colectomy and wound dehiscence - weebly

COLECTOMY AND WOUND DEHISCENCE

Casey Allred February 15, 2013

REVIEW OF THE DISEASE

A wound is a disruption of the normal function and structure of the skin and

underlying tissue. Different types of wounds include pressure ulcers, diabetic ulcers,

surgical wounds, venous and arterial wounds. While most surgical wounds heal without

any problem, 14 to 16% of infections from treatments in the hospital come because of

surgical wounds. In order for a wound to heal, keratinocytes, fibroblasts, endothelial

cells, macrophages, and platelets must be activated (1).

There are three phases of wound healing that occur: inflammatory, proliferative,

and maturation. The inflammatory phase is the first phase after acute injury and is

characterized by pain, swelling, redness, and function loss. Second is the proliferative

phase where granulation tissue is formed from glycosaminoglycans, proteoglycans, and

collagen to facilitate wound healing. The final phase is the maturation phase or the

remodeling phase. This includes collagen cross-linking, collagen remodeling, wound

contraction, and repigmentation of the wound. Factors that affect wound healing include

impaired arterial or venous circulation, age greater than 65, immune compromise,

dehydration, immobility, neuropathy, obesity, malnutrition, nutrient deficiencies, and

diseases such as diabetes (1).

Specific nutrients that aid in wound healing include glutamine for increased

proliferation and energy, and zinc for cellular replication and collagen formation. Zinc

supplementation is only a benefit if there is a deficiency (2). Vitamin C is another

nutrient that is beneficial in wound healing because of its role in collagen formation and

possible resistance to infection. Overall, a diet with adequate calories and protein is vital

for wound improvement (1).

PATIENT PROFILE DW is a 38-year-old Caucasian male. He is divorced and has one daughter. He

uses tobacco, crack cocaine and methamphetamine. DW has a history of diverticulosis

and seizure disorder.

PRESENT ILLNESS

DW came to the hospital with worsening abdominal pain and distention after

having pain for several months especially in the left lower quadrant. He also had nausea

and vomiting with some diarrhea and was unable to tolerate any PO intake. A CT scan

showed a large bowel obstruction with a sigmoid mass and possible malignancy. He was

admitted to the hospital on January 4. A sigmoidoscopy was performed to explore the

obstruction, which proved to be a non-malignant diverticular stricture. DW underwent a

sigmoid colectomy to remove the obstructed bowel. Eight inches were removed from the

colon, and an end-to-end anastomosis was done to reconnect the colon. For safe measure

the surgeon also performed a loop ileostomy to insure healing of the colon and removed

his appendix to prevent future problems.

Just as it appeared DW was recovering well from his surgery, the anastomosis

dehisced spilling fecal matter into his peritoneal cavity and causing peritonitis. He was

taken back to the OR where his abdomen was washed out, the anastomosis was taken

down and a descending mucous fistula was put in place. DW was moved to the ICU on

January 10 to be treated for respiratory failure for whch he was intubated and sedated

with propofol. Because of the anastomotic leak, DW developed peritonitis, sepsis, and

septic shock for which he was treated with antibotics. The sepsis led to acute kidney

injury, and DW was given fluid resuscitation to help normalize his kidney function.

On January 11, DW became tachycardic and suffered a post-op ST elevated

myocardial infarction. This was difficult to treat because of his instability. On January

13, the abdominal surgical wound became infected with E coli, pseudomonas, and gram

positive bacteria and two days later began to gape open and ooze. Because of this

dehiscence his surgical staples were removed to enable the Wound Care team to place a

wound vac to keep the wound clean and help it heal more quickly. At this point his

respiratory system improved, and he was extubated. However, the fascial tissue in the

wound continued to die and break down to the point that on January 18, when the wound

vac was taken off, his bowels eviscerated, and he immediately was taken to surgery for

debridement. Necrotic tissue, debris, and cloudy brown fluid were removed, and

retention sutures were put in place to assist in holding the wound together and to protect

his exposed bowels. DW continued to improve and was moved from the ICU a few days

later. On January 23, a CT scan showed dilated small bowel loops, developing abscesses,

and fluid collection. The abscesses and fluid were drained, and DW continued to

improve until he was discharged to a skilled nursing facility on February 7. Below is a

list of the medications DW was given during the course of this hospitalization (3).

