1. Strangulated Ventral Hernia Case Study Spenser Parker April 2, 2014

2. Overview O Patient Profile O Disease Background O Research Articles O Application to Patient O Nutrition Care Process O Summary O Personal Impression O Questions

3. Patient Profile O DR is a 46 year single Hispanic women O Was admitted January 25 till February 19 O Was discharged to Kindred Hospital O Was in contact with Bariatric Surgeon O Is not a smoker or tobacco user

4. Medical History O Diabetes Mellitus Type 2 O Hypertension O Bronchial Asthma O Previous SBO with resection 2 years ago O Morbid Obesity

5. Disease Background O Video of Ventral Hernia Video of Ventral Hernia O Two possible causes of hernia are previous surgery and obesity O Obstruction can lead to distention O Severe distention leads to occlusions O Occlusion’s lead to necrosis, sepsis, fever, and perforation Huether, S. E., 2002 p.1270, Nucleus Medical Group, 2011 (Video)

6. http://www.openabdomen.org/diseases/trauma.cfm Pus from 5 Day Old Small Bowel Perforation

7. Signs/Symptoms O Abdominal pain O Vomiting/Nausea O Dehydration O Constipation-or-Diarrhea O Minor obstructions have waves of pain O Major obstructions have constant severe pain Huether, S. E., 2002 p.1271

8. A randomized study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement O Sought to find how fish oil compared to olive oil in lipid based parenteral nutrition on infection rates in high risk surgery O Prospective double-blind study in Barcelona Spain O 27 participants Badia-Tahull et. al. 2010

9. A randomized study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement O Inclusion criteria was patients that were having gastro-intestinal surgery that would require at least 5 days of parenteral nutrition O Patients with renal failure, hepatic disease, hemorrhagic disorder, or unstable diabetes were excluded from the study Badia-Tahull et. al. 2010

10. A randomized study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement O Control group received lipids through olive oil O Intervention group received fish oil O Both groups received same type of AA, DEX, and trace elements O Data was collected using t-test O P value set at P<0.05 O Only significant difference was the rate of non-septic infection, intervention group had lower rate (P<0.007) Badia-Tahull et. al. 2010

11. Strength of Article O Huge limiting factor or sample size O Authors stated they were not comfortable actually stating fish oil is the reason O Further studies with larger populations are needed O For the reasons I give the article a grade of fair Badia-Tahull et. al. 2010

12. Early versus Late Parenteral Nutrition in Critically Ill Adults O Compare the effects of late and early start of parenteral nutrition on rates of death and complications in ICU patients O Prospective, randomized, controlled, parallel-group, multicenter trial O 4640 underwent the trial Casaer et. al. 2011

13. Early versus Late Parenteral Nutrition in Critically Ill Adults O Early start began parenteral nutrition on day 2 post operation (according to ESPEN) O 20% Dextrose on Day 1 O 80% of needs Day 2 O 100% needs (between enteral + parenteral) Day 3 O Late start began day 8 (according to APSEN) O Started on 5% Dextrose then if needs were not meet by enteral by day 8 parenteral was started Casaer et. al. 2011

14. Early versus Late Parenteral Nutrition in Critically Ill Adults O Data was compared using chi-square test O Student t-test O Median stay for ICU patients was 6.3% earlier discharge with late start group P<0.04 O Lower infection rate in late start group P<0.008 Casaer et. al. 2011

15. Strength of Article O Had a large sample size O Did not just look at parenteral nutrition, it was the combination of enteral and parenteral O The researchers did look over many different areas for comparison between early and late start O Also give this article a fair grade Casaer et. al. 2011

16. Application to the Patient O DR was admitted with necrotic bowel secondary to strangulated ventral hernia with septic shock and perforated bowel O Did end up growing E. coli in abdomen O DR spent her entire stay in the ICU at Mission Trails O DR was on mechanical ventilation, later received a tracheostomy O Started TPN on January 27 (2 day of admission)

17. Treatment O Exploratory laparotomy with transverse colon resection leaving the abdomen open https://www.cedars-sinai.edu/Patients/Programs-and-Services/Colorectal-Cancer- Center/Services-and-Treatments/Right-Hemicolectomy.aspx

18. Treatment O Damage control laparotomy with open abdomen (over 40 washouts) O Gastric Sleeve performed mid hospital course O TPN for 26 days O Tracheostomy O PEG placed before LTAC

19. Medications O Cocktail of antibiotics-ampicillin, levofloxacin, vancomycin, zosyn, and more O Furosemide and bumetanide O Iron sucrose, KCl, K Na Phos, Ca Gluconate O Micafungin and fluconazole O Propofol O Albumin O Solu-cotef Joseph et. al. 2010

20. Nutrition Assessment O DR is 5’3” O Admitted with a weight of 392 pounds O 340% of Ideal Body Weight O Adjusted weight was 185 pounds O BMI was 69.6 kg/m 2 O This classifies her as Morbid Obese

