frequency has decreased but nausea still persist
  29. 29. Follow-Up Assessment (11/19) Cont. 29  Significant Lab Changes:  Alkphos (39-117): 306   ALT (17-67): 127   AST (15-65): 181   Suggestive of potential hepatic dysfunction and common with TPN
  30. 30. Updates 30  11/20: Gastric stent placed  11/22: Restarted TPN  11/24: Started to cycle TPN – due to SNF requirements  11/27: Reached cyclic goal of 12 hours  11/28: Switched TPN back to continuous due to acute renal failure  TPN providing an average of 1,314 kcal  12/2: Bariatric Phase III – Pureed/Soft with Boost Glucose Control and continuous TPN
  31. 31. Questions? 31
  32. 32. References 32  Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.  CAMC Standards of Practice  http://www.cornellweightlosssurgery.org/pdf/dietar y_guidelines_sleeve_gastrectomy.pdf  http://www.camc.org/surgicalweightloss
  33. 33. Appendix: Patient Labs 33 11/11 11/13 11/14 11/15 11/16 11/17 11/18 Glucose (74106) 127  120  140  112  106 135  117  Na (136-145) 135  137 139 139 143 140 139 K (3.5-5.1) 3.4  3.3  3.3  3.7 3.5 3.4  3.5 BUN (7-18) 21  27  31  37  44  50  60  Creat (0.6-1.3) 1.4  2.0  2.0  1.9  1.6  1.6  1.7  GFR (>60) 47  31  31  33  40  40  37  2.5 2.3  3.1 3.6 Phosphorus (2.5-4.9) Albumin (3.45) 3.4 1.6  1.7  Pre-Alb. (2040) Triglycerides (50-200) 1.6  1.8  15.5  224 

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