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L.M. 52 y.o . female

Follow the treatment journey of a 52-year-old female patient with COPD, Type 2 Diabetes, Hyperlipidemia, Obesity, Fibromyalgia, and other conditions as she undergoes surgeries and receives TPN support.

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L.M. 52 y.o . female

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  1. L.M. 52 y.o. female Maureen Donah 2013 SodexoSouthcoast Dietetic Intern

  2. Past Medical History • COPD • Type 2 Diabetes • Hyperlipidemia • Obesity • Fibromyalgia • Hx of recent UTIs • Kidney Stones • Irritable Bowel Syndrome • Depression

  3. L.M. was admitted 1/8/13 • Caucasian • 5’0” 212# (stated) • BMI 41.4 • Social Hx: patient doesn’t drink alcohol and used to smoke in the past 140 99 16 186 4.3 27 1.1

  4. Emergency Room • In the ER L.M. presented with left-sided flank pain • CAT scan showed UPJ stone with hydronephrosis and diverticulitis • Hydronephrosis is the swelling of the kidney due to a back up of urine. http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm

  5. Procedure 1/9/13 • Pre-op dx: ?colovesical fistula (due to air in the bladder) and left proximal ureteral stone • Cystoscopy • Fistulogram • Left retrograde pyelography • Left ureteral stent placement • Post-op dx: Left proximal ureteral stone and colovesical fistula confirmed

  6. The Plan • The pt was treated with IV antibiotics, IV fluids, and IV narcotics • 1/11/13 pt started clear liq diet and tolerated well and was adv to a DM diet • Pain was off and on and was better controlled with p.o. medications • 1/12/13 pt was d/c home

  7. The Plan • The pt was told to follow up with primary doctor within 5-7 days • Follow up with GI for colonoscopy after antibiotic is finished • Follow up with surgery in 2-3 weeks

  8. Re-admitted 1/25/13 • Left flank pain • Diarrhea and vomiting PTA 139 101 11 189 4.3 27 1.0 Started DM 1800cal dt 1/26/13-2/1/13 with fair to poor intake

  9. RD Assessment 2/4/13 • 5’0” 212# (Stated) BMI 41.4 • Adj. body wt: 128#/58kg • Kcals 1450-1750 (25-30 kcals/kg) • Protein 69-76g (1.2-1.3g/kg) • Fluid 1750mL (30mL/kg) • On full/clears since 2/1/13 with fair intake • Prep for surgery

  10. 2/5/13 Surgery • Dx: Sigmoid diverticulitis with colovesical fistula • Laparotomy with sigmoid colon resection and repair of colovesical fistula

  11. Nutrition after Fistula Repair • NPO 2/5-2/8 • Started clear liquid 2/9-2/10 • Not tolerating clears, episodes of vomiting • NPO 2/11-2/13

  12. 2/13/13 POD#8 • Anastomotic leakage • Confirmed by a barium enema • Procedure: Diverting loop ileostomy

  13. Nutrition after Ileostomy • Nutritional Needs (58kg) • Kcals 1450-1750 (25-30kcals/kg) • Protein 75-87g (1.3-1.5g/kg) • Fluid 1750mL (30mL/kg) • IVF D5 ½ NS + 20mEq KCl • Diet advance to clear liquids 2/13 • Diet advance 2/14 to diabetic diet for breakfast only • L.M. not tolerating, vomiting continues

  14. The Plan • Patient not tolerating liquids at all • In 2 weeks L.M. had 2 surgeries and was NPO for 7 days and received 7 days of liquid trays • With this minimal nutrition the plan was to start TPN - Central line 2/15/13 • Pt at refeeding risk! • Potassium 3.7 • Magnesium ? • Phosphorous ?

