CASE STUDY: VF GALLSTONE PANCREATITIS

Hannah StraussDietetic Intern Class of 2013

History and Physical (12/31/12)

VF is an 86 YO male presented to ER for abdominal pain

Noted to have congestion, cough, whitish sputum Jaundiced for a few days Short term memory loss S/P craniotomy Rhinitis and bloody nose

PMH: Herpes Encephalitis Left temporal craniotomy for glioblastoma, Type II DM Hypertension, Dyslidemia CAD S/P CABG, LSS S/P lumber spine fusion AAA S/P repair

PMH diagnoses defined

Malignant gliomas are rapidly progressive brain tumors named by their histopathologic featurs.

Glioblastomas: Develop from glial cells.

Symptoms: Headaches, Seizures, Short term memory loss, Muscle weakness, Vision changes, Language problems, Personality changes

Lumber Spinal Stenosis is An anatomic condition that includes narrowing of the intraspinal (central) canal or neural foramena.

Causes: Spondylosis, herniated disks, bone disease, tumors

Symptoms: Numbness, cramping pain, weakness

Glioblastoma LSSHerpes Encephalitis

Swelling of the brain caused by Herpes simplex virus-1

Most common cause of sporadic fatal encephalitis worldwide

Symptoms: Fever, Headach, Psych symptoms, seizure, vomiting, focal weakness, memory loss

Emergency Room- Orders

Increased markings on right mid lower lung base (small infiltrate)

Cholelithiasis, mild prominence of gallbladder lumen with trace fluid in hepato-renal pouch (Morison’s Pouch), partial SBO

Chest X Ray Ultrasound of abdomen

CT Abdomen and Pelvis

Small gallstone in bile duct, mild extrahepatic biliary dialation, gallbadder luminal distention

Dilation of small bowel loops (possible SBO)

“Hopefully he will make a rapid recovery”

Assessment and Plan• Acute pancreatitis, likely secondary to obstructive

etiology from gallstone• Possible PNA. • Plan: Admitted to SICU, kept n.p.o and started on

levofloxacin and flagyl, IV fluids, BiPAP trial, NG Tube LWS• GI consulted

Abnormal Labs Admission Value Normal Range

Glucose 251(H) 70 -11Total Bilirubin 4.4 (H) 0.2-1.2AST/SGOT 175 H) 0-40ALT/SGPT 255 (H) 0-45Alk Phos 317 (H) 40-180Lipase 1262 1262 (VH) 0-65Urinalysis showed protein > 500, glucose 50, Bili 4

Gallstone Pancreatitis Sudden inflammation of the

pancreas due to obstructive stones in the biliary tract or Ampulla of Vater are responsible for pancreatitis

Intervention: ERCP w/ papillotomy or surgical intervention to remove bile duct stones

Cholecystectomy should be performed after recovery in all patients with gallstone pancreatitis

GI- Ileus, Gallstone Pancreatitis, cholecystitis, Difficulties tolerating Enteral NutritionPulmonary- PNA, Acute Resp FailureCardiac- Atrial Fibrillation, Rapid Ventricular Response, Septic ShockRenal- Acute Renal Failure, left HD cath placed Jan 2Neurologic- Gliobastoma, mental status waxed and weaned, encephalopathy?, Seizures?Infectious Disease- Possible UTI on admissionEndocrine- DM “fairly well” controlled during hospitalizationHemotology- Leukocytosis, AnemiaExtremities- Gross Anasarca since ARF

Gallstone Pancreatitis- Our Focus

(12/03/12) – (02/07/13)…

Day 2- (01/01) Respiratory Failure Endotrachial intubation -Acute Renal Failure

Potassium 4.6-5.4BUN- From 24 to 47Creatinine- From 1.1-2.5Phos 8.4

Day 3 (01/02)- Insertion of Left Femoral HD catheter Left jugular tri-lumen central venous line

The Complications Begin

Initial Nutrition Assessment (Day 3)

HRR SICU- pt w/ gallstone pancreatitis, will need ercp in the future, ngt to suction. weight trending up, kub showing partial obstruction npox2 days lft's improving, low ca+, rec repl.

1. Clinical data reviewed for today, 1/2/13 and time, 09002. Recent Weight Changes? Yes Comment: 5’6” 176# (1/2), 168# on admit BMI 27.73. Estimated Nutritional Needs: Based on actual wt a. Kcals 1900-2200 (25-30 Kcals/Kg) b. Protein (in grams) ~100 (1.3 g/Kg) c. Fluid (in ml) per md ( 1 ml/Kg)Degree of Nutritional Risk: High Risk t+3DDiet: npox2 days kub showing partial obstructionNutrition Intervention: discussed @ intensivist rounds, pt remains npo w/gallstone pancreatitis, will need eventual ERCP 1) follow for diet progression if unable to advance by 1/4/13 consider nutrition support. 2) when diet is advanced recommend low fat renal dietNutritional Monitoring/Evaluation: labs, renal fx, i/o's and weights, poc.goal^diet progression within 72hrs

Should we replete his Calcium?

