CASE STUDY

GIT bleeding & perforated

duodenal ulcer
BACKGROUND
 Madam JS
 66/M/female
 ROA: admit for right diabetic foot gangrene in

orthopedic ward
DIAGNOSIS
Current:
-GIT bleeding
-Perforated duodenal ulcer (done Heineke
Mikulitz pyroplasty)
-Right BKA

Medical history:
-Diabetes Mellitus
-Hypertension
CLINICAL PROGRESSION
 Become hypovolemic
 Transferred to ICU for fluid resuscitation &

management of severe metabolic acidosis

In ICU (Day 1):

-stable without inotropes support
-response to call
-weak cough with secretion +++
ICU (Day 2):
-noted malaena stool
-no abdominal distention with minimal gastric
residual volume
-PPN: Nutriflex (52 ml/H)

 ICU (Day 4):

-soft abdomen, no distended
-minimal gastric residual residual
-right abdominal fluid noted 1000 ml serous fluid
-given IV human albumin 20% (to reduce ascites)
-tachypnoeic with bilateral chest creps
-acute pulmonary oedema noted
 ICU (Day 6):
 given 30 ml/h with Glucerna
 plan to wean off Nutriflex
 Noted generalized oedema

 ICU (Day 8):

 no more malaena stool

 Transfer to surgical ward (Day 12):

 still on NG feeding (bolus 200 ml polymeric
formula 3H)
 suggest to allow nourishing fluid orally
 Medication
Drug Indication Side effect
Unasyn Upper and lower rep tract GI disturbances, skin
infections,UTI,prophylaxis rashes,blood
against post op sepsis disorder
Metronidazole Antibiotoc-associated colitis, GI disturbances,
anerobic bacterial infections nausea, vomiting,
diarrhoea
Omeprazole Duodenal ulcer Diarrhea,nausea,
vomit,flatulance,
Acid regurgitation
MgSO4 Hypomagnesaemia Watery diarrhea,
nausea,vomit,thirst
Dopamine Acute heart failure Nausea,vomit,
tachycardia,
hypotension
Drug Indication Side effect
Ceftriazone Suscceptible infection, GIT Superinfection, diarrhea,
infection,UTI,sepsis rash,fever,leucopenia
Tramadol Moderate to severe pain Sweating, nausea,
vomiting,dry mouth,fatigue
Losec Duodenal and gastric ulcer Diarrhea,nausea,vomit,flat
(proton-pump inhibitor) ulance,headache
Frusemide Eddema Dehydration,GI
(cardiac,hepatic,renal),HTN disturbance, metabolic
alkalosis
Prazosin HTN, heart Nausea,edema,chest
failure,raynaud’s syndrome pain,diarrhea,vomit,lack of
energy
Metoprolol HTN Bradycardia,hypotension,e
dema,diarrhea,GI
pain,nausea,heartburn
Pantaprazole GERD,peptic ulcer Diarrhea,dizziness,GI tract
infection,nausea,pain,
 Anthropometry
Day 2 4 6 9
Weight 52 54.5 51 56.8
(kg)
Height 154 154 154 154
(cm)
 IO chart
Day Input Output Balance Urine
output
(ml/hr)
2 2573 2556 +17 50-60
4 2285.5 2977 -691.5 40-60
6 2226.5 2897 -670.5 65-90
9 2505.8 2322 +183.8 60-110
BIOCHEMICAL DATA
Parameter Day 2 Day 4 Day 6 Day 9 Normal
range
Hb(g/L) 12.5↓ 11.1↓ 10.2↓ 12.8↓ 13.0-18.0
Urea (mmol/L) 6.6↑ 8.5↑ 13.1↑ 8.2↑ 2.5-6.4
Creatinine 82 105 93 88 80-132
(µmol/l)
Sodium 136 140 134↓ 137 136-145
(mmol/l)
Potassium 4.2 4.0 3.9 3.7 3.6-5.2
(mmol/l)
Albumin (g/l) 21↓ 14↓ 15↓ 16↓ 35-50
Dextrostix 4.0- 12.2-14.2 4.6-12.4 9.5-10.6 3.9-6.1
(mmol/l) 4.7
 QUESTION 1
Madam JS was referred to you for
nutritional assessment in ICU. Please
comment on her anthropometric
measurements and how would you
determine the reference weight
Anthropometric Measurement
Day 2 Day 4 Day 6 Day 9
Weight, kg 52 54.5 51.0 56.8
Height, cm 154
IBW, kg 53.4

