CASE STUDY: GI Surgery Cristel Moubarak – Dietetic Intern – 2014 Candidate Elena Tejedor –...
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Transcript of CASE STUDY: GI Surgery Cristel Moubarak – Dietetic Intern – 2014 Candidate Elena Tejedor –...
CASE STUDY:GI Surgery Cristel Moubarak – Dietetic Intern – 2014 Candidate
Elena Tejedor – GI/ENT Surgery RD – Preceptor
March 2014
OUTLINE
Introduction Patient Case Initial Screening Nutrition Diagnosis Nutrition Needs Interventions Complications Follow-ups
Ms. C
66 year old female Admitted with Peritoneal
Mesothelioma on Dec 10 PMHx: Hypercholesterolemia and
depression Baseline Diet: Good appetite and
intake No recent significant weight loss ETOH Hx (2-3 glasses of wine/day)
INITIAL NUTRITION ASSESSMENT
Usual Weight = 61.4 kg Current Weight = 60 kg Height = 165 cm
BMI = 22 kg/m2
Nutritional Status Risk Factors: Nausea, NPO x4 days, hypercatabolism, substance abuse (ETOH Hx), fatigue, decreased mobility
SGA: Mildly malnourished, at moderate risk
PROCEDURES
Lysis of Adhesions Right Hemicolectomy Omentectomy Cholecystectomy Partial Vaginectomy Bilateral Salpingo-
oophorectomy HIPEC
BASIC DEFINITIONS
Peritoneal Mesothelioma: Rare cancer that develops in the mesothelium cells (usually due to exposure to asbestos) in the peritoneum (abdomen cavity lining).
Cytoreductive Surgery: Removing all visible tumors that can be removed throughout the peritoneal cavity.
Hyperthermic Intraperitoneal Chemotherapy (HIPEC): It is designed to kill any remaining cancer cells by circulating a sterile solution--containing a chemotherapeutic agent--throughout the peritoneal cavity, for a maximum of two hours.
NUTRITION DIAGNOSIS
P: Malnutrition E: related to altered GI function/predicted ileus
and increased needs with stress of OR S: as evidenced by cytoreductive surgery and
HIPEC treatment (x5d), post-operative nausea, ETOH Hx (2-3 glasses/d), and NPO x 5d to date and expected to be NPO for ≥ 5d.
NUTRITION NEEDS
Goal of Nutrition Care:
PREVENT REFEEDING SYNDROME
HBE = 1218 kcal REE x 1.2 – 1.4 = 1460 kcal – 1705 kcal [24-28
kcal/kg] Protein [1.2 – 1.5 g/kg/day] = 72 – 90 g/d CHO [ 2 – 3 g/kg/day] = 120 – 180 g/d
INTERVENTION #1: Day 2 Post-Op TPN ORDER Calculated
Requirements 1st: Dec 12 – Refeeding
Total Calories 1460 kcal – 1705 kcal
1290 kcal (20 kcal/kg)
Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg)
CHO 120 – 180 g/d (refeeding)
150 g/d (39% - 2.5 g/kg)
Fat U/L 90 g/d 50 g/d (39% - 0.8g/kg)
Phosphate 30 mmol 30 mmol
Potassium 60 mmol 55.2 mmol
Magnesium 5 mmol 7.5 mmol
Folic Acid 5 mg
Zinc 2.5 mg
Vitamin C 200 mg
Thiamine 100 mg
COMPLICATIONS
Ileus Nausea Abdominal Fluid and high NG drainage
Magnesium, potassium and phosphate depletion
Day 2 Day 3
Magnesium (0.8 – 1.45)
0.63 0.60
Potassium (3.5 – 5) 3.5 3.4
Phosphate (0.7 – 1.10)
0.71 0.65
INTERVENTION #2: Day 4 Post-Op