Medication Function Possible Nutrition Related Side Effects

Depakote Anti-seizure N/V/D, constipation Fentanyl Narcotic for pain Anorexia Propofol Sedative Diarrhea Piperacillin Antibacterial agent that

blocks bacterial cell wall growth

Dry mouth, taste changes, N/V/D

Famotidine Histamine-2 blocker that decreases stomach acid

Decreases iron and vitamin B12 absorption, N/V/D, constipation

Zosyn Antibiotic combination of piperacillin and tazobactam

Dry mouth, taste changes, N/V/D

Protonix Proton pump inhibitor that Decreases iron and B12

decreases stomach acid absorption, nausea, abd pain, diarrhea

Vasopressor Increase blood pressure Levofloxacin Broad spectrum antibiotic

(including E. coli and pseudomonas)

Taste loss, N/V/D, constipation, abd pain, flatulence

Vancomycin Antibiotic to treat gram positive infections

Bitter taste, nausea

Valproic acid Anticonvulsant and mood stabilizing drug

Increases appetite, weight, and vit D absorption, anorexia and decreased weight

Aldactone Potassium-sparing diretic Anorexia, decreased weight, increased thirst, dehydration, dry mouth, N/V/diarrhea, gastric bleeding

Lasix Diuretic Increased thirst, anorexia, N/V/D, cramps, constipation

Phenylephrine Maintain adequate blood pressure

Anorexia, N/V

NUTRITION ASSESSMENT

Food/Nutrition Related History

For about one month prior to admit, DW had a decreased appetite and N/V/D, but

he reported he did not lose any weight at his time. He usually ate about eight small meals

each day.

After surgery, DW was put on a clear liquid diet and advanced to fulls the next

day because he was tolerating it very well. He was then advanced to a post-op surgical

diet because he was having good ostomy output and tolerating 75-100% of his meals.

However, on January 10, DW began to have decreased bowel function, and the

anastomotic leak was discovered. He was put on TPN via PICC so that he could continue

to receive nutrition. In order to maintain the gut, a small bowel feeding tube (SB FT)

was placed on January 11 but was not able to be advanced to the bowel and remained in

the stomach until the next day when it was repositioned in the small bowel. However, the

tube became clogged, so the feedings were not started until January 13 with a rate at 20

ml/hr of Impact Peptide 1.5 to ensure tolerance of the formula. At this time, DW’s

prealbumin was severely depleted at 3.0 so he was given 45 g of Glutamine and a

multivitamin for extra nutrients. TPN was also discontinued at this time.

On January 14 his TF rate was increased to 55 ml/hr to provide more kcals and

protein. Because his prealbumin remained low, 36 g of Beneprotein was added, along

with 220 mg of Zinc Sulfate and 1000 mg of vitamin C to promote wound healing. Once

DW was extubated, his TF was increased to 80 ml/hr, and he was not given any more

Beneprotein because he was getting enough protein from the formula. On January 19 his

diet was advanced to clear liquids and continued to advance to a regular diet. Although

DW was tolerating a normal diet, he had a poor appetite and was not eating very much,

so he remained on the TF until he pulled it the next day. It was replaced and bridled the

next day although the goal TF rate was never reached in the next several days. On

January 24, DW was switched to a nocturnal TF in order to promote PO intake during the

day, and he was given more Glutamine because his prealbumin level had dropped.

However, that night three liters of fluid was collected from his NG tube indicating a small

bowel obstruction. TPN was started once more along with a trophic TF to maintain the

gut. DW was not able to tolerate the small amount coming from the TF, and so it was

held for several days while he received TPN. On January 28 the TF was started again at

10 ml/hr and increased by 10 ml/hr for the next two days until it was at 50 ml/hr. TPN

was discontinued on February 1. DW was receiving nutrition from the TF and a regular

diet at this time. Although he was tolerating PO intake, DW had a poor appetite and was

eating less than half of his meals. He did not like Boost so he was given Magic Cup and

Instant Breakfast to supplement his PO intake. His TF was stopped on the February 3,

and DW was encouraged to increase his PO intake to make up for the lack of calories and

protein in his diet. Below is a table that portrays DW’s diet and nutrition support

throughout his hospitalization.