• Day 2 – Day 4: Increased might be due to ascites

• Day 4 – Day 6: Improved oedema
• Day 6 – Day 9: Increased might be due to oedema

Reference Weight: as on Day 2, 52 kg

 QUESTION 2
Once the nutritional assessment done,
would you consider early enteral feeding
for this patient? Explain your
recommendations
Early Enteral Feeding Consideration
 Early enteral feeding is recommended for this
patient
 Patient has no abdominal distension and

minimal gastric residual volume

 Safe and early achievement of the positive

nitrogen balance in cases of gut perforation

 QUESTION 3

What are her short & long term nutrition

support goals? Calculate her nutritional
requirements (energy, protein &
electrolytes)
Short term goals
 To improve nutritional status by providing
nutrition support
 To provide adequate energy and protein to

prevent weight loss and malnutrition

 To maintain good hydration status and

prevent electrolyte imbalance to avoid

complication
 Energy requirement (1)
Harris-Benedict Equation
BEE = 665.1 + 9.56 wt (kg) + 1.85 Ht (cm) – 4.68 Age (yrs)
= 665.1 + 9.56(52) + 1.85(154) – 4.68(66)
= 1138.24 kcal

TEE = 1138.24 x AF x SF
= 1138.24 x 1.1 x 1.2
= 1502.48 kcal/day

Since pt is ventilated, TEE will be reduced for 20%-30%

(MNT,2005)

TEE = 1502.48 kcal x 80%

= 1202.0 kcal/day

Activity factor = 1.1 (bed rest)

 Stress factor = 1.2 (surgery)
 Energy requirement (2)

 MEE = 25 kcal/kg/day (Jolliet P et al.,1998)

= 25 x 52 kcal/day
= 1300 kcal/day
• ASPEN, 2009 = 25-30 kcal/Actual BW/day
= (25-30) x 52 kcal/day
= 1300 – 1560 kcal/day

# Energy Requirement Range = 1200 – 1560 kcal/day

Protein & fluid requirement
Protein Requirement
= (1.2-1.5 g) x 52 kg/day
= 62.4 – 78.0 g/day

Fluid requirement (30-40ml/kg BW)

(MNT, 2005)
= (30-40)ml/day X 52 kg
= 1560 – 2080 ml/day
 Requirement For Electrolyte
(Grant JP, 1992)
Electrolyte Requirement (mmol)

Calcium 7.5 – 10

Magnesium 4 – 10

Phosphorus 20 – 50

Sodium 80 – 100

Potassium 80 - 100
Long term goals
 To obtain adequate calories and protein with reference
to her actual daily requirements

 To maintain her weight within healthy normal range of

43.9-59.0kg

 To improve her biochemical values and maintain the

value within the normal range

 To improve her nutritional status and quality of life

 Energy requirement

 Quick Method
= 30 - 35 kcal/kg/day
= 30 – 35 kcal/day x 53.4
= 1602 – 1869 kcal/day

- wt at BMI 22.5 kg/m2 = 53.4 kg

# Energy Requirement Range = 1600 – 1870 kcal/day

Protein requirement
Protein Requirement
= (1.0-1.2 g/day) x 53.4 kg
= 53.4 – 64.1 g/day
 QUESTION 4
On day 7, patient suddenly developed loose
stools more than 3 times per day and put on
rectal tube. Enteral feeding was withheld by
specialist and suggest to start again on
parenteral nutrition. Would you consider
parenteral nutrition at this stage? Plan a feeding
regime and your monitoring strategies for her.
 No
 Initiation of PN is not advisable because

patient has functioning gastrointestinal tract.

 Initiation of PN increases the risk of infection

and causes gut mucosal atrophy.

 Because the frequency of loose stool is only 3

times per day (moderate), so will maintain TF

infusion rate and re-examine in 6 hours.
(MNT 2005)
 Feeding regime
 Step 1: 150cc Glucerna + 1 scoop Myotein,
run 30cc/hr for 5 hours, rest 1 hour
(Energy: 704 kcal) (Protein: 44g/day)

 Step II : 250cc Glucerna + 1 scoop Myotein,

run 50cc/hr for 5 hours, rest 1 hour
(Energy: 1104 kcal) (Protein: 60g/day)

