a kliewer case_2_presentation
TRANSCRIPT
CASE ILEUS
Allison Kliewer
Baptist Dietetic Internship
April 10, 2013
Outline
Introduction Patient Profile Disease background of Ileus Trophic feeds in the Critically Ill Admission Nutrition Care Process Summary and Reflection
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 86
from MI; father passed away from prostate cancer
Pt Profile
Allergy to hydrocodone PMH: CVA, sacral fracture, HTN,
dyslipidemia, CAD, osteoporosis, deconditioning
Past surgical Hx: hernia repair, hysterectomy, diskectomy, exploratory surgery and pyloroplasty form perforated duodenal ulcer, cholestectomy and sacroplasty
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
Impression
Acute upper gastrointestinal tract bleed With hematemesis, coffee ground in
nature NPO IV fluids Proton pump inhibitors d/c aspirin and Fosamax Plan endoscopy GI consult
Ileus Refers to the partial or complete blockage
of the small and/or large intestine due to either impaired peristalsis or a mechanical obstruction
Most common complication in critically ill May affect all parts of the GI tract Degree of impairment of intestinal motility is
correlated to the severity of illness and mortality
(Madl and Druml, 2003)
Symptoms Nausea Vomiting Constipation Gastric Pain Discomfort Characterized by abdominal distention, lack
of bowel sounds, accumulation of gas and fluids in the bowel and decreased GI passage with delayed or absent defecation
(Allen et al, 2012)
Etiology
Blockage of small or large intestine Mechanical and paralytic bowel
obstruction outside or within the gut wall, or intraluminal
Surgical procedures
(Madl and Druml, 2003)
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-abdominal
hematomas Metabolic disturbances
(Madl and Druml, 2003)
Pathophysiology
Loss of synchronization resulting in impaired peristalsis
GI dysmotility = luminal pressure and intestinal dilatation
Intestinal dilatation leads to neutrophils invading and damaging muscle layer
= release of nitric oxide = paralyses muscle cells
(Madl and Druml, 2003)
Pathophysiology
Dilatation and pressure = Gut wall ischemia = system uptake of cytokines and other inflammatory mediators
Inflammatory response contributes to the systemic symptoms of ileus and correlates with severity of ileus
(Madl and Druml, 2003)
Aspiration Impaired motility promotes reflux of
intestinal juices back into stomach = gastric residuals = gastric colonization with intestinal
bacteria Ascension of microorganisms into the
esophagus, into the pharynx, into the trachiobranchial tree
risk of pneumonia
(Madl and Druml, 2003)
Hypovolemia
distention and intra-luminal pressure = compromises intestinal profusion, impairs microcirculation, and ultimately results in fluid sequestration into the intestinal wall and lumen
Inflammation promotes fluid loss into luminal space
= hypovolemia and circulation impairment
(Madl and Druml, 2003)
Bacterial Overgrowth
Ileus associated with alterations in intestinal flora and overgrowth of bacteria
Microorgansisms and/or endotoxins/exotoxins may invade mucosa
= mucosal inflammation, mucosal perfusion and hypersectrection
(Madl and Druml, 2003)
Bacterial Translocation
Intestinal wall impaired or systemic immunocompetence is compromised = spillover of microorganisms into the lymphatic system and/or portal circulation
= systemic infections or septicemia Bacterial overgrowth, inflammation and
impairment of barrier function of the intestinal wall, impaired immunocompetence
(Madl and Druml, 2003)
Impaired Cardiac Output
intraluminal pressure and intrathoracic pressure affects venous return, cardiac filling, ventricular compliance, and contractility
cardiac output mean arterial pressure
(Madl and Druml, 2003)
Decreased Respiratory Function
Compressed pulmonary parenchyma Drop in functional residual capacity Negative affect on lung mechanics and
chest wall ↓ lung compliance = atelectasis alveolar pressure Negative influences gas exchange
(Madl and Druml, 2003)
Nutrition Considerations
EN for restoration and maintenance of intestinal function, perfusion, motility, and barrier function
Minimal EN can help support intestinal function in pts whom sufficient EN is impossible
(Madl and Druml, 2003)
Prognosis Outcome depends on the cause of the
blockage Consequences and recovery time vary Underlying cause, time taken to diagnose,
and treatment Margin of complications and mortality range
