Initiation of Peripheral Parenteral

Nutrition with Appendicitis and

Small Bowel Obstruction

Tiffany Peters

Andrews University Dietetic Intern

September 2015-April 2016

Outline

Introduction

Social History

Past Medical History

Normal Anatomy and Physiology of Appendix and Bowel

Hospital Stay

Labs

Medications

Treatment

Medical Nutrition Therapy

Prognosis

Conclusion

Introduction of K.C.

12 year old Caucasian female

Weight: 73.9 kg (162.5 lbs.)

Height: 64 inches

BMI: 27.9

97th percentile BMI for age and 151% IBW

Obese

Less active in winter months

Case Study: March 28 – April 5, 2016

Body mass index-for-age percentiles. (2000). Retrieved April 17, 2016, from http://www.cdc.gov/growthcharts

Social History

6th grade

Active during the summer

Likes to play outdoors

Lives at home with father, mother, and two brothers

No preferred religion

Past Medical History

No significant history

Lip laceration - stitches

First admission to St. Francis Hospital

Normal Anatomy and Physiology

of the Appendix

No major function – we can live without it

Descends from the lower cecum

Bound to the abdominal wall, anterior loops of ileum, and the omentum

Average length is 9 cm but ranges from 2-20 cm

End artery

Nundy, S. (Ed.). (2014). The Appendix-ECAB. Elsevier Health Sciences.

Normal Anatomy and Physiology

of the Small Bowel

Imperative to nutrient absorption

Duodenum, Jejunum, and Ileum

Finger-like projections – villi

Hair-like projections – microvilli

Complete bowel obstruction

Inability for nutrients to be absorbed and waste to be excreted properly

Another source of nutrition is indicated – parenteral nutrition

Nelms, M. Sucher, K., Lacey, K., and Roth, S.L. Nutrition Therapy & Pathophysiology. 2nd ed. Brooks/Cole Cengage Learning, Belmont, CA; 2011