 Step III : 350cc Glucerna + 1 scoop Myotein,

run 70cc/hr for 5 hours, rest 1 hour
(Energy: 1504 kcal (29 kcal/kg IBW)
(Protein: 76g/day (1.4 g/kg IBW)
Monitoring
 Feeding tolerance
 Stool frequency and consistency
 Dextrostix
 Albumin level
 Renal profile
 IO chart
 QUESTION 5
Two weeks later, she was transferred out
from ICU to general ward and ready for oral
feeding. Design further nutritional
management plan for this patient?
Transition from Enteral Tube Feeding
to Oral Feeding
Patient able and willing to eat orally
(allow orally + tube feeding)

Begin full liquid

Begin Additional Supplements

If oral intake is <1/2 nutritional requirements

Cyclic Enteral Feeding

- Determine the amount of formula, caloric density & volume
- Determine formula infusion rate over a time period (8-20hours)
-Monitor patient’s tolerance
 Discontinue Enteral Tube Feeding
- If oral intake is between 2/3 and ¾ of nutritional
requirements

Oral Feeding

MNT for Nutrition Support in Critically Ill Adults, 2005

8 scoops Nutren Diabetic + 300cc water 3 hourly, 6 times/day

(1728 kcal, 67.2g/day Protein)

Energy Requirement
• Quick Method
E = 30 - 35 kcal/kg/day
E = 30 – 35 kcal/day x 53.4
E = 1602 – 1869 kcal/day

- wt at BMI 22.5 kg/m2 = 53.4 kg

 Protein Requirement  Post-op
= (1.0-1.2) x 53.4 g/day
= 53.4 – 64.1 g/day
 Menu Planning (after stop enteral feeding)
Sample of menu E=1600 kcal, Prot=53.4-64.1g
Soft, high Protein, diabetic diet

Breakfast (7-8 am) Morning Tea (10 am) Lunch (12 – 1 pm)

9 Tbsp cereals +
2 pcs soft bun (plain) + 2 cup chicken porridge
2/3 glass of soy milk or
1 tsp soft margerin + (soft) +
LFM + Plain water (1 glass)
Vegetables soup (spinach +
¾ cup yogurt (plain)
potatoes)

+2 tsp blended oil

+1 piece of mashed papaya

Afternoon Tea (4-5pm) Dinner (7-8 pm) Supper (10 pm)

2 cup fish porridge + 2 pcs soft bun +

6 Tbsp oats +
Vegetables soup (carrots, sawi) ¾ glass of LFM
Menu planning (cont.)
 In case of:
 If patient has put off the tube feeding but the

energy intake from oral feeding still not met

the recommendation, provides patient with
nutritional fluid supplement.
 Suggestion: Nutren Diabetic
 Question 6
Currently nutrition support practices in your hospital
are not satisfactory and you are planning to design an
evidence-based nutrition support protocol for
patients in ICU. Draft the suggested enteral feeding
protocol based on MNT guidelines.
Protocol of Enteral Feeding
 Definition: Delivery of enteral products through an enteral access device
into a functioning gastrointestinal (GI) tract.

 Target group: Physicians, nurses, dietitian, pharmacists, respiratory and

physical therapists

 References:
◦ ASPEN. 2009. Enteral Nutrition Practice Recommendations. Journal of
Enteral and Parenteral Nutrition.
◦ ASPEN. 2009. Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: : Society of Critical
Care Medicine (SCCM) and American Society for Parenteral and
Enteral Nutrition (A.S.P.E.N.). Journal of Enteral and Parenteral
Nutrition.
◦ Ministry of Health. 2005. Medical Nutrition Therapy for Critically Ill
Addult.
A- Initiation
 Enteral nutrition should be provided within the first 24 – 48 hours
following admission for those who are hemodynamically stable and fully
resuscitated.

 Enteral nutrition is the preferred choice whenever GI is functioning and

with sufficient length and absorptive capacity.

 Presence of bowel sounds or evidence of passage of flatus and stool is not

required for the initiation of enteral feeding.

 Patients at high risk for refeeding syndrome and other metabolic

complications should have mineral and electrolytes replaced prior to
initiating feeding.

(ASPEN 2009, MNT 2005)

B- Administration of Feeding
 “Trickle” or trophic feeds (10 – 30 ml/hour) should be given when full enteral
feeding is not possible.
 50 % - 60 % of goal calories should be achieved within the first week of
hospitalization.
 Adequacy of protein provision should be assessed and additional modular protein
can be supplemented in order to achieve requirement.
 For bolus feeding, enteral feeding can be started at the rate of 50 ml 3 hourly and
advance the feed rate by 20 – 40 ml 3 hourly if patients tolerate (refer part D:
Monitoring).
 For intermittent feeding, enteral feeding can be started at the rate of 10 ml – 40
ml/hour and advance the feed rate by 10 – 20 ml if patients tolerate (refer part D:
Monitoring).
 Conservative initiation and advancement rates are recommended for patients who
are:
◦ Critically ill
◦ Have not been kept NBM for some time
◦ Receiving high-osmolality or calorie-densed formula.
(ASPEN 2009, MNT 2005)
C- Safety Practice of Enteral Feeding
 Aseptic techniques should be practiced during handling,
preparation and delivery of enteral formula.