Abnormal Labs

Admission Value

Normal Range

Total Protein 6.4 6.4-8.6Albumin 2.7 3.4-4.8Sodium 143 135-145Potassium 4.9 3.3-5.2Chloride 107 96-107Glucose 140 40-180BUN 78 0-65Creatinine 4.5 0.5-1.3Phos 8,4 2.5-4.7Mag 1.9 1.8-2.4Calcium 6.0 8.4-10.3

DAY 3: NUTRITION SUPPORT

KUB- Maximial caliber of dilated loop bowel is 4.5cm previously 3.9cmModerate stool remaining in ascending colon

1. Clinical data reviewed for today, 1/3/13 and time, 11002. Recent Weight Changes? Yes Comment: 186#1/3, 176#1/2, 168# on admit bmi35.13. Estimated Nutritional Needs: Of admission wt a. Kcals 1700-1900 (22-25 Kcals/Kg) b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) c. Fluid (in ml) 1900 or per md ( ml/Kg)

Nutrition Intervention: discussed @ intensivist rounds, pt now vented onpressors. (gallstone pancreatitis/partial bowel obstruction) MD order to startTPN 1)discussed w/ PharmD Ca+repleting c/w ivf D51/2ns@75 (90gdext) day 1tpn50gAA/60gdext/31glipid 1023kcal 2)day 2 dc ivf increase macros to80gAA/200gdext/40glipid 1404kcal, day 3 goal 110gAA/250gdext/50glipid 1800kcal100% een, monitor trigl and cbg closely and adjust macronutrients asappropriate.

Day 5 (03/04)- Enteral Nutrition KUB showed improvement

Continued to be several dilated loops, however less fecal residual in right colon, calcified gallstones visualized

Heather was consulted to begin Trickle Feed Labs: Hct (29.5) Hgb (10.6), Na (136), K

5.2, Glucose (302), BUN (80), Cr (5.7), Phos (10.1), Mag (1.8)

Intervention: Start vital 1.2@10cc/hr, WHY? tpn macros 90/190/50 1511kcal, tf to provide

288kcal 18g protein. monitor bowel fxn, labs, poc/ability to adv tf wean tpn

Day 6 (01/05/13) Renal Labs Improving- BUN decreases (51), Cr

decreases (4.4), Phos normal (4.5), Mag Low (1.7) EEG- Abnormal, poor background activity1. Clinical data reviewed for today, 1/5/13 and time, 11002. Recent Weight Changes? Yes Comment: 186#1/3, 176#1/2, 168#

on admit3. Estimated Nutritional Needs: Of admission wt a. Kcals 1700-1900 (22-25 Kcals/Kg) b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) c. Fluid (in ml) 1900 or per md ( ml/Kg) Nutrition Intervention: pt remains vented on pressors, s/p HD ¼

1)tpn macros tonight 90gAA/190gdext/50glipid 1511kcal; replete Mag+ and Ca+ 2)trickle feed vital 1.2 @10cc/hr (288kcal, 18g protein) +bm, KUB improved

Nutritional Monitoring/Evaluation: labs, renal fx, i/o's and weights, poc. goal^tf tolerance min residuals

(01/05) – (01/10) No Improvement in Renal Labs, H&H

continues to drop, Mag and Phos have been repleated.

Two chest X-Rays, KUB, Abdominal Ultrasound, MRI of the Brain.

Wt Continues to increase- Now 208# (gained 40# since admission. Extreme pitting edema and anasarca.

Nutrition Support- Recommend GI re-evaluates pancreatitis before increasing TF Needs fluid restriction. If OK w/ GI

recommend Δ TF to Vital 1.5, increase as tolerated to goal 45cc/hr w/ prostat TID ~800cc fluid

A Step in the Wrong Direction

VF continued to have residuals > 250, needed more protein and calories to meet needs

Nutrition Intervention (01/12/13) If unable to advance TF tomorrow,

recommend increasing TPN macros to 85AA/100Dex/60IVFE

When OK with GI to advance TF, change formula to Vital 1.5 goal rate 45cc/hr

I finally meet VF

My first note. Day 18 (01/17/13)

1. Clinical data reviewed for today, 1/17/13 and time, 1440 2. Recent Weight Changes? Yes Comment: Currently 212# 1/17, 176# 1/2,

168# adm, Anasarca, pitting BLE. Anuric, 2.5 liters removed HD (1/16). 3. Estimated Nutritional Needs: Of admission wt of 76.4kg a. Kcals 1700-1900 (22-25 Kcals/Kg) b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) Continues on TPN (tv 1200 w macros 95/120/60, providing 1249kcal) &

trickle TF (vital 1.5 @ 10cc/hr providing 355 kcal, 16gpro) until GI consult approves TF progression Noted C/S for PEG placement (1/17) +BM today, LFTs improving 1/17..