Date Diet Order TF (kcal, g protein)

TPN Supplement

1/4 NPO 1/5 (surgery) NPO 1/6 Post-op clear

liquid

1/7 Full liquid 1/8 Post-op surgical

diet

1/9 NPO 1/10 return to OR

NPO 1620 kcals 130 g 10% AA 1100 kcals D70W

1/11 (and TPN weaned)

TF placed 1700 kcals 130 g 10% AA, 1180 kcals D70W

1/12 TF delayed 1700 kcals 130 g 10% AA, 1180 kcals D70W

1/13 Impact Peptide 1.5 @ 20

D/C TPN

1/14 2250 kcal 169 g Impact Peptide 1.5 @ 55

Glutamine 15 g TID Theragran-M (MV) daily

1/15 2400 kcal 205 g IP 1.5 @ 55

Glut 15 g TID Beneprotein 12 g TID MV

1/16 (admit wt 92 kg)

2870 kcal 217 g IP 1.5 @ 55

Glut 15 g TID Bene 12 g QID MV Zinc sulfate 220 mg daily Vit C 500 mg bid


2532 kcal 228 g IP 1.5 @ 60

Glut 15 g TID Bene 12 g QID MV Zinc 220 mg Vit C 500 mg bid


3150 kcal 225 g IP 1.5 @ 80

Glut 15 g TID Bene 12 g QID MV Zinc 220 mg Vit C 500 mg bid

1/19 Clear liquid 3150 kcal 240 g IP 1.5 @80

Glut 15 g QID MV Zinc 220 mg Vit C 500 mg bid

1/20 Full liquid/Regular diet

Pt pulled TF Glut 15 g QID check for QID MV Zinc 220 mg Vit C 500 mg bid


Regular diet TF replaced and bridled 3180 kcal 240 g IP 1.5 @ 80

Glut 15 g Daily MV Zinc 220 Vit C 500 mg bid

1/22 Regular diet 3180 kcal 240 g IP 1.5 @ 80


1/23 Regular diet 3180 kcal 240 g IP 1.5 @ 80


1/24 NPO/clear liquid 2190 kcal 165 g Glut 15 g TID

(based on IBW) Nocturnal: IP 1.5 @ 80 ml/16hr 60 DO

MV Zinc 220 mg Vit C 500 mg BID

1/25 Clear liquid Trophic TF 20ml/hr

2400 kcals 200 g 15% AA 1600 kcals D70W

Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID

1/26 Clear liquid 2400 kcals 200 g 15% AA 1600 kcals D70W


1/27 Clear liquid 2400 kcals 200 g 15% AA 1600 kcals D70W


1/28 Clear liquid 360 kcal 23 g IP 1.5 @ 10

2400 kcals 200 g 15% AA 1600 kcals D70W



2500 kcals 225 g 15% AA 1600 kcals D70W D/C TPN

Glut 15 g TID MV Zinc 220 mg

Vit C 500 mg BID


2500 kcals 225 g 15% AA 1600 kcals D70W D/C TPN


1/31 Full Liquid 1800 kcal 112 g IP 1.5 @ 50

Wean to 60% Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID

2/1 Regular 1800 kcal 112 g IP 1.5 @ 50

D/C TPN Glut 15 g TID MV Zinc 220 mg Vit C 500 mg BID

2/2 Regular 1800 kcal 112 g Glut 15 g TID

IP 1.5 @ 50 MV Zinc 220 mg Vit C 500 mg BID

2/3 Regular TF Stopped MV Zinc 220 mg Vit C 500 mg BID

2/4 Regular MV Zinc 220 mg Vit C 500 mg BID Instant breakfast Magic cup

2/5 Regular TF end officially MV Zinc 220 mg Vit C 500 mg BID IB/MC

2/6 Regular MV Zinc 220 mg Vit C 500 mg BID IB/MC

2/7 Regular MV Zinc 220 mg Vit C 500 mg BID IB/MC

Anthropometrics

Height 72” (6’) Weight 92 kg (203#) BMI 27.6 IBW 80.8 kg %IBW 114% Weight Gain 45# %Weight Gain 22%

Upon admit to the hospital, DW was slightly overweight. At McKay-Dee, when a

patient has a BMI over 27, the IBW is used to calculate calorie and protein needs.