Hospital Stay

Admission on March 28, 2016

Complaints of abdominal pain, nausea, loss of appetite, previous

fever

CT scan confirmed acute appendicitis

Inflammation and free fluid in the pelvis area – indicated

perforation

Laparoscopic appendectomy

Found adhesions to the retroperitoneum

Appendix was cut out and removed

Drain placed for intra-abdominal abscess

Hospital Stay

March 29, 2016 – Postop day #1

Diarrhea

Abdominal pain

Vomiting

Thought to be caused by medications

Hospital Stay

March 30, 2016 – Postop day #2

Nausea/vomiting especially after eating

Diarrhea had stopped

Generalized ileus and lack of bowel function

IV fluids were increased

Potassium chloride – hypokalemia

NPO

Hospital Stay

March 31, 2016 – Postop Day #3

Continued vomiting – bilious

Allergic reaction to Zosyn, switched to Meropenem

Abdominal scan – small bowel obstruction vs. postop ileus

CT scan ordered for confirmation

NG tube placed for suction

Started PPN

Hospital Stay

April 1, 2016 – second surgery

CT scan confirmed 4 cm intraloop abscess in the central

abdomen

Small bowel obstruction secondary to adhesions due to the

abscess

Adhesion severed

Abscess drained and irrigated

Hospital Stay

April 1, 2016 – Postop day #1

K.C. feeling much better

No pain or vomiting

NG tube returned light green bile

April 3, 2016 – Postop day #3

NG tube removed

Clear liquid diet

April 4, 2016 – Postop day #4

GI soft diet

PPN discontinued

Discharged on April 5, 2016

Labs

Admit

labs

3/28/16

Post-op 1

3/30/16

Post-op 2

3/31/16

Post-op 1

4/2/16

Post-op 3

4/4/16

Final labs

4/5/16

Normal lab

values

Sodium 134 L 136 137 133 L 136 136 136-144 mmoll

Potassium 3.6 3.2 L 3.5 L 4.1 3.9 4.0 3.6-5.1 mmoll

Chloride 103 103 101 101 104 103 101-111 mmoll

TCO2 20 L 23 28 27 26 24 22-32 mmoll

Glucose 125 H 126 H 115 H 96 83 79 70-100 mg/dL

BUN 9 7 8 9 12 12 6-25 mg/dL

Creatinine 0.7 0.7 0.5 0.5 0.5 0.5 0.6-1.2 mg/dL

Calcium 9.7 9.3 9.2 8.7 9.1 9.4 8.5-10.5 mg/dL

Hemoglobin 13.2 11.8 L - 12.2 - - 12-16 g/dL

Hematocrit 39.7 35.4 L - 36.9 - - 36-46 %

Total Protein 7.8 - 6.6 - 6.2 L - 6.5-8.1 gm/dL

Total Bili 0.8 - - - 0.2 L - 0.3-1.2 mg/dL

ALT/SGOT 16 - - - 16 - 10-42 IU/L

AST/SGPT 19 - - - 16 - 10-40 IU/L

Albumin 4.3 - 3.3 L - 3.0 L - 3.6-5.3 gm/dL

Alk Phos 161 - 98 - 95 - 70-200 IU/L

CRP - - - - - - < 0.1 mg/dL

Magnesium - - 1.9 2 1.9 - 1.7-2.3 mg/dL

Phosphorus - - 3.5 3.9 4.0 - 2.5-4.6 mg/dL

Prealbumin - - 13.1 - 22.9 - 18-38 mg/dL

Triglycerides - - 50 - 63 - <200 mg/dL

PRN

Medications

Medication Purpose Drug/Nutrient Interaction Possible Side Effects

Normal Saline

Flush

To clear medications

from the port to

make sure the drug

was delivered fully.

May alter how other

medications work

Possible allergic reaction.

Symptoms include rash,

itching/swelling, severe dizziness,

and trouble breathing.

Morphine Narcotic; pain

reliever

Avoid alcohol May cause dry mouth, taste

changes, anorexia, weight loss,

decreased gastric motility,

constipation, nausea, vomiting.

Hydrocodone Narcotic; pain

reliever

Take with food or milk to

decrease GI distress; avoid

alcohol. May cause

delayed digestion.

May cause dry mouth,

constipation, nausea, or vomiting.

Zofran Antiemetic,

antinauseant

N/A May cause dry mouth, abdominal

pain, constipation, or diarrhea

Promethazine Antiemetic, sedative Take with meals to

decrease GI distress;

increased need for

riboflavin; avoid alcohol

May cause dry mouth,

constipation, nausea, or vomiting.

Phenol-

Phenolate

Sodium 1.4%

Oral anesthetic for

sore mouth or throat

N/A Possible allergic reaction.

Symptoms include nausea,

vomiting, rash, difficulty breathing.

Ativan Antianxiety Limit caffeine. Caution with

grapefruit/citrus.

Chamomile may increase

sedative effect. Echinacea

may decrease drug levels.

May cause weight loss or weight

gain, increased thirst,

constipation, diarrhea, nausea or

vomiting.

Dextrose 50% Used for dehydration

or to control blood

sugars

May lower serum sodium

and increase serum

potassium

Hyperglycemia, edema

Humulin Insulin; to lower blood

glucose levels

Diabetic meal plan to

balance carbohydrate

with insulin; alcohol may

increase effect of insulin

causing hypoglycemia

May cause weight gain or

hypoglycemia

Routine

Medications

Medication Purpose Drug/Nutrient

Interaction

Possible Side Effects

Flagyl Antibiotic Food may decrease

drug bioavailability

May cause anorexia,

metallic taste, nausea,

vomiting, epigastric

distress, or diarrhea

Zosyn Antibiotic Food may decrease

absorption of drug

May cause anorexia, oral

candidiasis, nausea,

vomiting, epigastric

distress, or diarrhea

Meropenem

injection

Antibiotic N/A May cause oral

candidiasis, glossitis,

nausea, vomiting,

diarrhea, GI bleeding, or

colitis

Omnipaque

240

Iodinated

contrast agent

given to

diagnose

problems. Used

during CT scans

to pinpoint

problem areas

Do not take with

Amiodarone or

Metformin

May cause nausea

Potassium

chloride

to prevent or to

treat low blood

levels of K+

Not to be taken

while using salt

substitutes.

May cause GI irritation,

nausea, vomiting,

abdominal pain, diarrhea,

or flatulence.

