Clinical Nutrition Management of Acute Mesenteric Ischemia

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CLINICAL NUTRITION
MANAGEMENT OF
SUPERIOR MESENTERIC ARTERY
THROMBOSIS
Dana Magee
ARAMARK Distance Dietetic Internship
OVERVIEW
 Disease Description
 Evidenced Based Nutrition Recommendations
 Case Presentation
 Nutrition Care Process
 Assessment
 Nutrition Diagnosis
 Interventions
 Monitoring and Evaluation
 Conclusion
ACUTE MESENTERIC ISCHEMIA (AMI)
Inadequate blood flow to the bowel caused by:
• Non- occlusive Mesenteric Ischemia (NOMI)
• Mesenteric Vein Thrombosis (MVT)
• Acute Mesenteric Atrial (AMA) Embolus
• Acute Mesenteric Atrial (AMA) Thrombosis
http://emedicine.medscape.com/article/191560overview#showall
OCCLUSIVE MESENTERIC ISCHEMIA
Embolus
Thrombosis
50% of AMI cases
25% of AMI cases
Occurs in distal branches
Occur at origin of SMA
Quick onset
Gradual onset
Low collateral blood flow
Larger portion of bowel
affected
Smaller portion of bowel
affected
Can affect multiple arteries
Associated with MI, mitral
stenosis, Afib, endocarditis,
mycotic aneurysm, dislodged
plaque
Associated with CAD, stroke,
PAD, dehydration, MI, HF
ACUTE MESENTERIC ISCHEMIA
 Risks for AMI
 Age over 50 years old
 Atherosclerosis (African Americans as higher risk)
 AFib
 Hypercoaguable states (Critical Care)
 Epidemiology
 AMI accounts for .1% of hospital admissions in US
 Mortality rate is 71% (AMA thrombosis is highest mortality rate)
SIGNS AND SYMPTOMS
 Abdominal pain out of proportion to expectation
 Benign abdominal exams
 Fear of eating due to postprandial pain
 N,V, D
 GI bleed
 Bad breath
 AFib
 Signs of sepsis
SMA BLOCKAGE
 Ischemia can lead to:
 Vomiting and diarrhea
 GI bleed
 Necrotic bowel (8-12 hrs)
 Bacterial overgrowth
 Perforated bowel
 Sepsis
 HF
 Multi- organ system failure
http://emedicine.medscape.com/article/191560-overview#showall
DIAGNOSIS
 Aortography gold standard
 Distinguish between SMA thrombosis and embolism
 CT scan / ultrasound
 Not as specific or sensitive
 Can see blockage of SMA
 Can rule out other reasons for abdominal pain
 Lab results helpful- not for diagnosis
 CBC, PPT, acid base balance, lactate
TREATMENT
 Immediate exploratory surgery
 Remove ischemic/ necrotic bowel
 Embolectomy
 In surgery:
 Peristalsis
 Coloring
 Doppler ultrasonography
 IV fluorescent under Woodlamp
 Second look surgery
CASE PRESENTATION
 Presented with abdominal pain out of proportion
 Admitting diagnosis: SMA thrombosis
 PMH: A-Fib, stroke, CAD, HTN, cardiomyopathy.
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm
CASE PRESENTATION
 CT scan showed SMA thrombosis
 Started on TPN
 Exploratory laparotomy
 30 cm small bowel resected, NGT decompression
 Second look surgery
 GI bleed
 Pacemaker
EVIDENCED BASED GUIDELINES
 Early or late parenteral nutrition: ASPEN vs. ESPEN
 Casaer MP, Mesotten D, Hermans G et al
 Objective: Comparing the early initiation of PN (European) vs. late
initiation of PN (American and Canadian)
 Prospective, randomized, controlled, parallel- group, multicenter trial
in Belgium
Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi:
10.1056/NEJMoa1102662.
EVIDENCED BASED GUIDELINES
 Protocol:
 2312 patients receiving PN in 48 hours
 2328 patients receiving PN after seven days
 Patients must be at nutritional risk
 Excluded patients with BMI<17
 To keep fluid intake the same received dextrose at the same
rate at PN
Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi:
10.1056/NEJMoa1102662.
EVIDENCED BASED GUIDELINES
 PN 48 hours post admission ICU
 1 day shorter LOS in ICU (p<0.04)
 2 days shorter LOS in hospital (p<0.04)
 Fewer infections 22.8% vs. 26.2% (p<0.0008)
 Less days on dialysis 7 days vs. 10 days (p<0.008)
 10% less patients needing >2 days on vent (p<0.006)
Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi:
10.1056/NEJMoa1102662.
