L.M. 52 y.o . female

L.M. 52 y.o. female

Maureen Donah 2013 Sodexo Southcoast Dietetic Intern

Past Medical HistoryCOPD Type 2 Diabetes HyperlipidemiaObesityFibromyalgiaHx of recent UTIs Kidney StonesIrritable Bowel Syndrome Depression

L.M. was admitted 1/8/13Caucasian5’0” 212# (stated) BMI 41.4Social Hx: patient doesn’t drink

alcohol and used to smoke in the past

140

4.3

99

27

16

1.1186

Emergency RoomIn the ER L.M. presented

with left-sided flank painCAT 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

Procedure 1/9/13Pre-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

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

The PlanThe pt was told to follow up with

primary doctor within 5-7 daysFollow up with GI for colonoscopy

after antibiotic is finishedFollow up with surgery in 2-3

weeks

Re-admitted 1/25/13Left flank painDiarrhea and vomiting PTA

139

4.3

101

27

11

1.0189

Started DM 1800cal dt 1/26/13-2/1/13 with fair to poor intake

RD Assessment 2/4/135’0” 212# (Stated) BMI 41.4Adj. 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

2/5/13 SurgeryDx: Sigmoid diverticulitis with

colovesical fistulaLaparotomy with sigmoid colon

resection and repair of colovesical fistula

Nutrition after Fistula RepairNPO 2/5-2/8Started clear liquid 2/9-2/10

◦Not tolerating clears, episodes of vomiting

NPO 2/11-2/13

2/13/13 POD#8 Anastomotic leakageConfirmed by a barium enemaProcedure: Diverting loop

ileostomy

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 KClDiet advance to clear liquids 2/13Diet advance 2/14 to diabetic diet for

breakfast onlyL.M. not tolerating, vomiting continues

The PlanPatient not tolerating liquids at allIn 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 ?

Nutrition Support (TPN) 2/15Day 1 custom bag 1,000mL/day

50g AA, 100g dextrose, no lipids due to shortage

IVF (D5 ½ NS) kept at 100mL/hr will decrease by day 2 per PA

Day 2 TPN 2/16/132,000mL/day 80g AA, 175g

dextrose, no lipids, 20 units insulin

IVF switched to Normal SalineIVF decreased to a combined rate

with TPN to 100mL/hr

◦Potassium 3.1◦Magnesium 1.7◦Phosphorous 1.9

Day 3 TPN 2/17/13TPN at goal: 1,800mL/day 85g AA,

160g dextrose, 25 units insulinIVF (NS) at combined rate of

100cc/hr To provide 884 kcals/day Only meeting 55% of calorie needs

◦Potassium 3.1◦Magnesium ?◦Phosphorous 1.6




◦Pt now not passing gas and has hypoactive bowel sounds

2/18/13Vomited KUB showed multiple dilated

small bowel loops, consistent with a small bowel obstruction.

Started NGT to LWS 1500cc output


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 ?



NGT to LWS output


3000cc 3000c

*Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale) BMI 37.5 Down 19.5# since admission

Gastric SecretionsProduction 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.

Gastric Secretions

Date 2/18 2/19 2/20

NGT output 1500cc 2550cc 3000cc

Chloride 92 (L) 92 (L) 93 (L)

Bicarbonate 34 36 (H) 37 (H)

* No blood gas labs taken

pH PCO2 HCO3- Differential

Metabolic Acidosis

Normal or decreasing

Diabetes, renal failure,

increased acid

production

Metabolic Alkalosis

Normal or increasing

Vomiting, increased

NGT output, administrati

on of alkaline solutions

RespiratoryAcidosis

Normal or increasing

Obstruction, pneumonia, mediastinal

disease

Respiratory Alkalosis

Normal or decreasing

Anemia, CHF,

exuberant mechanical ventilation


dextrose, 50g lipids, 60 units insulin

NGT to LWS 1500cc output Started to pass flatus but still

hypoactive bowel soundsKUB still seeing multiple dilated

loops



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

TPN ContinuesPt continued on clear liquid diet

and TPN, with fair PO intakeSBO resolving 2/25/13 per KUBDiet advanced to full liquid on

2/27/13 with good intakeLunch on 2/28/13 diet advanced

to soft easy to chew and TPN d/c’d

Cleared for DischargePt was tolerating soft diet with

fair intake and supplements. Pt was discharged home with

VNA on 3/2/13Pt was told to follow up with

surgery for barium enema as an outpatient and eventually reverse her ileostomy

Re-admitted on 3/6/13Abdominal pain and minimal

output from ileostomy. Low sodium of 122 on admission Hyponatremia resolved after

hydrationElectrolytes were stable and she

was tolerating a full diet. D/c’d home 3/12/13

Re-admitted 3/20/12Fatigue, nausea, and abdominal

painFound to have another low

sodium on admission of 129 Pt was hydrated and stableD/c’d home on 3/22/13Still follow up with surgery

regarding ileostomy

Re-admitted 3/25/13Nausea, vomiting, and abdominal

painPt vomiting and unable to keep

any food or fluids downPt was again found to be

dehydrated Sodium on admission 132Pt was given fluids and tolerated

diet D/c’d 3/31/13 to nursing home

facility

ReferencesJohnson 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





L.M. 52 y.o . female

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