Initiation of Peripheral

Parenteral Nutrition with

Appendicitis and Small Bowel

Obstruction

Case Study By:

Tiffany Peters

4/21/16

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Introduction

K.C. is a 12 year old Caucasian female who came to St. Francis Hospital on March 28,

2016 with complaints of nausea, loss of appetite, previous fever, with periumbilical and right

lower quadrant abdominal pain. Her symptoms, along with a CT scan, confirmed acute

appendicitis with possible perforation. She currently weighs 73.9 kg and is 64 inches tall with a

BMI of 27.9. According to the BMI for age growth chart, K.C. is in the 97th percentile which is

classified as obese.1 She is also 151% of her ideal body weight. Her height, however, is in the

60th percentile according to stature for age charts.1 This patient was chosen for a case study

review due to her unusual surgical complication and need for peripheral parenteral nutrition

support. This study begins upon admission on March 28, 2016 and concludes at time of

discharge on April 5, 2016. This study focuses on surgical complications of the bowel and

evidence of nutrition support in pediatric patients.

Social History

K.C. is in 6th grade at her local middle school. Her mother reports she does very well in

school and gets along well with her peers. She states she is very active and likes to be outdoors.

She lives at home with her father, mother, and two brothers. She has a healthy home

environment where she is well provided for. Her and her family have no preferred religion at

this time.

Normal Anatomy and Physiology of Appendix and Bowel

Historically, the appendix has not been found to have any major function in the body.

This is because removal is common and lends no real deficit to digestion or the immune system

in any way. The appendix descends from the lower cecum.2 It is bound to the abdominal wall,

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the anterior loops of the ileum, and the omentum. It ranges in length from 2-20 cm, averaging

about 9 cm.2 The appendicular artery that supplies the appendix with blood is an end artery.

The appendix has no other blood supply, making it easily targeted for gangrene or perforation

when a thrombosis occurs due to inflammation.2

The small bowel is imperative to nutrient absorption. This coiled-like tube provides the

optimum environment for the digested food molecules to attach to its hair like projections and

be absorbed into the blood stream to be used by cells.3 Without a functioning small intestine,

other means of nutrition are needed to supply energy to the body. When K.C.’s appendix was

removed, abscesses formed and caused inflammation. These internal wounds along with post-

operative adhesions led to an obstruction in the distal ileum. Once this happened, there was no

feasible way for the digested food particles to move into the colon, which led to intractable

vomiting. Oral diet had to be postponed until the obstruction was cleared. In this case, the

dysfunction of the small bowel increased the need to find additional means of nutrition.

Past Medical History

K.C. has no significant past medical history. She has had stitches for a lip laceration, but

no previous admission to St. Francis Hospital. Otherwise, she is a typical adolescent who

occasionally gets minor scrapes and bruises.

Present Medical Status and Treatment

The patient’s main medical concern was perforated appendicitis. However, it became

more complicated when K.C. did not quickly recover from the appendectomy as planned. She

became nutritionally compromised when the small bowel obstruction prohibited her from an

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oral intake. The normal nutrition treatment for this condition is initiation of parenteral nutrition

due to the dysfunction of the gut.4

Upon admission, K.C. was discovered to have acute appendicitis. The pain in her right

lower abdomen, nausea, and loss of appetite were significant in her diagnosis. The CT scan

confirmed this theory. The admitting physician stated inflammation of the appendix as well as

free fluid in the pelvis area, indicating perforation. He decided it was necessary to do a

laparoscopic appendectomy; however, depending on what they found, they would possibly

have to do an open surgery.

During the appendectomy, the surgeon found purulent fluid in the peritoneal cavity, as

expected from the CT scan. At closer look of the appendix, adherence to the retroperitoneum

was identified. The appendix was indeed perforated, but was blocked off by the omentum. The

appendix was cut away and removed. A drain was placed for the intra-abdominal abscess.

On March 29th, postoperative day #1, K.C. had several episodes of diarrhea, abdominal

pain, and emesis, thought to be caused by pain medications. On postop day #2, the patient

continued to have nausea and vomiting, especially after eating, but the diarrhea had stopped. It

was determined that she may have a generalized ileus and lack of complete bowel function,

despite episodes of diarrhea from the previous day. IV fluids were increased and potassium

chloride was given to correct hypokalemia. The patient was not able to tolerate any oral intake.

