Diarrhea in LTAC patient

[Jennifer]

Hello all-

 

68yo Female w/ VDRF secondary to Guillain-Barre (onset Oct 2011).  Admitted to our facility for respiratory management on March 13.

 

Pt has been having intractable diarrhea since 3/27 despite negative C.diff, multiple TF & med/abx changes.  Fecal management system in place, loose & unformed output noted prior to bowel prep (previously liquid consistency).  TF held x1hr for synthroid and an additional 4hrs during the day for bowel rest & easier mobility w/ PT/OT.

 

Colonoscopy done 4/19- results per discussion with RT/RN/NP shows edematous bowel, (?) ischemic colitis.  I would like to wait for the GI & Int. Med. physicians to become available to discuss results directly with them.  Through the grapevine, the GI physician wants to "thicken" the TF and decrease H2O provided.  Pt receiving 726mL H2O from TF, 475mL H2O via autoflush.  The only TF I can think to use at this point would be TwoCal HN for reduced H2O & discontinuing the autoflush.

 

I have tried these forumlas with this patient- Promote w/ Fiber, Osmolite 1.2, Jevity 1.2.  Currently Vital 1.5 is infusing x19hr/day.

 

MEDS: acidophilus 3tabs QID, questran 4g q8hr, B12 IM, lasix 20mg/d, sythroid qDay, prilosec 20mg qDay, pancrelipase 1tab TID, Zinc Sulfate 220mg (started 4/9).

 

What would you do? I'm leaning towards bowel rest & TPN, but our chief nursing officer does not want this.

 

Any help/insight you could provide would be greatly appreciated.

[Jennifer]

Pt also receiving Lomotil.  Immodium also to be ordered by the NP.

 

 

[Drover, Dr. John W.]

These cases are often a challenge and even when we are dealing with them directly it is hard to know what the best answer is. It is even harder when we aren’t directly involved and can never know all the details of what the patient is like or what you have tried already. I would make a couple of broad statements first and a recommendation.

 

Having diarrhea does not imply malabsorption and I would not assume this is present. I am guessing that is why the patient is receiving pancreatic enzyme but is there evidence of malabsorption such as a fecal fat study.

 

The nature of the diarrhea you describe does imply to me a failure of water absorption and this would be consistent with the non-specific finding of bowel edema on colonoscopy. The patient is on furosemide does she have increased total body water and does she have intravascular volume overload, which could be contributing to the bowel edema.

 

Given the patient profile you have given the likelihood of ischaemic colitis is remote to non-existence. I would want to see stronger evidence.

 

I generally would not use Lomotil as it is a narcotic analogue and does cross the blood brain barrier. If the other agents aren’t working maybe they should be stopped.

 

The use of concentrated feed is a bit of crap shoot like the other feed changes. The volume of water (feed) delivered into the stomach is so small compared to the fluid produced and excreted throughout the gut that it probably doesn’t affect the diarrhea much one way or the other. If you are giving furosemide to get rid of water then changing to a concentrated formula to reduce water intake makes sense.

 

I would generally recommend pressing on with enteral feeding (it is good for the gut) and good fecal management and skin care.

 

Respectfully,

 

John W. Drover, MD, FACS, FRCSC, CCPE
Associate Professor
Chair and Program Medical Director
Critical Care Program
Queen's University
Kidd 2
Kingston General Hospital
76 Stuart Street
Kingston, Ontario
Canada
K7L 2V7
Phone 613-549-6666 ext 6335
Fax 613-548-2480

 

The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain confidential or privileged information.  If the reader of this message is not the intended recipient, or the agent responsible to deliver it to the intended recipient, you are hereby notified that any review, retransmission, dissemination or other use of this communication is prohibited.  If you received this in error, please contact the sender and destroy all copies of this e-mail.

---

--
You received this message because you are subscribed to the Google Groups "Critical Care Nutrition" group.
To view this discussion on the web visit https://groups.google.com/d/msg/criticalcarenutrition/-/sfUaD9PZhiQJ.
To post to this group, send email to criticalca...@googlegroups.com.
To unsubscribe from this group, send email to criticalcarenutr...@googlegroups.com.
For more options, visit this group at http://groups.google.com/group/criticalcarenutrition?hl=en.

[JRCF]

I agree…no TPN. (Unless you can confirm malabsorption) – I would stay [closest to iso-osmolar TF] as possible

 

How much Cals & protein are you providing? I have found that these pts need a high protein load, as they are losing muscle protein r/t atrophy.

 

Why can’t Metamucil dosing be used to slow transit time? (2-3 TBsp  BID or TID)

Does the QUESTRAN really need to be used?

 

Why the Pancreolipase?

 

Have never heard of holding TF for synthroid administration – whats that about?

 

Cyndy

 

From: criticalca...@googlegroups.com [mailto:criticalca...@googlegroups.com] On Behalf Of Jennifer
Sent: Friday, April 20, 2012 9:47 AM
To: criticalca...@googlegroups.com
Subject: [Critical Care Nutrition] Diarrhea in LTAC patient

 

Hello all-

--

[Jennifer]

Thank you all for your replies. 

 

Currently, we decreased the amount of fluids provided by discontinuing the autoflush.  The pt has been able to have the fecal management system discontinued over the weekend.  Yesterday, she had 3 BMs, loose+/soft- per RN.  Today, there has not been a BM (as of this writing).  I will continue the elemental TF until we are sure the diarrhea has passed.

 

We have continued to use the Penn St. equation estimate caloric needs due to the VDRF & 2-2.5g/kg IBW for prot needs.

 

The medication end of things has been managed by the Int.Med. physicians, so I cannot give specifics as to why each med was ordered.  I often see them in pts with diarrhea or C.diff.  Benefiber was given as part of pt's admitting orders, however, this was d/c'd when the diarrhea first started.  I believe the docs were worried excess fiber was causing the diarrhea.  There was also question whether the pt was having malabsorption, though no fecal fat study was conducted.

 

The pt came to our facility with anasarca.  This has been greatly reduced, trace edema B/L UE.  Her albumin was also <2 mg/dL, which likely contributed to the difficultly in diuresis. 

 

Our Pharmacist recommends holding TF for 30min before & after giving Synthroid to aid with absorption of the medication.