MAJOR CLINICAL CASE STUDY

MAJOR CLINICAL CASE STUDY

Scheduled Colostomy Reversal

Complicated by Pre-op Hypocalcemia and Post-op Ileus

2º to Previous Parathyroidectomy

Jennifer K. Duvall

Dietetic Intern, University of Maryland

April 20, 2004 – Anne Arundel Medical Center

Table of Contents

· Executive Summary

· General Information

· Social History

· Medical/Surgical Data

Ø PMH/PSH

Ø History of Present Illness

Ø Physical Exam

Ø Assessment

Ø Pertinent Surgical Procedures with findings

· Allergies

· Hospital Course of Patient

Ø Medical Treatment

Ø Nutritional Treatment

· Case Discussion

Ø Medical Considerations

Ø Nutritional Considerations

· Implications of Findings to the Practice of Dietetics

· Appendices

Ø Lab Values

Ø Medications

· Glossary

· References

Executive Summary

Although in most age groups greater BMI is associated with increased mortality risk, among the elderly the reverse has been found to be the case. A BMI <22 is an independent predictor of mortality, while a BMI <19 in long-term care patients has been found to be a risk factor for malnutrition. (5)

In general, undernutrition is poorly recognized and treated in elderly persons. Appropriate use of short-term aggressive caloric supplementation can save lives. Recent studies have suggested that at least half of elderly persons in hospitals receive insufficient calories to meet their basic needs. These patients have much worse outcomes than those who receive adequate calories. In addition, recent research indicates that elderly persons with an albumin level < 3 g/dL will benefit from short-term tube feeding. Total parenteral nutrition should be reserved for severely undernourished persons (those with an albumin level < 3 g/dL) and for those who cannot tolerate enteral feedings (3).

TC is a 78 year old “frail” female that was admitted to AAMC for a colostomy reversal and bowel resection. Advanced age, surgery, and low BMI place this patient at high nutritional risk. Secondary to a previous parathyroidectomy, her hospital course was complicated by her body’s inability to maintain homeostasis of serum nutrients and electrolytes. Adequate nutrition is an extremely important component in the postoperative care of this high-risk patient for optimal healing and prevention of further complications. It is the role of the dietitian to use critical thinking to support nutritional status despite medical restraints and psychosocial barriers.

General Information

TC is a 78 year old white female who came in on February 17, 2004 for a colostomy reversal, developed hypocalcemia with carpopedal spasms and a post-op ileus. This patient was discharged home in a wheelchair on February 28, 2004.

Social History

History of smoking, but quite remote. Alcohol none. She lives with her daughter but is fully functional, tends the house, and has no limitations.

Medical/Surgical Data

1. PMH/PSH

Diverticulitis

o 1991 diverticular bleed

o June 2003 perforated diverticula with septic shock and a bleed à bowel resection, colostomy

Hyperparathyroidism, evident with hypercalcemia

o July 2003 partial parathyroidectomy

o Hypertension

Anxiety
Frequent UTI’s
Degenerative Joint Disease
s/p cholecystectomy

2. History of Present Illness

Pt came in on 2/17/04 for colostomy reversal, was given phosphosoda prep the night prior and started to develop severe cramping in her legs, as well as with the blood pressure cuff testing, and cramping of her thumbs inward, as well as numbness in her left upper extremity. Her electrolytes were checked and calcium came back significantly low at 5.7. Calcium gluconate 2 grams was given. A repeat value was slightly low a 6.7. She was given Os-Cal 1 gram p.o., as well as another 2 grams IV calcium gluconate. At this time the patient was still having some slight carpopedal spasm, but her tingling had definitely resolved.

3. Physical Exam

Information from 2/17/04 medical consultation notes:

· Temperature 98.6, pulse 88, blood pressure 110/78. In general, the patient is a well developed, well nourished female in no apparent distress. Normal HEENT exam, lungs are clear to auscultation bilaterally. The thyroid is without nodule. The heart is a regular rate and rhythm. The abdomen is soft, nontender, nondistended, with normoactive bowel sounds, no guarding, rebound, nor rigidity, no hepatosplenomegaly. In the abdominal wall, there is a colostomy site with yellowish watery fluid draining. Genitourinary: The Foley catheter is in place. Psychiatrically, she is quite appropriately neurologically. The only atypical neurologic finding is the carpopedal spasm on the bilateral upper extremities, left worse than right.

