CHARLES UNIVERSITY GERIATRIC NUTRITION CASE STUDIES PARENTERAL NUTRITION CASE STUDY I PARENTERAL NUTRITION It is 9.4.2020 9:00am, you receive a referral from The Stroke Unit and Rehabilitation Department to see Mr. H. *1949, who was admitted the previous day (8.4.2020) from Surgery Department after total gastrectomy (adenocarcinoma, dg. 3/2016), the finding was revised on March 3, 2020 by a two-cavity operation with partial replacement of the thoracic aorta due to tumor ingrowth (relapse of the tumor process in the esophagus). Postoperatively remains weak paraparesis of lower extremities with micturition and defecation dysfunction. Figure 1: Total gastrectomy Mr. H. is a 70-year-old pensioner with a good social situation - the patient is cared for by his wife, before the relapse of cancer he was fully self-sufficient. The pacient doesn't accentuate severe weight loss, but he is indicating that he has lost approximately 3 kg in the last month. At your first visit, the patient is pale, sweaty, with painful grimaces during recurrent spams in the area of the right lower with stomach rumble (borborygmus) - the convulsions allegedly disappear when the stool leaves. He has a sipping next to him, which is half drunk. He hasn't eaten since the beginning of his hospitalization, he doesn't know when he last defetace. Abdomen is above level, less palpable and palpably painful, there is a hypersonic percussion, increased flatulence and peristalsis is present diffusely. You can't examine him properly for persistent algic manifestations - you agree with attending physician on rectal tube placement, administration of a postoperative diet - d. n. 1S (dysphagic post-operative diet), chilled ONS - Nutridrink Compact Protein 125 ml 0-1-0-1 according to patient tolerance and monitoring of food intake. The second day of the examination is repeated - the patient is calm, somatically significantly better than at the initial visit. According to the attending physician - the stool management was successful (using a rectal tube), pacient regulary defecate bigger amount of stool; dyspeptic problems, spasms, borborygmus - everything now negates, abdomen is soft, palpable, palpably painless. C O M E V I S I T U S Appetite slightly better - we agree on an individual diet, continueF ine nburtruitiaonrayl su1 5pp otrot u s2in0g ,O N2S0. D2ue0 to the patient's subrepressivity, the administration of appetite-promoting antidepressant therapy is indicated - Mirtazapine 15 mg 0-0-0-1. P r e m i e r e C i t y P r i v a t e H o s p i t a l CASE STUDY I PARENTERAL NUTRITION Antropometry: Actual bodyweight: cannot be determined, arm circumference (AC) = 27 cm BMI (by AC) = 22,6 (corresponds to the habit aspection) Usual weight: 72 kg (according to the patient by the time of dg. ca in 2016) Body hight: 170 cm (according to the patient) Unintentional weight loss in the last 3-6 months: 3 kg, 4,2% Hand-Grip test: 25 kg (cut off = 27 kg); sarcopenia MUST - score 2 points (high risk of malnutrition) - minimal oral intake Medication p.o. (at admission): Euthyrox 137 mikrog tbl 0-0-0-1 Siofor 500 mg tbl 0-1-0-0 Elontril 150 mg tbl 0-0-0-1 Milurit 100 mg tbl 0-0-0-1 Kinito tbl 1-1-0-1 Novalgin 500 mg tbl 1-1-1-1 Espumisan cps 2-2-0-2 Nutridrink Compact Protein 125 ml 0-1-0-1 For anxiety, insomnia - Neurol 0,25mg 1 tbl p.o. in 6 hours max 2times a day For pain in over 3/10 NRS Novalgin 500mg 1 tbl. p.o. max 3times a day in 6 hours s.c. Fraxiparine 0,3 ml... 18:00....06:00 Mr. H. is an enineer of economy, formerly made a living as a businessman, now retired. He lives with his wife in an apartment at the 2nd floor with an elevator, children come to visit. Prior to admission to hospital, Mr. H. was fully self-sufficient. Currently, the overall severe deconditioning after extensive and complicated surgery, significantly worsened in his functional condition. Mr. H initially verticalized to sit with the help of 1 physiotherapist - sitting is stable, but he is quickly tired. He is verticalized to standing - in the stable walker with help of 1 physiotherapist. - max. semi-reflective posture. Anamnestically is possible to find out that the patient received NJT postoperatively in 2016 with good tolerance (Home-Care service was provided, patient's wife was fully able to operate the tube). Now he is transmitted from Surgery Depatrment only on oral intake (no supplements, no artificial nutrition), which according to the food record - so far he was able to consume a maximum 1/3 of the dysphagia diet (2790.5 kJ / 36.8 g B), which was recommended due to lack of a reservoir (stomach) and ONS Nutridrink Compact Protein 125 ml (1260 kJ / 18 g B) - is completely insufficient. Total energy intake 10. 4. 