Osf Healthcare

Case Study
Patient with Acute Pancreatitis,

Amputation Wound, and High INR
Date Presented:
February 29th, 2024
Assessment
Medical History
12/2/23
Patient experienced arterial thromboembolism and ischemia in the
right leg; requiring:
foot amputation through the metatarsal and fasciotomy
prescription of Warfarin/coumadin
2/18/23
Patient presented to ER with abdominal pain and discomfort
2/19/23
Patient admitted to Sacred Heart with acute pancreatitis, and NRS
placed for large nonhealing wound, burn, or pressure injury
Primary Acute Pancreatitis
problem Inflammation of the pancreas
Normally, acinar cells of pancreas release zymogens (inactivated digestive

enzymes) into ducts that for transportation to the duodenum
With pancreatitis, zymogens get activated within the

pancreas- causing autodigestion
Caused by:
obstruction of pancreatic ducts
damage to acinar cells
Gallstones (most common) Viral infections Hypercalcemia Trauma

Ethanol (2nd most common) Drugs Anatomical variats Tumor
Hypertriglyceranemia Smoking Scorpion bites
Symptoms
Epigastric or diffuse abdominal pain (80–95%)
nausea and vomiting (40–80%) (1)
abdominal distension ileus tachypnoea
fever oliguria tachycardia
breathlessness impaired consciousness hypotension
irritability low oxygen saturation abdominal guarding
Diagnosis
requires 2 of 3 criteria
abdominal pain consistent with pancreatitis
a serum amylase or lipase >3x the upper limit of normal
findings consistent with pancreatitis on CT or MRI

Acute pancreatitis can range in severity
Potential complications
pancreatic necrosis Osteoporosis

organ failure Malnutrition
post pancreatic diabetes mellitis Chronic pancreatitis
Medical Management of Acute Pancreatitis
NPO
IV fluids
analgesics
H2-receptor antagonists, somatostain
Nutritional Management of
Acute Pancreatitis
Per ESEN recommendations (2):
Patients with pancreatitis should be considered at moderate-high nutrition risk
due to catabolic nature of disease and impact of nutrition on disease
progression
Oral nutrition should be initiated as soon as clinically tolerated

recommended to start with soft, easy to digest foods if possible
Enteral or Parenteral nutrition should be considered for
Pancreatic enzymes should not be supplemented generally except in patients with

obvious pancreatic exocrine insufficiency (PEI).
Past Medical History
Hypertension Foot Amputation through Metatarsal

Polysubstance abuse disorder Acute lower limb ischemia (right leg)
arterial thromboembolism Suspected duodenal ulcer
Cocaine abuse Iron deficiency anemia
Atherosclerotic Heart Disease Acute GI bleeding
Osteoarthritis of hip Erthrocytosis
Supracentricular tachycardia Fascioctomy
200.0
Weight history
Height: 5' 10'’
150.0
Current weight: 138 lbs

BMI: 19.8 kg/m^2* Amputation
Surgery
100.0
Per Patient
UBW ~155 lbs before
amputation surgery 50.0
Lost weight following surgery
increased from 127-141
0.0
*BMI adjusted by 0.7% for foot amputation 5/4 5/9 6/29 11/13 11/19 12/2 12/18 12/24 1/4 1/16 1/25 2/18
Diet History
Clear Full
NPO
Liquid Liquid
Day 1 Day 2
Intake following admission
Per CBORD, 1 very small
full liquid meal ordered
Per EMR, no documented PO Per Patient, had eaten 100%

intake of meal
Per Patient
Appetite was decreased with onset of symptoms PTA.
Appetite has been increasing while in hospital
Has had Ensure supplements while last hospitalized for foot

amputation, but has not drank any since being discharged
Suspected intake less than 50% over
past 5 days d/t:
NPO/CL 3x
1 small meal over past 3 days per CBORD
decreased appetite per patient
Nutrition Impact Symptoms
Chewing/
Pain affecting Swallowing Food Allergies
PO Intakes
Per EMR, teeth None per EMR
None per EMR Absent with no
dental appliances
present
Per Patient:
Some diarrhea PTA
Per EMR:
GI Abdominal pain/discomfort
symptoms Abdominal distention
Intermittent nausea
vomiting
Last BM 2/17
Per EMR, no PI present
Skin Surgical wound from amputation

was well healed except for
scabbed area in center of
incision per wound RN
Medications
Sodium chloride
Aspirin
Carvedilol
Ferrous sulfate
Hydromorphone
Pantoprazole
sucralflate
Wafarin
Labs
Sodium 135 (L) eGFR above 60

Potassium 3.6 BUN/Creatinine ratio 11 (L)
Chloride 108 (H) INR 3.9 (H)
BUN 8 Hemoglobin 17.3 (H)
Creatinine 0.72 Hematocrit 53.7 (H)
Estimated Nutrition Needs
(based on 62.6 kg)
Calorie goal: 1565-2191 kcal (25-35 kcal/kg)

