MMC Mini Case

Study

Ashley Edwards
 Outline

Medical Medical
Assessment PMH Diagnose Nutrition Prognosis
s Therapy
Assessment

99% IBW
59 YO Male 129lbs / 58.6kg
BMI 22.0

Date
Unit: 2C Surgical
64 inches Admitted:12/4/19
ICU
HYPERTENSION

CONSTIPATION

HYPERCHOLESTEROLEMIA
Past
Medical
FORMER DRINKER: 6-8 BEERS/DAY History

SMOKER: 1 PPD X 40 YEARS

 Admitted 12/4

• Diagnosed with SCC of the tongue on

10/9/19
• Removal of Cancer on R side of tongue
Medical:
Admission/ • R hemiglossectomy with tracheostomy
Diagnosis •
•
Bilateral neck dissection & reconstruction
Admit to ICU
• Keofed placed for meds, TF to start POD2

Nutrition:

• NPO - trach
• Pt cleared to start TF POD2
 Oral Cancer

Risks:

• Alcohol Intake may increase risk of oral

cancers six-fold
• Smoking, tobacco use
• When combined, the risk of oral cancer
increases 15 times
• Human papillomavirus (HPV)

https://oralcancerfoundation.org/understanding/tobacco/
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology and
Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
 Oral Cancer
Complications

• Dysphagia and xerostomia
• Symptoms related to the tumor
• Mechanical obstruction, dysphagia, odynophagia, & anorexia
• Tumor-specific therapy
• N/V/D
• Changes in the taste
• Extraction of unhealthy teeth before radiotherapy
• Opioid-induced GI dysfunction
• Surgery:
• Remove tissues, lymph nodes in neck often also removed

https://oralcancerfoundation.org/understanding/tobacco/
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology and
Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
 Dry Mouth (Xerostomia)/Sore
Throat/Mouth
• Increase fluids
• Moist, soft foods, lukewarm foods with gravies
Head and Taste Changes
Neck • Plastic utensils
• Use seasonings
Cancer
Poor Appetite & N/V
MNT • Eat small meals or snacks every 1-2 hrs
• Avoid liquids with meals
• Eat dry foods (crackers/toast)
• High calorie, high protein snacks on hand
  Associated with poor prognoses
 WL important predictor of mortality
 Especially prevalent in GI cancers
MALNUTRITIO  affects >80% of cancer patients with
N IN CANCER upper GI cancers
 50-70% experience significant WL before
PATIENTS prognosis
 20-40% of cancer patients die from the
effects of malnutrition and its complication,
rather than from the cancer itself

Hark, L., Deen, D., & Morrison, G. (2014). Medical nutrition & disease: A case-based approach (5th ed.). Chichester, West Sussex, UK: Wiley Blackwell.
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of
Practical Oncology and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
 Cancer Cachexia
Pre-Cachexia
• Early metabolic signs such as
• loss of appetite
• impaired glucose
intolerance
• involuntary weight loss
of 5%
• Dependent on:
• Type
• Stage
• Inflammation
• Response to therapy
Refractory
Cachexia Cachexia
• Ongoing loss of skeletal • Advanced cancer or pre-
muscle mass (with or w/o terminal
loss of fat mass
• Rapidly progressive
• Cannot be fully reversed
cancer
through conventional
nutrition support • Presence of factors
• 50% experience sarcopenia making management no
longer possible or
• Characterized by:
appropriate
• Weight loss > 5% OR
• Life expectancy of less
• BMI < 20 w/ WL >2% than 3 months
OR
• Sarcopenia & WL >2%
Initial Nutrition Assessment: 12/5
Info From Patient and Wife
RD consult for TF Recs
• Pt difficulty eating and High Nutrition
• <50% usual intake >/= 1 month Risk Screening
• WL: 6.8 kg (10%) in 3 months
• Severe Chronic Malnutrition Dx

