POST ICU MANAGEMENT OF INTESTINAL FAILURE IN AN ISCHAEMIC BOWEL PATIENTA CASE PRESENTATION GRAHAM TURNER

GASTROENTEROLOGIST

BELFAST

A CASE STUDY

‘SAM’ 1964 MALE

• Presented to local hospital late on 5/10/2017• 1 week history intermittent pain

• Morbidly obese (140kg, BMI 44.1kg/m2)

• New Atrial Fibrillation

• CT – SMA thrombosis

• Transferred to Vascular unit• Failed thrombectomy

• Laparotomy

SURGICAL HISTORY

• First Laparotomy 6/10/2017:• Areas of ischaemia, ?viable section

• Two (80cm and 90cm) sections removed - ?where

• Proximal stoma and second segment closed off, no anastomoses

• Planned second-look laparotomy in 24-48 hrs

• Echocardiograph:• Left Ventricular filling defect ? Thrombus +/- tumour

SECOND LAPAROTOMY 8/10/2017

• Extensive necrotic bowel

• Approximately 20cm from DJ flexure viable

• Right and most of transverse colon dead

• IF surgeon called• Proceed with resection

• Difficult stoma ++

ICU ADMISSION (6TH TO 24TH OCTOBER)

• Sepsis x 1

• CT – 2 intra-abdominal collections:• 1 small peri-stomal (not treated)

• Larger para-colic – drained

• Reducing inotropes

• TOE – large thrombus

• Fit for transfer to IF unit 23rd October 2017 (day 17)

ACUTE BOWEL ISCHAEMIA AND INTESTINAL FAILURE

• Acute mesenteric ischaemia:• Acute arterial occlusion

• Non-occlusive

• Venous thrombosis

• Mortality 50 to 80%

Bala et al. World Society of Emergency Surgery. 2017

ACUTE BOWEL ISCHAEMIA AND INTESTINAL FAILURE

• Acute mesenteric ischaemia:• Acute arterial occlusion

• Non-occlusive

• Venous thrombosis

• Mortality 50 to 80%

Bala et al. World Society of Emergency Surgery. 2017

Pathology: ischaemia with organised emboli

24TH OCTOBER 2017 (DAY ZERO)

• Transferred to ward

• Short bowel (est 20cm to stoma)

• Retracted stoma

• Para-colic collection drain in situ

• New Atrial Fibrillation

• Ventricular thrombosis (??other pathology)

• Obese (140kg/BMI 44kg/m2)

• Confused, hypoxic

• Other details:

• 5 lumen temporary CVC (2nd line, day 12)

• Ciprofloxacin/metronidazole/Vancomycin /fluconazole stopped on day of transfer

• 140mg Enoxaparin BD

ADMISSION DETAILS

• Very immobile at home – days in bed at a time

• Severe Hip pain ‘arthritis’

• Depressed at times, rarely leaves house

• 2 young children (8 and 10)• Separated, lives alone

• kids stay 2-3 nights/week

PROBLEMS ON THE HORIZON

• Intra-abdominal sepsis

• Left ventricular thrombus/other

• Mobility• Hip

• Shoulder pain

• Depression

• Obesity

PROBLEMS ON THE HORIZON

• Intra-abdominal sepsis

• Left ventricular thrombus/other

• Mobility• Hip

• Shoulder pain

• Depression

• Obesity

ANTICOAGULATION – 20CM??

A. None

B. DOAC/NOAC

C. Long term Low molecular weight heparin

D. Dual antiplatelets

E. Trial of warfarin

INITIAL MANAGEMENT PLAN

• Short Bowel regimen:• 300ml oral fluid restriction• PPI – omeprazole 40mg BD

• Loperamide/codeine??

