Nutrition case study

NUTRITION CASE STUDY

WENDY THOMPSONWVU DIETETIC INTERN

DECEMBER 2N D , 2013

Bariatric Surgery Complications

Outline

Overview of the PatientSleeve Gastrectomy SurgeryMedical Nutrition Therapy for Bariatric

SurgeryNutrition Care Process of the Patient

Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Monitoring/Evaluation Follow-Ups

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Patient Overview

58-year-old femaleCurrent Medical

History: s/p Gastric Sleeve

Surgery (July 2013) Persistent Leakage Gastric Stenting Left Upper Quadrant

Abscess Nausea and Vomiting Leukocytosis

Past Medical History: Morbid Obesity (BMI

45 pre-surgery) Hypertension Hyperlipidemia GERD Cholecystectomy Hysterectomy

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What is a Laparoscopic Sleeve Gastrectomy?

Laparoscopic Sleeve Gastrectomy Overview

Removes 60-80% of the stomachShrinks stomach capacity to ≤300 mLWeight loss mechanism = gastric restriction

and possible decreased levels of ghrelin Ghrelin = appetite stimulating hormone primarily

produced in fundus and with small amounts produced in the pancreas

Potential nutritional risk factors = nutrient deficiencies due to: Decreased intake Removal of the majority of parietal cells

Decreased hydrochloric acid and intrinsic factor (B12)

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Who is a Candidate for Bariatric Surgery?

BMI ≥ 40 or 35-39.9 with comorbidities: Type 2 diabetes Sleep apnea Hypertension Cardiovascular disease Osteoarthritis

Age 16-70 (some exceptions possible)Failed attempts at diet and exerciseHave been obese for at least 5 yearsFree of substantial psychological disease, drug or alcohol

dependencyCandidates must be able to understand surgery and post-

surgery lifestyle requirementsMotivated and well-informed

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Outcomes of Sleeve Gastrectomy

Weight Loss Outcomes for average % of excess body weight: 1 month: 18-30% 3 months: 37-41% 6 months: 54-61% 1 year: 58-70% 2 years: 61.5% 5 years: no long-term

data

Potential Complications: Nausea/Vomiting GERD Anemia Leakage along the staple

line causing peritonitis or abscess

Sleeve Stricture Bowel Obstruction Pneumonia Deep Venous Thrombosis

(DVT) Acute Kidney Injury Liver Failure

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Post-Bariatric Surgery Behavior

Eat slowly and chew thoroughly – at least 25 times!Avoid concentrated sugars, especially in liquid formLimit fats and fried foodsShrink your portions – do NOT overeat!Do not drink liquids with a meal – try not to drink

30 minutes before and after a meal or snackIf you can no longer tolerate diary – try a lactose-

free diary sourceExercise – after 2 months more strenuous exercise

can be tolerated

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MNT for Sleeve Gastrectomy

Typical Diet Progression: Bariatric Phase I: Clear Liquids (begins post-op for 2-3 days) Bariatric Phase II: Full Liquid (advance as tolerated) Bariatric Phase III: Pureed/Home Soft Diet (progress as

tolerated, usually begins 1 week post-op) Bariatric Phase IV: Solids (progress as tolerated, usually

begins 1 month post-op)Protein Needs:

No set standard – typically 80-120g/day or 1-1.5 g/kg IBW CAMC Weight Loss Center = 1.5 g protein/kg of IBW

Adequate Hydration – goal 64 oz. day Rule of Thumb: Sip 1-2 ounces every 15 minutes

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Sample Menu for 1 Month Post Op(Bariatric Home Soft Diet)

8:00AM Breakfast: ¼ - ½ cooked cereal ¼ - ½ cup skim plus milk

10:00AM Snack: ½ cup protein supplement

12:00PM Lunch: ¼ - ½ cup sugar free yogurt ¼ cup pureed fruit

2:00PM Snack: ¼ - ½ cup unsweetened applesauce 1 sugar free popsicle

6:00PM Dinner: ¼-1/2 cup blended soup with protein ¼ cup pureed fruit

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MNT Life-Long Bariatric Diet

