Case Report: Nutrition Support for Patient with a Perforated Ulcer with Peritonitis

Katie Ruhmann ARAMARK Distance Learning Dietetic Internship

Disease Discription
Peptic Ulcers Stomach Duodenal Causes: H. pylori, NSAIDs, Aspirin, Corticosteroids, Lifestyle choices Symptoms: Pain, belching, nausea, decreased appetite, weight loss fatigue Treatment:
Antibiotics
Lifestyle changes Other medications

Complications

Ulcer Perforation
What is it?
Mostly caused by H. pylori Bacteria Infections from leakage out of GI tract

Treatment: Needs medical attention ASAP! Surgery

Leakage from ulcer can cause Peritonitis Description Treatment Complications

Evidenced-Based Nutrition Recommendations-Early Nutrition Support

The Academy of Nutrition and Dietetics evidenced based

recommendations support to the start of enteral nutrition within 24-48 hours of admit if not contraindicated
Contradictions: hemodynamic instability, bowel obstruction,

high output fistula, or severe ileus

ASPENs Guidelines for the Provision and Assessment of

Nutrition Support Therapy in the Adult Critically Ill Patient also support starting enteral nutrition within 24-48.
Reach caloric and protein needs within 48-72 hours

Evidenced-Based Nutrition Recommendations-Enteral vs Parenteral

ASPEN and AND support enteral nutrition over parenteral

nutrition with critically ill patients

No decrease in mortality rates

Benefits
Reduce infectious morbidity Shorter LOS

Cost Effective
Gut motility and build immune system

Early Enteral Nutrition

Doig et all, Meta Analysis, start of early enteral nutrition
6 total studies examined 234 patients total, mechanically ventilated ICU patients Decrease of frequency of pneumonia in early EN Decrease failed organ systems in early EN
2.5 + 0.7 vs 3.1 + 0.8 organ failures per patient

No differences in:
Vomiting
Positive blood cultures

Limitations

Gastric Residuals
Montejo et all; open, perspective, radomized study;

Gastric Residual Limits

Comparing limits of 200 ml vs 500 ml 28 different ICUs in Spain
322 total patients, mechanically ventilated in need of EN Control- 200 ml limit, Study-500 ml limit

Reasoning for study

Avoidance of stopping TF

Gastric Residuals-cont.
Gastrointestinal complications higher in control group 63.6%

vs 47.8%
No difference in ICU acquired pneumonia
45 (27.3%) in the control group and 44 (28.0) in study

All other aspects observed such as ICU stay, ventilator-free day,

ICU mortality and hospital mortality results were all very similar
Importance?
Raising gastric residual limit to 500 ml has no difference in

complications

Case Presentation
80 year old Caucasian female
Chief complaint: abdominal pain, N/V Trip to Las Vegas

Poor appetite
CT scan results: Large amount of free intraperitoneal air with moderate abdominal ascites Suspected perforated ulcer Admitted to ER

Nutrition Care ProcessAssessement

Client History
Widowed, no children Retired funeral home director Estranged brother in Germany

Lives alone Completely independent

Smoker No pertinent family medical history

Vague personal medical history Osteoarthritis Hypertension

Nutrition Care ProcessAssessment

Food/Nutrition Related History Poor appetite Limited nutrition history related to intubation Medications
Amlodipine (HTN)
Tylenol Aspirin

No oral diet advancement Parenteral and Enteral Nutrition

Nutrition Care ProcessAssessment

Nutrition-Focused Physical Findings Decreased appetite N/V No reports of weight loss No reports of chewing/swallowing problems After admission:
Speech Therapy Consulted 20-30 lb weight gainfluid overload

Edema
Pressure Ulcer NPO >4 Days

Nutrition Care ProcessAssessment

Anthropometric Measurements Admission: Weight: 130 lbs (or 140 lbs, unsure of accuracy) Height: 63 inches 113% of IBW, BMI 23 Four days after admit: Weight: 175 lbs 35% weight gain Fluid Overload At Last Assessment: Weight: 149 lbs