Treatment

Diagnosis – traditionally using a CT scan

Exposure to radiation – increased risk for developing cancer1

Study in Cleveland, OH2

Iterative reconstruction technique – reduces background noise and uses a lower dose of radiation

Tested specifically on diagnosing children with acute appendicitis

Found to be just as successful as regular CT scans

1Miglioretti, D. L., Johnson, E., Williams, A., Greenlee, R. T., Weinmann, S., Solberg, L. I., ... & Smith-Bindman, R. (2013). The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA pediatrics, 167(8), 700-707.

2Didier, R. A., Vajtai, P. L., & Hopkins, K. L. (2015). Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatric radiology, 45(2), 181-187.

Treatment

Removal

Laparoscopic vs. open surgery

Most physician and patients prefer laparoscopic1

Three small incisions1

Less recovery time, decreased risk for formation of adhesions, and faster return of bowel function2

K.C. had laparoscopic surgeries

Perez, E. A., Piper, H., Burkhalter, L. S., & Fischer, A. C. (2013). Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis. Surgical endoscopy, 27(4), 1367-1371.

Di Saverio, S., Coccolini, F., Galati, M., Smerieri, N., Biffl, W. L., Ansaloni, L., ... & Fraga, G. P. (2013). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg, 8(1), 42.

Medical Nutrition Therapy

Typical eating pattern

Skips breakfast

Lunch at 12:00pm school cafeteria food

After school snack crackers & fruit

Dinner is prepared by K.C. mom

Dislikes mushrooms and cabbage

Breakfast

Carbs

(g)

Protein

(g)

Fat

(g)

Sodium

(mg)

Calories

N/A 0 0 0 0 0

Lunch

1 slice pepperoni pizza 32 14 11 560 280

½ cup carrots 8 2 0 65 39

16 oz raspberry lemonade

smoothie

61 2 0 73 240

Snack

1 cup goldfish crackers 20 4 5 250 140

1 banana 30 1 0 1 110

Dinner

1 cup Lasagna 43 23 14 670 400

½ cup corn 16 2 1 0 75

¾ cup applesauce 18 0 0 15 75

1 cookie crumble ice cream

cone

32 3 8 0 213

TOTAL 260g 51g 39g 1634mg 1572

kcal

Medical Nutrition Therapy

K.C.’s Energy Needs

Kcal: 2049 (Schofield Equation with 1.3 stress factor for surgery)

Protein: 111-148 grams (1-1.2 g/kg for draining abscess)

Fluid: 2578 ml (according to body surface area)

Pediatric Multivitamin

Electrolytes to replete as needed

Corkins, M., Balint, J., Seebeck, N. & American Society for Parenteral and Enteral Nutrition. (2010). The A.S.P.E.N.

Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.

Medical Nutrition Therapy

Prescribed Diets

Clear liquid → Regular → NPO + TPN → Clear liquid → GI soft

Initiation of PPN

According to American & European Guidelines on Parenteral Nutrition

PN is NOT beneficial for postoperative complications if the child was well nourished AND will be NPO for less than 7 days

The risk of infection is more of a concern than the lack of nutrition

Lack of sufficient energy intake does not prove to have any deleterious effect on growth status as long as the child was well nourished prior to surgery

Mueller, C., McClave, S., Kuhn, J. M., & American Society for Parenteral and Enteral Nutrition. (2012). The A.S.P.E.N. adult nutrition support core curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.

Mantegazza, C., Landy, N., Hill, S. M., Zuccotti, G. V., & Koglmeier, J. (2016). Parenteral Nutrition in Hospitalized Children. Medical & Clinical Reviews.

Medical Nutrition Therapy

Peripheral Parenteral Nutrition

3/31/16 4/1/16 - 4/2/16

Total fluid 2400 ml 3000 ml

Total kcals 990 kcal 1448 kcal

Non-protein calories 750 kcal 1160 kcal

Amino acids 60 g 72 g

Dextrose 150 g 200 g

Lipids 24 g 48 g

Kcal from dextrose 52% 47%

Kcal from protein 24% 20%

Kcal from lipids 32% 33%

GIR (mg/kg/min) 1.41 1.88

Kcal needs: 2049 Protein needs: 111-148

At goal rate, the PPN meets 71% kcal needs and 65% protein needs.

Prognosis

K.C. comprehended and cooperated

Strong family support

Complete healing with no other complications

Return in one week to have drains removed

Thank you for listening!