By the third day, K.C. was continuing to vomit and emesis was bilious. She developed a

truncal rash in which Zosyn was discontinued and she was switched to Meropenem. Another

abdominal scan was performed which confirmed small bowel obstruction versus a postop ileus.

This could possibly be due to peritonitis caused by her perforated appendicitis or adhesions

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caused by the surgery. A CT scan was ordered to rule out any other possibilities for failed

improvement of the patient. An NG tube was placed for suction and she was started on

peripheral parenteral nutrition.

On April 1, the CT scan was reviewed and confirmed a 4 cm intraloop abscess in the

central abdomen with a small bowel obstruction secondary to adhesions due to the abscess.

Another procedure was performed to drain the abscess and to release adhesions. The abscess

was next to the descending colon which was causing the small bowel to become inflamed and

wall off the abscess. The small bowel obstruction was due to the inflammatory adhesion. The

adhesion was severed and the abscess was drained and irrigated.

The next day, K.C. was feeling much better. Her pain and vomiting had subsided since

the surgery. The NG tube remained in place for suction which returned some light green bile.

On April 3, the NG tube was removed and she was started on clear liquids. She tolerated the

clear liquids well and was advanced to a GI soft diet the following day. PPN was discontinued as

well. The patient was discharged on April 5, 2016 with instructions to return to outpatient clinic

for removal of drains.

Labs

At first examination in the Emergency Room, K.C.’s labs were fairly normal with no

immediate need for concern. Her labs throughout her entire hospital stay are listed in the table

below along with the normal values for comparison.

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

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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 - 0.2 L - 0.3-1.2 mg/dL

ALT/SGOT 16 - 8 L - 16 - 10-42 IU/L

AST/SGPT 19 - 8 L - 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 - - - - 7.8 H - < 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

Medications

Medication Purpose Drug/Nutrient Interaction

Possible Side Effects

PRN:

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.

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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:

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

Traditionally, diagnosis of appendicitis is made with a CT scan. This has been done

routinely for most populations. However, due to the patient being 12 years old, there is

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reasonable concern for the exposure of radiation given by a CT scan. Exposure has been found

to increase the risk for developing cancer later in life.5 A Cleveland, Ohio health institution has

initiated the iterative reconstruction technique which reduces background noise during the CT

scan.6 This provides the same quality resolution imaging while using a lower dose of radiation.

This method has been tested specifically on children with acute appendicitis and found to be

just as successful at diagnosis as regular CT scans. Due to the large number of pediatric patients

presenting with abdominal pain and the routine CT scans to check for acute appendicitis, this

technique helps reduce the exposure of radiation to children.

Appendicitis is treated by removal of the affected organ. Most physicians and patients

prefer the less invasive laparoscopic approach compared to an open surgery.7 A small incision is

made close to the umbilicus, and two other lateral incisions to insert the laparoscope, dissector

and grasper.7 After detaching the appendix, it is removed through one of the ports.7 However,

in K.C.’s case, the procedure was a bit more complex due to the discovery of an abscess.

Draining bulbs were placed to encourage fluid removal from the abscess and to prevent buildup

of the extra fluid in the peritoneal cavity.

By postop day #4, it was obvious that K.C.’s abscess was not healing and adhesions had

formed on the small bowel causing inflammation and obstruction. This was causing the emesis

and total intolerance of an oral diet. The second surgery was to lyse the adhesions. The surgeon

again chose to do a laparoscopic procedure over an open surgery. This method proves to be

advantageous for several reasons including less recovery time, decreased risk for formation of

additional adhesions, and faster return of bowel function.8

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Medical Nutrition Therapy

K.C.’s typical eating pattern at home consists of lunch, an afterschool snack, dinner, and

dessert. She often skips breakfast in the morning because she does not have an appetite. Her

first meal of the day is about 12:00pm where she mostly eats school cafeteria food. An

afternoon snack is usually crackers and a piece of fruit. Dinner is prepared by K.C.’s mom who is

the main cook of the family. She also does all of the grocery shopping. Ms. C stated she avoids

mushrooms and cabbage at all costs, but enjoys most other foods. An analysis of foods she

would normally eat in a typical day is in the table below.