from 12 to 27% Mean length of stay is 15 days
(Rojas, 2012)
Feeds in Critically Ill Associating between inadequate feeding and
poor clinically outcome in critically ill patients EN has been shown to attenuate
hypermetabolism of critical illness, decrease infectious complications, and shorten ICU stays compared to PN, and reduce mortality
EN supports intestinal structure and function, prevents increased permeability, bacterial translocation, systemic inflammation
(Heyland et al, 2010)
Enteral Nutrition
Stimulates epithelial cell growth and proliferation
Maintains mucosal mass and microvilli height
Preserves tight junctions between epithelial cells
Promotes blood flow Enhances brush-border enzyme activity
(Rice et al, 2011)
Trophic Feeds
Trophic feeds appropriate for patients deemed unsuitable for high volume intragastric feeds
Feeding small volume of enteral feeds in order to stimulate the GI tract
Improves GI enzyme activity, hormone release, blood flow, motility, and microbial flora
(Rice et al, 2011)
Trophic Feeds
ARF affects more than 3 million pts in US and is the single most common reason ICU pts cannot eat
Conclusive evidence supports early feeds in the ICU
Lack of conclusive evidence regarding the caloric intake dose required for the ICU pt
(Rice et al, 2011)
Trophic vs. ENStudy Design Subjects Purpose Intervention Results
Rice and colleagues 2011’03-’09
Random open-label study
200 pts with acute respiratory failure expected to require ventilation for over 72 hrs
Compare clinical outcomes and GI complications with trophic feeds and full-energy EN
Randomly received trophic feeds (10 ml/hr) or full energy EN for the initial 6 days of ventilation
Trophic feeds resulted in similar clinical outcomes with fewer episodes of GI intolerance
ARDS clinical trials‘08-’11
RandomOpen- labelstudy
1000 pts44 hospitalsWith acute lung injuryRequiring ventillation
Determine if trophic feeds would increase ventillator-free days and decrease GI intolerance
Randomly received trophic or full EN for first 6 days
Trophic feeds did not improve VFD, 60-day mortality, or infectious complications Trophic feeds had less GI intolerance
Progression of Disease
Acute Upper GI bleed with coffee ground emesis
Ileus with gastritis and esophagitis Fever and left lobe pneumonia Acute respiratory distress and
transferred to the ICU NPO Clear liquid Full
Progression of Disease
Ileus Erosive esophagitis and gastritis Aspiration pneumonia Hypoxia Hypokalemia, hypophosphatemia,
hypomagnesemia Leukopenia Sepsis Began TPN
Progression of Disease
Metabolic disorder Small bowel obstruction Intubated and sedated with mechanical
vent Decreasing respiratory status Failed extibation to BIPAP TPN + Trophic Feeds Comfort Care
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 actual
wt)
NCP
Severely compromised nutrition status PES: Inadequate oral food intake related
to her current condition as evidence by intake record, BMI, and albumin lab values
Rec Mighty Shake BID
NCP
TPN assessment Pt met ASPEN criteria for TPN with
nonfunctional GI tract (ileus) Rec feeds of 85 g amino acids, 275 g
dextrose, 40 g lipids Provide 1675 kcals with 2.3 glucose
infusion rate
NCP
TPN + insulin + EN trophic feeds of Pulmocare @ 20
ml/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)
NCP
PES: Altered GI function related to ileus as evidence by PN and EN
Rec continue trophic feeds with Vital AF 1.2 at 20 ml/hr to help manage inflammation and promote GI tolerance
Reflection
Effective nutritional support for critically ill patients represents a difficult aspect of overall management of complex patients
The is a need to challenge commonly used nutritional support practices and to achieve an individualized, evidence-based approach for optimal nutritional therapy
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 benign gynecologic surgery. International Journal of Gynecology and Obstetrics.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 in critically ill patients: A single center feasibility of the PEP uP protocol. Critical Care. 14: R78.
Madl, C., & Druml, W. (2003). Systemic consequences of ileus. Best Practice & 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-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Critical Care Medicine. 39(5): 967-974.
Rojas, D. J., Martinez-Ordaz, J. L., & Romero- Hernandez, T. (2012). Biliary ileus: 10-years experience. Case Series. Cirugia y Cirujanos. 80(3): 228-232.