High proteinLow in refined carbohydratesIdeally, choose protein first, then fruits and

vegetables, and then whole grainsMaintain adequate hydration

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Vitamin and Supplement Rx

First 3 Weeks Post-Op: Chewable multi-vitamin Chewable calcium Vitamin D – only if levels are low Vitamin B12 – if needed Protein supplements

Must be high in protein (15-25g/serving) and low in sugar (less than 10g/serving)

After 3 Weeks Post-Op: Multi-vitamin Calcium Citrate (1200 mg) Vitamin B12- if needed Vitamin D – only if levels are low Iron – only if prescribed by MD Protein Supplements – if unable to consume 50-70g protein/day Ursodiol – “Gall Bladder Pills” only for the first 6 months

Helps prevent gallstones due to rapid weight loss

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Nutrition Care Process

Nutrition Assessment (11/12)

Secondary To: TPN protocol consult

Current Medical History: s/p sleeve gastrectomy, persistent gastric leak, morbid

obesity, HTN, hypokalemia, tachycardiaPast Medical History:

HTN, hyperlipidemia, GERD, cholecystectomy, partial hysterectomy

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Bariatric Past Medical History

7/8/2013: Laparoscopic Sleeve Gastrectomy N/V started 2 weeks post-op

8/9/2013: Upper GI Endoscopy – found mild stricture in the opening of the gastroplasty (between esophagus and stomach), performed balloon dilation

8/15/2013: Admitted to ER with N/V, HTN, leukocytosis, lactic acidosis – conducted CT scan to find left upper quadrant abscess and left pleural effusion

8/16/2013: Transferred to Cleveland Clinic and had abscess drained 8/19/2013: Re-drained abscess 8/23/2013: Re-drained abscess, placed gastric sleeve stent, re-sealed

the leak at the staple line 8/29/2013: Endoscopic exploration found stent partially collapsed so it

was adjusted 9/2/2013: Double stenting placed to correct the collapse stent 11/02/2013: Transferred from Cleveland Clinic to CAMC

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Patient Medications and Supplements16

Medication Name

Reason

Protonix PPI to decrease stomach acid to treat GERD

Mylanta Neutralizes existing stomach acid to treat GERD

Reglan Reduces nausea, vomiting, and GERD

Phenergan Helps treat existing nausea and vomiting

Zofran Helps prevent nausea and vomiting

Metoprolol Beta-blocker to lower blood pressure

Lasix Loop diuretic to lower blood pressure

Dilaudid Treats pain

Folic Acid Individuals post bariatric surgery are at an increased risk for deficiency – used to prevent deficiency

Vitamin B6

Vitamin B12

Thiamine

Anthropometric Measurements

Height 165.1 cm (5’5”)

Weight 112 kg (10/30 – Bed Scale)

IBW 57 kg

% IBW 196%

Adjusted/Feeding Weight 71 kg

BMI 41.1 (Class III Obesity)

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Nutrient Needs18

Current Diet Order (11/12): Vivonex RTF @ goal rate of 60ml/hr to provide

1440kcal, 72g protein, and 1224ml free H2O NG tube

Bariatric Phase I - Clear Liquids

Estimated Needs

Per Kg of IBW Per Day

Energy (kcal) 18 – 22 kcal 1278 – 1562 kcal

Protein 1 – 1.5 grams 71 – 106 grams

Fluid Per MD Per MD

Subjective Information (11/12)

Patient was consuming ~50% of clear liquid diet and tube feeding was up to 40ml/hour

Very nauseousVomits multiple times a day and has since 2

weeks post-surgery in JulyPatient has had nothing but clear liquids and

tube feedings since surgery

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Patient Labs

11/11 Potential Reasons for Abnormalities

Glucose (74-106) 127 Stress, insulin resistance

Na (136-145) 135 Occurs with prolonged vomiting

K (3.5-5.1) 3.4

BUN (7-18) 21 Potential decrease in kidney function or dehydrationCreatinine (0.6-

1.3)1.4

eGFR (>60) 47 Based on creatinine levels – potential decrease in kidney function

Albumin (3.4-5) 1.6 Sign of inflammation with potential protein/energy deficiency

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Nutrition Diagnosis21

Altered GI function related to persistent gastric leak and stent placement as evidenced by intolerance to tube feed

Notes: High risk for refeeding syndrome

due to minimal intake: Advance feedings slowly Monitor electrolyte values closely