· Relevant lab data from the 2/17/04 admission examination showed a sodium of 148, potassium 3.8, chloride 114, bicarb 21.1, BUN 15, creatinine 1.1, and glucose 90, as well as calcium 6.7. (See Appendix I for comprehensive lab results).

4. Assessment

Hypocalcemia with carpopedal spasm. Symptoms expected to resolve with a calcium greater or equal to 7. At this time, with a calcium of 6.7 and two more grams infusion, anticipated no reason to delay surgery. NPO status however, she will probably continue to need calcium intravenously. With the achlorhydria that may occur with Zantac or Protonix use or just postoperatively, she will have decreased p.o. absorption. Magnesium should be checked and/or repleted. Two grams of magnesium sulfate will give her some cardiac protection from dysrhythmia and is a good idea pre and/or post-op. K-Fos (increases urinary phosphate and pyrophosphate) has already been given, and will need a separate IV or ppt with calcium and phosphorus. The electrocardiogram should be evaluated to make sure that her QT is reasonable and not too prolonged. Her hypocalcemia is likely evident of a phosphosoda prep with phosphorus binding. Regarding hypertension, continue beta blocker which will also give some cardiac protection.

5. Pertinent surgical procedures since admission – procedure with findings

Information from operative report 2/17/04:

· Preoperative Dx: hx of diverticulitis with colostomy

· Operation: Colostomy takedown with colon resection

· Procedure/Findings: Incision into abdominal cavity. Attention directed to colostomy, adhesions were lysed and colon was freed up from the anterior abdominal wall. Stapling device was used to divide the colostomy from the proximal valve. Next, the distal rectal stump was mobilized for connection to the proximal colon, but proximal colon was noted not able to extend down there. Therefore the splenic flexure was taken down in order to obtain length for the colon to reach. Using a 25mm EEA as the anastomotic device; the anvil part was placed in the distal colon, the EEA stapling device was popped through the anterior rectal wall and then connected with the anvil—good anastomosis was performed. The colostomy in the left lower quadrant was removed. Patient was then irrigated and closed up. The old colostomy site was also irrigated and sutured. Patient was awakened and taken to recovery, still extubated and in stable condition.

Labs (See Appendix I)

Medications (See Appendix II)

Allergies: NKDA

Hospital Course of Patient

1. Medical treatment

2/17	Hypocalcemia
2/17	Colostomy takedown and bowel resection. NPO
2/19	NGT secretions coffee ground in color.
2/20	Liquid green stool x2. Sent for Cdiff x 3. Clear liquid diet started.
2/21	+Nausea. Full liq diet
2/22	Diarrhea decreasing. Transfused 2 UPRBC, IVMgSO4 x2, KPO4 x1
2/23	Temperature 99.4. Ileus. NPO
2/24	Temperature 100.4. WBC 12.8. IV MgSO4. B-Clear liquid, D-Full liquid
2/25	Abd mod distended. WBC 16.0. Diarrhea. Full liquid diet cont.
2/26	WBC 14.7. +Flatus. Toast, crackers added to full liquid diet. Resolving ileus. Plan-encourage ambulation.
2/27	Temperature 99.2. WBC 15.8. +Flatus. Abdomen mod severe distention. Plan-ambulate
2/28	D/C’D

2. Nutritional Treatment (My intervention begins w/2-24 documentation.)

2/18 Nutrition Screen

** Surgical Pt >75yrs: s/p colostomy takedown

** Albumin <3.3

** BMI <20: Moderate risk

** Modified diet: NPO

** Diet education for D/C: Not ready to learn

** Comments: albumin 1.9 hx HTN, cholecystectomy, partial parathyroidectomy. Consult patient when diet advances; Follow on 2/20.