Protein: 75-94 grams (1.2-1.5 grams/kg)
Fluids: 1565-2191 ml (1 ml/kcal)
Diagnosis
A.S.P.E.N Criteria
Clinical Assessment Criteria/Location
Suspected intake less than 50% needs

Energy Intake Inadequate
over past 5 days
Weight Loss None Noted None per EMR
Subcutaneous Fat Loss Mild Buccal, Orbital
Muscle Loss Mild Temporal, Calf Region
Fluid Accumulation None Noted None per EMR

These characteristics are not indicative of
moderate/severe malnutrition. However, at risk
pending trend of mild characteristics
Per patient, appetite was increasing

Previously gaining weight
during hospital stay
NFPE findings done visually

Nutrition Diagnosis
Inadequate oral intake related to decreased ability to
obtain nutrient needs as evidenced by NPO/CLx3, 1 small
meal over past 3 days per CBORD, and decreased appetite
PTA per patient
Increased protein and calorie needs related to increased

demand for protein/calories as evidenced by partial right
foot amputation and fasciotomy 12/3 an dcurrent medical
diagnosis of acute pancreatitis
Intervention
Nutrition Prescription
Continue full liquid diet;

Add Ensure Plus High Protein TID
(1050 kcal, 60g protein)
1. RD to order Ensure plus HP TID
2. Recommend MVI to MD
3. Request RN place referral for SLP
Interventions 4. Provided nutrition education on
increased protein/calorie needs;
nutrition for pancreatitis; warfarin
and vitamin K foods
4. Nutrition Education
Provided
01 02 03
Increased Pancreatitis Vitamin K and
Nutrition Needs Nutrition Warfarin
01 Increased Nutrient Needs
Educated on increased protein and calorie needs for
helping recover from surgery and pancreatitis
Discussed some food options high in protein on full

liquid diet and encouraged drinking supplements
Handouts provided: “High-Calorie, High-Protein

Nutrition Therapy”
02 Pancreatitis Nutrition
Educated on basic principals of nutrition for
pancreatitis
Discussed trying smaller, more frequent meals and

trying lower fat diet if experiencing any
symptoms/pain following meals
Handouts provided: “Pancreatitis Nutrition

Therapy”, “Pancreatitis Label Reading Tips”
03 Vitamin K and Wafarin
Educated on interaction between vitamin K and
Warfarin medications
Identified different foods high in vitamin K
Handouts provided: “Vitamin K and

Medications”, “Vitamin K Content of Foods”
Goals
01
Patient to consume 75% of supplement through next
follow up date
02
Patient to consume 75% of 3 meals daily through next
follow up date
Monitoring and Evaluation
PO intake GI symptoms
Weight Medical plan
of care
Labs
High Nutrition Risk Level

RD to follow up in 2-4 days (F 2/22-2/24)
References
1. Szatmary P, Grammatikopoulos T, Cai W, et al. Acute pancreatitis: Diagnosis and
treatment. Drugs. 2022;82(12):1251-1276. doi:10.1007/s40265-022-01766-4
2. Arvanitakis M, Ockenga J, Bezmarevic M, et al. Espen guideline on clinical
nutrition in acute and chronic pancreatitis. Clinical Nutrition. 2020;39(3):612-631.
doi:10.1016/j.clnu.2020.01.004
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Case Study

Patient with Acute Pancreatitis,

Normally, acinar cells of pancreas release zymogens (inactivated digestive

With pancreatitis, zymogens get activated within the

Gallstones (most common) Viral infections Hypercalcemia Trauma

abdominal pain consistent with pancreatitis

a serum amylase or lipase >3x the upper limit of normal

findings consistent with pancreatitis on CT or MRI

pancreatic necrosis Osteoporosis

Medical Management of Acute Pancreatitis

Oral nutrition should be initiated as soon as clinically tolerated

Enteral or Parenteral nutrition should be considered for

Pancreatic enzymes should not be supplemented generally except in patients with

Hypertension Foot Amputation through Metatarsal

Current weight: 138 lbs

Per EMR, no documented PO Per Patient, had eaten 100%

Appetite has been increasing while in hospital

Has had Ensure supplements while last hospitalized for foot

Skin Surgical wound from amputation

Sodium 135 (L) eGFR above 60

Calorie goal: 1565-2191 kcal (25-35 kcal/kg)

Suspected intake less than 50% needs

Weight Loss None Noted None per EMR

Subcutaneous Fat Loss Mild Buccal, Orbital

Muscle Loss Mild Temporal, Calf Region

Fluid Accumulation None Noted None per EMR

Per patient, appetite was increasing

NFPE findings done visually

Increased protein and calorie needs related to increased

Continue full liquid diet;

Discussed some food options high in protein on full

Handouts provided: “High-Calorie, High-Protein

Discussed trying smaller, more frequent meals and

Handouts provided: “Pancreatitis Nutrition

Identified different foods high in vitamin K

Handouts provided: “Vitamin K and

High Nutrition Risk Level

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