However, when DW’s abdominal wound became infected and his prealbumin was

severely depleted, his admit weight of 92 kg was used to calculate estimated needs in

order to provide a more accurate amount of what his body needed.

DW had a lot of fluid retention and edema during his stay. Below is a graph

depicting his weight throughout his hospitalization (4).

DW gained about 45# of fluid, a 22% weight gain, and was given diuretics to

achieve his normal weight. Along with diuretics, the improvement of his protein stores

most likely helped reduce the fluid retention. DW’s weight returned to normal before he

was discharged.

Biochemical

The most significant lab that was used to assess nutrition status was prealbumin.

Throughout the course of DW’s illness, his prealbumin was extremely low, and although

it did improve, it never normalized before he left. This indicated a severe protein

depletion but was most likely also decreased because of inflammation. Below is a graph

depicting his prealbumin levels along with CRP (4). Prealbumin and CRP are typically

inversely related. On Jan 21, an important change occurred that confirmed DW’s protein

stores were improving. Prealbumin increased from 3.0 to 3.9 with a decrease in CRP

from 22.7 to 21.3. Although this was a small increase of prealbumin with a small

decrease of CRP, it was the first sign that he was receiving enough protein. Towards the

end of his stay, DW’s prealbumin continued to increase despite the increase in CRP,

which also indicated that his protein needs were being met.

BUN was also an important lab that was monitored. These levels were elevated at

the beginning of his stay most likely because of the amount of inflammation, sepsis, and

the stressed metabolic state that he was in (5). With adequate fluid resuscitation BUN

normalized. Because of DW’s increased need for protein to facilitate wound healing, he

was receiving about 2.5 g/kg of protein which is a very high amount. BUN was

monitored carefully to insure that his kidneys were able to tolerate the amount of protein

in his diet. The normalized levels of BUN during the periods of high protein intake

indicated that his body was using the protein for tissue proliferation.

Because toxicity with a zinc supplementation can be detrimental, DW’s zinc level

was measured on Jan 31 and found to be low at 55 (normal: 60-120). Supplementing

with zinc was therefore safe and beneficial for DW.

Nutrition-Focused Physical Findings

Because of the 45# fluid gain that DW experienced throughout his hospitalization,

his skin was very tight, and he was extremely swollen and puffy. His feet looked like

balloons because they were so stretched and swollen. He also looked very pale

throughout most of his hospitalization until toward the end when he was recovering.

Besides the abdominal wound, he also had a stage II pressure ulcer on his coccyx and a

necrotic sore on his wrist. Below are pictures that depict the healing progression of his

abdominal wound.

The wound began to dehisce so the surgical staples were removed and the fascia was exposed. The yellow/brown tissue indicates necrotic fascial tissue (slough). The sutures inside the wound are beginning

to be pulled and stretched.

DW’s abdomen was very distended with a lot of fluid retention. Wound gaped open more widely and is pale pink indicating unhealthy tissue with even more slough and bowel exposure. Sutures are pulled even

tighter still.

Wound after emergency surgery due to eviscerated bowel. Surgeon pulled surrounding muscle tissue and skin to provide covering for bowel and placed retention sutures for more support. Wound remains pale

pink.

Beefy red color and begin to see granulation tissue. Still a little bit of slough.

Continual increase in granulation with beefy red color. Not as much undermining. Still some slough but

too close to bowel to remove.

Wound has closed dramatically. Healthy tissue indicated by granulation and beefy red color.

Comparative Standards

Based on Calories: 25-30 kcals/kg

Protein: 1.5-2.0 g protein

Fluid: 30 ml/kg

1/5: IBW 80 kg 2000-2400 kcals 120-160 g 2400 ml

Based on Calories: 30 kcals/kg

Protein: 2.5 g protein Fluid: 30 ml/kg

1/16: ABW 92 kg 2750 230 2760 ml

Client History

Because DW had some appetite loss along with nausea and vomiting for a month

prior to admit, it was important to provide enough calories and protein soon after his

surgery. When the anastomotic dehiscence occurred he was immediately started on TPN

because of his poor PO intake before hospitalization.

NUTRITION DIAGNOSIS

Increased nutrient needs related to healing as evidenced by multiple GI surgeries

and open abdominal wound with vac.

