Initiation of Peripheral Parenteral
Nutrition with Appendicitis and
Small Bowel Obstruction
Tiffany Peters
Andrews University Dietetic Intern
September 2015-April 2016
Outline
Introduction
Social History
Past Medical History
Normal Anatomy and Physiology of Appendix and Bowel
Hospital Stay
Labs
Medications
Treatment
Medical Nutrition Therapy
Prognosis
Conclusion
Introduction of K.C.
12 year old Caucasian female
Weight: 73.9 kg (162.5 lbs.)
Height: 64 inches
BMI: 27.9
97th percentile BMI for age and 151% IBW
Obese
Less active in winter months
Case Study: March 28 – April 5, 2016
Body mass index-for-age percentiles. (2000). Retrieved April 17, 2016, from http://www.cdc.gov/growthcharts
Social History
6th grade
Active during the summer
Likes to play outdoors
Lives at home with father, mother, and two brothers
No preferred religion
Past Medical History
No significant history
Lip laceration - stitches
First admission to St. Francis Hospital
Normal Anatomy and Physiology
of the Appendix
No major function – we can live without it
Descends from the lower cecum
Bound to the abdominal wall, anterior loops of ileum, and the omentum
Average length is 9 cm but ranges from 2-20 cm
End artery
Nundy, S. (Ed.). (2014). The Appendix-ECAB. Elsevier Health Sciences.
Normal Anatomy and Physiology
of the Small Bowel
Imperative to nutrient absorption
Duodenum, Jejunum, and Ileum
Finger-like projections – villi
Hair-like projections – microvilli
Complete bowel obstruction
Inability for nutrients to be absorbed and waste to be excreted properly
Another source of nutrition is indicated – parenteral nutrition
Nelms, M. Sucher, K., Lacey, K., and Roth, S.L. Nutrition Therapy & Pathophysiology. 2nd ed. Brooks/Cole Cengage Learning, Belmont, CA; 2011
Hospital Stay
Admission on March 28, 2016
Complaints of abdominal pain, nausea, loss of appetite, previous
fever
CT scan confirmed acute appendicitis
Inflammation and free fluid in the pelvis area – indicated
perforation
Laparoscopic appendectomy
Found adhesions to the retroperitoneum
Appendix was cut out and removed
Drain placed for intra-abdominal abscess
Hospital Stay
March 29, 2016 – Postop day #1
Diarrhea
Abdominal pain
Vomiting
Thought to be caused by medications
Hospital Stay
March 30, 2016 – Postop day #2
Nausea/vomiting especially after eating
Diarrhea had stopped
Generalized ileus and lack of bowel function
IV fluids were increased
Potassium chloride – hypokalemia
NPO
Hospital Stay
March 31, 2016 – Postop Day #3
Continued vomiting – bilious
Allergic reaction to Zosyn, switched to Meropenem
Abdominal scan – small bowel obstruction vs. postop ileus
CT scan ordered for confirmation
NG tube placed for suction
Started PPN
Hospital Stay
April 1, 2016 – second surgery
CT scan confirmed 4 cm intraloop abscess in the central
abdomen
Small bowel obstruction secondary to adhesions due to the
abscess
Adhesion severed
Abscess drained and irrigated
Hospital Stay
April 1, 2016 – Postop day #1
K.C. feeling much better
No pain or vomiting
NG tube returned light green bile
April 3, 2016 – Postop day #3
NG tube removed
Clear liquid diet
April 4, 2016 – Postop day #4
GI soft diet
PPN discontinued
Discharged on April 5, 2016
Labs
Admit
labs
3/28/16
Post-op 1
3/30/16
Post-op 2
3/31/16
Post-op 1
4/2/16
Post-op 3
4/4/16
Final labs
4/5/16
Normal lab
values
Sodium 134 L 136 137 133 L 136 136 136-144 mmoll
