Parenteral Nutrition in Oncology

Transcription

1 Parenteral Nutrition in Oncology Presenter: Pam Wagner, RD, CNSC Learning Objectives List indications for initiating PN in oncology patients Describe considerations when determining an appropriate candidate for home PN Identify risk factors for and signs of refeeding syndrome List two required Medicare PN coverage criteria Agenda Indications/Contraindications PN Order Home PN considerations Monitoring Home Coverage/CMS guidelines Safe Practices 1

2 2012 Consensus Statement Identification and Documentation of Adult Malnutrition 3 Malnutrition(cachexia) in Cancer 5 2

3 Oncology and Malnutrition5,6 Protein-calorie malnutrition most common secondary diagnosis in patients with cancer Severe malnutrition and cachexia account for an estimated 20% to 40% of all cancer deaths 80% of patients with upper GI cancer and 60% with lung cancer already have significant weight loss by the time of diagnosis Energy needs may be higher than previously estimated in certain cancers: calories/kg just to maintain their body weight ER reports that ~ 48% of oncology patients seen are dehydrated, but actual percentage may even be much higher. The amount of lean skeletal muscle remained the same among patients whose BMIs differed. Underweight, normal and obese patients were found to have the same amount of skeletal muscle mass. For those with a BMI >26, weight gain was found to be only fat not LBM. Malnutrition Unintentional weight loss Evidence of inadequate intake Loss of muscle mass Loss of subcutaneous fat Fluid accumulation Reduced hand grip strength The presence of two or more necessary for the diagnosis of malnutrition 3

4 Clinical Indications General Indications: Short bowel syndrome Bowel obstruction Inflammatory bowel disease Enterocutaneous fistula Malabsorption Pancreatitis Hyperemesis Gravidarum Specific Indications in Oncology Failed enteral access Head and neck ca Gastric and Esophageal ca Inability to place enteral access Thrombocytopenia Fistula of the GI tract Intestinal Obstruction Malabsorption Short bowel syndrome -following debulking or bowel resections Severely malnourished, perioperative patients Other Benefits in Parenteral Nutrition Correction of deficiencies Improved Energy and Protein Balance Increased Body Weight Improved Quality of Life Prolonged Survival 4

5 Parenteral Nutrition 101 Macronutrients Carbohydrate Dextrose 3.4kcal/g Lipids 10kcal/g if 20% lipid emulsion Amino Acids 4 Kcal/g Water Micronutrients/ Additives Electrolytes Na, K+, Phos, Mag, Ca MVI Patient additive in home setting Trace elements Insulin and other additives Patient additive in home setting Other considerations Acetate vs. Chloride Steps in Determining PN Prescription Assessment determine total calorie goals Determine fluid volume total 25-35mL/kg IBW vs. actual Calculate carbohydrate calories 50%(-65%) of total kcals or 3-5 mg per kg per min Determine protein goals Gms/kg IBW Provide remainder of calorie needs as fat Review current labs and status to consider acid/base needs, electrolytes and deficiencies Hospital or Home 5

6 Home Parenteral Nutrition Considerations Long-term or short-term therapy Safe and suitable home environment Caregiver willing to assist with therapy Patient willing to assist with therapy Central venous access device Reimbursement Private payer Public payer Coverage criteria subject to change without notice Outcomes in Parenteral Nutrition Management: Preventing Hospitalization Intervention Managed Electrolyte Imbalance Total Hospital Interventions Days* Saved over 3 months Healthcare Dollars Saved ($2000/d)* $420,000 Managed Hyperglycemia $96,000 Prevented Dehydration $156,000 Initiated PN in the home safely Total hospital days/ dollars saved 2 6 $12, $684,000 *Reference for hospital days saved=median length of stay for diagnosis listed (Agency for Healthcare. Research and Quality (ahrq.gov). Reference for average cost hospital day stay-- Shelley S. Home infusion providers struggle with unfriendly reimbursement policies. Pharmaceutical Commerce Sept 30, Other Relevant Current Issues Ingredient Shortages Electrolytes Lipids Vitamins Trace Elements Individualized PN versus Pre-Mixed Solutions 6

7 Home Initiation Requires team approach between clinic and home care team and dietitian involvement prior to start of therapy Start as a continuous infusion and begin to cycle when consecutive lab results are stable Start low, go slow Anaphylaxis kit Glucose meter, scale, thermometer Refeeding Syndrome Starvation Decreased insulin secretion in response to decreased intake of carbs Fat and protein stores catabolized resulting in intracellular loss of electrolytes (phosphate, sodium, potassium, magnesium) Feeding Shift from fat to carbohydrate metabolism Insulin secreted Cellular uptake of phosphate for oxidative phosphorylation (Krebs cycle) Hypophosphatemia, hypokalemia, hypomagnesemia and fluid imbalances = refeeding syndrome Consequences Cardiac failure, respiratory failure, sudden death Increased cellular thiamine utilization. TPN may require short-term supplementation MEDICARE (CMS) GUIDELINES A condition involving the small intestine and/or its exocrine glands that significantly impairs the absorption of nutrients. OR A motility disorder of the stomach and/or intestine that impairs the ability of nutrients to be transported through the GI system AND Documentation that the condition is to be of a long or indefinite duration, usually 90 days or longer. must require PN to maintain weight and strength.which must not be able to be maintained by modifying the nutrient composition of an enteral diet or by pharmacologic treatment Objective supporting documentation in medical record versus LMN 7

