CASE ILEUS

Allison Kliewer

Baptist Dietetic Internship

April 10, 2013

Outline

Introduction Patient Profile Disease background of Ileus Trophic feeds in the Critically Ill Admission Nutrition Care Process Summary and Reflection

Patient Profile

Stay: 1/25 – 2/06 77 year old white female Lives independently Two daughters and friend Does not drink, smoke or use drugs Family Hx: mother passed away at 86

from MI; father passed away from prostate cancer

Pt Profile

Allergy to hydrocodone PMH: CVA, sacral fracture, HTN,

dyslipidemia, CAD, osteoporosis, deconditioning

Past surgical Hx: hernia repair, hysterectomy, diskectomy, exploratory surgery and pyloroplasty form perforated duodenal ulcer, cholestectomy and sacroplasty

Pt Profile

Chief complaint: coffee ground emesis Vomited for 24 hrs before admission Midepigastric pain and weakness Chronic aspirin use Lungs are clear Good bowel sounds

Impression

Acute upper gastrointestinal tract bleed With hematemesis, coffee ground in

nature NPO IV fluids Proton pump inhibitors d/c aspirin and Fosamax Plan endoscopy GI consult

Ileus Refers to the partial or complete blockage

of the small and/or large intestine due to either impaired peristalsis or a mechanical obstruction

Most common complication in critically ill May affect all parts of the GI tract Degree of impairment of intestinal motility is

correlated to the severity of illness and mortality

(Madl and Druml, 2003)

Symptoms Nausea Vomiting Constipation Gastric Pain Discomfort Characterized by abdominal distention, lack

of bowel sounds, accumulation of gas and fluids in the bowel and decreased GI passage with delayed or absent defecation

(Allen et al, 2012)

Etiology

Blockage of small or large intestine Mechanical and paralytic bowel

obstruction outside or within the gut wall, or intraluminal

Surgical procedures

(Madl and Druml, 2003)

Etiology Intraperitonial or retroperitoneal infection Edema 2/2 to massive fluid resuscitation Bacterial or parasitic infection Toxic megacolon Abdominal arterial injury Venous injury Retroperitoneal or intra-abdominal

hematomas Metabolic disturbances

(Madl and Druml, 2003)

Pathophysiology

Loss of synchronization resulting in impaired peristalsis

GI dysmotility = luminal pressure and intestinal dilatation

Intestinal dilatation leads to neutrophils invading and damaging muscle layer

= release of nitric oxide = paralyses muscle cells

(Madl and Druml, 2003)

Pathophysiology

Dilatation and pressure = Gut wall ischemia = system uptake of cytokines and other inflammatory mediators

Inflammatory response contributes to the systemic symptoms of ileus and correlates with severity of ileus

(Madl and Druml, 2003)

Aspiration Impaired motility promotes reflux of

intestinal juices back into stomach = gastric residuals = gastric colonization with intestinal

bacteria Ascension of microorganisms into the

esophagus, into the pharynx, into the trachiobranchial tree

risk of pneumonia

(Madl and Druml, 2003)

Hypovolemia

distention and intra-luminal pressure = compromises intestinal profusion, impairs microcirculation, and ultimately results in fluid sequestration into the intestinal wall and lumen

Inflammation promotes fluid loss into luminal space

= hypovolemia and circulation impairment

(Madl and Druml, 2003)

Bacterial Overgrowth

Ileus associated with alterations in intestinal flora and overgrowth of bacteria

Microorgansisms and/or endotoxins/exotoxins may invade mucosa

= mucosal inflammation, mucosal perfusion and hypersectrection

(Madl and Druml, 2003)

Bacterial Translocation

Intestinal wall impaired or systemic immunocompetence is compromised = spillover of microorganisms into the lymphatic system and/or portal circulation

= systemic infections or septicemia Bacterial overgrowth, inflammation and

impairment of barrier function of the intestinal wall, impaired immunocompetence

(Madl and Druml, 2003)

Impaired Cardiac Output

intraluminal pressure and intrathoracic pressure affects venous return, cardiac filling, ventricular compliance, and contractility

cardiac output mean arterial pressure

(Madl and Druml, 2003)

Decreased Respiratory Function

Compressed pulmonary parenchyma Drop in functional residual capacity Negative affect on lung mechanics and

chest wall ↓ lung compliance = atelectasis alveolar pressure Negative influences gas exchange

(Madl and Druml, 2003)

Nutrition Considerations

EN for restoration and maintenance of intestinal function, perfusion, motility, and barrier function

Minimal EN can help support intestinal function in pts whom sufficient EN is impossible

(Madl and Druml, 2003)

Prognosis Outcome depends on the cause of the

blockage Consequences and recovery time vary Underlying cause, time taken to diagnose,

and treatment Margin of complications and mortality range

from 12 to 27% Mean length of stay is 15 days

(Rojas, 2012)

Feeds in Critically Ill Associating between inadequate feeding and

poor clinically outcome in critically ill patients EN has been shown to attenuate

hypermetabolism of critical illness, decrease infectious complications, and shorten ICU stays compared to PN, and reduce mortality