NUTRITION INTERVENTION

Problem: Increased nutrient needs related to healing as evidenced by multiple GI surgeries and open abdominal wound with vac. Intervention: Enteral Nutrition, Parenteral Nutrition, Meals and Snacks, Medical Food Supplements, Vitamin and Mineral Supplements Long-Term Goal: Meet nutrition needs.

Short-Term Goal: Build up protein and vitamin/mineral stores.

Specific Intervention and Client Objectives

1. Intervention: Enteral Nutrition (ND-2.1) a. TF via SB FT: Impact peptide 1.5 @ 55 ml/hr

• Objective: Preserve the gut and provide patient with enough calories and protein to meet needs.

2. Intervention: Parenteral Nutrition (ND-2.2) a. PN via PICC: 200 g 15% AA, 1600 kcals D70W

• Objective: Meet calorie and protein needs.

3. Intervention: Meals and snacks (ND-1) a. Clear liquid, Full liquid, Regular diet

• Objective: Meet calorie and protein needs.

4. Intervention: Medical Food Supplements (ND-3.1) a. Glutamine, Beneprotein, Magic Cup, Carnation Instant Breakfast

• Objective: Facilitate wound healing with added protein and calories.

5. Intervention: Vitamin and Mineral Supplements (ND-3.2) a. Zinc sulfate, vitamin C, Multivitamin

• Objective: Facilitate wound healing.

NUTRITION MONITORING AND EVALUATION

The goal for DW was to provide enough calories, protein, zinc, and vitamin C to

meet his needs for wound healing. He was monitored quite frequently throughout his

hospitalization. When he was in the ICU, he was monitored every day to make sure he

was tolerating the nutrition support and to assess his prealbumin levels. Once he was

advanced to a regular diet, DW’s PO intake was monitored every day or every other day.

Intervention Goal/Expected Outcome

Indicator(s) Criteria for evaluation

Parenteral Nutrition/IV Fluid Intake (FH-1.3.2)

Meet calorie and protein needs

PN via PICC: 200 g 15% AA, 1600 kcals D70W

Meet Goal PN rate

Enteral Nutrition Intake (FH-1.3.1)

Meet calorie and protein needs

TF via SB FT: Impact peptide 1.5 @ 55 ml/hr

Meet Goal TF rate

Protein Intake (FH-1.5.2), Vitamin Intake (FH-1.6.1), Mineral/Element Intake (FH-1.6.2)

Provide extra protein and nutrients to facilitate wound healing

Glutamine 15 g TID, Beneprotein 12 g QID, Theragran-m daily, Zinc sulfate 220 mg daily, Vitamin C 500 mg bid

Meet indicator amount

Food Intake (FH-1.2.2)

Meet kcal and protein needs

(FH-1.2.2) Amount of PO intake

75-100% of meals or 2000-2400 kcals and 120-160 g protein

APPROPRIATENESS OF CARE

Overall, I think that DW’s nutrition care was mostly appropriate, but there are a

few occurrences that were inappropriate. On occasion his TF would be turned off or not

advanced to the goal rate when it should have been. I also felt that his TF was pulled

prematurely. DW was only consuming 25-50% of his meals, which would not have met

his needs. A few times the nurse would forget to give him the glutamine he needed

which decreased the amount of protein he received for wound healing. Once DW was

out of the ICU, instead of using his actual body weight to calculate his needs, ideal body

weight was used. Although his BMI was high at admit indicating IBW should be used, it

may have been more beneficial to err on the side of caution by giving a little too much

protein as long as the extra protein did not elevate BUN. Also, if there could have been

extra precautions taken with his colectomy, perhaps the anastomotic leak could have been

prevented, and a lot of time, money, and pain could have been saved for the patient.

REFERENCES

1. Nutrition Care Manual. Wound Care. Available at http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=19869. Accessed on February 13, 2013.

2. Fullmer S. Lecture slides. Clinical Nutrition, Brigham Young University, October

2010.

3. Pronsky ZM, Crowe JP. Food Medication Interactions. 16th ed. Birchrunville, PA. 2004.

4. ChartGo. Create graphs online. Available at http://www.chartgo.com/modify.do.

Accessed December 4, 2012.

5. Pagana, K.D., Pagana, T.J. Mosby’s Manual of Diagnostic and laboratory Tests. 3rd ed. St. Louis, Missouri. 2006.

colectomy and wound dehiscence - weebly

Documents