cancer w/ emphasis on home tube feeding
DESCRIPTION
CANCER W/ EMPHASIS ON HOME tube feeding. PRESENTED BY Megan Fuetterer. INTRODUCTION. 70 Year-old female Dx : Esophageal Carcinoma (February 2013) Reason for TF: Not keeping food/liquid down Weight loss of 11% in 1 month PMHx : Brain mets with resection (March 2012) - PowerPoint PPT PresentationTRANSCRIPT
P R E S E N T E D BY M E G A N F U E TT E R E R
CANCER W/ EMPHASIS ON HOME TUBE FEEDING
INTRODUCTION
• 70 Year-old female• Dx: Esophageal Carcinoma (February 2013)• Reason for TF: Not keeping food/liquid down
Weight loss of 11% in 1 month• PMHx: Brain mets with resection (March 2012)
Metastatic lung cancer (March 2012)• Reason for admit: Difficulty “finding words” & confusion
• Issues: Malnutrition Refeeding Home enteral care
ASSESSMENT• Anthropometrics• Height: 66”• Weight: 33.2 kg (73 lbs)• BMI: 11.8 kg/m2
• Diet History• Eating well after brain resection • Intake decreased after esophageal tumor found• Ensure 1/day, minimal intake since Oct 2012
• Social History: Smoker x 40 years (15 cigarettes/day)• Meds: Decadron (4mg) - can increase appetite & weight• No labs before TF initiation
WEIGHT DECLINE OVER PAST YEAR
3/22/1
24/6
/12
4/21/1
25/6
/12
5/21/1
26/5
/12
6/20/1
27/5
/12
7/20/1
28/4
/12
8/19/1
29/3
/12
9/18/1
2
10/3/
12
10/18
/12
11/2/
12
11/17
/12
12/2/
12
12/17
/121/1
/13
1/16/1
3
1/31/1
3
2/15/1
33/2
/1330
32
34
36
38
40
42
44
46
48
50
WEIGHT (kg)
Date
Wei
ght
(kg)
NUTRITIONAL NEEDS
• PES: Inadequate oral intake related to swallowing difficulty as evidenced by esophageal mass, low tolerance to liquid diet, and continued weight loss over the past year (BMI 11.8 kg/m2).
• Kcal Needs: 35 – 40 kcals/kg to promote wt gain• 1160 – 1327 kcals/day
• Protein Needs: 1.5 – 2 grams protein/kg• 50 – 66 grams/day
• Fluid Needs: 1 ml/kcal fluid/day• 1160 – 1327 ml/day
PHYSICAL EXAM
• SEVERLY MALNOURISHED• Triceps/Biceps: no fat between fingers• Under eye: hollow with loose skin• Temple: depressed• Interosseous muscle: very depressed• Knee: bones very prominent• Nails: contain black pigment• Edema in feet• Skin: Dry and flaky, no turgor
PHYSICAL EXAM
PHYSICAL EXAM
PHYSICAL EXAM
PHYSICAL EXAM
A.S.P.E.N. MALNUTRITION CRITERIA
• In the context of chronic illness:• Insufficient energy intake• < 75% of estimated energy intake for ≥ 1 month
• Weight loss• >5% in 1 month • >7.5% in 3 months• >10% in 6 months• 20% in 1 yr
• Severe depletion of subcutaneous fat • Severe depletion of muscle mass • Severe fluid accumulation• Measurably reduced grip strength
ESOPHAGEAL CANCER
• Estimated Incidence (U.S. 2013)• New cases: 17,990• Deaths: 15,210
• Two Types• Adenocarcinoma• Squamous cell carcinoma
• Medical Treatment• Surgery• Radiation• Chemotherapy• Targeted therapy
NUTRITIONAL MANAGEMENT
• Difficulty swallowing impacts nourishment• Six small meals/day• Choose soft foods• Nutritional supplements• Cut food into small bites• Moisten foods with sauces• Sit upright when eating
• Stent placement• Enteral or parenteral nutrition• PEG tubes placed with 95 – 98% of H&N cancer patients• 80% of patients reported improved quality of life on EN
REFEEDING SYNDROME
• Potentially fatal shifts in fluids & electrolytes
• Hallmark sign is hypophosphataemia
• Glycaemia leads to increased insulin• Stimulates glycogen, fat, & protein synthesis• Process requires Phos & Mg• Insulin stimulates absorption of K into cells • Glucose, Phos, & Mg are also taken up into cells
CRITERIA FOR REFEEDING RISK
• One or more: • BMI <16• Weight loss >15% in 3-6 months• No intake >10 days • Low levels of K, Phos, or Mg before feeding
• Two or more:• BMI <18.5• Weight loss >10% in 3-6 months• No intake >5 days• History of alcohol/drug use including chemo, insulin,
