Memorial Case Study

Lauren Chan
Illinois State University
Fall 2017
Patient SM
• Admitted: 11/30/17
• Age/Gender: 42 YO F
• Height: 5’5”
• Weight: 67.1 kg (~148 lbs)
• BMI: 24.6
• Family: Mother & Father
• Attending Physician: Trauma Team (Choudry, Whitehurst)
• Unit: 2C, Surgical ICU
Brief Medical History
• Morbid Obesity
• Hypertension
• Type 2 Diabetes
• NSTEMI
• Laparoscopic Cholecystectomy
GI Surgical Hx
Petersen’s
Roux-En- Current
Defect &
Y Admission
Hernias
May 2016 Jan 2017 Nov/Dec
April 2017 2017
Nov 2017
Roux-En-Y Gastric Bypass
Marginal Ulcer

Gastrojejunal
Anastomosis
Internal Hernia
Repairs

Area of Petersen’s Defect

Internal Hernia
Current Admission
November 30, 2017 - Present
Prior to
Surgery pouch

remnant
Roux Limb

BP Limb
Surgical Plan
1. Suction & flush out abdominal cavity
2. Suction out content from BP limb and remnant
stomach
3. Resect necrotic remnant stomach
4. Resect necrotic jejunum and revise Roux-En-Y
5. Place G-tube in remnant stomach
Following
Surgery
G-Tube
Pouch

Roux
Limb w/
Revision
Remnant

Decompressed
BP Limb
 11/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/ 12/
30 1 2 3 4 5 6 7 8 9 10 11 12 13
Levo > 5
mcg/min

TPN

TF

Refeeding
Risk

Thiamine

Other
Supplements

Bowel
Regimen
• General Disposition: 11/30
 Surgical ICU LOS 1
 Ventilator Dependent
 Hypotensive Risk
 Hypoglycemic Risk
 Septic
 Bowel Function
 Wound VAC & JP Drains
 Fluid Overloaded & Diuresing
• Nutrition Concerns:
12/4
LOS 5
 NPO x at least 5 days
 Levo > 5 mcg/min
 Fluid Overload

• Nutrition intervention:
 Initiate TPN 1L
 TPN + IV Fluids = 100 mL/hr
 Thiamine Supplementation
• Nutrition Concerns:
12/6
LOS 7
 TPN below needs
 Refeeding Risk
 No BM since PTA
 Wound VAC & Pressure Ulcer

• Nutrition intervention:
 Continue TPN 1L
 Initiate trickle TF
 Start Vitamin Supplementation
• Nutrition Concerns:
12/10
LOS 11
 TF leaking into abdomen

 Potentially dislodged G-tube

• Nutrition intervention:
 Continue TPN 1L

 Hold TF
• Nutrition Concerns:
12/11
LOS 12
 GI status

 Altered lab values

 Significant wt gain

• Nutrition intervention:
 Hold TF

 Provide Custom TPN

• Nutrition Concerns:
12/12
LOS 13
 GI Status

 Extensive draining (JPs, chest tube)

• Nutrition intervention:
 Hold TF

 Restart on TPN 1.5 L

• Nutrition Concerns:
12/13
LOS 14
 GI Status

 Increased Nutrition Needs

 Vitamin Needs

• Nutrition intervention:
 Hold TF

 TPN 2 L
Current Nutrition Diagnoses
• Altered GI function related to closed loop obstruction of
biliopancreatic limb, leading to necrosis and perforation of the
proximal remnant stomach and hx of gastric bypass, as
evidenced by MD report, NPO diet order, TPN started 12/4
and TF started 12/6 (currently held)
• Inadequate energy intake related to NPO diet order and GI
status as evidenced by NPO status, pt intubated on vent, TPN
started 12/4, and TF started 12/6 (currently held)
• Increased nutrient needs related to increased needs for
healing post surgery and abdominal wounds, as evidenced by
post surgery healing, abdominal wound w/ VAC dressing
(currently off), deep tissue injury on coccyx, and sepsis
Plans for Continued Care
• TPN as long as necessary
• Reintroduce TF (hold until confirmed GI system)
• Moving off respiratory support, extubate or trach
• Contrast out of system, retest patent of bowel and G-
tube, r/o fistula or bowel obstruction
• Restarting vitamins
What Did I Learn?
• Anatomy of Roux-En-Y

• Advocating for the patient

• Some things look better on paper than they are

in real life
Questions?
Sources
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199621/

• https://radiopaedia.org/articles/petersen-hernia-1

• https://radiopaedia.org/articles/internal-hernia

• https://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/roux-en-y_gastric_bypass_weight-
loss_surgery_135,65

• http://bariatrictimes.com/marginal-ulcers-after-roux-en-y-gastric-bypass-pain-for-the-patient%E2%80%A6pain-for-the-
surgeon/

• https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers
Thank you!