Potassium 3.6 3.2 L 3.5 L 4.1 3.9 4.0 3.6-5.1 mmoll
Chloride 103 103 101 101 104 103 101-111 mmoll
TCO2 20 L 23 28 27 26 24 22-32 mmoll
Glucose 125 H 126 H 115 H 96 83 79 70-100 mg/dL
BUN 9 7 8 9 12 12 6-25 mg/dL
Creatinine 0.7 0.7 0.5 0.5 0.5 0.5 0.6-1.2 mg/dL
Calcium 9.7 9.3 9.2 8.7 9.1 9.4 8.5-10.5 mg/dL
Hemoglobin 13.2 11.8 L - 12.2 - - 12-16 g/dL
Hematocrit 39.7 35.4 L - 36.9 - - 36-46 %
Total Protein 7.8 - 6.6 - 6.2 L - 6.5-8.1 gm/dL
Total Bili 0.8 - - - 0.2 L - 0.3-1.2 mg/dL
ALT/SGOT 16 - - - 16 - 10-42 IU/L
AST/SGPT 19 - - - 16 - 10-40 IU/L
Albumin 4.3 - 3.3 L - 3.0 L - 3.6-5.3 gm/dL
Alk Phos 161 - 98 - 95 - 70-200 IU/L
CRP - - - - - - < 0.1 mg/dL
Magnesium - - 1.9 2 1.9 - 1.7-2.3 mg/dL
Phosphorus - - 3.5 3.9 4.0 - 2.5-4.6 mg/dL
Prealbumin - - 13.1 - 22.9 - 18-38 mg/dL
Triglycerides - - 50 - 63 - <200 mg/dL
PRN
Medications
Medication Purpose Drug/Nutrient Interaction Possible Side Effects
Normal Saline
Flush
To clear medications
from the port to
make sure the drug
was delivered fully.
May alter how other
medications work
Possible allergic reaction.
Symptoms include rash,
itching/swelling, severe dizziness,
and trouble breathing.
Morphine Narcotic; pain
reliever
Avoid alcohol May cause dry mouth, taste
changes, anorexia, weight loss,
decreased gastric motility,
constipation, nausea, vomiting.
Hydrocodone Narcotic; pain
reliever
Take with food or milk to
decrease GI distress; avoid
alcohol. May cause
delayed digestion.
May cause dry mouth,
constipation, nausea, or vomiting.
Zofran Antiemetic,
antinauseant
N/A May cause dry mouth, abdominal
pain, constipation, or diarrhea
Promethazine Antiemetic, sedative Take with meals to
decrease GI distress;
increased need for
riboflavin; avoid alcohol
May cause dry mouth,
constipation, nausea, or vomiting.
Phenol-
Phenolate
Sodium 1.4%
Oral anesthetic for
sore mouth or throat
N/A Possible allergic reaction.
Symptoms include nausea,
vomiting, rash, difficulty breathing.
Ativan Antianxiety Limit caffeine. Caution with
grapefruit/citrus.
Chamomile may increase
sedative effect. Echinacea
may decrease drug levels.
May cause weight loss or weight
gain, increased thirst,
constipation, diarrhea, nausea or
vomiting.
Dextrose 50% Used for dehydration
or to control blood
sugars
May lower serum sodium
and increase serum
potassium
Hyperglycemia, edema
Humulin Insulin; to lower blood
glucose levels
Diabetic meal plan to
balance carbohydrate
with insulin; alcohol may
increase effect of insulin
causing hypoglycemia
May cause weight gain or
hypoglycemia
Routine
Medications
Medication Purpose Drug/Nutrient
Interaction
Possible Side Effects
Flagyl Antibiotic Food may decrease
drug bioavailability
May cause anorexia,
metallic taste, nausea,
vomiting, epigastric
distress, or diarrhea
Zosyn Antibiotic Food may decrease
absorption of drug
May cause anorexia, oral
candidiasis, nausea,
vomiting, epigastric
distress, or diarrhea
Meropenem
injection
Antibiotic N/A May cause oral
candidiasis, glossitis,
nausea, vomiting,
diarrhea, GI bleeding, or
colitis
Omnipaque
240
Iodinated
contrast agent
given to
diagnose
problems. Used
during CT scans
to pinpoint
problem areas
Do not take with
Amiodarone or
Metformin
May cause nausea
Potassium
chloride
to prevent or to
treat low blood
levels of K+
Not to be taken
while using salt
substitutes.
May cause GI irritation,
nausea, vomiting,
abdominal pain, diarrhea,
or flatulence.
