Nutrition Database Presentation

Presenter: Meghan Keenan

Patient Background
72 YOM admitted from NH, has Admitting Dx:
been bedridden for 2+ years. Pt
ESRD, Ogilvie’s Syndrome, Abdominal pain
reports following a regular diet w/
1000 mL fluid restriction at NH.
Reports good PO intake PTA.

PMH:

CHF, COPD, T2DM, ESRD on HD (MWF),

HTN, morbid obesity, spina bifida/clubfoot
and Ogilvie’s Syndrome
Anthropometrics & NFPE
Ht: 5’8” (172.7 cm) Per EMR wt hx:

Wt: 111 kg (245 lb) 18# wt loss x 2 mo (-7% wt change)

BMI: 38.6
Pt appears well-nourished upon observation,
IBW: 72 kg (158 lb) however obesity and distention could be masking
signs of wasting
Adj BW: 82 kg (180 lb)

UBW: ~260 lb per pt

Ogilvie’s Syndrome
A rare, acquired condition Distention of the colon can potentially
characterized by abnormalities lead to serious complications, such as
affecting peristalsis within the colon perforation or ischemia to the colon

Symptoms mimic those of If left untreated, the

mechanical obstruction of the colon condition can cause
but there is no physical obstruction malnutrition, bacterial
present. Symptoms include: overgrowth in the
● Nausea intestines, and weight
● Vomiting loss
● Abdominal distension/bloating
● Constipation
Course Of Care
Course of care complicated as pt continues to frequently change
his mind re: surgical intervention

GI:

12/25: NPO for now, NG tube for decompression, IV fluid hydration

and Neostigmine

12/28: NG tube removed

1/2: KUB unchanged, distended D/T air-fluid levels in the colon

Surgery:

12/27: Offered operative intervention but patient refusing surgery

PO Intake & Appetite
Diet Hx During Admission: Current Diet Order:

12/26 - 1/1: NPO (x 5 days) Regular w/ 3 gm Na and 2 gm K

1/1 - 1/2: Clear Liquids ● Good PO intake (75-100%)

1/2 : Full Liquids, 1800 kcal DM

1/3 -1/4: NPO

1/4 : Full Liquids, 1800 kcal DM

Medication & Labs
Medications: Labs:
Reglan
Na 131 Ca 8.3
Vitamin C
Renvela
Nephrocaps K 3.5 Alb 2.3
Calcium
Folic acid BUN 25 Phos 3.8
Gabapentin
MVI Cre 4.9 Mg 1.8
Miralax
Coumadin Glu 96
Lactulose Senokot

Dulcolax
Corrected Ca = 9.7 mg/dL (WNL)
Prosource 1x/d

Metamucil
Nutrition Dx 1:

P Altered GI Fxn

E Dilated colon 2/2 Ogilvie’s Syndrome

GI note, pt reported abdominal pain/

S distention, reasoning for bowel rest
Nutrition Dx 2:

P Unintended weight loss

E HD 2/2 ESRD vs. GI fxn

S Pt report of lost wt w/ HD,

18# wt loss x 2mo
Nutrition Intervention
1. Consider adding 1800 kcal DM and GI soft (low fiber) modifications to current diet

order. Assist pt with appropriate menu selections.

2. Provide Prosource 1x/d w/ beverage on tray at lunch to optimize protein intake

3. Review diabetic and renal diet -- Pt does not follow recommended diets at NH. Pt

declining education at this time, will continue to offer education as needed.

4. Consider continuing phos binder inpatient

 Monitor Evaluation
1. Wt loss D/T fluid shifts
2. Diet advancement/tolerance
3. PO/supplement intake Continue as a Level 2
4. Lab values, glucose, renal labs follow up, reassess patient
5. GI fxn, further distention of status in 5 days
abdomen
6. Renal fxn
7. Adherence to recommended diet
8. Plan of care
Discharge Plans
● Surgery scheduled in 1 week
● Follow up post-surgery and
provide ileostomy nutrition
education
● Pt to return to NH when
medically stable
Journal Article
Comparison of multi-modal early oral nutrition for the
tolerance of oral nutrition with conventional care after
major abdominal surgery
Oral Nutrition Initiation Post-Surgery
● Surgery is a major stress factor for the human body
● Well nourished patients have been shown to have
easier recoveries post-surgery, shorter LOS, and
reduced complications
● An early start of oral nutrition is beneficial and has been
associated with reduced mortality rate
● However, early start of oral nutrition isn’t successful in
all patients and often fails during 1st week after
surgery
Research Background
Type of study: Prospective, randomized,
single-blind
Published: Nutrition Journal (BioMed
Central) in 2017
Location of study: China
Data collected: April 25 2014 - April 1
2016
178 eligible patients undergoing
major abdominal surgery
Including patients undergoing elective, radical
oncologic surgery for gastric or colorectal
cancer
71 patients excluded
Exclusion criteria: Diabetes, severe pulmonary
and cardiovascular disease, liver dysfunction,
Miles surgeries
Stratified Random Sampling
After enrollment, patients were assigned to 1 of 4
groups: gastrectomy, colectomy & resection for rectal
cancer, R hepatic resection, and
pancreaticoduodenectomy
Multi-Modal Early Oral Nutrition or
Conventional
Patients in each subgroup were randomly
assigned to either intervention or control
Intervention
Multimodal EON Group: Conventional Care Group

● Sugar-free gum ● Intake of water and 300 mL enteral

● Appetite stimulation: seeing colors nutrition suspension
and tasting of favorite foods,
watching other people dine
● Drinking water immediately on
waking and drinking 100 mL juice
6-hr after surgery, oral administration
of 300 mL enteral nutrition
suspension initiated 12-hr after
surgery
Results
● Success rate of oral nutrition was 83% in the intervention group vs. 57% in the
control group (P = 0.004)
● Time to first defectaton and time to flatus occurred earlier in the intervention
group (P <0.001) and bowel sounds returned soon (P <0.001)
● 24% of control patients experienced a prolonged post-op ileus, compared to
9.4% in the intervention group
● LOS: 8 days for intervention group, 10 days for control group (P <0.001)
● Total cost and cost of nutritional support was less for the intervention group
 Clinical Application
● Multi-modal early oral nutrition
increased the success rate of oral
nutrition during the first week of
surgery
● Early provision of oral nutrition may
decrease inflammation and decrease
duration of post-op ileus
● RDs may suggest introducing oral
nutrition within the first 24-hrs post
abdominal surgery
Limitations
● Markers of GI fxn recovery and
diagnosis of post-op ileus may be
subjective
● Did not separate early oral nutrition
group from chewing gum group --
could not assess if multi-modal
protocol was more effective than
these groups alone
Questions?

Reference:
Comparison of multi-modal early oral nutrition for the tolerance of oral nutrition with conventional care after
major abdominal surgery: a prospective randomized, single-blind trial. Sun D, et al. Nutrition Journal (BioMed
Central). 2017;16(11):1-10. doi:10.1186/s12937-017-0228-7.