STEPHANIE BUSH
KEENE STATE COLLEGE DI
FEBRUARY 8, 2017
OUTLINE
Pathophysiology - SBO
Hospital Admission- RF
Summary
CONCORD HOSPITAL
5 Centers
Center for Cardiac Care
Center for Urologic Care
Payson Center for Cancer Care
The Orthopaedic Institute
Women's Health Services
SMALL BOWEL
OBSTRUCTION1
Interruption of the normal flow
of bowel contents.
Causes
Mechanical: high, low, closed,
open, high grade, low grade,
simple, complicated
Functional
Symptoms
Distention
Constipation/Obstipation
Vomiting: bilious or feculant
Pain/Abd cramping
ETIOLOGY OF SBO
Misc
11%
Hernia
2%
Malignancies
5%
Crohn's Disease
7%
Adhesions
75%
SMALL BOWEL OBSTRUCTION: PROGRESSION & COMPLICATIONS1
Ischemia
Necrosis
Perforation
Sepsis
Electrolyte
imbalances &
hypotension
Edema
https://www.youtube.com/watch?v=sBm12CkNtAo
DIAGNOSIS AND TREATMENT1
Medical diagnosis
Presenting symptoms, PMH
Confirmed w/ X-ray, CT scan,
luminal contrast studies, or ultrasound
Treatment options
Surgical vs non surgical treatments
IVF, NPO, NG tube, e-, pain meds
Laparotomy
http://link.springer.com/article/10.1007/ s00268-014-2733-6
webmd medscape
MNT RECOMMENDATIONS
Dallasbehavioral.com
Medical Hx (from med rec) Social Hx (from med rec and pt, family)
HTN Mechanic--retired
ASSESSMENT 1/08/17 Hyperlipidemia Wife and sister
Asthma Part of Dana Farber
Client Hx Reflux experimental
Anthropometrics Major depression, Anxiety chemotherapy trial
Osteoarthritis
Food and Nutrition Related
Claudication
Hx Previous Surgeries (from med
TIA rec)
Food and Nutrition Related Hx UBW: 66.4kg (146 lbs) as of July 2016
Biochemical
%UBW: 81%
Nutrition Focused Physical
Findings
Weight Loss: 12.5kg in 6 mos
http://www.cancertherapyadvisor.com/
1620 kcals (30kcal/g)
65-76g protein (1.2-1.4g/kg)
PATIENT NEEDS Recommendations for HNCA are:
30-35kcal/kg
1-1.5g pro/kg
Escott Stump & UK Natl Multidisciplinary Guidelines
NUTRITION DIAGNOSIS
http://slideplayer.com/slide/6493752/
DAY 4: 1/10/17
BMI <16 Unintentional weight loss <15% in 3-6 mos Little intake <10 d K<2.5,
P<1.5, s
Mg<1
Or: Two of the following criteria:
BMI <16 Unintentional weight loss <15% in 3-6 mos Little intake <10 d K<2.5,
P<1.5, s
Mg<1
Or: Two of the following criteria:
@ Goal
1.4 L ClinimixE 5/20 @ 60ml/hr
Plan to stop TPN 1/15
Advanced to fulls
Medications:
Kcal count initiated:
Atorvastatin-statin
488 kcal (30%) Escitalopram-antidepressant
Heparin-anticoagulant
18 g protein (27%) Oxycodone-narcotic
Did low residue ed, sending
CIB TID
DAY 9: 1/15/17
DAY # 6 TPN 1.4 L ClinimixE 5/20 @60ml/hr
Delayed Ileus
Rising WBC
Nausea, increased distention
No longer advancing diet
Labs: Creat: .50 L
Kcal count Glu: 126 WBC: 15.69H
136 kcal (8%) Na: 128 L HGB: 8.4 L
Cl: 93 L HCT: 25.2 L
4 g pro (6%)
DAY 10: 1/16/17
DAY # 7 TPN
Labs:
Diet: NPO
Na 124 L
? anastomotic leak Cl 89 L
Creat: .89 L
Custom TPN for Na goals (doc) & increase protein
WBC 17.42 H
closer to actual needs (RD) HGB 7.9 L
HCT: 23.8 L
CUSTOM TPN @ 45 ML/HR W/ DAILY LIPIDS, NA @
NS IN TPN
Macronutrient mL Grams Kcals Percent kcals
15% AA 450 ml 68g 270kcal 1.2 g/kg 16%
70% Dex 350 ml 245 g 833kcal 3.1 mg/kg/min 51%
20% Lip 250 ml 50g 500kcal .9g/kg, 31%
104 ml/hr max rate
1,050 ml 1603kcal
DAY 12: 1/18/17
DAY # 9 TPN
OR today
Found adhesive partial SBO
Tried to place NG tube
Hiatal hernia
Decompression
UTI
Days 13-18 1/19/17- 1/24/17
Continue Custom TPN, @ goal 1/20 Advanced to clears, then fulls (w/ toast,
Na trending up crackers, muffins??), dysphagia
128 136 worsening
Other labs 240-480ml/d intake
WBC: 20 15 Generally getting 5-6% kcals, 0-6%
BUN High 19th-21st pro orally
Ux Na Random: 14mMol/L (20th) Consulted for PEG placement
Meds added:
Cipro-abx, Ketolorac-NSAID, Ondansetron-n/v, Pantoprazole- GI prophylaxis, Megestrol appetite stimulant
DAY 19-20: 1/25/17-1/26/17
TPN DAY # 16
DC day!
Weight: 59.9kg
Recc DC on oral & TPN 2L, NS, w/ Flintstones MVI
Followed by NELC, weekly labs, VNA, wife and sister helping
Will begin cycle at home
Surgical soft/low res diet, 100% lunch
SUMMARY
Maintained weight
Increased Na at least for a while
Whole team encouraged food intake
tried multiple diets, supplements, app
stimulants
Kulaylat MN, Doerr RJ. Surgical Treatment: Evidence-Based and Problem-Oriented. Small bowel obstruction. 2001.
https://www.ncbi.nlm.nih.gov/books/NBK6873/
Attard JP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg. 2007 Aug; 50(4):
291300. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386166/
Hasudungan A. Small Bowel Obstruction. Armando Hasudungan Biology and Medicine videos.
https://www.youtube.com/watch?v=sBm12CkNtAo.
Meier, R.P.H., de Saussure,W.O., Orci, L.A. et al. Clinical Outcome in Acute Small Bowel Obstruction after Surgical or
Conservative Management. World J Surg (2014) 38: 3082. http://link.springer.com/article/10.1007/s00268-014-2733-6.
August DA, Huhmann MB. A.S.P.E.N Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Support Therapy During Adult
Anticancer Treatment and in Hematopoietic Cell Transplantation. First Published January 5, 2017
Escott-Stump. Nutrition Diagnosis and Related Care. 8th ed. Pg 754.
THANK YOU !