Case conference- Early feeding s/p gastrectomy

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Case conference-Early feeding s/p gastrectomy

• ????
• ??? ???
• 2005/11/22

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????????7???? ???????(total parenteral
nutrition TPN),????????? (????)??? (Ikeda et
al. 2004)
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Protein-energy malnutrition in the gastrectomized
patient (Papim 2002 )
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Early enteral Feeding
???????,???? ??????(early enteral
feeding) ??????????????, ?????????????
(Huckleberry 2004 )
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Early enteral Feeding
???????????????,???????????????? (Papim 2002 )
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Early enteral Feeding
????????,????????????????,??????????????????,??
??????????,?????? ????????????????? (Papim
2002 )
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Treat adverse effects of EEN

• 1.Abdominal cramps
• - traded first with non-steroid analgesic drug
  (Cataflam, Relifex)
• - with opioid as second choice (Morphine)
• - infusion rate reduced by 20 ml/h
• - temporary stopped for 6-12 hours and resumed
  at a lower rate
• 2.Abdominal bloating
• - traded first with prokinetics drugs
  (Gascon, Biofermin)
• - infusion rate reduced by 20 ml/h
• - temporary stopped for 6-12 hours and resumed
  at a lower rate

(M. Braga et al 2002 )
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Treat adverse effects of EEN

• 3.Vomiting
• - treated by temporary stop of infusion
  followed by diagnostic procedures
• - if no intestinal obstruction was
  detected,
• infusion was resumed at the same rate
  
• 4.Diarrhea
• - reduction of infusion rate by 20 ml/h
• - temporary stop for 6-12h and later with
  resumption at a lower rate
• - In patient with persistent diarrhea ,
  Clostridium difficile infection was always ruled
  out

(M. Braga et al 2002 )
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Case report
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??????

• ????
• ??78? (??16?10?27?)
• ??163.5 ??
• ????61.8??(BW loss 20.8)
• ????78?? ( 6 months ago)
• ????59 ? 5.9??
• BEE 1190 kcal /day
• TER 1700 1800 kcal/day
• PT req. 73 80 g/ day

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??????

• Medication histories
• 1. HTN
• 2. Old CVA
• 3. Old TB
• 4. CRI
• 5. PU (about 3 years ago)
• 6. Thalassemia (???? )

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????

• ????94/10/12
• ?? ????
• ????
• UGI massive bleeding (about 2000c.c.) 8 days
  ago then admitted in TVGH
• (Dx Gastric ca by PES CT study)
• ?? Gastric cancer

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Operation

• Date 94/10/18
• Pre-Dx Gastric cancer
• Clinical finding(10/13)
• ulcerative tumor at LCS (mid-body) with
  invasion to mesocolon 5.54.5cm
• Method 1.Radical B-?subtotal gastrectomy
• 2. Cholecystectomy
• 3. Feeding jejunostomy
• 4. LN dissection No
  1,3,4,5,6,7
• Biopsy 1. Adenocarcinoma, intestinal type
• 2. LN ? negative for metastic
  carcinoma

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Nutrition support progress
Date TPN order Energy/AA Date (Kcal / g ) EN Energy/PT (Kcal / g )
10/12 A160 c.c./hr 20 lipofundin 200ml 1399 / 50 10/12 NPO -
10/14 A260 c.c./hr 20 lipofundin 200ml 1840 / 63 10/13 As tolerance 10/14 500 / 20
10/16 10/17 CLD NPO
10/19 NPO ED ¼ s rate 20c.c./hr 18hr
10/21 A2300 c.c./hr 20 lipofundin 200ml 10/20 10/21 ED ½ s ?FS rate 30c.c./hr 18hr
10/24 TPN DC 10/22 10/23-24 rate 40c.c./hr 18hr rate 50c.c./hr ?60
10/24 D10W run 60c.c./hr 10/24 D10W run 60c.c./hr 10/25 10/26 MD 50c.c./hr DC
Oral
TF (Jejunostomy)
12days
OP day on 10/18
25 / 1
NPO
300 / 16
1385 / 32
NPO
540 / 28
NPO
720 / 38
NPO
800 / 42
530 / 22
NPO
500 / 0
NPO
10/25 Kabiben run 60c.c./hr
1037 / 34
10/28 oral CLD 11/2 Soft diet
Diarrhea
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TPN ???
?? ?? Glucose gm/L AA gm/L Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L) Electrolyte (mEq/L)
TPN A1 Standard 163 35 46 37 12 8 6 37 71 694
TPN A2 High stress 187 44 50 40 15 8 6 36 77 812
TPN A3 Hepatic failure 239 38 50 40 15 8 6 60 47 965
TPN A4 Renal failure 333 23 - - - - - - - 1224
TPN B1 Aminomix 200 50 50 30 15 5 5 100 - 1000
Total Kcal/L
Na
K
P
Mg
Ca
Cl
Acetate
Fat emulsion 20 Lipofundin 100ml/BT
20 Intralipid 100ml/BT 10
Lipovnous 500ml/BT
Infuvita (Vit A, D E, B1, B2, B6 ,B12 VitC,
Niacin , Pathenol, Bioin, Folat)
Trace element Zn, Cr, Cu, I, Mn
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Nutrition support (Energy)
MBD 11/7
OP day
Early enteral Feeding
TER
BEE
PPN EN
TPNEN
10/26NPO Diarrhea
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Nutrition support (Protein)
MBD 11/7
OP day
Early enteral Feeding
PT req.
PPN EN
TPNEN
10/26NPO
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Nutrition Status
OP (10/18)
Admission
10/19 Alb 1 BT bid2days
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Nutrition Status
OP (10/18)
Admission
174
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Nitrogen Balance
OP (10/18)
10/12
10/25
10/31
10/17
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Nutrition Status
OP (10/18)
MBD (11/7)
Admission
BW loss 6.7 in 2 weeks
11/20
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Nutrition Status
OP (10/18)
Admission
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Hb (14-18) / Hct (42-52)
10/17
10/19
10/25
11/ 3
10/31
OP (10/18)
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Discussion
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Diarrhea

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• ?? ? ???
• ???????????????????????
• ???????

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??????????

• ?????????????
• ??????Diet record
• ????
• Diarrhea or steatorrhea

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Thanks for your attention