+

Case Study:Patient with Colon Cancer/Ileostomy placement

Laura SalinasKSC 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

Nutritional Assessments

MNT recommendations & Diet Orders

Goals

Interventions

Evaluation/reassessment

+Northeast Methodist HospitalOperational 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

+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

+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

+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

+Digestive System

http://digestive.niddk.nih.gov/ddiseases/pubs/ileostomy/

+Site of Nutrient Absorption

http://www.tuberose.com/Digestion.html

+Right hemicolectomy

+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

+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)

+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

+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

+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

+Washout and Ileostomy

+Nutrition Assessment 6/10/13* Initial Nutrition Screening Assessment

Diet Order: NPOWeight: 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

+Nutrition Assessment 6/10/13* Initial Nutrition Screening Assessment

Diet Order: NPOWeight: 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

+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

+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.”

+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

+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

+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

+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

+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

+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

+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

+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

+Clinical Course: Nutrients

Nutrients of greater concern Iron B12 Sodium Potassium Chloride Total kcal Total protein

+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.

+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

+Questions?

Thank You!

+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