2/22 Assessment
BMI	17: Underweight
Albumin	2.4: Low w/o other factors.
PO intake	<25%. Not adequate.
IBW	54kg
BEE	Increased needs 30-35 Kcal/kg Est kcal >1650 kcal/d (used IBW)
Protein:	Albumin <3.0. 1.2-1.5 gm/kg Est pro needs: >64g
Pt interview: Reports nausea, afraid to eat. States Boost is ‘too sweet’.
Assessment: High risk – oral intake Comment: pt underweight, w/poor p.o. intake, low albumin. Recc. Reglan for nausea to help assist with p.o. Will follow p.o. closely.

2/24 Reassessment
New findings	Ileus
Diet Order	CL >25% but <50%. Not Adequate.
Supplements	Initiated
Pt interview: Discussed importance of supplement/nutritient dense p.o. intake. Pt agreed. Had pt try different Boost Plus flavors; requests strawberry tid when diet advances to FL again.
Assessment: High risk – oral intake Comment: Pt underweight w/low albumin. Recommend nutrition support if nutritionally adequate diet not tolerated by 36hrs. Will follow closely to monitor p.o. intake.
Recommendations/Plan 50% meal and supplement intake by 2/26 Recommend parenteral nutrition support Send Boost Plus tid with diet adv

2/26 Reassessment/Follow-up
Diet Order	FL >25% but <50%. Not Adequate.
Supplements	>75%
Pt interview: Pt reports drinking 2 cans Boost Plus yesterday. Likes strawberry flavor. Provided strawberry boost over ice mixed w/ small amt instant coffee for flavor preference. Pt likes; agrees to try at least 3 cans/d.
Assessment: High risk – oral intake Comment: Pt underweight w/low albumin. Has had poor po intake >10d. Pt is tolerating FL; recommend diet advancement or nutrition support.
Recommendations/Plan 50% of meals by 2/28 75% of supplements by 2/28 Supplement Boost Plus tid Kitchen to honor pt preferences Recommend nutrition support or diet advancement

Case Discussion

1. Medical Considerations

Ca:P Homeostasis: normal physiology / pathophysiology with disorder

Under normal circumstances, plasma calcium concentration is tightly regulated through the interaction of a number of organs, including the kidneys, digestive tract, bone and skin. Calcium can be added to the plasma from bone and absorbed via the digestive tract, and it can be removed from the plasma by bone and the kidneys (1).

Several hormones regulate plasma calcium levels, including parathyroid hormone (PTH), calcitrol, and calcitonin. PTH is the primary regulator of plasma calcium levels. PTH is a peptide hormone produced in the parathyroid glands and secreted in response to a decrease in plasma calcium concentration. PTH:

(1) stimulates renal phosphate clearance and increases Ca resorption in the kidneys, which decreases excretion of Ca and sustains blood levels

(2) stimulates the activation in the kidneys of calcitrol (vitamin D), which stimulates calcium and phosphorus absorption in the digestive tract as well as calcium resorption in the kidneys

(3) Both PTH and vitamin D stimulate bone resorption, resulting in the release of bone mineral (calcium and phosphate) into the blood.

Again, PTH stimulation results in decreased urinary excretion of calcium, it results in increased urinary excretion of phosphorus. The increased urinary excretion of phosphorus is advantageous in bringing blood calcium levels up to normal because high blood levels of phosphate suppress the conversion of vitamin D to its active form in the kidneys (3, 6).

In normal situations, high blood phosphate levels reduce the formation of the active form of vitamin D (calcitriol) in the kidneys, reduce blood calcium, and lead to increased PTH release by the parathyroid glands. The increased PTH signals bones to release calcium and “bind” the phosphorus, that is, remove the phosphorus from the blood (4).

The body uses these homeostatic mechanisms in attempt to maintain a certain calcium:phosphorus ratio (in good health the ratio of calcium to phosphorus in the blood is 10:4). In this case study, given Ms. TC’s previous parathyroidectomy, the mechanism for PTH production and release is likely limited. Therefore, with a sharp increase of serum phosphorus from the phosphosoda prep, the body’s limited ability to release PTH (and subsequent calcium from the bone), left only the existing serum calcium to bind the excess phosphorus. The attempt to lower the phosphorus caused further reduction of serum calcium resulting in severe hypocalcemia.

