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CLINICAL NUTRITION MANAGEMENT OF SUPERIOR MESENTERIC ARTERY THROMBOSIS Dana Magee ARAMARK Distance Dietetic Internship

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OVERVIEW Disease Description Evidenced Based Nutrition Recommendations Case Presentation Nutrition Care Process Assessment Nutrition Diagnosis Interventions Monitoring and Evaluation Conclusion

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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/191560- overview#showall

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OCCLUSIVE MESENTERIC ISCHEMIA EmbolusThrombosis 50% of AMI cases25% of AMI cases Occurs in distal branchesOccur at origin of SMA Quick onsetGradual onset Low collateral blood flowLarger 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

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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)

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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

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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

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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

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TREATMENT Immediate exploratory surgery Remove ischemic/ necrotic bowel Embolectomy In surgery: Peristalsis Coloring Doppler ultrasonography IV fluorescent under Woodlamp Second look surgery

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CASE PRESENTATION Presented with abdominal pain out of proportion Admitting diagnosis: SMA thrombosis PMH: A-Fib, stroke, CAD, HTN, cardiomyopathy.

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http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum.htm

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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

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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.

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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

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EVIDENCED BASED GUIDELINES PN 48 hours post admission ICU 1 day shorter LOS in ICU (p