Clinical Nutrition Management of Superior Mesenteric Artery Thrombosis Dana Magee ARAMARK Distance Dietetic Internship

Overview Disease Description Evidenced Based Nutrition Recommendations Case Presentation Nutrition Care Process Assessment Nutrition Diagnosis Interventions Monitoring and Evaluation Conclusion

Acute Mesenteric Ischemia (AMI) Inadequate blood flow to the bowel caused by: Non- occlusive Mesenteric Ischemia (NOMI) Mesenteric Vein Thrombosis (MVT) Acute Mesenteric Atrial (AMA) Embolus Acute Mesenteric Atrial (AMA) Thrombosis http://emedicine.medscape.com/article/191560-overview#showall

Occlusive Mesenteric Ischemia Embolus Thrombosis 50% of AMI cases 25% of AMI cases Occurs in distal branches Occur at origin of SMA Quick onset Gradual onset Low collateral blood flow Larger portion of bowel affected Smaller portion of bowel affected Can affect multiple arteries Associated with MI, mitral stenosis, Afib, endocarditis, mycotic aneurysm, dislodged plaque Associated with CAD, stroke, PAD, dehydration, MI, HF

Acute Mesenteric Ischemia Risks for AMI Age over 50 years old Atherosclerosis (African Americans as higher risk) AFib Hypercoaguable states (Critical Care) Epidemiology AMI accounts for .1% of hospital admissions in US Mortality rate is 71% (AMA thrombosis is highest mortality rate)

Signs and Symptoms Abdominal pain out of proportion to expectation Benign abdominal exams Fear of eating due to postprandial pain N,V, D GI bleed Bad breath AFib Signs of sepsis

SMA Blockage Ischemia can lead to: Vomiting and diarrhea GI bleed Necrotic bowel (8-12 hrs) Bacterial overgrowth Perforated bowel Sepsis HF Multi- organ system failure http://emedicine.medscape.com/article/191560-overview#showall

Diagnosis Aortography gold standard CT scan / ultrasound Distinguish between SMA thrombosis and embolism CT scan / ultrasound Not as specific or sensitive Can see blockage of SMA Can rule out other reasons for abdominal pain Lab results helpful- not for diagnosis CBC, PPT, acid base balance, lactate

Treatment Immediate exploratory surgery Remove ischemic/ necrotic bowel Embolectomy In surgery: Peristalsis Coloring Doppler ultrasonography IV fluorescent under Woodlamp Second look surgery

Case Presentation Presented with abdominal pain out of proportion Admitting diagnosis: SMA thrombosis PMH: A-Fib, stroke, CAD, HTN, cardiomyopathy.

http://web. uni-plovdiv http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm

Case Presentation CT scan showed SMA thrombosis Started on TPN Exploratory laparotomy 30 cm small bowel resected, NGT decompression Second look surgery GI bleed Pacemaker

Evidenced Based Guidelines Early or late parenteral nutrition: ASPEN vs. ESPEN Casaer MP, Mesotten D, Hermans G et al Objective: Comparing the early initiation of PN (European) vs. late initiation of PN (American and Canadian) Prospective, randomized, controlled, parallel- group, multicenter trial in Belgium Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.

Evidenced Based Guidelines Protocol: 2312 patients receiving PN in 48 hours 2328 patients receiving PN after seven days Patients must be at nutritional risk Excluded patients with BMI<17 To keep fluid intake the same received dextrose at the same rate at PN Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.

Evidenced Based Guidelines PN 48 hours post admission ICU 1 day shorter LOS in ICU (p<0.04) 2 days shorter LOS in hospital (p<0.04) Fewer infections 22.8% vs. 26.2% (p<0.0008) Less days on dialysis 7 days vs. 10 days (p<0.008) 10% less patients needing >2 days on vent (p<0.006) Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.

Evidence Based Guidelines Conclusion: Late initiation better outcomes for patients. Limitations: No glutamine in PN or other modulators Premixed PN No indirect calorimetry Not double blinded study Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.

Evidence Based Guidelines ASPEN: Adult Critical Care Guidelines: Early PN feeding with protein calorie malnutrition Indicated with recent weight loss of 10-15% Studies show: Lower risk for complications (p<0.05) No nutrition support higher mortality risk ((p<0.05) McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.

Evidence Based Guidelines Efficacy of Parenteral Nutrition Supplemented with Glutamine Dipeptide to decrease Hospital Infections in Critically Ill Surgical Patients Estivariz CF, Griffith DP, Luo M, et al Double blind, randomized, controlled study Objective: Effect of glutamine PN (GLN-PN) vs. standard PN (STD- PN) on infections in critically ill surgery patients Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.

Evidence Based Guidelines Methods: 2 Cohorts: pancreatic necrosis surgery and cardiac/vascular/colonic surgery Ages 18-80 s/p one of five surgeries Required PN for at least 7 days Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.

Evidence Based Guidelines GLN- PN 30 subjects 0.5 g/kg/day glutamine with 1 g/kg/day amino acid solution STD- PN 29 subjects 1.5 g/kg/day amino acid solution Limitations: Availability of glutamine- two time periods of research Limited number of postoperative PN Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.

Evidence Based Guidelines No significant changes in infection in the pancreatic cohort In non- pancreatic cohort GLN- PN Decrease in total infections (p<0.03) Decrease bloodstream infections (p<0.01) GLN- PN had 5x less chance of Staph infection No significant difference in mortality Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.