Ileus: pathophysiology

Ileus is temporary absence of the normal contractile movements of the intestinal wall. Like an obstruction of the intestines, ileus prevents the passage of intestinal contents (but, rarely leads to rupture). Ileus commonly occurs for 24 to 72 hours after abdominal surgery. Disorders outside the intestine may cause ileus, such as kidney failure or abnormal levels of blood electrolytes--low potassium or high calcium levels, for example. Other causes of ileus are use of certain drugs and an underactive thyroid gland (2).

The symptoms of ileus are abdominal bloating, vomiting, severe constipation, loss of appetite, and cramps. A doctor hears few bowel sounds or none at all through a stethoscope. An x-ray of the abdomen shows bulging loops of intestine. The buildup of gas and liquid caused must be relieved. Sometimes a tube is passed through the anus into the large intestine to relieve the pressure. In this case study, a tube was passed through the nose into the stomach or small intestine, and suction was applied to relieve pressure and distention. The person is not allowed to eat or drink anything until intestinal function normalizes and fluids and electrolytes are given intravenously (2).

2. Nutritional Considerations

Ms. TC, a petite, frail, 78 year old female with known prior bowel complications, came to the hospital for surgery. 24 hours prior to her admission it is likely she maintained a clear liquid diet as indicated by the Phosphosoda protocol. Post-operatively, albumin was very low and p.o. intake was poor, complicated further with nausea, vomiting, diarrhea, and an ileus. Nutrient needs were increased related to surgical healing, low BMI, and low albumin. Diet order was NPO/CL 4 days post-op (totaling 5-6 days including pre-op diet), advanced to fulls for 48 hours, returned again to NPO/CL for 24 hours, and then to full liquids for 48 hours before adding crackers and toast. Nutritional recommendations for nutritional support and/or diet advancement were documented on 2/24 and 2/26. In the meantime, supplementation appropriate with diet order was pushed aggressively and followed closely. Given the following parameters and noted preoperative anticipation that “with the achlorhydria that may occur postoperatively, she will have decreased p.o. absorption”, would early postoperative nutritional support intervention have been the ideal treatment??

Implications of Findings to the Practice of Dietetics

The dietitian is the advocate for the patient’s nutritional status with respect to medical recommendation as well as with patient awareness and encouragement. Critical thinking is a necessity in order to support/maintain nutritional status given multiple medical restraints and psychosocial barriers. In this situation, the patient had increased needs, poor intake, severely restricted diet orders, and reportedly thought Boost Supplement was “too sweet”. As a dietitian, my job was to identify these issues and derive a solution that would get added nutrients into my patient. To the physicians, I made recommendations for nutrition support; with the patient, I set up taste test consisting of Boost Plus (in multiple flavors), plenty of ice, and a side of instant coffee in hot water. Through the various combinations, my patient found several concoctions of her liking and agreed to drink her goal of three/day. I left my patient with a starting supply of products, made sure thorough instructions were available to the kitchen staff, and followed up each day to ascertain she had her supplement in the desired variety and manner.

Appendix I

Labs

Normal Range

BUN

wnl

5-25 mg/dl

148

140

138

134

138

134

133

132

wnl

135-146 mmol/L

K+

wnl

3.2-5.0 mmol/L

Cl-

wnl

95-112 mmol/L

CO2

wnl

18-32 mmols/L

Glu

100

189

114

150

126

127

110

100

70-115 mg/dl

Creat

wnl

0.5-1.5 mg/dl

Calcium

5.5, 6.9

6.1

7.5

7.4

7.5

7.1

6.6

7.8

8.2

8.1-10.2 mg/dl

Phos

3.7

1.4

1.0

2.7

2.3

2.0-4.8 mg/dl

Total Pro

5.5

4.8

5.7-8.1 g/dl

Albumin

2.9

2.4

3.5-5.0 g/dl

Ion’d Ca

3.5

4.7

4.1-5.5 mg/dl

0.6

1.0

2.4

1.1

1.6

1.1

1.4

1.0-2.3 meq/L

PTH

64.4

79.4

15-65 pg/ml

WBC

10.9

14.4

12.7

10.4

10.2

7.1

12.8

16.0

14.7

15.8

4.8-10.8 k/cmm

RBC

3.45

2.78

2.82

3.12

2.97

3.87

4.16

4.12

3.87

3.94

4.1-5.3 m/cmm

Hgb

10.8

8.6

8.8

9.5

9.2

11.9

12.9

12.7

11.9

12.1

12.0-16.0 g/dl

Hct

31.8

25.6

25.9

29.5

27.2

36.0

38.2

37.4

35.4

35.8

37-47.0%

Platelet Ct

wnl

375

150-350 k/cmm

Appendix II

Meds

Amitriptyline (Anti-depressant)