Labs: Reminder:
• Glucose High (159) • Admit Weight: 58.6
• Phos Low (2.1) • 99% IBW
• BMI = 22.0
Additional Info
• Pt had dental extraction as advised before starting
radiation
• Keofed Nasogastric tube for meds only
Initial Assessment MNT: Thursday 12/5
Est. Nutritional Needs:
• 1760 – 2005 kcal (30-35 kcal/kg for Cancer/Wt Gain)
• 73 – 88 gm PRO (1.25-1.5 gm/kg IBW)

Tube Feed Recommendations

•Jevity 1.5 @ 60 mL x 21 hrs. Reminder:
•Provides 1260 mL, 1890 kcal, 80 gm PRO, and 958 mL free water. • Admit Weight:
•Add 1 pkt Beneprotein/day with 60 mL water and 150 mL flush Q4h 58.6
•TF + BP to provide 1915 kcals, 86 gm PRO, and 1918 mL Free water.• 99% IBW
• BMI = 22.0
Pt at Refeeding Risk
• Recommended starting TF @ 20 mL/hr., increase 10 mL Q12hr
• Recommend Thiamine 300 mg x 3 days

Nutrition Plan:
• Continue current nutrition plan
Medications
Cardiovascular Meds
• Amlodipine- HTN
• Ramipril (Altase) – HTN
• Heparin – Blood thinner
• Simvastatin – cholesterol

Surgery
• Propofol
• Phenylephrine – vasopressor
• Hydrocodone
• Hydromorphine
• Fentanyl
• Rocuronium – Muscle relaxant
• Sugammadex – reversal of neuromuscular blockage induced by rocuronium
• Decadron – Steroid/anti-inflammatory

Replete
• Thiamine
• Magnesium sulfate
• MVI with Minerals
 Assessment

• TF to start today
• Lactated ringers and potassium phosphate
infusing during visit.
• Pt down 1.5 kg since admission, but
experiencing negative fluid balance
• Pt received Mg Sulfate 12/5

Follow-up Labs

Friday 12/6 • ↓ Mg @ 1.5 mg/dL

• ↓ Ca, but Correct Ca WNL
• K & P WNL

MNT

• Thiamine started 12/5 @ 100mg

• New: Tolerate TF and increase to goal rate
 Follow-Up: Monday 12/9
Assessment
TF Provides
• Pt started Bolus feeds of Jevity 1.5 over the weekend • 1890 kcal
• Rate - 315 mL QID • 80 PRO,
• 958 mL
Information from Patient • Meets 100% Pt est.
• States tolerating feeds, no N/V or discomfort needs
• No BM, passing flatus burping, on MiraLAX

Positives
• Lytes WNL Weight Hx:
• Weight stable - Admit Weight: 58.6 kg
- Current weight: 59.5 KG
MNT:
• Continue to monitor TF tolerance • Watch Lytes
• Monitor BM, GI function • F/U Thursday
Prognosis

 Medical
 Anticipated D/C 12/12 – 12/14
 D/C home with Home Health & DME
 Radiation?

 Nutrition
 SLP to evaluate today
 G-tube placement TBD
 Gastrographic esophagram today
 Conclusion:
EAL: • 7 studies with 1.2 – 2.2 g EPA per day resulted in
improvement or preservation of LBM
• 2 studies showed same effect, but not sat. sig.
Medical food
• More research needed to determine optimal dose
supplements
(MFS)
containing fish Grade: I
oil on lean body
mass (LBM) in • Grade I means there is Good/Strong evidence
supporting the statement
adult oncology
patients
Additional studies agree: See handout
  Tried to figure out what is happening long
What I would term with TF

have done 


Can do at F/U on Thursday
Will he eat orally soon?
differently
QUESTIONS?
References

 https://oralcancerfoundation.org/understanding/tobacco/
 Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with
head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology
and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
 Hark, L., Deen, D., & Morrison, G. (2014). Medical nutrition & disease: A case-based approach (5th ed.).
Chichester, West Sussex, UK: Wiley Blackwell.
 Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with
head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology
and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
 Head and neck cancer nutrition therapy. Nutrition Care Manual.
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=135