• PICC line planned

• Cardiac MRI

• Low molecular weight heparin with trial of warfarin

• Stoma team – dilation/catheter

• Repeat abdominal imaging

DAY 3

• Temp spike 39.2OC• Line removed (awaiting PICC)• Full sepsis screen

• CT Abdomen/Pelvis

• Coagulase –ve Staphylococcus line cultures• 7 days vancomycin

• -ve repeat cultures/line tip -ve

• CT showed hip AVN, small drained para-colic collection x 1

• Cardiac MRI - thrombosis

‘SNAP’

SLOW PROGRESS WEEKS 2-4

• PICC in place

• Stoma OP 2000-4000ml/24hr

• Poor mobility/motivation

• Hip and shoulder pain

• Therapeutic INR and digoxin!

• Persistent CRP 20-45g/dL

MDM RECURRING THEMES

• Motivation a major issue

• Mobility very poor can’t stand/sit

• Bed bound – refusing physio most days

• Weight well down but still 121kg/BMI 38kg/m2

• Clinical psychology referral

EARLY THOUGHTS ON DISCHARGE PLANNING…….

A. Nursing Home

B. Stay in hospital until restoration, hopefully no need for HPN

C. Can go home and do PN himself

D. Can go home with nursing provision of PN

E. Refer for intestinal transplant

STOMA OUTPUT

• Pretty good about 2l when manages oral restriction

• Seen to be binging on sweets/drinks intermittently

• Modest effect of loperamide melts 16mg QDS

• Codeine 60mg QDS

• Stoma dilatation every day and stoma catheter removed

WEEK 5

• Severe hip pain, increased stoma OP

• Refusing to move at all

• In tears frequently

• CRP up to 80, LFT’s deteriorating (cholestatic)

• Low grade pyrexia 37.8 0C

• New early pressure sore left buttock – refusing to move to pressure mattress

LOW GRADE FEVER, RISING CRP, DERANGED LFT’S, HIP PAIN

A. Blood cultures and echocardiograph

B. Isotope bone scan and CT

C. CT Abdomen and Pelvis

D. Blood cultures and isotope bone scan

E. Blood Cultures, abdominal CT and MRI Hip/pelvis

BACTERAEMIA

• Enterobacter faecalis and Staph epidermidis

• PICC removed

• Vancomycin, amoxicillin (high dose) x 10 days

• Full sepsis screen including Hip

• CT collections all resolved

• Repeat cultures –ve

• Repeat ECHO – thrombus smaller

‘SNAP’

CHRISTMAS……..

• MRI severe OA, AVN no osteomyelitis

• Rheumatology – bilateral shoulder capsulitis, not willing to inject• Physio focusing on shoulders x 2-3 weeks

• Clinical psychology • Fear of pain

• Now agreeable to trial of antidepressant

• Mirtazepine started

• Acute pain team referral

ANALGESIA IN SHORT BOWEL

• Fentanyl patches

• IV paracetamol?

• Pregabalin (higher doses)

• Rectal NSAID

• Physio

• Psychology/motivation

PROBLEMS ON THE HORIZON

• Intra-abdominal sepsis

• Left ventricular thrombus/other

• Mobility• Hip

• Shoulder pain

• Depression

• Obesity

WEIGHT MANAGEMENT

• Options• Planned 1-2kg weight loss every 2 weeks

• Stoma output averaging 3000mls/day

• No physical activity!

• Standard bags, average 3000ml stoma OP/24hrs

• Challenging to reduce calories/maintain hydration with ‘off-the-shelf’ bags

‘SNAP’

Date Weight BMI Volume kCals Protein Na2.11.17 136 44 2500 2300 104 7016.11.17 120.6 38 4100 2384 96 4002.1.18 113 35 4100 2384 96 40017.1.18 114 35 4100 1984 96 4005.3.18 110.7 4100 1584 96 40023.3.18 108.4 4100 1284 96 4005.4.18 106 33 4100 1284 96 40015.4.18 106.4 33 4100 1284 96 40027.04.18 106.6 33 4100 882 96 4004.5.18 106.6 33 4000 900 88 400

NEW YEAR

• Better form!