Treatment
Diagnosis – traditionally using a CT scan
Exposure to radiation – increased risk for developing cancer1
Study in Cleveland, OH2
Iterative reconstruction technique – reduces background noise and uses a lower dose of radiation
Tested specifically on diagnosing children with acute appendicitis
Found to be just as successful as regular CT scans
1Miglioretti, D. L., Johnson, E., Williams, A., Greenlee, R. T., Weinmann, S., Solberg, L. I., ... & Smith-Bindman, R. (2013). The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA pediatrics, 167(8), 700-707.
2Didier, R. A., Vajtai, P. L., & Hopkins, K. L. (2015). Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatric radiology, 45(2), 181-187.
Treatment
Removal
Laparoscopic vs. open surgery
Most physician and patients prefer laparoscopic1
Three small incisions1
Less recovery time, decreased risk for formation of adhesions, and faster return of bowel function2
K.C. had laparoscopic surgeries
Perez, E. A., Piper, H., Burkhalter, L. S., & Fischer, A. C. (2013). Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surgical endoscopy, 27(4), 1367-1371.
Di Saverio, S., Coccolini, F., Galati, M., Smerieri, N., Biffl, W. L., Ansaloni, L., ... & Fraga, G. P. (2013). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg, 8(1), 42.
Medical Nutrition Therapy
Typical eating pattern
Skips breakfast
Lunch at 12:00pm school cafeteria food
After school snack crackers & fruit
Dinner is prepared by K.C. mom
Dislikes mushrooms and cabbage
Breakfast
Carbs
(g)
Protein
(g)
Fat
(g)
Sodium
(mg)
Calories
N/A 0 0 0 0 0
Lunch
1 slice pepperoni pizza 32 14 11 560 280
½ cup carrots 8 2 0 65 39
16 oz raspberry lemonade
smoothie
61 2 0 73 240
Snack
1 cup goldfish crackers 20 4 5 250 140
1 banana 30 1 0 1 110
Dinner
1 cup Lasagna 43 23 14 670 400
½ cup corn 16 2 1 0 75
¾ cup applesauce 18 0 0 15 75
1 cookie crumble ice cream
cone
32 3 8 0 213
TOTAL 260g 51g 39g 1634mg 1572
kcal
Medical Nutrition Therapy
K.C.’s Energy Needs
Kcal: 2049 (Schofield Equation with 1.3 stress factor for surgery)
Protein: 111-148 grams (1-1.2 g/kg for draining abscess)
Fluid: 2578 ml (according to body surface area)
Pediatric Multivitamin
Electrolytes to replete as needed
Corkins, M., Balint, J., Seebeck, N. & American Society for Parenteral and Enteral Nutrition. (2010). The A.S.P.E.N.
Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.
Medical Nutrition Therapy
Prescribed Diets
Clear liquid → Regular → NPO + TPN → Clear liquid → GI soft
Initiation of PPN
According to American & European Guidelines on Parenteral Nutrition
PN is NOT beneficial for postoperative complications if the child was well nourished AND will be NPO for less than 7 days
The risk of infection is more of a concern than the lack of nutrition
Lack of sufficient energy intake does not prove to have any deleterious effect on growth status as long as the child was well nourished prior to surgery
Mueller, C., McClave, S., Kuhn, J. M., & American Society for Parenteral and Enteral Nutrition. (2012). The A.S.P.E.N. adult nutrition support core curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.
Mantegazza, C., Landy, N., Hill, S. M., Zuccotti, G. V., & Koglmeier, J. (2016). Parenteral Nutrition in Hospitalized Children. Medical & Clinical Reviews.
Medical Nutrition Therapy
Peripheral Parenteral Nutrition
3/31/16 4/1/16 - 4/2/16
Total fluid 2400 ml 3000 ml
Total kcals 990 kcal 1448 kcal
Non-protein calories 750 kcal 1160 kcal
Amino acids 60 g 72 g
Dextrose 150 g 200 g
Lipids 24 g 48 g
Kcal from dextrose 52% 47%
Kcal from protein 24% 20%
Kcal from lipids 32% 33%
GIR (mg/kg/min) 1.41 1.88
Kcal needs: 2049 Protein needs: 111-148
At goal rate, the PPN meets 71% kcal needs and 65% protein needs.
Prognosis
K.C. comprehended and cooperated
Strong family support
Complete healing with no other complications
Return in one week to have drains removed
Thank you for listening!