conditioning of the surgical schumann risk patient - case ... · 10 days after surgery fistula...
TRANSCRIPT
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ESPEN Congress Leipzig 2013
Conditioning of the surgical Schumann risk patient - Case discussion
Case presentation
M. Panisic (RS)
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Case disscusion
Marina Panisic – Belgrade - Serbia
MILITARY MEDICAL ACADEMY
Leipzig, August Leipzig, August 2013.
2013.
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Old Testament’s Book of Judges
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Eglon
sustained an
acute posttraumatic
enterocutaneous fistula
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„...and Ehud
put forth his hand,
and took the dagger
and thrust it into his belly...
And the dirt came out.“
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Celsus Aulus Cornelius
“ Cicero medicorum ”
25y b.c. – 50y a.c.
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“...when the colon has been penetrated,
it can be sutured,
not with any certain assurance,
but because this doubtful hope
is preferable to certain despair;
for occasionally it heals up.”
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John Hunter
first recorded
conservative approach !!!
...fistulas occasionally close spontaneously ...
“ In such cases nothing is to be done but dressing the
wound superficially, and when the contents of the
wounded viscus become less, we may hope for cure.”
1728 - 1793
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Surgical catastrophes
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C A S E
19 years-old female
Hospitalized in another center for abdominal pain and
necrosis of abdominal wall, one month after incision in
the right inguinal region according to acute lymphangitis
Hemicolectomia lat. dex. was performed
PH: Ileitis terminalis et colitis regionalis – Mb Crohn
10 days after surgery fistula enterocutanea appeared,
patient’s general condition rapidly decreased
No nutritional support instituted – only I.V. fluid therapy
MILITARY MEDICAL ACADEMY
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For further treatment
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
30.000 pts/y
30% operated
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H Y S T O R Y
Abdominal pain
Necrosis of abdominal wall
No nausea, no vomiting
No allergic reactions
No previous diseases
Negative family history
MILITARY MEDICAL ACADEMY
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PHYSICAL EXAMINATION
Tachycardia
No fever
Signs of severe malnutrition
H = 165 cm W = 28 kg
BMI = 10.28 Tenderness in all abdominal regions
Drains on both sides of the abdomen, with purulent
secretion
MILITARY MEDICAL ACADEMY
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weight and height on admission
W-28 kg H-165 cm
BMI = 10.28
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
Fistula output – 850 ml/day
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LABORATORY FINDINGS on admission
CRP 102 mg/l
KKS:
WBC 3,5x10^9, Hgb 11.4 gr/dL, MCV 84 fl, Plt 56x10^9
Coagulation status: INR 1.35, APTT 41 s
II 0.46, VII 0.28, IX 0.65, X 0.54,
Antitrombin III 0.39
D-dimmer 1522 μg/l
Mg: 0.65 mmol/l
Ca: 1.45 mmol/l
Fe: 3 umol/l
Feritin: 1084 μg/l
Albumin: 22 g/l
AST: 57 U/L, ALT: 60 U/L, GGT: 234 U/L, ALP: 1009 U/L
Urino-culture: Klebsiella sp.
Haemmo-culture: Fungal sepsis
MILITARY MEDICAL ACADEMY
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laboratory on admission
• Na 130 mmol/L
• K 2,5 mmol/L
• Cl 98 mmol/L
• GLU 4.6 mmol/L
• BUN 2.5 mmol/L
• CREA 50 µmol/L
• TP 42 g/L
• Alb 22 g/L
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
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INITIAL NUTRITION THERAPY
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
initial nutritional therapy
Maybe we need some extra information
before starting nutritional support?
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ENERGY
20-30 kCal/kg per day
A Actual body weight (28 kg)
B Ideal body weight (57 kg)
C Adjusted body weight (46 kg)
Ideal weight + 0.25x(actual weight-ideal weight)
1050 – 1750 kCal/day (1400 kCal/day)
MILITARY MEDICAL ACADEMY
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PROTEINS AND AMINO ACIDS
C 1.5 - 2 g/kg ideal body weight / day
85.5 - 114 g proteins
MILITARY MEDICAL ACADEMY
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DETERMINATE
glucose : fat RATIO?
