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Case Study: Patient with Colon Cancer/ Ileostomy placement

Case Study: Patient with Colon Cancer/ Ileostomy placement . Laura Salinas KSC Dietetic Intern 12-13. Today, we will discuss. 1. Pathophysiology of colon cancer/ colectomy/ileostomy 2. Medical Nutrition Therapy & Nutrition Care Process Diagnosis & Hospital course

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Case Study: Patient with Colon Cancer/ Ileostomy placement

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  1. Case Study:Patient with Colon Cancer/Ileostomy placement Laura Salinas KSC Dietetic Intern 12-13

  2. Today, we will discuss 1. Pathophysiology of colon cancer/colectomy/ileostomy 2. Medical Nutrition Therapy & Nutrition Care Process Diagnosis & Hospital course Nutritional Assessments MNT recommendations & Diet Orders Goals Interventions Evaluation/reassessment

  3. Northeast Methodist Hospital Operational Vision: To meet the needs and exceed the expectations of those we serve by working together as a team in a culture dedicated to never-ending improvement. 179 Licensed beds • NEMH offers a full array of services: • ER • CABG & cardiac catheterizations • Inpatient rehabilitation • Orthopedic surgery • Oncology/Cancer Care • ICU/PCU • Inpatient and outpatient surgeries and procedures

  4. Role of the RD at NEMH • 2 Full Time Registered Dietitians • Screening, Evaluations, Assessing Nutritional Needs • Screening triggers with a score of 7: • N/V, Skin comp, decreased intake, weight loss, difficulty swallowing, TPN/EN, >65 with surgery, Kidney dx, Cancer, DM, GI, Stroke, Liver Dx • Ventilated patient automatically trigger • LOS > 6 days or NPO > 3 days • Works with full health care staff • Diet office, RN, Doctors, ICU & Rehab rounds • Consultations & Diet Educations

  5. Meet Ms. A • 42 year old female admitted June 3, 2013 • Diagnosis: Colon Cancer, Laparoscopic Right Hemicolectomy • Severe Iron Deficiency Anemia • Iron 18 mcg/dL, Iron Saturation 5%, Hgb 9.8 g/dL • Colonoscopy • polyps with tubulovillous adenoma with high-grade dysplasia • Medical History: Hyperlipidemia, Bipolar Disorder, Anemia, Gastric Bypass (2004) • Diet Order: Clear Liquid Diet (POD #1) • Labs (POD #2): Glu 115, Ca 8.0, PO4 1.7, Mg 1.4, Alb 2.6, Hgb 8.5, Hct 25.7 • (POD #3): Iron 9 mcg/dL, Iron Sat. 4%, Transferrin 184 mg/dL

  6. Colon Cancer: Pathophysiology • Most cases of colon cancer begin as small benign clumps of cells called adenomatous polyps. • Over time, polyps can develop into colon cancers. • Treatment: • Surgery • Early stage • Invasive*** • Advanced • Chemotherapy • Radiation Therapy • Targeted Drug Therapy

  7. Digestive System http://digestive.niddk.nih.gov/ddiseases/pubs/ileostomy/

  8. Site of Nutrient Absorption http://www.tuberose.com/Digestion.html

  9. Right hemicolectomy

  10. What went wrong? • POD #4 (6/7/13) • Pt experiencing persistent abdominal pain and dark urine • Enema revealed brownish/red stool • Temperature spiked to 100.4 F. • Hold heparin, protonix, KUB ordered • KUB revealed ileus with free air • Lab Values: Na 134, Cl 97, BUN 28, ALB 2.2, GFR 58, GLU 114, CA 8.4, MG 2.7 • Nutrition Status • Diet Order: Bariatric/Gastric Bypass Diet

  11. Clinical Course • POD #5 (6/8/13) • Nutrition Status • Declining – notes indicate pt is unable to eat • Pain with passing gas and burping • Phenergan for N/V • POD #6 (6/9/13) • Pt required 2 units of blood (327 cc)

  12. Clinical Course • POD #7 (6/10/13) • Problem List: • S/P right hemicolectomy • Severe Iron Deficiency Anemia • PMH of gastric bypass – limited ability to absorb oral iron • IV iron • Anemia • Acute on chronic; blood loss from surgery; iron deficiency • Hypophosphatemia • IV replaced • Hypomagnesemia • IV replaced • Ileus

