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CANCER W/ EMPHASIS ON HOME tube feeding

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)

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CANCER W/ EMPHASIS ON HOME tube feeding

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  1. CANCER W/ EMPHASIS ON HOME tube feeding PRESENTED BY Megan Fuetterer

  2. 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

  3. 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

  4. Weight decline over past year

  5. 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

  6. 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

  7. Physical Exam

  8. Physical Exam

  9. Physical Exam

  10. Physical Exam

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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)

  17. 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

  18. 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

  19. Lab Values after TF Initiation

  20. 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

  21. 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

  22. 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

  23. 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 AcadNutrDiet. 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. ExpTher 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. NutrClinPract. 2007;22:68-73. • A.S.P.E.N. Board of Directors. Standards for specialized nutrition support: home care patients. NutrClinPract. 2005;20:579-590. • A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force. Enteral Nutrition Practice Recommendations. J Parenter Enteral NutrOnlineFirst. 2009:1-19. • Nourish Nutrition Support Program. Medicare Guidelines: Medicare Part B. Apria Healthcare, Inc., 2011.

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