EVIDENCE BASED GUIDELINES
 Conclusion: Late initiation better outcomes for patients.
 Limitations:
 No glutamine in PN or other modulators
 Premixed PN
 No indirect calorimetry
 Not double blinded study
Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. New England Journal of Medicine. 2011; 365 (6): 506-517. Doi:
10.1056/NEJMoa1102662.
EVIDENCE BASED GUIDELINES
 ASPEN: Adult Critical Care Guidelines:
 Early PN feeding with protein calorie malnutrition
 Indicated with recent weight loss of 10-15%
 Studies show:
 Lower risk for complications (p<0.05)
 No nutrition support higher mortality risk ((p<0.05)
McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically Ill Patient. Journal
of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.
EVIDENCE BASED GUIDELINES
 Efficacy of Parenteral Nutrition Supplemented with Glutamine
Dipeptide to decrease Hospital Infections in Critically Ill Surgical
Patients
 Estivariz CF, Griffith DP, Luo M, et al
 Double blind, randomized, controlled study
 Objective: Effect of glutamine PN (GLN-PN) vs. standard PN (STD-
PN) on infections in critically ill surgery patients
Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill
surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.
EVIDENCE BASED GUIDELINES
 Methods:
 2 Cohorts: pancreatic necrosis surgery and cardiac/vascular/colonic
surgery
 Ages 18-80
 s/p one of five surgeries
 Required PN for at least 7 days
Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill
surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.
EVIDENCE BASED GUIDELINES
 GLN- PN
 STD- PN
 30 subjects
 29 subjects
 0.5 g/kg/day glutamine with
 1.5 g/kg/day amino acid
1 g/kg/day amino acid
solution
solution
Limitations:
 Availability of glutamine- two time periods of research
 Limited number of postoperative PN
Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill
surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.
EVIDENCE BASED GUIDELINES
 No significant changes in infection in the pancreatic cohort
 In non- pancreatic cohort GLN- PN
 Decrease in total infections (p<0.03)
 Decrease bloodstream infections (p<0.01)
 GLN- PN had 5x less chance of Staph infection
 No significant difference in mortality
Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill
surgical patients. Journal of Parenteral and Enteral Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.
EVIDENCE BASED GUIDELINES
 Critical Illness Nutrition Practice Guidelines 2012
 Recommend glutamine considered in treatment for critically ill
 Associated with decreased risk of infection
 Not sufficient evidence for decreased LOS, intubation period,
medical cost, or mortality
Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine. Evidence Analysis Library.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. Accessed March 22, 2013.
EVIDENCE BASED GUIDELINES
 Aspen Adult Critical Care Guidelines
 Recommend 0.5 g/kg/day glutamine in PN
 Associated with decreased risk of infection, LOS, and mortality
McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in Adult Critically Ill Patient.
Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290. Doi: 10.1177/0148607109335234.
NUTRITION CARE PROCESS
 Assessment: Client History
 A-Fib uncontrolled
 Does not work
 Lives at home with a caregiver
NUTRITION CARE PROCESS
 Assessment: Food/Nutrition-Related History:
 Poor appetite after stroke, 40 pound weight loss
 Patient reported 11 pound weight loss in one week
 PTA following a low fat diet
 Assessment: Nutrition-Focused Physical Findings:
 Nausea and vomiting X two days
 Abdominal pain out of proportion to expectation
NUTRITION CARE PROCESS
 Assessment: Anthropometric Measurements
 Height discrepancies 62-71 inches
 Weight 145 pounds
 BMI 22.79
 Usual weight 156 pounds
NUTRITION CARE PROCESS
 Assessment: Nutrient Needs
 Energy: 1650-1848 kcal
 (25-28 kcal/kg actual body weight)
 Protein 79-99g protein
 (1.2-1.5g/kg actual body weight)
 Fluid needs: 1680-1890 ml
 (25-30 ml/kg actual body weight)
NUTRITION CARE PROCESS
 Assessment: ARAMARK Nutrition Status Classification
Nutrition Care Indicator Category
Highest Points Assigned
Nutrition History
3 (poor appetite and vomiting)
Feeding Modality/Nutrition Care Order
4 (anticipated TPN)
Unintentional Weight Loss
4 (greater than 2% weight loss in one week)
Weight Status
0
*Serum Albumin or Pre-albumin
0
Dx/Condition
3 (anticipated GI surgery)
TOTAL POINTS
14 Nutritionally severely compromised
NUTRITION CARE PROCESS
 DRG Coding
 Weight loss of 5-10% of usual body weight
 Albumin 3.5-5
 Mild Protein calorie malnutrition
NUTRITION CARE PROCESS
 Nutrition Diagnosis
 Inadequate oral intake related to GI distress as evidenced by NPO diet
order, 0% intake and not meeting estimated kcal or protein needs.
