1 / 26

Case Study: VF Gallstone pancreatitis

Case Study: VF Gallstone pancreatitis. Hannah Strauss Dietetic Intern Class of 2013. History and Physical (12/31/12). VF is an 86 YO male presented to ER for abdominal pain Noted to have congestion, cough, whitish sputum Jaundiced for a few days Short term memory loss S/P craniotomy

sirius
Download Presentation

Case Study: VF Gallstone pancreatitis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case Study: VF Gallstone pancreatitis Hannah Strauss Dietetic Intern Class of 2013

  2. History and Physical (12/31/12) • VF is an 86 YO male presented to ER for abdominal pain • Noted to have congestion, cough, whitish sputum • Jaundiced for a few days • Short term memory loss S/P craniotomy • Rhinitis and bloody nose • PMH: • Herpes Encephalitis • Left temporal craniotomy for glioblastoma, • Type II DM • Hypertension, Dyslidemia • CAD S/P CABG, • LSS S/P lumber spine fusion • AAA S/P repair

  3. PMH diagnoses defined Glioblastoma LSS Herpes Encephalitis • Malignant gliomas are rapidly progressive brain tumors named by their histopathologicfeaturs. • Glioblastomas: Develop from glial cells. • Symptoms: Headaches, Seizures, Short term memory loss, Muscle weakness, Vision changes, Language problems, Personality changes • Lumber Spinal Stenosis is An anatomic condition that includes narrowing of the intraspinal (central) canal or neural foramena. • Causes: Spondylosis, herniated disks, bone disease, tumors • Symptoms: Numbness, cramping pain, weakness • Swelling of the brain caused by Herpes simplex virus-1 • Most common cause of sporadic fatal encephalitis worldwide • Symptoms: Fever, Headach, Psych symptoms, seizure, vomiting, focal weakness, memory loss

  4. Emergency Room- Orders Chest X Ray Ultrasound of abdomen • Increased markings on right mid lower lung base (small infiltrate) • Cholelithiasis, mild prominence of gallbladder lumen with trace fluid in hepato-renal pouch (Morison’s Pouch), partial SBO CT Abdomen and Pelvis • Small gallstone in bile duct, mild extrahepaticbiliarydialation, gallbadder luminal distention • Dilation of small bowel loops (possible SBO)

  5. Assessment and Plan • Acute pancreatitis, likely secondary to obstructive etiology from gallstone • Possible PNA. • Plan: Admitted to SICU, kept n.p.o and started on levofloxacin and flagyl, • IV fluids, BiPAP trial, NG Tube LWS • GI consulted “Hopefully he will make a rapid recovery”

  6. Gallstone Pancreatitis • Sudden inflammation of the pancreas due to obstructive stones in the biliary tract or Ampulla of Vater are responsible for pancreatitis • Intervention: ERCP w/ papillotomy or surgical intervention to remove bile duct stones • Cholecystectomy should be performed after recovery in all patients with gallstone pancreatitis

  7. (12/03/12) – (02/07/13)… Gallstone Pancreatitis- Our Focus GI- Ileus, Gallstone Pancreatitis, cholecystitis, Difficulties tolerating Enteral Nutrition Pulmonary- PNA, Acute Resp Failure Cardiac- Atrial Fibrillation, Rapid Ventricular Response, Septic Shock Renal- Acute Renal Failure, left HD cath placed Jan 2 Neurologic- Gliobastoma, mental status waxed and weaned, encephalopathy?, Seizures? Infectious Disease- Possible UTI on admission Endocrine- DM “fairly well” controlled during hospitalization Hemotology- Leukocytosis, Anemia Extremities- Gross Anasarca since ARF

  8. The Complications Begin Day 2- (01/01) Respiratory Failure Endotrachial intubation -Acute Renal Failure Potassium 4.6-5.4 BUN- From 24 to 47 Creatinine- From 1.1-2.5 Phos 8.4 Day 3 (01/02)- Insertion of Left Femoral HD catheter Left jugular tri-lumen central venous line

  9. Initial Nutrition Assessment (Day 3) 1. Clinical data reviewed for today, 1/2/13 and time, 0900 2. Recent Weight Changes? Yes Comment: 5’6” 176# (1/2), 168# on admit BMI 27.7 3. Estimated Nutritional Needs: Based on actual wt a. Kcals 1900-2200 (25-30 Kcals/Kg) b. Protein (in grams) ~100 (1.3 g/Kg) c. Fluid (in ml) per md ( 1 ml/Kg) Degree of Nutritional Risk: High Risk t+3D Diet: npox2 days kub showing partial obstruction Nutrition Intervention: discussed @ intensivist rounds, pt remains npo w/ gallstone pancreatitis, will need eventual ERCP 1) follow for diet progression if unable to advance by 1/4/13 consider nutrition support. 2) when diet is advanced recommend low fat renal diet Nutritional Monitoring/Evaluation: labs, renal fx, i/o's and weights, poc. goal^diet progression within 72hrs HRR SICU- pt w/ gallstone pancreatitis, will need ercp in the future, ngt to suction. weight trending up, kub showing partial obstruction npox2 days lft's improving, low ca+, rec repl.