2020 (per os + ONS): 4050,5 kJ, 54,8 g B CASE STUDY I PARENTERAL NUTRITION Other dg .: Arterial hypertension of the white-coat character Type 2 DM on PAD Dyslipidemia Hyperuricemia Prostate hyperplasia - st.p. TUR 2011 St.p. total strumectomy - substitution St.p. APE St.p. hepatitis A Laboratory anemia, mineral imbalance Recommendations from Surgery Department - control if necessary, suitable GFS control of the anastomosis after stomach resection and esophagus. Realimentation per os. C A R E P L A N ? CARE PLAN INITIAL PLAN: NUTRITIONAL ASSESSMENT: Subjectvie Global Assessment (SGA) / Patient-Generated Subjective Global Assessment (PG-SGA) - including functional capability CONSULTATION OF ARTIFICIAL NUTRITION AND ONCOLOGICAL TREATMENT: here suitable to focus on supplementary parenteral nutrition and ensuring long-term entry FOOD INCOME MONITORING: continuous monitoring, important especially after PN initiation CONTROL OF LABORATORY RESULTS - Alb, TP, CRP, Gly, Hb, K, Na, Ur, Leu, HT INPUT RESULTS E V A L U A T I O N O F T H E N U T R I T I O N A L S T A T E : Moderate malnutrition - combined etiology (chronic cancer - cachexia + acute complications (catabolism) - severe postoperative bleeding, complicated operational procedure, residual dysfunction) according to GLIM classification, PG-SGA C. Consilium with attending physician - due to postoperatively complicated terrain in the GIT area, dyspeptic difficulties and very likely future need for a long-term access for chemotherapy - we consensually indicate PICC (additionally consulted with the leading nutritionist), until the permanent access is performed, we administer a small- volume peripheral PN (in night mode), monitoring P, K, Mg Continuous diet monitoring - monitoring whether PN affects oral intake, changing dysphagia diet to individual diet (normal consistency - see below) Minerals + Osmolality: Na: 135, K: 3.3, Cl: 95, Nitrogen metabolites: Urea: 6.0, Creat .: 98, Protein: Albumin: 31.6, CB: 63.9, CRP: 24, 4, Peripheral blood count: Leu: 7.10, HB: 101 PG-SGA CALCULATION AND SCHEDULE OF THE NUTRITIONAL THERAPY IBW: 66,5 kg Actual weight: 65,4 kg EBW: 66,5 kg Caloric requirement: 9642 kJ (35 kcal / EBW) Protein requirement: 99,8 g (1,5 g / EBW) Hydratation: 1995 ml (30 ml / kg) Per os: Individual diet PND - Nutridrink Compact Protein 125 ml 1-0-0-1 (according to tolerance) via PICC: Smofkabiven 986 ml R 65 ml/h 16:00-08:00 - food intake in small portions very frequently during the day (6-8x), salting the diet, high carbohydrate meals are not served, diabetic form of individual, ONS according to tolerance - treat PICC aseptically, connect PN set in night mode, monitor blood glucose - if necessary, apply insulin to PN PN - REALIZATION? PICC provided within 2 days of consensus consent, Nutriflex PERI peripheral nutrition (1000 ml, 2010 kJ / 40 g B) administered only for a limited time, then switching to initial PV - SmofKabiven 986 ml (4620 kJ / 50 g B) Clinical condition of the patient - stationary condition - satisfactory hydration, abdomen in the level, calm, painless, peristalsis adequate, diffuse, surgical wound healed, PICC environment calm without signs of inflammation, stool - patient emptied repeatedly during the day (bigger volume), if necessary rectal tube indicated, anti-obstipation medication given. Individual diet and food according to the patient's preferences, ONS - Nutridrink Compact Protein sol. 125 ml 1-0-0-1 (these with worse tolerance - given only once a day) Nutritional balance: Oral intake - individual diet = 3418.8 kJ, 28.3 g B ONS - Nutridrink Compact Protein 125 ml 1-0-0-0 = 1260 kJ, 18 g B SmofKabiven 986 ml (C) = 4620 kJ, 50 g B Total energy intake = 9298.8 kJ, 96.3 g B Calculated requirement = 9642 kJ, 99.8 g = the regime is satisfactory, we keep the actual nutritional support FOLLOW-UP CONTROLS the patient's condition and follow-up care plan are consulted with the attending oncologist - in the actual postoperative condition, patient is not able to provide any therapy at this time, only the NNB's (Prague hospital) dispensary care is indicated body weight during hospitalization is stationary - 65.2 kg (other follow-up examinations are without significant changes) RHB - there is a significant improve in general - patient is able to verticalized himself to sit independently. Sitting is stable. Provide verticalization in the walker by the bed independently. For walking he is using a roller (able to walk 30 m independently). during the hospitalization we were tested if discontinuation of PN has an effect on patient's taste (= determine whether the patient will be able to consume more orally) for 2 days (13th and 14th May). According to the result we considered the indication for enteral tube placement with a radiologist assistance (due to the complicated terrain of the GIT) also patient dismission with established