WHIPPLE

Darlene Piper
Illinois State University Dietetic Intern
Memorial Medical Center
Patient Information
D. L. - 76 Y.O.F.
– Mother of 3 adult children
– Lives alone

Date of admission: 10/28

– Attending physician: Mellinger MD, John D.
– Unit: General Surgery

Previous Medical History

– Pancreatic Cancer
– Whipple Procedure 7/25/2018
– C. Diff
 S/p Whipple Procedure
 Readmission in Oct
Present Admission
Fatigue, weakness, fall
Diagnosis: Pt admitted d/t elevated liver function enzyme, noting PMH
■ Labs: leukocytosis, electrolyte abnormalities, and elevated liver function enzymes
■ CT scan: periportal edema
– AST, ALT, Alk Phos, T. bili
■ MD Plan: Primary concern to treat C. Diff and Failure to Thrive
Anthropometrics
– Admit wt: 67.8kg
– BMI: 24.943 - Normal
– IBW: 59kg, 115%
– Usual body wt: 77.7kg, 9.9kg wt loss x 3 months
Whipple Procedure
aka Pancreaticoduodenectomy
Initial Assessment: 10/30
■ MD consult
■ Whipple procedure handout, request to come back
– Ensure Enlive TID and calorie count initiated
– Megace started this admission
■ Labs: Sodium, Mag- low; Phos- wnl
■ Estimated needs: 1,760-2,110 kcals, 92-99 g protein
■ PES: Unintentional wt loss related to decline in appetite post Whipple procedure as
evidenced by 13% wt loss since Whipple procedure in July (3 months).
■ Monitor: Calorie count, Ensure shakes, PO intake, and wt trends
■ Goal: Increase oral intake, nutrient needs, lean body mass, stable wt., skin break
down, regular bm
10/31
Pt in pain and not interested in education
– No PO intake, TF for nutrition
Plan: TF under fluoroscopy
– Refeeding: Check mag, phos, pot daily and replenish as necessary
■ Phos and potassium started this date
– Recommend thiamine daily
TF recs: Osmolite 1.5 @ 15 mL/hr = 315 mL, 473 kcals, 20 g pro, 240 mL water
– Goal: 60 mL/hr: 1940 kcals, 91 g pro, 1080 mL water
11/1
Nasojejunal tube placed under Fluro today
– Calorie count: 10/30 130 kcals, 3 g pro, 10/31 & 11/1: N/A
Physical Assessment Completed
– Malnutrition risk: Thiamine started this date, Check fat soluble vitamins
PES Malnutrition related to inadequate oral intake post whipple as evidenced by 13% wt
loss (severe) x 3 months and less than 75% estimated energy intake for greater than 1
month.
11/2
Wt 68.7kg
TF initiated and infusing 15 mL/hr plan to advance today
Vitamin D low, replenish to start this date
Labs: glucose elevated d/t initiation of TF, sodium, potassium, magnesium low
Plan to slowly reach goal and add beneprotein Monday
11/5
TF held on 11/4 due to GRV in 100’s and pt abd pain and diarrhea
-TF at 30 mL
Positive stool cultures for campylobacter (food poisoning)
Reglan prn
Labs A and E pending
Prognosis
11/7
TF at goal 60 ml: Actual 2035 kcals, 85 g pro= 108%
Cancer has metastasized- narrowing of main portal vein, enlarging periportal lymph
nodes
MD goals of care- Palliative/hospice, chemo, stenting – pending family
Add 2 beneprotein? & Retinol returned low
Sodium continues to trend low rec to stop IVF
11/12
wt 71.4kg, 5% since admit
Family held meeting- DNR
Decided to go comfort to sustain until grandson comes home from Afghanistan
Vitamin E returned wnl
Continue to TF with beneprotein pending palliative and POC
QUESTIONS?