◦ Practice good hand washing technique and use of disposable gloves

when handling enteral formula and enteral tube is recommended.
◦ Strict adherence to the recommended hang time of enteral formula (4 –
6 hours for powder formula and 6 – 8 hours for decanted formula)
◦ Opened decanted formula should be covered and kept in refrigerator and
be discarded after 24 hours.
◦ Administration sets for enteral feeding should be changed at least every
24 hours. Washing with tap water is not recommended to prevent
introducing of micro-organisms into the administration sets.

(Adapted from ASPEN ALERT Campaign 2009)

C- Safety Practice of Enteral Feeding
 Make sure correct enteral formula and feeding rate is administered to
the patient as ordered.

 Patient’s head of bed should be elevated at least 30 degrees when

clinically possible during feeding in order to mitigate risk of reflux and
aspiration.

 Flushing feeding tube with 30 ml of clear fluid before and after the
feeding is recommended.

 Medications should not be added into enteral feeding together. Instead it

should be administered as directed by pharmacists.

(Adapted from ASPEN ALERT Campaign 2009)

D – Monitoring Feeding Tolerance
1. Gastric Residual Volume (GRV)
◦ If > 250 ml, please continue the same rate of the feeding
again. Consecutively of GRV > 250 ml twice might require
use of pro-kinetic agents.
◦ If > 500 ml please check patient’s tolerance to the feeding.
◦ If high GRV consistently being aspirated, please consider:
 Reduce the rate of feeding
 Reduce the calorie density of the formula
 Intermittent/continuous feeding (if patient is on bolus feeding)
 Post pyloric feeding
(MNT 2005)
D – Monitoring Feeding Tolerance
2. Diarrhea
◦ It is not an indication to stop feeding
◦ Checking etiology of diarrhea is important (such as medications
(lactulose, oral magnesium salts, wide-range antibiotics) or having
faecal impaction.
◦ Consistent diarrhea without any possible etiology found might suggest
use of formula with soluble fiber or small peptides.
◦ If 1-2times/day, continue feeding as protocol
◦ If 3-4 times/day, maintain feeding rate
◦ If more than 4 times/day, decrease TF infusion rate by 50%, review
medications, send stool for fecal leucocytes and toxins. If persist more
than 48hour, change to elemental feeding
(MNT 2005)
D – Monitoring Feeding Tolerance
3. Vomiting
◦ >1 time/12 hour
◦ Check feeding tube
◦ Decrease feeding rate by 50% and notify dietitian

(MNT 2005)
D- Monitoring of feeding tolerance
4) During acute phase, preferably receive feeding continuously. Can switch to
intermittent feeding later

(i) Continuous Feeding

- Start 20 – 40 ml/hr continuously & aspirate every 4hr

- If aspirate < 200ml

Return all aspirate

↑ rate 20ml/hr every 3 cycles til meet target caloric needs

After, may further diluted with water to meet fluid requirement

- If aspirate > 200ml

Return 200ml aspirate & ↓ rate by 50% of initial rate

Exclude bowel obstruction  administration prokinetic agents

Further aspirate < 200ml

(a)
-Follow “if aspirate < 200ml”

(b) Further aspirate cont > 200ml

(a)
-Consider small bowel feeding & elemental formulas
D- Monitoring of feeding tolerance
(i) Intermittent Bolus Feeding
- Start 50ml every 3 hr & aspirate before every feed
- If aspirate < 200ml
 Return aspirate
 ↑ by 50ml after every 4 feeds
 ↑ by 100ml/feed every 24hr till caloric needs meet
 After, may further diluted with water to meet fluid requirement 
- If aspirate > 200ml
 Return 200ml aspirate & ↓ by 50ml/feed
 Exclude bowel obstruction  administration prokinetic agents
(a) Further aspirate < 200ml
 -Follow “if aspirate < 200ml”
(b) Further aspirate cont > 200ml
 -Consider use of continuous feeding

(MNT 2005)