Nate Medunick
 91
YO female
 Dry weight – 121# (55kg)
 Height- 66”
 BMI-19.5
Admission diagnosis: POD#3Hiatal hernia
repair, Nissen fundoplication and wedge
resection (SLH), followed by a MI with a stent
placed. Barium swallow showed a small
perforation at the distal esophagus.
 Based
on actual weight in recent PMH (54kg)
 Kcals 1350-1620 (25-30kcals/kg)
 Protein – 70-81g (1.3-1.5g/kg)
 Fluid 1620ml (30ml/kg)
 High Nutritional risk
A
surgeon wraps the part of the stomach
known as the gastric fundus around the lower
esophagus (including the LES) in a Nissen
fundoplication. This helps to strengthen the
barrier and prevent the back flow of acids
into the esophagus
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Patients must make dietary and lifestyle adjustments for about six weeks following Nissen
fundoplication surgery. Three days following surgery, most patients are on a clear liquid diet,
which may include:
apple juice
beef broth
chicken broth
cranberry juice
decaffeinated tea
grape juice
Jell-O
After the clear liquid diet, most patients are put on a full liquid diet for an additional three days.
This diet consists of anything on the clear liquid diet plus the following:
Carnation instant breakfast (not chocolate)
creamed soups (strained, no broccoli or tomato)
cream of wheat (or cream of rice)
ice cream (vanilla or strawberry)
milk (no chocolate milk)
sherbet
yogurt (plain, blended, or custard with fruit or seeds)
Seven days after surgery, most patients are able to tolerate a soft food diet. However, to heal
properly, patients must keep their stomach from stretching. This will require them to eat small,
frequent meals six to eight times per day
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A hiatal hernia is what doctors call it when a
part of the stomach moves up into the chest
area. Normally, the stomach sits below the
diaphragm, the layer of muscle that
separates the organs in the chest from the
organs in the belly. The esophagus, the tube
that carries food from the mouth to the
stomach, passes through a hole in the
diaphragm. In people with a hiatal hernia,
the stomach pushes up through that hole,
too.
 Burning
in the chest, known as heartburn
 Burning in the throat or an acid taste in the
throat
 Stomach or chest pain
 Trouble swallowing
 A raspy voice or a sore throat
 Unexplained cough
 91
YO female
 Dry weight – 121# (55kg)
 Height- 66”
 BMI-19.5
Admission diagnosis: POD#3Hiatal hernia
repair, Nissen fundoplication and wedge
resection (SLH), followed by a MI with a stent
placed. Barium swallow showed a small
perforation at the distal esophagus.
 TPN
initiated with Day 1 bag- 50g/AA,
100g/dextrose, and no lipids
 Recommendations
Day 2/goal- 80g/AA,
250g/dextrose, providing 1170 calories
 50
g lipids Monday and Thursday ( lipid shortage
at the time) with lipids, provides 1670 calories
 Recommendations
based on 25 kcal to
30 kcal per Kg for CCU Patient, not vented.