  15. Nutrition Support (TPN) 2/15 • Day 1 custom bag 1,000mL/day 50g AA, 100g dextrose, no lipids due to shortage • IVF (D5 ½ NS) kept at 100mL/hrwill decrease by day 2 per PA

  16. Day 2 TPN 2/16/13 • 2,000mL/day 80g AA, 175g dextrose, no lipids, 20 units insulin • IVF switched to Normal Saline • IVF decreased to a combined rate with TPN to 100mL/hr • Potassium 3.1 • Magnesium 1.7 • Phosphorous 1.9

  17. Day 3 TPN 2/17/13 • TPN at goal: 1,800mL/day 85g AA, 160g dextrose, 25 units insulin • IVF (NS) at combined rate of 100cc/hr • To provide 884 kcals/day • Only meeting 55% of calorie needs • Potassium 3.1 • Magnesium ? • Phosphorous1.6

  18. Day 4 TPN 2/18/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 35 units insulin • Potassium 3.2 • Magnesium 2.3 • Phosphorous2.3 • Pt now not passing gas and has hypoactive bowel sounds

  19. 2/18/13 • Vomited • KUB showed multiple dilated small bowel loops, consistent with a small bowel obstruction. • Started NGT to LWS 1500cc output

  20. Day 5 TPN 2/19/13 • 1,800mL/day 85g AA, 160g dextrose, 50g lipids, 45 units insulin • To provide 1334kcals, meeting ~83% of calorie needs • NGT to LWS 2550cc output • Potassium 3.3 • Magnesium 2.3 • Phosphorous?

  21. Day 6 TPN 2/20/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 55 units insulin • NGT to LWS output • Potassium 3.3 • Magnesium 2.2 • Phosphorous4.3 3000cc 3000c *Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale) BMI 37.5 Down 19.5# since admission

  22. Gastric Secretions Production and composition of gastric secretions varies. Daily estimates ~1-3L ~1liter saliva and ~2 liters gastric secretions: ~3 liters total The electrolyte composition of each liter is estimated at 20-100mEq sodium, 50-160mEq chloride, and 5-15mEq potassium Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18.

  23. Gastric Secretions * No blood gas labs taken

  24. Day 7 TPN 2/21/13 • 1,800mL/day 85g AA, 160g dextrose, 50g lipids, 60 units insulin • NGT to LWS 1500cc output • Started to pass flatus but still hypoactive bowel sounds • KUB still seeing multiple dilated loops

  25. Day 8 TPN 2/22/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 60 units insulin • Started clear liquid diet • NGT clamped for 3hrs then LWS for 1hr • NGT to LWS 2250cc output • Pt was given MOM (30mL) q2h while awake

  26. TPN Continues • Pt continued on clear liquid diet and TPN, with fair PO intake • SBO resolving 2/25/13 per KUB • Diet advanced to full liquid on 2/27/13 with good intake • Lunch on 2/28/13 diet advanced to soft easy to chew and TPN d/c’d

  27. Cleared for Discharge • Pt was tolerating soft diet with fair intake and supplements. • Pt was discharged home with VNA on 3/2/13 • Pt was told to follow up with surgery for barium enema as an outpatient and eventually reverse her ileostomy

  28. Re-admitted on 3/6/13 • Abdominal pain and minimal output from ileostomy. • Low sodium of 122 on admission • Hyponatremia resolved after hydration • Electrolytes were stable and she was tolerating a full diet. • D/c’d home 3/12/13

  29. Re-admitted 3/20/12 • Fatigue, nausea, and abdominal pain • Found to have another low sodium on admission of 129 • Pt was hydrated and stable • D/c’d home on 3/22/13 • Still follow up with surgery regarding ileostomy

  30. Re-admitted 3/25/13 • Nausea, vomiting, and abdominal pain • Pt vomiting and unable to keep any food or fluids down • Pt was again found to be dehydrated • Sodium on admission 132 • Pt was given fluids and tolerated diet • D/c’d 3/31/13 to nursing home facility

  31. References • Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18. • Medline Plus. Hydronephrosis. (2013). http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm

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