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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/191560
-overview#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/191560overview#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

1.5 g/kg/day amino acid

with 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

*Serum Albumin or Pre-albumin

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/191560-overview. 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/Whatis-Atrial-Fibrillation-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/Coronary-ArteryDisease---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/PreventionTreatmentofHighB
loodPressure/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: FoodMedication Interactions; 2010.