EN supports intestinal structure and function, prevents increased permeability, bacterial translocation, systemic inflammation

(Heyland et al, 2010)

Enteral Nutrition

Stimulates epithelial cell growth and proliferation

Maintains mucosal mass and microvilli height

Preserves tight junctions between epithelial cells

Promotes blood flow Enhances brush-border enzyme activity

(Rice et al, 2011)

Trophic Feeds

Trophic feeds appropriate for patients deemed unsuitable for high volume intragastric feeds

Feeding small volume of enteral feeds in order to stimulate the GI tract

Improves GI enzyme activity, hormone release, blood flow, motility, and microbial flora

(Rice et al, 2011)

Trophic Feeds

ARF affects more than 3 million pts in US and is the single most common reason ICU pts cannot eat

Conclusive evidence supports early feeds in the ICU

Lack of conclusive evidence regarding the caloric intake dose required for the ICU pt

(Rice et al, 2011)

Trophic vs. ENStudy Design Subjects Purpose Intervention Results

Rice and colleagues 2011’03-’09

Random open-label study

200 pts with acute respiratory failure expected to require ventilation for over 72 hrs

Compare clinical outcomes and GI complications with trophic feeds and full-energy EN

Randomly received trophic feeds (10 ml/hr) or full energy EN for the initial 6 days of ventilation

Trophic feeds resulted in similar clinical outcomes with fewer episodes of GI intolerance

ARDS clinical trials‘08-’11

RandomOpen- labelstudy

1000 pts44 hospitalsWith acute lung injuryRequiring ventillation

Determine if trophic feeds would increase ventillator-free days and decrease GI intolerance

Randomly received trophic or full EN for first 6 days

Trophic feeds did not improve VFD, 60-day mortality, or infectious complications Trophic feeds had less GI intolerance

Progression of Disease

Acute Upper GI bleed with coffee ground emesis

Ileus with gastritis and esophagitis Fever and left lobe pneumonia Acute respiratory distress and

transferred to the ICU NPO Clear liquid Full

Progression of Disease

Ileus Erosive esophagitis and gastritis Aspiration pneumonia Hypoxia Hypokalemia, hypophosphatemia,

hypomagnesemia Leukopenia Sepsis Began TPN

Progression of Disease

Metabolic disorder Small bowel obstruction Intubated and sedated with mechanical

vent Decreasing respiratory status Failed extibation to BIPAP TPN + Trophic Feeds Comfort Care

Nutrition Care Process

BMI: 16.8 80 % IBW N/V/C and loss of appetite Wt gain (30-35 kcal/kg actual wt) 1420-1700 kcals/day 56-71 g protein (1.2-1.5 g/kg actual wt) 1420-1700 ml/day (1ml/kcal/kg actual

wt)

NCP

Severely compromised nutrition status PES: Inadequate oral food intake related

to her current condition as evidence by intake record, BMI, and albumin lab values

Rec Mighty Shake BID

NCP

TPN assessment Pt met ASPEN criteria for TPN with

nonfunctional GI tract (ileus) Rec feeds of 85 g amino acids, 275 g

dextrose, 40 g lipids Provide 1675 kcals with 2.3 glucose

infusion rate

NCP

TPN + insulin + EN trophic feeds of Pulmocare @ 20

ml/hr Hold for NG residuals >200 cc Adjust ENN for IBW 1300- 1600 kcals (22-27 kcal/kg IBW) 88-118 g protein (1.2- 2.0 g/kg IBW)

NCP

PES: Altered GI function related to ileus as evidence by PN and EN

Rec continue trophic feeds with Vital AF 1.2 at 20 ml/hr to help manage inflammation and promote GI tolerance

Reflection

Effective nutritional support for critically ill patients represents a difficult aspect of overall management of complex patients

The is a need to challenge commonly used nutritional support practices and to achieve an individualized, evidence-based approach for optimal nutritional therapy

References Allen, A. M., Antosh, D. D., Grimes, C. L., Crisp, C. C., Smith, A. L.,

Friedman, S., Mcfadden, B. L., Gutman, R. E., & Rogers, R. G. (2012). Management of ileus and small-bowel obstruction following benign gynecologic surgery. International Journal of Gynecology and Obstetrics.121: 56-59.

Heyland, D. K., Cahill, N. E., Dhaliwal, R., Wang, M., Day, A. G., Alenzi, A., Aris, F., Muscedere, J., Drover, J. W., & McClave, S. A. (2010). Enhanced protein-energy provision via the enteral route in critically ill patients: A single center feasibility of the PEP uP protocol. Critical Care. 14: R78.

Madl, C., & Druml, W. (2003). Systemic consequences of ileus. Best Practice & Research Clinical Gastroenterology. 17(3): 445-456.

Rice, T. W., Mogan, S., Hays, M. A., Bernard, G. R., Jensen, G., L., & Wheeler, A. P. (2011) A randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Critical Care Medicine. 39(5): 967-974.

Rojas, D. J., Martinez-Ordaz, J. L., & Romero- Hernandez, T. (2012). Biliary ileus: 10-years experience. Case Series. Cirugia y Cirujanos. 80(3): 228-232.