• Pain improving

• Starting to see a future!

• Willing to see physio/OT again

• Weight 113kg BMI 35.6kg/m2

NEW YEAR

• Better form!

• Pain improving

• Starting to see a future!

• Willing to see physio/OT again

• Weight 113kg BMI 35.6kg/m2

Stoma OP 5500mls!

NEW YEAR, WEEKS 8-10

• Better form!

• Pain improving

• Starting to see a future!

• Willing to see physio/OT again

• Weight 113kg BMI 36.9kg/m2

Stoma OP 5500mls!

‘SNAP’

WEEK 12

• Wants to go home

• Unable to stand for long or independently

• Mobilising with zimmer for short distances (with assistance of 2)

• Agreeable to see othopaedic team for discussion

• Stoma OP about 4-5l/day• Clinical psychology helping understand fluid balance and coping

• Allowing home for breaks at weekends

• Often ‘dry’ on Mondays

WEIGHT MANAGEMENT

• On site compounding

• Increasing oral intake and stoma OP, needs more fluid

• Unable to reduce calories• Alternate fluids and PN

• 4500mls

LONGER TERM-CURRENT OPTIONS?

• 20cm (estimated, bad stoma), half colon, poor complianceA. No surgery, accept situation

B. Restoration of continuity with colostomy

C. Restoration of continuity without colostomy

D. Intestinal Transplant

E. Bowel lengthening surgery – STEPS/BIANCHI

‘SNAP’

MDM WITH COMMUNITY TEAMS

• Will need large package of support

• DN team may not be able to visit twice a day - ??once only

• Repeated ward NNS assessment – not suitable for training

• Await orthopaedic opinion

WEEKS 15-25

• Orthopaedic team • Needs Hip replacement (refused)

• Steroid injection arranged

• Major difficulties with housing and District Nursing arrangements

• Not willing to engage in any treatments to improve situation:• No to continuity surgery

• No to hip replacement

• “I just want home now”

WEEK 36 (!!) DISCHARGE

• Community staffing reduced over summer – further delays

• Discharged to own house

• DN team twice daily

• Package of care

• Community rehab

WEEK 36 (!!) DISCHARGE

• Community staffing reduced over summer – further delays

• Discharged to own house

• DN team twice daily

• Package of care

• Community rehab

Weight (kg) BMI Volume Kcals Protein Na Kcal reqs12.11.17 rep 140 44 2500 2300 104 7016.11.17 120.6 38 4100 2384 96 400 23002.1.18 113 35 4100 2384 96 40017.1.18 114 35 4100 1984 96 400 21005.3.18 110.7 4100 1584 96 400 210023.3.18 108.4 4100 1284 96 400 21005.4.18 106 33 4100 1284 96 40015.4.18 106.4 33 4100 1284 96 40027.04.18 106.6 33 4100 882 96 4004.5.18 106.6 33 4000 900 88 400 210020.5.18 101 3224.5.18 100.620.6.18 98.227.6.18 995.7.18 97.4 4500 300/d 12.5/d 400 Needs more

volume –PN bags too dilute with low kcalories.

Switch to alternate fluids

and pn

15.7.18 96.8 31.525.7.18 93.41.8.18 93.8

Weight on discharge

91.2

10.10.18 85.3 26.9 4500 339 12.5 400 Increased kcal by 200

17.10.18 81.9 25.8 4500 410 22 400

RECENT REVIEW

• BMI 25.8 (grip strength improving, never felt better!!)

• Independently mobile, unaided

• Ongoing hip pain

• Severe aversion to admission• Will be a problem!!

• NO to THR or restoration of continuity

SUMMARY

• Typical early admission• Sepsis

• Anticoagulation

• Pain/antidepressants

• Psychology vital

• Increasingly dependent population – prolonged bed-days• Social input

• Full nursing support for PN