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

Throughout her hospital stay, K.C. was prescribed several different diets. Right after her

first surgery, she was given a clear liquid diet. This was soon advanced to regular. However, it

quickly became evident that the patient was not able to tolerate any oral intake due to severe

nausea and vomiting. She was made NPO and immediately started peripheral parenteral

nutrition. This was indicated for small bowel obstruction. Interestingly, the American and

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European Guidelines on Parenteral Nutrition specify that starting PN for postoperative

complications is not beneficial if the child is adequately nourished and will be NPO for less than

seven days.9 In fact, the risks of infection is more of a concern than the lack of nutrition for a

few days. It is understandable why the physician did not want to deprive the child of nutrition;

however, the evidence does not support an immediate advantage. Also, the lack of sufficient

energy intake does not prove to have any short-term deleterious effect on growth status as

long as the child was well nourished prior to surgery.9

Both the patient and her mother expressed concern regarding parenteral nutrition. K.C.

was willing to cooperate and understood eating an oral diet would continue to cause problems

until they could surgically appease the inflammation that was causing the obstruction. Prior to

admission, Ms. C was healthy and well nourished. According to the CDC growth chart, she is

obese for body mass index-for-age, scoring in the 97th percentile.1 Her mother stated she

usually puts on weight during the winter when she is less active. During the summer months,

K.C. plays outdoor sports and tends to shed a few pounds. Using the Schofield Equation, her

caloric needs are 2049 kcal.10 This includes a stress factor of 1.3 for recent surgery. Her protein

needs are 111-148 grams (1.5-2 g/kg).10 This provides enough to compensate for loss of protein

from the draining abscess as well as healing from surgery. Pediatric multivitamins and

electrolytes are also important while on parenteral nutrition, especially with fluid losses from

wounds. These can be added directly to the PN bag, but must be monitored carefully to ensure

adequate intake and to prevent toxicities.

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Peripheral Parenteral Nutrition Order

3/31/16 4/1/16 - 4/2/16

Total fluid 2400 ml 3000 ml

Total Kcal 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.

Once K.C. was able to tolerate solid food, PN was discontinued and she started on a GI

soft diet. According to A.S.P.E.N., parenteral nutrition should be discontinued when the patient

is able to tolerate 75% of their needs by using the gut.4 K.C. regained full function of her gut,

and was able to eat solid foods the next day after surgery. After discharge, the patient will

resume with her regular eating pattern at home with instructions to continue taking a daily

pediatric multivitamin. Due to her overweight status, she is encouraged to make healthier food

choices, eat three meals per day, and increase exercise.

Prognosis

K.C comprehended and cooperated with each nutrition recommendation made and had

positive family support. Upon discharge, she was eager to get back to her normal life. Her

prognosis is extremely good, and after healing, she should not have any other complications in

regards to her appendectomy.

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Summary & Conclusion

With this study, I combined a surgical case with a pediatric patient. It was very

interesting to learn about the differences in needs from adults to children. This was my first

pediatric patient and I enjoyed it very much. I found myself talking very differently to a 12 year

old than I would an adult. It was good to get some experience with adapting my language in

that way. This case study allowed me to get a great clinical experience with pediatrics since we

were not able to get any live involvement during our pediatric rotation. Also, during this case

study, I was able to work with pharmacy. I received a thorough overview of parenteral nutrition

in both pediatrics and adults. Since pharmacy calculates TPN and PPN at this facility, I believe it

is especially important to work together to provide nutritional care for patients. I look forward

to working with more pediatric patients in the future.

References

1. Body mass index-for-age percentiles. (2000). Retrieved April 17, 2016, from http://www.cdc.gov/growthcharts

2. Nundy, S. (Ed.). (2014). The Appendix-ECAB. Elsevier Health Sciences.

3. Nelms, M. Sucher, K., Lacey, K., and Roth, S.L. Nutrition Therapy & Pathophysiology. 2nd

ed. Brooks/Cole Cengage Learning, Belmont, CA; 2011

4. 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.

5. Miglioretti, 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.

6. Didier, 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.

7. 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.

8. 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.

9. Mantegazza, C., Landy, N., Hill, S. M., Zuccotti, G. V., & Koglmeier, J. (2016). Parenteral

Nutrition in Hospitalized Children. Medical & Clinical Reviews.

10. 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.