antacids, & diuretics
INTERVENTION
• Home enteral feeding pump through PEG• Nutren 1.0 with Fiber (5 cans/day)• Stomach and intestines intact• No signs of malabsorption• 1.0 formula sufficient to meet needs• Specialized formulas are harder to get covered with insurance
• 1250 ml/day to provide:• 1250 kcals, 50 grams protein, & 1050 ml useable fluid• 39 kcal/kg, 1.7 gm protein/kg, & 54 ml fluid/kg• Meets 100% of kcal and protein needs
• Boost Plus as tolerated• Currently keeping down ~25% of 1/day (30 kcals, 5 gm
pro)
INTERVENTION
• Tube Feeding Administration• Initiate at 15 ml/hr x 24 hours for pt with high
refeeding risk• Advance by 15 ml/hr q 24 hours until goal rate achieved• Took 10 days to reach goal (reached on 3/25)
• Goal rate = 80 ml/hr x 16 hours• 60 ml flushes q 6 hours• Monitor electrolytes, especially K, Phos, & Mg for
refeeding
INSURANCE COVERAGE
• ICD-9 Codes• Used to classify diagnoses • Certain codes warrant Medicare coverage of EN• 230.1 esophageal CA
• Additional documentation required for pump• Reflux or aspiration, severe diarrhea, dumping syndrome,
administration < 100 ml/hr, blood glucose fluctuations, circulatory overload, J-tube used for feeding
• Specialty Formulas/Additives • Standard formulas are B4150 or B4152• Others require documentation of medical necessity
LAB VALUES AFTER TF INITIATION
Date Lab Value Reference Range
3/18/13 K 3.9 3.5 - 5.1 mmol/L
Glucose 111 74 - 106 mg/dL
PO4 2.8 2.5 - 4.9 mg/dL
Magnesium 1.8 1.8 - 2.4 mg/dL
FOLLOW UP PLAN
• Once tolerating goal rate & stable, monthly FU• Monitor weight and labs• electrolytes (Na, K, Cl, CO2), BMP, protein status, CRP
• Progression of oral food/beverage intake • Assess need for continued nutrition support• Review of home environment• Currently living at home with husband• Conducive to home enteral administration
• Address feeding administration/trouble shooting questions
• Home health RN following 2-3x per week• DTR checks in also
AT HOME ENTERAL MANAGEMENT
• Stoma Site Complications• Bacterial Infection• Yeast Infection• Pressure Necrosis• Skin Breakdown• Hypergranulation• Allergic Reaction
• Feeding Tube Complications• Occlusion• Migration• Tube Dislodgement• Balloon Burst/Leak
OUTCOMES
• Palliative Radiation• Decrease pain• Increase quality of life• Increase swallowing ability
• Enteral Feeding• Weight gain (pt reached 80 lbs)• Improve strength• Increase quality of life
• Re-hospitalization w/ delirium on 3/31 • Brain mets causing confusion• Spent 1 week in hospital and passed away on 4/6
REFERENCES• National Cancer Institute at the National Institutes of Health. Esophageal Cancer.
http://www.cancer.gov/cancertopics/types/esophageal.• White JV, et al. Consensus Statement of the Academy of Nutrition and Dietetics/American
Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012 May;112(5):730-8.
• Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, an how to prevent and treat it. BMJ. 2008 June 28; 336(7659): 1495–1498.
• Akbulut G. New perspective for nutritional support of cancer patients: enteral/parenteral nutrition. Exp Ther Med. 2011 Jul-Aug; 2(4): 675–684.
• Kimberly-Clark Worldwide, Inc. Enteral Feeding: Stoma Site and Enteral Feeding Tube Troubleshooting Guide. Roswell, GA 2005.
• Raykher A, et al. Enteral nutrition support of head and neck cancer patients. Nutr Clin Pract. 2007;22:68-73.
• A.S.P.E.N. Board of Directors. Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579-590.
• A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr OnlineFirst. 2009:1-19.
• Nourish Nutrition Support Program. Medicare Guidelines: Medicare Part B. Apria Healthcare, Inc., 2011.