Weights

Biochemical Data

Nutrition Care ProcessAssessment

ASPEN Evidenced Based

Recommendations
Protein needs should be

increased when patient is on dialysis Maximum 2.5 g/kg Pressure Ulcers

Nutrition Care ProcessAssessment

ARAMARK Nutrition Status Classification
2-3 points for poor appetite (unsure of timeframe of poor

appetite) 4 points for NPO for >4 days 4 points for serum albumin <2.4 4 points for AKI, vent dependency, sepsis Total of 14-15 points Severely Compromise
Assess every 4 days

Nutrition Care ProcessAssessment

Malnutrition Identification
Unable to assess nutrition related history
Report poor appetite

Unable to assess weight history Without accurate information, the patient can not identified

as malnourished.

Nutrition Care Process-Diagnosis

Inadequate oral intake (NI-2.1) related to perforated ulcer

and poor swallowing functions as evidenced by start of TPN/possible start of enteral nutrition.

Nutrition Care ProcessInterventions

Medical Interventions
Exploratory Laparoscopy
Graham patch omental

Dobhoff tube placement Nasogastric tube Several Intubations Tracheostomy

Dialysis

Nutrition Care ProcessIntervention

Nutrition Interventions Parenteral Intervention
Standard TPN is 5% amino acids/15% dextrose with lipids at 250

ml at 20% biweekly First @ 70 ml/hr, decreased to 45 ml/hr RD Recommendation: Taper down TPN, start EN
Enteral Nutrition Stopped for high residuals Running at 25 ml/hr of Nepro RD Recommendation: Increase to 35 ml/hr to meet needs Complications with feedings Defer fluid needs to physician

Nutrition Care ProcessIntervention

Nutrition Care ProcessMonitoring & Evaluation

Parenteral Nutrition Intake Meeting goals? Needed Intervention Monitoring labs for refeeding syndrome Enteral Nutrition Intake Meeting Goals? Intervention needed to increase rate Monitored labs for formula intolerance Fluids monitored by physicians Weight Weight gain Weight loss Edema Dry weight?

Conclusion
Peptic ulcers can cause serious problems
Enteral nutrition should be started 24-48 hours
Without contradictions

It is safe to increase gastric residuals limit to 500 ml

Mahan LK, Escott-Stumo S, Raymond JL. Krauses Food & the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012 Stomach and Duodenal Ulcers (Peptic Ulcers). John Hopkinds Medicine. http://www.hopkinsmedicine.org/healthlibrary/conditions/digestive_disorders/stomach_and_duodenal_ulcers_peptic_ulcers_85,P00394/ Accessed December 15, 2013. Vaidya BB, Garg CP, Shah JB. Laparoscopic Repair of Perforated Peptic Ulcer with Delayed Presentation. J Laparoendosc Adv Surg Tech A. 2009; 19: 153-156. Peritonitis. John Hopkins Medicine. http://www.hopkinsmedicine.org/healthlibrary/conditions/adult/digestive_disorders/peritonitis_85,P00391/ Accessed December 15, 2013. Ehrlich SD. Peritonitis. University of Maryland Medical Center. http://umm.edu/health/medical/altmed/condition/peritonitis Updated on May 7, 2013. Accessed December 15, 2013. CIU: Initiation of Enteral Nutrition. Academy of Nutrition and Dietetics Evidence Analysis Library. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3205&auth=1 Accessed December 15, 2013. McClave SA, Marindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in the Adult Critically Ill Patients. J Parenter Enteral Nutr. 2009: 33 (3): 277-316. http://www.nutritioncare.org//Professional_Resources/Guidelines_and_Standards/Guidelines/2009_Adult_Critical_Care__Initiate_Enteral_Feeding/ Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009; 35: 2018-2027 Montejo JC, Minambres E, Bordeje L, et al. Gastric residula volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010; 36: 1386-1393. Guillaume A, Seres DS. Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis. Nutr Clin Pract. 2012;27:513-520 American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL. 2012. McClave SA, Marindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in the Adult Critically Ill Patients. J Parenter Enteral Nutr. 2009: 33 (3): 2009. http://www.nutritioncare.org//Professional_Resources/Guidelines_and_Standards/Guidelines/2009_Clinical_Guidelines__Renal_Failure/