Atenolol (B-blocker)

Calcium Gluconate 10

Calcium

Calcitriol (Active Vit D – stimulates Ca absorption)

Cefazolin (Antibiotic)

Benzocaine (Local anesthetic)

Dextrose 5% lactated

Dextrose 5% in Water

Diazepam (Anti-anxiety)

Fentanyl (Pain/sedation)

Heparin Lock Solution (Anti-coagulant)

Potassium Chloride

Potassium Cl Ext Rel

Potassium Phospate

Levofloxacin (IV - antibiotic)

Aluminum-Magnesium H (Antacid)

Magnesium Oxide (Antacid)

Metoclopramide (Reglan, anti-enemic)

Metoprolol (B-blocker)

Metronidazole (IV – antibiotic)

Midazolam (sedative)

Magnesium Sulfate (laxative)

Minerol oil light

Morphine Sulfate (pain)

Sodium Chloride 0.9%

Naloxone (Pure narcotic antagonist)

Neosporin

Olanzapine (Anitpsychotic)

Ondansetron Inj (Anti-emetic)

Pantoprazole (AntiGERD)

Piperacillin-Tazobac (Antibiotic-pneumonia)

Premix IV Solution

Promethazine (Anti-histamine, anti-emetic)

Zinc Oxide USP (Ointment/protectant)

**(reference 6)

Glossary

· Achlorhydria: lack HCL in stomach

· Anastomotic: Refers to something located at the site of the surgical connection of two tubular structures.

· Auscultation: The act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs and for the detection of pregnancy.

· Carpopedal: Relating to the wrist and the foot, or the hands and feet; denoting especially carpopedal spasm.

· Degenerative joint disease: A form of arthritis that results in the destruction of the articular cartilage that line the joints. Seen predominately in the larger weight bearing joints of the hips, knees and spine, but may also be evident in the small joints of the hands.

· EEA: end to end anastomosis

· Phosphosoda prep: used as part of a bowel cleansing regimen in preparing the colon for surgery

· Splenic flexure: The bend at the junction of the transverse and descending colon.

**reference 9

References

1. Endocrine Control of Calcium and Phosphate Homeostasis. Bowen, R. A., et al. Biomedical Hypertexts. 2003. Available at http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/calcium.html.

2. Gastrointestinal Emergencies. The Merck Manual of Diagnosis and Therapy. Sec 132, Ch 9. Available at http://www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual_home2/sec09/ch132/ch132e.jsp%3Fregion%3Dmerckcom&word=ileus&domain=www.merck.com#hl_anchor.

3. Geriatric Medicine. The Merck Manual of Diagnosis and Therapy. Sec. 91, Ch. 293. Available at http://www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section21/chapter293/293a.jsp%3Fregion%3Dmerckcom&word=geriatric&domain=www.merck.com#hl_anchor.

4. Hypocalcemia. Christopher B Beach, MD. eMedicine. 2001. Available at http://www.emedicine.com/emerg/topic271.htm#

5. Involuntary Weight Loss and Malnutrition: Screening, Evaluation and Treatment. Saffel-Shrier Susan, et al. Geriatric Times. 4(3). 2003. Available at http://www.geriatrictimes.com/g030629.html

6. Nutrition and Diagnosis Related Care 5^th Edition. Stump, Sylvia Escott. Lippincott, Williams, and Wilkins. Baltimore, MD. 2002.

7. Parathyroid Hormone. Bowen, R. A., et al. Biomedical Hypertexts. 2003. Available at http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/thyroid/pth.html.

8. RxList: The Internet Drug Index. Sandow, Neil. Available at http://www.rxlist.com/.

9. Taber’s Cylcopedia medical Dictionary. 19^th Edition. F.A. Davis Company. Philadelphia, PA. 2001.