  13. Clinical Course • POD #7 (6/10/13) • Acute events: • severe abdominal pain/abdominal distention • Nausea & vomiting • KUB showed ileus and nonspecific inflammation • Likely anastomotic leak • Ms. A to OR for washout and Ileostomy • 2 L washed out of the abdomen • Nutrition Status: NPO • TPN & Lipids ordered through triple lumen IJ

  14. Anastomotic Leak • Complication affects 2-10% of patients undergoing GI surgery • Negative impact on oncologic outcome in patients undergoing curative resection for colon cancer • Increased risk for AL: • Patients with Albumin <3.5 g/dL *Ms. A: Alb 2.2 g/dL • Intraoperative blood loss of 200 mL or more • OR time >200 minutes • Intraoperative transfusion requirement http://archsurg.jamanetwork.com/article.aspx?articleid=405870

  15. Washout and Ileostomy

  16. Nutrition Assessment • 6/10/13* Initial Nutrition Screening Assessment • Diet Order: NPO Weight: 226 lb (reported by patient) • Estimated needs: 1659-1990 (MSJ*1.0-1.2) • Actual weight • Protein needs: 113-135 gm/day (1.1-1.3 gm/kg) • Labs: NA 133, GLU 100, CR 0.5, ALB 1.9, WBC 15.6, H/H 9.6/30.0 • Meds: Insulin, Lovenox, Protonix, Pepcid, Phenergan, Lasix, Zofran, Morphine, Narcan, Bactroban, Ativan

  17. Nutrition Assessment • 6/10/13* Initial Nutrition Screening Assessment • Diet Order: NPO Weight: 226 lb (reported by patient) • PES: Altered GI function related to altered GI structure as evidence by CT scan showing air/fluid in RLQ, patient experiencing n/v, abdominal distention, and no BM. • Goal: • Determine nutritional status & GI function post op • Advance oral diet if functional; if not, consider nutrition support • Intervention: Monitor symptoms, lab values, & diet changes

  18. Clinical Course • POD #8 (6/11/13) • Ms. A S/P exploratory laparoscopy after finding free air on KUB • Ileostomy Placement • Postoperatively Hypotensive (secondary to third spacing of fluid or septic shock) • Requiring high doses of Levophed • ICU: Intubated/sedated (propofol) • TPN running at goal rate of 75 cc/hr with 150 cc 20% lipids • 2 JP drains to left abdomen with bloody output • Ileostomy with liquid brown output http://www.cc.nih.gov/ccc/patient_education/pepubs/jp.pdf

  19. Academy’s Recommendation • “Enteral nutrition should always be considered as the first line of nutrition support, with parenteral nutrition used only when the GI tract is nonfunctional either as a result of physical or physiologic (obstruction) events.” “In some cases, the GI tract may be functional but cannot be accessed due to anatomical or pathophysiologic conditions; in those cases, parenteral nutrition should be considered.”

  20. MNT Recommendation: TPN • TPN with Lipids • Clin 5/25 • 1050 kcal/L • Amino Acid: 50 g/L (5%) • Dextrose: 250 g/L (25%) • Clin 5/25 at a rate of 75 mL/hr with 150 mL of 20% lipid per 24 hour infusion: • 2100 total kcal • 1700 non-protein kcal • 90 gm protein

  21. Clinical Course • POD #10 (6/13/13) • Weight: 255 lb • Ms. A remains critically ill – TPN still running • POD #12 (6/15/13) • Orders to extubate – TPN still running • POD #13 (6/16/13) • Weight: 246 lb • Ms. A advanced to Full Liquid Diet – TPN still running

  22. MNT recommendations: PES: Malnutrition related to alteration in GI structure and function as evidence by lap right colectomy and anastomotic leak repair with ileostomy placement, NPO status, critically ill, and ventilated/sedated. Goal: Monitor TPN & provide adequate energy to meet increased needs. Intervention: Monitor TPN, lab values, weight changes, and diet advancement