21. Biochemical 1-261- 28 1- 30 2- 02 2- 05 2-072- 10 2- 12 2- 15 2-172- 19 Na137139138133136138145 149152147 K3.33.74.14.35.43.73.33.82.83.7 CO 2 2028 233033 353233 GFR57>60 Glu132164145148155116136148135128124 PO 4 2.82.33.93.84.43.93.14.72.41.8 Mg1.52.01.8 1.7 1.9 2.12.2 Alb3.02.31.72.21.62.31.81.62.63.73.8

22. Diet History/Intake O Poor intake prior to admission due to severe abdominal pain (3+ days) O Was started on TPN day 2 of admission O Started on half strength and worked to full strength on day 4 of admission O Halfway through hospital course she was started on trophic feeds of Glucerna @10ml/hr. O Towards the end of her stay she was consulted for the Dietitian to start full enteral feeds O Vivonex @85ml/hr

23. Macronutrient Needs O Based on weight/intubation/condition O 2140-2340kcal/kg –around 12kcal/kg O 105-125g/kg (didn’t have weight to start so 20% of calories to be protein) O Later was increased to 125-135g/kg based on low albumin and multiple washouts O Fluid needs was through TPN and started at 2,250ml per 24 hour

24. Nutrition Diagnosis O Inadequate energy intake related to current condition of perforated bowel as evidenced by NPO clear liquid diet O Altered GI function related to current condition of necrotic bowel/perforated bowel as evidenced by parenteral nutrition/multiple abdominal washouts

25. Nutrition Intervention O Started half strength of 55 AA 120 DEX & 20 FAT on January 27 O TPN ran at 125 AA 325 DEX O FAT @2250ml starting day 3 of TPN initiation O Received PEG on February 18 th then was started on Vivonex @ goal of 85ml/hr. O Never reached goal, she was discharged the next day but left at a rate of 40ml/hr. O TPN was ordered to start weaning at Kindred Hosptial

26. Summary O Severe case of a ventral hernia leading to necrotic bowel O Very extensive surgical intervention O Extensive medication intervention O Condition often time becomes worse (E coli growing in abdomen-sepsis O On TPN for almost a month

27. Personal Impressions O Nutrition played a key role in the success of the patient O Interesting that the patient received gastric sleeve during the hospital stay O Extensive surgical intervention (over 40 washouts) O Challenging to transition patient to enteral feeds (worries of surgeon)

28. References O Badía-Tahull, M.,B., Llop-Talaverón, J.,M., Leiva-Badosa, E., Biondo, S., Farran- Teixidó, L., Ramón-Torrell, J.,M., & Jódar-Masanes, R. (2010). A randomised study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement. The British Journal of Nutrition, 104(5), 737-41. doi:http://dx.doi.org/10.1017/S0007114510001066dx.doi.org/10.1017/S0007114510001066 O Bansal, V., & Coimbra, R. (2013). Nutritional support in patients following damage control laparotomy with an open abdomen. European Journal of Trauma and Emergency Surgery, 39(3), 243-248. doi:http://dx.doi.org/10.1007/s00068-013- 0287-1dx.doi.org/10.1007/s00068-013- 0287-1 O Casaer, M. P., Mesotten, D., Hermans, G., Wouters, P. J., Schetz, M., Meyfroidt, G.,... Van, d. B. (2011). Early versus late parenteral nutrition in critically ill adults. The New England Journal of Medicine, 365(6), 506-17. O Huether, S. E. (2002). Alterations of digestive function. In K., McCance, S., Huether, Pathophysiology: The biologic basis for disease in adults & children 4 th ed. (pp. 1261-1313). St. Louis, Missouri: Mosby, Inc.

29. References O Joseph, B., Julie, L. W., Stanley, J. D., & Latifi, R. (2010). Nutrition in trauma and critically ill patients. European Journal of Trauma and Emergency Surgery, 36(1), 25-30. doi:http://dx.doi.org/10.1007/s00068-010-9213-ydx.doi.org/10.1007/s00068-010-9213-y O Mueller, C., Bloch, A. S. (2008). Intervention: Enteral and parenteral nutrition support. In L. K., Mahan, S., Escott-Stump, Krause’s food & nutrition therapy 12 th ed. (pp. 506-530). St. Louis, Missouri: Saunders Elsevier. O Nucleus Medical Media. (2011, October 28). Laparoscopic ventral hernia [Video File]. Retrieved from https://www.youtube.com/watch?v=j29lt89_AOg&feature=em-share_video_user https://www.youtube.com/watch?v=j29lt89_AOg&feature=em-share_video_user O Pronsky, Z. M., & Crowe, J. P. (2010). Food medication interactions, 16 th ed. Birchrunville, Pennsylvania: Food Medication Interactions. O Pus [Digital Image]. Retrieved from:http://www.openabdomen.org/diseases/trauma.cfmhttp://www.openabdomen.org/diseases/trauma.cfm