Nutritional Intervention: 1. Continue w/ TPN @ TF as noted above 2. If PEG placed/GI orders adv TF, recommend: Goal rate of 45cc Vital 1.5/hr w/ 3 prostat. When TF tolerated at 30cc/hr D/C TPN.

Monitor/Evaluation: Monitor Labs, Dialysis, I's and O's, GI input, POC

Plan for PEG tomorrow Tracheostomy the next day

S/P PEG placement- ? Seizure

Awaiting approval from GI to resume Vital 1.5 @ 10cc/hr (providing 355kcal 15g protein)

Neurology was consulted for questionable seizure activity Friday afternoon. Decided against it but increased Keppra anyway. No EEG until Monday.

Over the weekend Alyssa was Consulted by GI to adv Tube Feed to 20cc/hr.

When she arrived @ SICU , TF was off d/t “high” residuals TPN continued @ 95gAA/120gDex/60gIVFE

Monday (01/20)- TF continued @ 20cc/hr, not increased due to GRV 190-195

I decreased TPN to 80/100/50 in min volume to provide 1110 kcals

TF was providing 720kcals , for a total of 1830kcal

01/21/13

GI felt comfortable advancing TF per protocol to 45cc/hr

EEG negative- Since the EEG was negative for any active seizures which would suggest status epilepticus, we have decreased his. Our suspicion is that the shaking of shoulder is most likely myoclonus related to the patient's hemodialysis. We do not feel any further workup is needed for this in the hospital.

HSS: SICU pt w/ pancreatitis, PNA. TF rate increased to goal of 45ml/hr. Discussed D/C TPN with pharmacy, insulin decreased to 10 units. Minimal GRV documented in AM, distended abd, no BM since 01/20. Wt slowly decreasing, 99kg. HD removed 1.9L (01/21) Providing1836kcal,

117g pro, 915ml fluid

Weaned off Neo (01/20) TF @ Goal (01/21)

Status Epliepticus and Myoclonus

Status epilepticus generally refers to the occurrence of a single unremitting seizure with a duration longer than 5 to 10 minutes or frequent clinical seizures without an return to the baseline clinical state”

Myoclonus is a clinical sign that is characterized by brief, shock-like, involuntary movements caused by muscular contractions or inhibitions. Muscular contractions. "jerks," "shakes," or "spasms."

(01/25/13) 1. Clinical data reviewed for today, 1/25/13

and time, 1320 2. Recent Weight Changes? Yes Comment:

Currently 220#, 219# (1/22), 168# adm. Anasarca present, +4 BLE, BUE Edema. 1500ml removed HD (01/21)

TF held yesterday for GRV (250), restarted TF @ 25ml/hr w/ goal of 45ml/hr. Phos 8.0 (pt on HD). Pt not appropriate for change to low electrolyte formula r/t pancreatic fx and gallstones. High serum BG on cs#2. Levo was restarted (01/23) @ 10, has decreased to 7.

Nutrition Intervention: 1) Continue TF Vital 1.5 w/ goal of 45ml/hr and 2) Recommend increase to cs#3. 3) When TF stable, consider adding basal insulin.

(01/28) NPO for new HD tunneled

access/dc femoral line, D5ns@40 10 lantus

TF residuals ~270x4 nights tf held/resumed ?add reglan (pt w/?sz)

k/phos climbing. If TF at goal it is providing 1056mg phos Labs: Phos 10 (From 8.5) ?add phos binder q4 or q6 when

TF resumed

RN to RD consultPt not seen since

01/17 ????????????????

01/30/13- Educating Nurses

Some things we just cannot control. SICU- pt went for MRCP had to cancel r/t pt unstable. RN changed to Nepro

(no order, Nephrology suggests change IF ok w/ GI). Intervention: When OK w/ MD, recommend resume TF Vital 1.5 @15cc/hr goal of 45ml/hr and Prostat TID, providing 1836kcal, 117g pro, 915ml fluid (includes fluid for Prostat)

Vital @ goal rate provides 1058mg phos NEPRO would provide ~700mg Phos@goal rate.

D/C 02/07/13… To be Continued

Pt transferred Lahey Clinic for further management of multisystem organ failure.

• Cost of health care- not just for insurance companies or even our nation, but for the patient.

• “When we debate health care policy, we seem to jump right of the issue of who should pay the bills, blowing past what should be the first question, why are the bills so high?”• Cancer treatment- often half a million to a million dollars• Trip to the ER for chest pain (ending in indigestion) - more than

a semester @ college• Simple lab work can often exceed the cost of a new care.

• Where is all of this money going?• Is it a broken system? Or do we as American’s have the wrong

mentality when it comes to treatment vs end-of life care.

The Bitter Pill…

References

Rombeau, J and R. Rolandelli. Clinical Nutrition Parenteral

Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101:2379-2400. [PubMed]

Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;371:143-152. [PubMed]

Owyang C. Pancreatitis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 147.