1. L.M. 52 y.o. female Maureen Donah 2013 Sodexo Southcoast Dietetic Intern

2. Past Medical History COPD Type 2 Diabetes Hyperlipidemia Obesity Fibromyalgia Hx of recent UTIs Kidney Stones Irritable Bowel Syndrome Depression

3. L.M. was admitted 1/8/13 Caucasian 5’0” 212# (stated) BMI 41.4 Social Hx: patient doesn’t drink alcohol and used to smoke in the past 140 4.3 99 27 16 1.1 186

4. Emergency Room In the ER L.M. presented with left-sided flank pain CAT 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

5. Procedure 1/9/13 Pre-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

7. 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

8. The Plan The pt was told to follow up with primary doctor within 5-7 days Follow up with GI for colonoscopy after antibiotic is finished Follow up with surgery in 2-3 weeks

9. Re-admitted 1/25/13 Left flank pain Diarrhea and vomiting PTA 139 4.3 101 27 11 1.0 189 Started DM 1800cal dt 1/26/13-2/1/13 with fair to poor intake

10. RD Assessment 2/4/13 5’0” 212# (Stated) BMI 41.4 Adj. 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

11. 2/5/13 Surgery Dx: Sigmoid diverticulitis with colovesical fistula Laparotomy with sigmoid colon resection and repair of colovesical fistula

12. Nutrition after Fistula Repair NPO 2/5-2/8 Started clear liquid 2/9-2/10 ◦ Not tolerating clears, episodes of vomiting NPO 2/11-2/13

13. 2/13/13 POD#8 Anastomotic leakage Confirmed by a barium enema Procedure: Diverting loop ileostomy

14. 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 KCl Diet advance to clear liquids 2/13 Diet advance 2/14 to diabetic diet for breakfast only L.M. not tolerating, vomiting continues

15. The Plan Patient not tolerating liquids at all In 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 ?

16. Nutrition Support (TPN) 2/15 Day 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

17. Day 2 TPN 2/16/13 2,000mL/day 80g AA, 175g dextrose, no lipids, 20 units insulin IVF switched to Normal Saline IVF decreased to a combined rate with TPN to 100mL/hr ◦ Potassium 3.1 ◦ Magnesium 1.7 ◦ Phosphorous 1.9

18. Day 3 TPN 2/17/13 TPN at goal: 1,800mL/day 85g AA, 160g dextrose, 25 units insulin IVF (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

19. Day 4 TPN 2/18/13 1,800mL/day 85g AA, 160g dextrose, no lipids, 35 units insulin ◦ Potassium 3.2 ◦ Magnesium 2.3 ◦ Phosphorous 2.3 ◦ Pt now not passing gas and has hypoactive bowel sounds

20. 2/18/13 Vomited KUB showed multiple dilated small bowel loops, consistent with a small bowel obstruction. Started NGT to LWS 1500cc output

21. Day 5 TPN 2/19/13 1,800mL/day 85g AA, 160g 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 ?

22. Day 6 TPN 2/20/13 1,800mL/day 85g AA, 160g dextrose, no lipids, 55 units insulin NGT to LWS output ◦ Potassium 3.3 ◦ Magnesium 2.2 ◦ Phosphorous 4.3 3000cc3000c *Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale) BMI 37.5 Down 19.5# since admission

23. Gastric Secretions Production 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.

24. Gastric Secretions Date2/182/192/20 NGT output1500cc2550cc3000cc Chloride92 (L) 93 (L) Bicarbonate3436 (H)37 (H) * No blood gas labs taken

25. pHPCO 2 HCO 3 -Differential Metabolic Acidosis Normal or decreasing Diabetes, renal failure, increased acid production Metabolic Alkalosis Normal or increasing Vomiting, increased NGT output, administration of alkaline solutions Respiratory Acidosis Normal or increasing Obstruction, pneumonia, mediastinal disease Respiratory Alkalosis Normal or decreasing Anemia, CHF, exuberant mechanical ventilation

26. Day 7 TPN 2/21/13 1,800mL/day 85g AA, 160g dextrose, 50g lipids, 60 units insulin NGT to LWS 1500cc output Started to pass flatus but still hypoactive bowel sounds KUB still seeing multiple dilated loops

27. Day 8 TPN 2/22/13 1,800mL/day 85g AA, 160g dextrose, no lipids, 60 units insulin 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

28. TPN Continues Pt continued on clear liquid diet and TPN, with fair PO intake SBO resolving 2/25/13 per KUB Diet advanced to full liquid on 2/27/13 with good intake Lunch on 2/28/13 diet advanced to soft easy to chew and TPN d/c’d

29. Cleared for Discharge Pt was tolerating soft diet with fair intake and supplements. Pt was discharged home with VNA on 3/2/13 Pt was told to follow up with surgery for barium enema as an outpatient and eventually reverse her ileostomy

30. Re-admitted on 3/6/13 Abdominal pain and minimal output from ileostomy. Low sodium of 122 on admission Hyponatremia resolved after hydration Electrolytes were stable and she was tolerating a full diet. D/c’d home 3/12/13

31. Re-admitted 3/20/12 Fatigue, nausea, and abdominal pain Found to have another low sodium on admission of 129 Pt was hydrated and stable D/c’d home on 3/22/13 Still follow up with surgery regarding ileostomy

32. Re-admitted 3/25/13 Nausea, vomiting, and abdominal pain Pt vomiting and unable to keep any food or fluids down Pt was again found to be dehydrated Sodium on admission 132 Pt was given fluids and tolerated diet D/c’d 3/31/13 to nursing home facility

34. References Johnson 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/ar ticle/000506.htm