Patient required intubation post op day
exploratory laparotomy, drainage of mediastinal
fluid collection, and placement of gastric and
jejunal tubes
 Day 1 nutrition intervention followed initiating
RD care plan:
 50g AA, 100g dextrose, no lipids
 Day 2 Nutrition plan based on dry wt-121
 Kcals 1200-1375 (22-25kcal/kg--intubated)
 Protein- 72-83g (1.3-1.5) wound healing
 Fluid – Per Intensivist
 Needs remained constant during care
 POD
#1 S/P exploratory laparotomy, drainage
of mediastinal fluid collection, and
placement of gastric and jejunal tubes
 POD #5 hiatal hernia repair, Nissen
fundoplication
 patient continued on mechanical ventilation
without sedation, but high doses of
neosynephrine
 lab values include: WBC 17.3 trending up
(TU), total bilirubin 1.5 - TU, urine outputapproximately 10 – 33 cc/hr
(intubated) Custom TPN- 1500ml-80gm/AA,
115gm/dextrose + 90 gm dextrose from D5
containing IVF, no lipids. Total: 1017 calories
 Reviewed with Intensivist and asked if IVF would
be adjusted
 Plan moving forward: increase dextrose in TPN
because D5 1/2NS was transitioned to NS
 lipids would be added Monday and Thursday due
to national shortage
 nutritional monitoring and evaluation:
tolerance of TPN with goal of 80gm/AA,
200gm/dextrose, transition to jejunal tube
feeding when appropriate per surgery
recommendations
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PES
 P-Inadequate energy intake(improvement shownunresolved)
 E- S/P exploratory laparotomy (2/18)
 S-TPN prescribed
GI assessment
 abdomen-distended and soft
 Bowel Sounds-hypoactive
 Emesis color- tan
Skin
 2+ General edema
 wounds-six total wounds including surgical wounds,
Jackson Pratt, and G tube
fluid balance-2411.1ml
pharmacy-calcium chloride repletion
POD#2 S/P exploratory laparotomy. Diet: NPO,
TPN, and trophic feeding jevity 1 cal@ 10ml/hr
(254kcal, 11gm/protein) prescribed by Thoracic
surgeon (jevity 1 cal was MD preferred)
 labs included: phosphorus 3.0 trending down
(TD), potassium 4.1 stable, calcium 7.6 stable,
magnesium 2.0 (TD), CO2/PCO2 38 (TD)
 TPN order and discussed with Intensivist1500ml, amino acids-80gm (320kcal), dextrose140gm (476kcal), lipids-40gm (400kcal)- no MVI,
no trace elements, with trophic feeding, total
calories/protein: 1450 total kcals, 91 gm
protein
 Custom electrolytes K acetate 40mEq (potassium
stable), Na phosphate 25 mEq ( repletion), Na
acetate 22, Ca gluconate 9(stable), Mg sulfate
7(repletion)
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 the
original electrolyte plan - K acetate
40mEq , Na phosphate 25 mEq , Na acetate
22, Ca gluconate 9, Mg sulfate 7
 Plan changed following a discussion with the
Intensivist - concern was- Although; CO2 was
TD, pH-7.38 Slightly more Acetate would
possibly increase pH over 7.38
 Acetate is added to correct Acidosis;
Intensivist felt that the Patient was not
trending toward acidosis at the time
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POD#3 S/P exploratory laparotomy. Diet: NPO, TPN, and
trophic feeding jevity 1 cal @ 10ml/hr (254kcal,
11gm/protein)
patient continued on mechanical ventilation with propofol
sedation and Neo-Synephrine weaned to lower dose
IVF-NS @ 50ml/hr continued
Labs include: Ca 8.0, Cl 112, Mg 2.0, Phos 1.8, and
Potassium 3.7
nutritional intervention-TPN – 1500ml:
80gm/amino acids (320kcal),
165 gm /Dextrose (561kcal)
6 ml/hr propofol (158 calories )
trophic TF (254 calories, 11 gm protein)
D5 carriers with multiple antibiotics (127 kcal)
Total ~1420 calories, 91 gm protein
TPN electrolytes 40mEq K acetate, 15 mEq K phosphate,
25 mEq Na phosphate, 9 mEq Ca gluconate, 7 mEq Mg
sulfate. TPN discussed with Intensivist
JH was in poor condition toward the end of my
nutritional care rotation:
 Patient was requiring multiple antibiotics,
including zyvox
 LFTs/renal labs were elevating, multisytem
organ failure ensued
 I found out that JH soon expired due to poor
condition and advanced age
 I would not have changed anything with my
nutritional plan of care
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What I learned
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What I learned:
TPN and electrolyte needs
 pH and acid/base balance
 Intensivists are approachable and a great information
source
 RD’s recommendations can show direct results in lab
work
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 http://www.healthline.com/health/gerd/nis
sen-fundoplication#2
 http://www.uptodate.com/contents/hiatalhernia-thebasics?source=search_result&search=Hiatal+h
ernia&selectedTitle=2%7E75