  10. Should we replete his Calcium?

  11. KUB- Maximial caliber of dilated loop bowel is 4.5cm previously 3.9cm Moderate stool remaining in ascending colon 1. Clinical data reviewed for today, 1/3/13 and time, 1100 2. Recent Weight Changes? Yes Comment: 186#1/3, 176#1/2, 168# on admit bmi35.1 3. Estimated Nutritional Needs: Of admission wt a. Kcals 1700-1900 (22-25 Kcals/Kg) b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) c. Fluid (in ml) 1900 or per md ( ml/Kg) Nutrition Intervention: discussed @ intensivist rounds, pt now vented on pressors. (gallstone pancreatitis/partial bowel obstruction) MD order to start TPN 1)discussed w/ PharmD Ca+repleting c/w ivf D51/2ns@75 (90gdext) day 1tpn 50gAA/60gdext/31glipid 1023kcal 2)day 2 dc ivf increase macros to 80gAA/200gdext/40glipid 1404kcal, day 3 goal 110gAA/250gdext/50glipid 1800kcal 100% een, monitor trigl and cbg closely and adjust macronutrients as appropriate. Day 3: Nutrition Support

  12. Day 5 (03/04)- Enteral Nutrition • KUB showed improvement • Continued to be several dilated loops, however less fecal residual in right colon, calcified gallstones visualized • Heather was consulted to begin Trickle Feed • Labs: Hct (29.5) Hgb (10.6), Na (136), K 5.2, Glucose (302), BUN (80), Cr (5.7), Phos (10.1), Mag (1.8) • Intervention: Start vital 1.2@10cc/hr, WHY? • tpn macros 90/190/50 1511kcal, tf to provide 288kcal 18g protein. monitor bowel fxn, labs, poc/ability to adv tf wean tpn

  13. Day 6 (01/05/13) • Renal Labs Improving- BUN decreases (51), Cr decreases (4.4), Phos normal (4.5), Mag Low (1.7) • EEG- Abnormal, poor background activity 1. Clinical data reviewed for today, 1/5/13 and time, 1100 2. Recent Weight Changes? Yes Comment: 186#1/3, 176#1/2, 168# on admit 3. Estimated Nutritional Needs: Of admission wt a. Kcals 1700-1900 (22-25 Kcals/Kg) b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) c. Fluid (in ml) 1900 or per md ( ml/Kg) • Nutrition Intervention: pt remains vented on pressors, s/p HD ¼ 1)tpn macros tonight 90gAA/190gdext/50glipid 1511kcal; replete Mag+ and Ca+ 2)trickle feed vital 1.2 @10cc/hr (288kcal, 18g protein) +bm, KUB improved • Nutritional Monitoring/Evaluation: labs, renal fx, i/o's and weights, poc. goal^tf tolerance min residuals

  14. (01/05) – (01/10) • No Improvement in Renal Labs, H&H continues to drop, Mag and Phos have been repleated. • Two chest X-Rays, KUB, Abdominal Ultrasound, MRI of the Brain. • Wt Continues to increase- Now 208# (gained 40# since admission. Extreme pitting edema and anasarca. • Nutrition Support- Recommend GI re-evaluates pancreatitis before increasing TF • Needs fluid restriction. If OK w/ GI recommend Δ TF to Vital 1.5, increase as tolerated to goal 45cc/hr w/ prostat TID • ~800cc fluid

  15. A Step in the Wrong Direction • VF continued to have residuals > 250, needed more protein and calories to meet needs • Nutrition Intervention (01/12/13) • If unable to advance TF tomorrow, recommend increasing TPN macros to 85AA/100Dex/60IVFE • When OK with GI to advance TF, change formula to Vital 1.5 goal rate 45cc/hr

  16. I finally meet VF

  17. My first note. Day 18 (01/17/13) Plan for PEG tomorrow Tracheostomy the next day • 1. Clinical data reviewed for today, 1/17/13 and time, 1440 • 2. Recent Weight Changes? Yes Comment: Currently 212# 1/17, 176# 1/2, 168# adm, Anasarca, pitting BLE. Anuric, 2.5 liters removed HD (1/16). • 3. Estimated Nutritional Needs: Of admission wt of 76.4kg • a. Kcals 1700-1900 (22-25 Kcals/Kg) • b. Protein (in grams) 100-115 (1.3-1.5 g/Kg) • Continues on TPN (tv 1200 w macros 95/120/60, providing 1249kcal) & trickle TF (vital 1.5 @ 10cc/hr providing 355 kcal, 16gpro) until GI consult approves TF progression Noted C/S for PEG placement (1/17) +BM today, LFTs improving 1/17.. • Nutritional Intervention: 1. Continue w/ TPN @ TF as noted above 2. If PEG placed/GI orders adv TF, recommend: Goal rate of 45cc Vital 1.5/hr w/ 3 prostat. When TF tolerated at 30cc/hr D/C TPN. • Monitor/Evaluation: Monitor Labs, Dialysis, I's and O's, GI input, POC