  23. Clinical Course • POD #16 (6/19/13) • Weight: 242 lb • Ms. A advanced to Bariatric/Gastric Bypass Diet & TPN d/c • MD notes indicate Ms. A tolerating PO with imodium • POD #18 (6/21/13) • Ileostomy bag continually leaking • Ms. A not eating well, nausea Malnutrition related to altered GI structure/function as evidence by s/p lap right colectomy, ileostomy, and 25% full liquid diet intake. • POD #23 (6/26/13) • Ms. A discharged to Heartland for Rehab

  24. Re-admit: July 3, 2013 • Diagnosis: Sepsis; Intra-abdominal abscess; Peritonitis • Nutritional Indicators with Ileostomy: • Inadequate oral intake; Inadequate fluid intake • Fluid and electrolyte imbalances • Evidence of malabsorption • Weight loss 15# since past admission • Reduced visceral protein stores Albumin 2.1 • Vitamin & Mineral Deficiencies

  25. Nutritional Assessment • 7/3/13* Initial Nutrition Consult for Supplementation • Diet Order: Full Liquid Weight: 212 lb (reported by patient) • Estimated needs: 1770-1930 (MSJ*1.1-1.2) • Protein needs: 82-109 gm/day (1.5- 2.0 gm/kg IBW) • Labs: NA 131, GLU 101, ALB 1.7, MG 1.7, WBC 19.2,H/H 11.5/34.5 • Meds: Lactinex, Pepcid, Zofran, Imodium, Folic Acid, Marinol

  26. Nutritional Assessment • 7/3/13* Initial Nutrition Consult for Supplementation • Diet Order: Full Liquid Weight: 212 lb (reported by patient) • PES: Malnutrition related to altered GI structure/function & complications as evidence by inadequate oral intake and increased protein/kcal needs. • Goal: • Pt will tolerate oral diet >75% to meet estimated nutrition needs. • Pt will consume meals with supplements to meet estimated needs • Correct protein calorie malnutrition and promote repletion of visceral protein stores • Intervention: monitor PO intake/tolerance; monitor lab values

  27. Clinical Course: Goals • 7/5/13: Calorie count consult received • Goal to correct protein/calorie malnutrition • Optimize postoperative healing needs • Correct nutrient deficiencies & meet estimated needs • Prevent dehydration and electrolyte imbalances • Intervention • Calorie Counts (7/5/13-7/8/13) • Ensure Enlive Q4hrs • Each Ensure Enlive provides 200 kcal & 7 gm protein • Food Preferences/Monitoring by dietary staff & RD • Diet Education • Minimize symptoms of malabsorption/maldigestion • Prevent gas/odor/obstruction

  28. Clinical Course: Nutrients • Nutrients of greater concern • Iron • B12 • Sodium • Potassium • Chloride • Total kcal • Total protein

  29. Clinical Course • 7/10/13 • Continuing calorie count • Patient visited on many occasions to encourage PO • Ms. A voiced that she is trying to get her appetite up • Frustrations with ileostomy bag leaking/coming off • Explained symptoms and foods to avoid • Low intakes continually on calorie counts • 7/6: 753 kcal, 49 gm protein • 7/7: 766 kcal, 39 gm protein Inadequate oral intake related to dx/hx and poor appetite as evidence by patient unable to meet estimated needs in two 24 hour calorie counts.

  30. Plan for d/c: • Low-fiber diet that provides adequate energy, protein, fluid, and electrolytes (Sodium/Chloride/Potassium) for healing • Increase sodium intake because of losses • Smaller more frequent meals with supplementation • Limit fluids with meals to decrease output • Education: supplementation and higher kcal/protein needs • Obstruction/Odor/Gas • Avoid chewing gum, drinking straws, carbonated beverages

  31. Questions? Thank You!

  32. References: American Cancer Society. Ileostomy: A Guide. Available at: www.cancer.org/acs/groups/cid/documents/webcontent/002870-pdf.pdf National Institute of Health. How to Care for the Jackson-Pratt Drain. Available at: http://www.cc.nih.gov/ccc/patient_education/pepubs/jp.pdf Nutrition Care Manual. Available at: www.nutritioncaremanual.org Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk Factors for Anastomotic Leak Following Colorectal Surgery: A Case-Control Study. Arch Surg. 2010;145(4):371-376. doi:10.1001/archsurg.2010.40. UPMC. Ostomy Nutrition Guide. Available at: www.upmc.com/patients-visitors/education/nutrition/pages/ostomy-nutrition-guide.aspx

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