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

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

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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

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

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

11. http://web. uni-plovdiv

12. 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

13. 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): Doi: /NEJMoa

14. 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): Doi: /NEJMoa

15. 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): Doi: /NEJMoa

16. 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): Doi: /NEJMoa

17. 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): Doi: /

18. 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 ; 32 (4): doi: /

19. 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 ; 32 (4): doi: /

20. 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 ; 32 (4): doi: /

21. 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 ; 32 (4): doi: /

22. 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. Accessed March 22, 2013.

23. 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): Doi: /

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

25. 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

26. Nutrition Care Process
Assessment: Anthropometric Measurements
Height discrepancies inches
Weight 145 pounds
BMI 22.79
Usual weight 156 pounds

27. Nutrition Care Process
Assessment: Nutrient Needs
Energy: kcal
(25-28 kcal/kg actual body weight)
Protein 79-99g protein
( g/kg actual body weight)
Fluid needs: ml
(25-30 ml/kg actual body weight)

28. 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

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

30. 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.

31. Nutrition Care Process
Interventions
Once PICC is functional initiate day one TPN 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.

32. 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

33. 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.

34. 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

35. 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

36. References
Dang CD. Acute Mesenteric Ischemia. Medscape. overview. Updated February 22, Accessed March 22, 2013.
Tessier DJ. Mesenteric Artery Thrombosis. Medscape. overview. Updated January 6, Accessed March 22, 2013.
American Heart Association. What is Atrial Fibrillation (AFib or AF)?. American Heart Association. Fibrillation-AFib-or-AF_UCM_423748_Article.jsp. Updated October 18, Accessed March 22,
American Heart Association. Coronary Artery Disease- Coronary Heart Disease. American Heart Association. Artery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsp. Updated February 27, Accessed March 22, 2013.
American Heart Association. Prevention and treatment of High Blood Pressure. American Heart Association. essure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsp. Updated June 6, Accessed March 22, 2012.

37. 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): Doi: /
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): Doi: /NEJMoa
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 ; 32 (4): doi: /
Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine. Evidence Analysis Library Accessed March 22,
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.