G 50 - 70%
F 30 - 50%
MILITARY MEDICAL ACADEMY
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initial nutritional therapy
it has been started
immediately, but how?
MILITARY MEDICAL ACADEMY
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?
?
?
a) Enteral
b) Parenteral
c) Combination
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
Immediately on receipt,
beside all symptomatic conservative therapy,
applied is TPN – system “all in one”
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CVC placed in v. subclavia l. sin….
MILITARY MEDICAL ACADEMY
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TPN
Composition of nutrients:
Proteins&AA – Glamin, Vamin 18,…….500-1000g
Carbon-hydrates – Glucosa, ………….100-150g
Fat emulsions 10% - ………………...250-750ml
+ electrolytes, vitamins, trace elements, heparin and
insulin crystal………………………………...on going
• Volume…………………………...1050 – 2000 ml
MILITARY MEDICAL ACADEMY
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20 days after admission
in severe currently condition
unconscious
psycho-motoric agitated
without peripheral pulsations
with peripheral cyanosis
three grand mal seizures
patient transferred to ICU…
MILITARY MEDICAL ACADEMY
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IMAGING STUDIES
ECG: sinus tachycardia Fr 135/min
DOPPLER showed thrombosis of v.
jugularis l. sin.
CT of ABDOMEN: hepato-splenomegalia
and colonic dilatation.
CT of BRAIN: without any signs of
pathological alteration of the tissue.
EEG: normal
MILITARY MEDICAL ACADEMY
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Thrombosis of v. jugularis l.sin
↓
CVC was removed from v. subclavia l.sin
↓
Another one was placed on the opposite
side of the body
MILITARY MEDICAL ACADEMY
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THERAPY STRATEGIES
Antibiotics
TPN
Anticoagulant therapy
Immunosuppressive (KS, azatioprim)
Mesalazine tabl.
Blood transfusions
Albumin, immunoglobulin, cгуоprecipitate
+ I.V. fluid therapy
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
Fistula output: ▼ 850 ml/day
▼ 470 ml/day
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MILITARY MEDICAL ACADEMY
Bowel in continuity / complitely disrupted ???
Fistula arrising from the lateral wall / end fistula
– no communication with bowel distally ???
Associated abscess cavity / drain into the cavity ???
Condition of adjacent bowel:
damaged, strictured, inflamed ???
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Distal obstruction ???
Arrising in what part of GIT ???
Ethiologic disease process ???
Lenght of the tract << / >> 2cm ???
Bowel wall defect greater 1 cm² ???
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
Fistula output: ▼ 470 ml/day
▼ 220 ml/day
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MILITARY MEDICAL ACADEMY
How long parenteral nutrition
should be given?
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Our TPN lasted for 35 days
Treatment gave a positive result and
fistula enterocutanea was closed
We started with enteral nutrition
two days before TPN stopped
MILITARY MEDICAL ACADEMY
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ENTERAL NUTRITION
Our choice was
Sip feeding
MILITARY MEDICAL ACADEMY
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Enteral nutrition
Sip feeding
1st and 2nd day - EN + TPN
3rd and 4th day - EN only
The rest of the treatment –
EN + special diet
MILITARY MEDICAL ACADEMY
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MILITARY MEDICAL ACADEMY
laboratory findings on departure
• Na 139 mmol/L
• K 3.9 mmol/L
• Cl 98 mmol/L
• GLU 5.7 mmol/L
• BUN 4.2 mmol/L
• CREA 68 µmol/L
• TP 65 g/L
• Alb 31 g/L
• Ca 2.24µmol/L
• WBC 6.1x10^9
• RBC 3.40x10^12
• Hgb 97g/L
• Hct 0.31
• Plt 189x10^9
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MILITARY MEDICAL ACADEMY
weight and height on departure
W-39.5kg H-165 cm
• BMI = 14.5
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RESULTS
Oral feeding re-established on
the 56th postoperative day
Discharged on the 45th day
of admission from our hospital
Weight 39.5 kg
MILITARY MEDICAL ACADEMY
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