 Inadequate parenteral infusion related to parenteral prescription does
not meet estimated nutritional needs as evidenced by parenteral
regimen providing 67% of estimated caloric needs.
NUTRITION CARE PROCESS
 Interventions
 Once PICC is functional initiate day one TPN. 1700 ml volume: 70g
protein, 150g CHO, 15g lipid.
 Day two recommend 1700 ml volume: 80g protein, 255g CHO, and 15g
lipids to provide 1337 kcal, 80g protein, GIR 2.68 (81% of nutritional
needs)
 Increase CHO in TPN to 255g.
NUTRITION CARE PROCESS
 Monitoring and evaluation
 Food and nutrient intake: Parenteral nutrition administration
Monitor parenteral access
 Food and nutrient administration: Parenteral nutrition intake
formula/ solution
 Anthropometric Measurements: Body weight
MONITORING AND EVALUATION
 Biochemical data, medical tests, and procedures: Electrolytes and
renal profile potassium, magnesium, and phosphorus
 Biochemical data, medical tests, and procedures: glucose endocrine
profile, glucose casual
 Nutrition- focused physical findings: Digestive system: return of GI
function.
CONCLUSION
 SMA thrombosis, NPO
 Patient reported recent significant weight loss, TPN initiated
 Small bowel resection
 NGT suctioning, GI bleed, low hemoglobin, multiple transfusions
 Pacemaker, NPO
 Aspiration, Chopped, nectar thickened liquids
 Weaning off TPN with cardiac diet
CONCLUSIONS
 Late initiation of PN linked to decreased LOS, time on dialysis, time on
ventilator, ad risk for infections
 Early PN support in patients that are admitted to the ICU
malnourished for less complications
 Consideration of adding glutamine to PN for patients in the ICU,
especially surgical patients
 Decrease infections
 More research on LOS and mortality
REFERENCES
 Dang CD. Acute Mesenteric Ischemia. Medscape. http://emedicine.medscape.com/article/189146-




overview. Updated February 22, 2013. Accessed March 22, 2013.
Tessier DJ. Mesenteric Artery Thrombosis. Medscape. http://emedicine.medscape.com/article/191560overview. Updated January 6, 2012. Accessed March 22, 2013.
American Heart Association. What is Atrial Fibrillation (AFib or AF)?. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-AtrialFibrillation-AFib-or-AF_UCM_423748_Article.jsp. Updated October 18, 2012. Accessed March 22,
2012.
American Heart Association. Coronary Artery Disease- Coronary Heart Disease. American Heart
Association. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/CoronaryArtery-Disease---The-ABCs-of-CAD_UCM_436416_Article.jsp. Updated February 27, 2013. Accessed
March 22, 2013.
American Heart Association. Prevention and treatment of High Blood Pressure. American Heart
Association.
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPr
essure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsp. Updated June 6,
2012. Accessed March 22, 2012.
REFERENCES
 McClave SA, Martindale RG,Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition







Therapy in Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; 33 (3): 285-290.
Doi: 10.1177/0148607109335234.
Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults.
New England Journal of Medicine. 2011; 365 (6): 506-517. Doi: 10.1056/NEJMoa1102662.
Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine
dipeptide to decrease hospital infections in critically ill surgical patients. Journal of Parenteral and Enteral
Nutrition. 2008; 32 (4): 389-402. doi: 10.1177/0148607108317880.
Academy of Nutrition and Dietetics. Recommendations Summary CIU: Supplemental Glutamine.
Evidence Analysis Library.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3201. Accessed March 22,
2013.
International Dietetics & Nutrition Terminology (IDNT) Reference Manual Third Edition. Chicago, IL: American
Dietetic Association; 2011.
ARAMARK. Patient Food Services Policies & Procedures Volume IV. Updated March 10, 2010.
ARAMARK. Malnutrition Assessment & Diagnosis (DRG coding form).
Pronsky ZM, Crowe JP. Food Medication Interactions 16th Edition. Birchrunville, PA: Food-Medication
Interactions; 2010.
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