  18. S/P PEG placement- ? Seizure • Awaiting approval from GI to resume Vital 1.5 @ 10cc/hr (providing 355kcal 15g protein) • Neurology was consulted for questionable seizure activity Friday afternoon. Decided against it but increased Keppra anyway. No EEG until Monday. • Over the weekend Alyssa was Consulted by GI to adv Tube Feed to 20cc/hr. • When she arrived @ SICU , TF was off d/t “high” residuals • TPN continued @ 95gAA/120gDex/60gIVFE • Monday (01/20)- TF continued @ 20cc/hr, not increased due to GRV 190-195 • I decreased TPN to 80/100/50 in min volume to provide 1110 kcals • TF was providing 720kcals , for a total of 1830kcal

  19. 01/21/13 Weaned off Neo (01/20) TF @ Goal (01/21) • GI felt comfortable advancing TF per protocol to 45cc/hr • EEG negative- Since the EEG was negative for any active seizures which would suggest status epilepticus, we have decreased his. Our suspicion is that the shaking of shoulder is most likely myoclonus related to the patient's hemodialysis. We do not feel any further workup is needed for this in the hospital. • HSS: SICU pt w/ pancreatitis, PNA. TF rate increased to goal of 45ml/hr. Discussed D/C TPN with pharmacy, insulin decreased to 10 units. Minimal GRV documented in AM, distended abd, no BM since 01/20. Wt slowly decreasing, 99kg. HD removed 1.9L (01/21) • Providing1836kcal, 117g pro, 915ml fluid

  20. Status Epliepticus and Myoclonus • Status epilepticusgenerally refers to the occurrence of a single unremitting seizure with a duration longer than 5 to 10 minutes or frequent clinical seizures without an return to the baseline clinical state” • Myoclonus is a clinical sign that is characterized by brief, shock-like, involuntary movements caused by muscular contractions or inhibitions. Muscular contractions. • "jerks," "shakes," or "spasms."

  21. (01/25/13) • 1. Clinical data reviewed for today, 1/25/13 and time, 1320 • 2. Recent Weight Changes? Yes Comment: Currently 220#, 219# (1/22), 168# adm. Anasarca present, +4 BLE, BUE Edema. 1500ml removed HD (01/21) • TF held yesterday for GRV (250), restarted TF @ 25ml/hr w/ goal of 45ml/hr.Phos 8.0 (pt on HD). Pt not appropriate for change to low electrolyte formula r/t pancreatic fx and gallstones. High serum BG on cs#2. Levo was restarted (01/23) @ 10, has decreased to 7. • Nutrition Intervention: 1) Continue TF Vital 1.5 w/ goal of 45ml/hr and 2) Recommend increase to cs#3. 3) When TF stable, consider adding basal insulin.

  22. (01/28) • NPO for new HD tunneled access/dc femoral line, D5ns@40 10 lantus • TF residuals ~270x4 nights tf held/resumed ?add reglan (pt w/?sz) • k/phos climbing. If TF at goal it is providing 1056mg phos • Labs: Phos 10 (From 8.5) • ?add phos binder q4 or q6 when TF resumed

  23. 01/30/13- Educating Nurses • Some things we just cannot control. • SICU- pt went for MRCP had to cancel r/t pt unstable. RN changed to Nepro • (no order, Nephrology suggests change IF ok w/ GI). • Intervention: When OK w/ MD, recommend resume TF Vital 1.5 @15cc/hr goal of 45ml/hr and Prostat TID, providing 1836kcal, 117g pro, 915ml fluid (includes fluid for Prostat) • Vital @ goal rate provides 1058mg phos • NEPRO would provide ~700mg Phos@goal rate. RN to RD consult Pt not seen since 01/17 ????????????????

  24. D/C 02/07/13… To be Continued • Pt transferred Lahey Clinic for further management of multisystem organ failure.

  25. The Bitter Pill… Cost of health care- not just for insurance companies or even our nation, but for the patient. “When we debate health care policy, we seem to jump right of the issue of who should pay the bills, blowing past what should be the first question, why are the bills so high?” Cancer treatment- often half a million to a million dollars Trip to the ER for chest pain (ending in indigestion) - more than a semester @ college Simple lab work can often exceed the cost of a new care. Where is all of this money going? Is it a broken system? Or do we as American’s have the wrong mentality when it comes to treatment vs end-of life care.

  26. References • Rombeau, J and R. Rolandelli. Clinical Nutrition Parenteral • Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101:2379-2400. [PubMed] • Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;371:143-152. [PubMed] • Owyang C. Pancreatitis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 147.

More Related