Watch for low potassium, phosphate, magnesium levels

Nutrition Intervention (11/12)22

d/c tube feeding and bariatric clear liquid diet Due to persistent N/V

PICC line placement was ordered by MD and x-ray was used to verify correct placement

Initiate TPN @ 8:00PM (11/12) per CAMC protocol TPN was discussed with Physician, who determined

the initial rate to be 75 ml/hour Nursing staff was notified

IPOC

Parenteral Nutrition Invention

PICC Line Start: subclavian vein End: superior vena cava

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Parenteral Nutrition Intervention24

Initial TPN Order - 11/12 Rate: 75ml/hour Macronutrients:

Amino Acids: 50g of 15%

Dextrose: 75g of 70% Lipids (M/W/F only) =

0g Total Calories: 455

kcal

Electrolytes: Sodium: 140 mEq Potassium: 30 mEq Calcium: 10 mEq Magnesium: 8 mEq Phosphate: 6 mEq

MVI: StandardAscorbic Acid: 125mgThiamine: 50mgTrace Elements: NoneInsulin: NonePepcid: None (on

Protonix)

Monitoring and Evaluation

Goals: Improve protein status Provision of adequate nutrition via nutrition support Stabilize blood glucose levels

Monitoring: High Risk – F/U in 5 days Will follow daily Will monitor weight, labs, and TPN/PPN tolerance

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TPN Monitoring and Evaluation26

Check labs per TPN protocol:Every 6 hours:

GlucoseDaily:

Basic Metabolic Panel (BMP)

Sodium Potassium Calcium Chloride

Weekly (unless abnormal): Complete Metabolic

Panel (CMP) Triglyceride Magnesium Phosphorus Ionized Calcium Pre-albumin Liver panel

Follow-Up Assessment (11/14)

Subjective Information: Patient was tolerating full liquid diet and a Boost Glucose

Control with lunch and dinner Patient was still nauseated but had only vomited once today Patient preferences of cream of chicken, tomato, chicken

noodle soup were recorded

Plan for Patient: Spoke with social worker and determined that the patient

must be on 12-hour cyclic TPN prior to discharge in order to be accepted into a skilled nursing facility Plan to start cycling on Monday (11/18)

Patient will require an stent placement – per MD notes, date planned for 11/20

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Follow-Up Assessment (11/19)28

Nutrition Orders: 11/17: TPN d/c due to lost access secondary to

multiple blood clots Bariatric Phase II – Full Liquid with Boost Glucose

Control w/ lunch and dinnerSubjective:

Patient was tolerating full liquid diet and consuming the majority of the supplement

Vomiting frequency has decreased but nausea still persist

Follow-Up Assessment (11/19) Cont.29

Significant Lab Changes: Alkphos (39-117): 306 ALT (17-67): 127 AST (15-65): 181

Suggestive of potential hepatic dysfunction and common with TPN

Updates30

11/20: Gastric stent placed11/22: Restarted TPN11/24: Started to cycle TPN – due to SNF

requirements11/27: Reached cyclic goal of 12 hours11/28: Switched TPN back to continuous due

to acute renal failure TPN providing an average of 1,314 kcal

12/2: Bariatric Phase III – Pureed/Soft with Boost Glucose Control and continuous TPN

Questions?31

References

Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.

CAMC Standards of Practicehttp://www.cornellweightlosssurgery.org/pdf/

dietary_guidelines_sleeve_gastrectomy.pdf http://www.camc.org/surgicalweightloss

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Appendix: Patient Labs

11/11 11/13 11/14 11/15 11/16 11/17 11/18

Glucose (74-106)

127 120 140 112 106 135 117

Na (136-145) 135 137 139 139 143 140 139

K (3.5-5.1) 3.4 3.3 3.3 3.7 3.5 3.4 3.5

BUN (7-18) 21 27 31 37 44 50 60

Creat (0.6-1.3)

1.4 2.0 2.0 1.9 1.6 1.6 1.7

GFR (>60) 47 31 31 33 40 40 37

Phosphorus (2.5-4.9)

3.4 2.5 2.3 3.1 3.6

Albumin (3.4-5)

1.6 1.7 1.6 1.8

Pre-Alb. (20-40)

15.5

Triglycerides (50-200)

224

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