8 CMS Guidelines- Criteria A-H A:Severe short bowel syndrome: Surgery within past 3 months, leaving 5 feet of small bowel beyond the ligament of the Treitz B: Severe short bowel syndrome (>3 months ago) that results in: evidence of electrolyte malabsorption AND fluid intake of L/day results in enteral losses that exceed 50% of the oral/enteral intake AND Urine output less that 1 L/day C: Bowel rest for at least 3 months Symptomatic pancreatitis with or without pancreatic pseudocyst OR severe exacerbation of regional enteritis OR proximal enterocutaneous fistula where tube feedings distal to the fistula is not possible. CMS Guidelines- Criteria A-H D: Complete mechanical small bowel obstruction where surgery is not an option and where tube feelings distal to the obstruction is not possible E: Malabsorption and malnutrition Severe fat malabsorption (fecal fat exceeds 50% or oral/enteral intake on a diet of at least 50 gm of fat per day as measured by a standard 72-hour fecal fat test). AND malnutrition, as evidenced by: 10% weight loss AND over 3 months or less AND serum albumin equal to AND or less that 3.4 gm/dl F: Motility disturbance and malnutrition Severe motility disorder of the small intestine and/or stomach, which is unresponsive to prokinetic medications and is demonstrated scintigraphically or radiographically. AND malnutrition, as evidenced by: 10% weight loss over 3 months or less AND serum albumin equal to or less that 3.4 gm/dl 8

9 CMS Guidelines- Criteria A-H G/H:Malnourished as evidenced by: 10% weight loss over 3 months or less AND serum albumin equal to or less that 3.4 gm/dl AND Has a disease and clinical condition documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients(e.g.,slow infusion of nutrients through a tube with the tip located in the distal jejunum) AND Patient has been unable to maintain weight and strength commensurate with his/her overall health status utilizing all of the following approaches Modifying nutrient composition of enteral diet AND utilizing pharmocologic means to treat etiology of the malabsorption CMS Guidelines Conditions That Do Not Qualify a Patient for Parenteral Nutrition Under Medicare Swallowing disorder Temporary impaired gastric emptying (e.g., metabolic or electrolyte disorder) Impaired nutrient intake due to depression or other psychological disorder Anorexia related to a metabolic disorder (e.g., cancer) Impaired oral intake of food with physical disorder (e.g., dyspnea of severe pulmonary or cardiac disease) Adverse effects of pharmacotherapy (including chemotherapy) End-stage renal disease Safe Practices and Safety Consensus Recommendations 2013 Safe Practice guidelines 2004 Recent survey results revealed severe gaps Use of standardized form electronic orders if possible Appropriate use of PN may still be an issue Goals not always clearly documented Order form not in accordance amounts listed per day order as a complete salt Only 60% of institutions dedicate a >0.6 pharmacist FTE for PN order review Dose limit warnings are only active in 2/3 of the compounding systems 35% of reported PN errors occur in the administration phase 9

10 Evaluation of PN Orders PN orders are complex and at high risk of medication errors during transfer Potential areas of concern: Unclear numbers or decimal points Phrases or abbreviations Electrolyte content Ion content Base component orders Lipid calculated into the final volume Total volume to be infused Overfill Additives PN Rx Safe Practices TPN Administration Infusion pump required Continuous Evaluate need for back-up pump in the home Cyclic - individualized Taper up/down over 1-2 hours Filtration 1.2 micron filtered tubing for 3:1 solutions 0.2 micron filtered tubing for 2:1 solutions 10

11 PN Refill Orders and Monitoring 6 Patients who are new to PN should be monitored daily until stable (more frequently if clinically significant metabolic abnormalities are found or patient is at risk for refeeding syndrome). Patients in an unstable clinical condition (eg, acutely ill, critically ill, recovering from criti- cal illness, recent surgery) should be monitored daily until stable (more frequently if clinically significant abnormalities are observed). Stable patients in the hospital with no required changes in formulation for 1 week should be monitored every 2 to 7 days. Stable patients in a hospital, long-term care, or home setting with no changes in formula-tion for more than 1 week should be monitored every 1 to 4 weeks or longer in select clinically stable patients. Clinical Monitoring of Home PN Patient Body weight baseline/weekly Labs baseline/weekly Complete blood chemistry analysis including magnesium and phosphorus Complete blood count with differential Glucose management Compliance Registered Dietitian Assessment Lean Body Mass, Functional Status, Quality of Life??? Monitoring Long Term PN Patients Anemia Micronutrient Deficiencies and Toxicities Metabolic Bone Disease Monitor PTH, Alk Phos, Calcium and Phosphorous Obtain physician orders for IV bisphosphonates or activated vitamin D therapy DEXA recommendation annually for high-risk groups (pediatric patients, chronic therapy) 11

12 Assess, Recommend..Repeat!!! Screen Valid Sensitive Efficient Assess New Malnutrition Concensus Timely Outcome Oriented Intervene Questions? References 1 Argiles JM. Cancer-associated malnutrition. Eur J oncol Nurs 2005;9 S DeLuis DA Nutritional assessment: predictive variables at hospital admission related with length of stay Ann Nutr Metab 2006;50: White J, Guenter P, et al. Consensus Statement: Academy of Nutrition and Dietetics and A.S.P.E.N.: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition. JPEN, May 2012; vol36,3: Fearon K. Strausser F, Aner SD, et al. Definition and Classification of Cancer Cachexia: an International Consensus. Lancet Oncol. 2011;12(5): Luszcz N, Patton A, Home Nutrition support can improve outcomes for patients with cancer; HemOnc today, March Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN 2014; 38: