Case Study: Nutritional Considerations of a Patient Undergoing Treatment for a Malignant Fibrous Histiocytoma s/p Limb Salvage

Transcription

1 Case Study: Nutritional Considerations of a Patient Undergoing Treatment for a Malignant Fibrous Histiocytoma s/p Limb Salvage Emily Izer UMD College Park Dietetic Intern April 6, 2012

2 Patient Data Patient: RG DOB: 6/1/ years old Diagnosis: Malignant fibrous histiocytoma distal right femur; s/p limb salvage (Jan 2012) Admission: Undergoing chemotherapy treatment protocol

3 Malignant Fibrous Histiocytoma (MFH)

4 History of Diagnosis March 2011 Pt presented with pain and swelling around right knee, worsening over the next month First biopsy - giant cell tumor September 2011 Second biopsy Malignant fibrous histiocytoma of the bone

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6 Treatment Protocol for MFH Roadmap 10 week chemo cycle Surgery & tumor eval G R O E O S D P O N S E P R O E O S R P O N S E 29 week chemo cycle 29 week chemo cycle + 74 weeks Ifn 29 week chemo cycle 40 week chemo cycle

7 MFH Treatment Protocol Medications 10 week chemo cycle Doxorubicin, cisplatin, & methotrexate Post surgery chemo cycle Doxorubicin, cisplatin, etoposide, ifosfamide Usually methotrexate

8 Current Admission: Medications Dexamethasone steroid used along with chemotherapy that prevents the release of substances in the body that cause inflammation Etoposide chemotherapy cancer medicine that interferes with the growth of cancer cells and slows their growth and spread in the body Ifosfamide chemotherapy cancer (antineoplastic) medication that interferes with the growth of cancer cells and slows their growth and spread in the body Gabapentin used to treat nerve pain

9 Current Admission: Medications Methadone opioid pain reliever Zofran anti-nausea medication Bactrim antibiotic 250mL/hr of NaCl 45% + Magnesium Sulfate 500mg X 13 hours

10 Lab Values Glucose 141H (ref. range ) Ca 8.2L (ref. range ) Adjusted Ca (4-4)* = 8.2 Mag 1.5L (ref. range )

11 Anthropometrics - Weight

12 Anthropometrics - BMI

13 Cancer Cachexia Pt may be in early stages of cancer cachexia Characterized by: Severe weight loss (especially lean body mass) Anorexia Poor appetite/early satiety Weakness Change in metabolism (Fearon, 2006)

14 Estimated Energy Requirements Kcals/kg: 39kcals/kg BEE = [66 + (13.7 X IBW of 84kg) + (5 X 183cm) (6.8 X 24)] X 1.6 = 3120kcals/day 3120kcals/day / 80kg = 39kcals/kg

15 Estimated Protein Requirements Grams Protein/kg: 2.3g/kg Based on Adult Nutrition Care Manual standards for patients receiving treatment and with muscle wasting ( g/kg)

16 Estimated Fluid Requirements ml/day to meet maintenance fluid needs: 2600mL/day Adult Nutrition Care Manual standard of 30-35mL/kg Chose 32.5mL/kg - middle of the range 32.5mL X 80kg = 2600mL/day

17 Diet History 24 hour recall Breakfast = 11:00am Two bowls of Rice Krispie s cereal with berries and a fruit platter Skips Lunch Dinner = 5:00pm Two plates of steak with rice, green beans, and beets Snack = 10:30pm corn chips, guacamole and popsicles Drinks water, Gatorade, and iced tea Takes 5000IU of Vitamin D3

18 Diet History Diet differs drastically when mother is in town Not consuming adequate servings of dairy per day Diet PTA was not adequately meeting kcal and protein needs Meeting ~50% of kcal and protein needs

19 Inpatient Diet Order High calorie/high protein diet Poor PO intake Decreased appetite related to apathy and chemo treatment

20 PES Involuntary weight loss (NC-3.2) related to inadequate energy intake with increased energy needs during treatment (pt consuming only two meals/day with one snack and no supplements) as evidenced by a 17% weight loss in 6 months (severe weight loss).

21 Intervention Ensure plus supplements TID 13kcals/kg = ~30% of estimated kcal needs 0.49g/kg = ~21% of estimated protein needs High calorie/high protein diet education

22 Intervention Progression of nutrition intervention: Supplements Periactin Feeding tube

23 Monitoring/Evaluation Follow up on: Current intake of meals and supplements Current weight and BMI

24 References University of Washington: Department of Radiology. Abbott Nutrition. Adult Nutrition Care Manual. Children s National Medical Center standards of care and CNMC Registered Dietitian guidance Fearon, K., Voss, A., & Hustead, D. (2006). Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. American Journal of Clinical Nutrition. Fearon, K. (1992). The mechanisms and treatment of weight loss in cancer. Proceedings of the Nutrition Society.

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