Continue to replete Mg (5g via IV), PO4 (15 mmol x 3) and K-lyte (40 mEq)
TPN ORDER
Calculated Requirements
1st: Refeeding 2nd: Goal
Total Calories
1460 kcal – 1705 kcal
1290 kcal (20 kcal/kg)
1565 (26 kcal/kg)
Protein 72 – 90 g/d 70 g/d (22% - 1.2 g/kg)
75 g/d (19% - 1.25 g/kg)
CHO 120 – 180 g/d (refeeding)
150 g/d (39% - 2.5 g/kg)
225 g/d (49% - 3.75 g/kg)
Fat 50 g/d (39% - 0.8g/kg)
50 g/d (32% - 0.83 g/kg)
Ranitidine
150 mg
INTERVENTION #3: Day 8 Post-Op
TPN ORDER
Calculated Requirements
2nd: Goal 3rd: Goal
Total Calories
1460 kcal – 1705 kcal
1565 (26 kcal/kg)
1565 (26 kcal/kg)
Protein 72 – 90 g/d 75 g/d (19%) 75 g/d (19%)
CHO 120 – 180 g/d (refeeding)
225 g/d (49%) 225 g/d (49%)
Fat 50 g/d (32%) 50 g/d (32%)
Magnesium
10 mmol
Sodium 40 mmol
PROGRESSION
Diet progression: Day 8 Post-Op: advance to CF Day 14: advance to FF Day 15: provide low residue diet education Day 16: dental soft; hold TPN Day 20: D/C on dental soft; low residue diet education
Dec 8 Day 16
Magnesium (0.8 – 1.45)
0.60 0.56
Potassium (3.5 – 5) 3.6 3.6
Phosphate (0.7 – 1.10)
1.08 1.2
FOLLOW-UP: Day 36 Post Op Re-Admission
Ms C was readmitted on January 16 for a Partial Obstruction
Weight loss of 10% over 2 months Loss of appetite, suboptimal intake Unresolved nausea and increased vomiting prior
re-admission and during Hypomagnesemia, Hypophosphatemia.
FOLLOW-UP: Day 78 Post-Op Post-Discharge
Controlled nausea with medications Regular bowel movements with medications Following a low residue diet Appetite is back! Eating 3 meals a day and 2 snacks Gaining lost weight (Currently at 124 lbs, aiming to
get back to 132 lbs)
REFERENCES
HIPEC Treatment. (2014). The hipec procedure; what is hipec and how does it work?. Retrieved from http://www.hipectreatment.com/about-the-hipec-procedure/
BC Cancer Agency. (2013, October). Mesothelioma. Retrieved from http://www.bccancer.bc.ca/PPI/TypesofCancer/Mesothelioma/default.htm
BC Cancer Agency. (2013, March). Hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Gastrointestinal/13-appendix/13.5+Hyperthermic+Intraperitoneal+Chemotherapy+(HIPEC).htm
Mulier, S. (n.d.). Hipec for peritoneal cancer; patient information. Retrieved from http://www.drmulier.com/3 en pat info hipec.html
Ceelen, W. P. (2013). Treatment of peritoneal carcinomatosis using surgery combined with hyperthermic intraperitoneal chemotherapy (hipec). Retrieved from http://www.surgery.ugent.be/pages/hipec_eng.htm
Ceelen, W. P., & Flessner, M. F. (2010). Intraperitoneal therapy for peritoneal tumors: Biophysics and clinical evidence. Nat. Rev. Clin. Oncol., 7, 108-115. doi: 10.1038/nrclinonc.2009.217
Tan, G. H., Cheung , M., Chanyaputhipong, J., Soo , K. C., & Teo , M. C. (2013). Cytoreductive surgery (crs) and hyperthermic intraperitoneal chemotherapy (hipec) for peritoneal mesothelioma. Ann Acad Med Singapore, 42(6), 291-6. Retrieved from http://www.annals.edu.sg/pdf/42VolNo6Jun2013/V42N6p291.pdf