Evidence Based Guidelines Critical Illness Nutrition Practice Guidelines 2012 Recommend glutamine considered in treatment for critically ill Associated with decreased risk of infection Not sufficient evidence for decreased LOS, intubation period, medical cost, or mortality Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine. Evidence Analysis Library. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. Accessed March 22, 2013.

Evidence Based Guidelines Aspen Adult Critical Care Guidelines Recommend 0.5 g/kg/day glutamine in PN Associated with decreased risk of infection, LOS, and mortality McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.

Nutrition Care Process Assessment: Client History A-Fib uncontrolled Does not work Lives at home with a caregiver

Nutrition Care Process Assessment: Food/Nutrition-Related History: Poor appetite after stroke, 40 pound weight loss Patient reported 11 pound weight loss in one week PTA following a low fat diet Assessment: Nutrition-Focused Physical Findings: Nausea and vomiting X two days Abdominal pain out of proportion to expectation

Nutrition Care Process Assessment: Anthropometric Measurements Height discrepancies 62-71 inches Weight 145 pounds BMI 22.79 Usual weight 156 pounds

Nutrition Care Process Assessment: Nutrient Needs Energy: 1650-1848 kcal (25-28 kcal/kg actual body weight) Protein 79-99g protein (1.2-1.5g/kg actual body weight) Fluid needs: 1680-1890 ml (25-30 ml/kg actual body weight)

Nutrition Care Process Assessment: ARAMARK Nutrition Status Classification Nutrition Care Indicator Category Highest Points Assigned Nutrition History 3 (poor appetite and vomiting) Feeding Modality/Nutrition Care Order 4 (anticipated TPN) Unintentional Weight Loss 4 (greater than 2% weight loss in one week) Weight Status *Serum Albumin or Pre-albumin Dx/Condition 3 (anticipated GI surgery) TOTAL POINTS 14 Nutritionally severely compromised

Nutrition Care Process DRG Coding Weight loss of 5-10% of usual body weight Albumin 3.5-5 Mild Protein calorie malnutrition

Nutrition Care Process Nutrition Diagnosis Inadequate oral intake related to GI distress as evidenced by NPO diet order, 0% intake and not meeting estimated kcal or protein needs. Inadequate parenteral infusion related to parenteral prescription does not meet estimated nutritional needs as evidenced by parenteral regimen providing 67% of estimated caloric needs.

Nutrition Care Process Interventions Once PICC is functional initiate day one TPN. 1700 ml volume: 70g protein, 150g CHO, 15g lipid. Day two recommend 1700 ml volume: 80g protein, 255g CHO, and 15g lipids to provide 1337 kcal, 80g protein, GIR 2.68 (81% of nutritional needs) Increase CHO in TPN to 255g.

Nutrition Care Process Monitoring and evaluation Food and nutrient intake: Parenteral nutrition administration Monitor parenteral access Food and nutrient administration: Parenteral nutrition intake formula/ solution Anthropometric Measurements: Body weight

Monitoring and Evaluation Biochemical data, medical tests, and procedures: Electrolytes and renal profile potassium, magnesium, and phosphorus Biochemical data, medical tests, and procedures: glucose endocrine profile, glucose casual Nutrition- focused physical findings: Digestive system: return of GI function.

Conclusion SMA thrombosis, NPO Patient reported recent significant weight loss, TPN initiated Small bowel resection NGT suctioning, GI bleed, low hemoglobin, multiple transfusions Pacemaker, NPO Aspiration, Chopped, nectar thickened liquids Weaning off TPN with cardiac diet

Conclusions Late initiation of PN linked to decreased LOS, time on dialysis, time on ventilator, ad risk for infections Early PN support in patients that are admitted to the ICU malnourished for less complications Consideration of adding glutamine to PN for patients in the ICU, especially surgical patients Decrease infections More research on LOS and mortality

References Dang CD. Acute Mesenteric Ischemia. Medscape. http://emedicine.medscape.com/article/189146- overview. Updated February 22, 2013. Accessed March 22, 2013. Tessier DJ. Mesenteric Artery Thrombosis. Medscape. http://emedicine.medscape.com/article/191560- overview. Updated January 6, 2012. Accessed March 22, 2013. American Heart Association. What is Atrial Fibrillation (AFib or AF)?. American Heart Association. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial- Fibrillation-AFib-or-AF_UCM_423748_Article.jsp. Updated October 18, 2012. Accessed March 22, 2012. American Heart Association. Coronary Artery Disease- Coronary Heart Disease. American Heart Association. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary- Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsp. Updated February 27, 2013. Accessed March 22, 2013. American Heart Association. Prevention and treatment of High Blood Pressure. American Heart Association. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPr essure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsp. Updated June 6, 2012. Accessed March 22, 2012.

References McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234. Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662. Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880. Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine. Evidence Analysis Library. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. Accessed March 22, 2013. International Dietetics & Nutrition Terminology (IDNT) Reference Manual Third Edition. Chicago, IL: American Dietetic Association; 2011. ARAMARK. Patient Food Services Policies & Procedures Volume IV. Updated March 10, 2010. ARAMARK. Malnutrition Assessment & Diagnosis (DRG coding form). Pronsky ZM, Crowe JP. Food Medication Interactions 16th Edition. Birchrunville, PA: Food-Medication Interactions; 2010.