Download Glioblastoma with Postextubation Dysphagia

OBJECTIVES
• Explore Risk & Prevalence of both Glioblastoma &
Postextubation Dysphagia
• ID Pathophysiology of Postextubation Dysphagia
• ID Nutrition Concerns
• Review Terms Associated with Case
• Introduce Patient
• Outline Hospital Visit with Corresponding NCP &
Relevant Research
GLIOBLASTOMA MULTIFORME
• Gliomas - Astrocytes, oligodendrocytes, ependymal
(can be mixed)
• Astrocytoma – tumor arises from the star shaped cells
(astrocytes) that form the supportive tissue of the
brain (glial tissue)
• 4 Grades
• 4th Grade – Glioblastoma
• Multiforme
• Primary vs. Secondary
GLIOBLASTOMA FACTS
• Adults between the ages of 50-80
• Men
• 23% of all primary brain tumors
• Pressure in brain is typically first symptom
• Treatments involve: surgery, radiation, and chemo
• Survival rate is 50% after 1st year and declines with
each passing year
NUTRITION’S ROLE
CONCERNS
• Poor intake
• Wt loss and wasting
• Malnutrition
• Alterations in
metabolism
NUTRITION GOALS
• Prevent & reverse
deficiencies
• Preserve lean body
mass
• Maximize quality of
life
• Protect immunity
TARGETING METABOLISM WITH A KETOGENEIC DIET
DURING THE TREATMENT OF GLIOBLASTOMA
MULTIFORME (CHAMP ET AL)
BACKGROUND
• Carbohydrate restricted and ketogenic diet (KD) gaining
popularity in treating various cancers due to proposed
ability to starve cancer cells.
• Malignant cells exhibit increased glucose uptake.
• Normal cells can derive energy from ketone bodies.
• Elevated serum glucose levels during treatment of
glioblastoma is associated with lower survival (steroid
use).
TARGETING METABOLISM WITH A KETOGENEIC DIET
DURING THE TREATMENT OF GLIOBLASTOMA
MULTIFORME (CHAMP ET AL)
STUDY AIM & METHODS
• Retrospective study analyzed records of glioma
patients, non-fasting glucose levels and serum ketone
levels between March 2010 and April 2013.
• Assessed toxicity of patients undergoing KD as well
as glucose levels between KD and regular diet.
• 53 patients included in study, 6 underwent a KD.
• Patient’s received biweekly labs.
• Diet guides for KD treatment were given to patients to
reduce CHO to <50g a day (individual results varied)
TARGETING METABOLISM WITH A KETOGENEIC
DIET DURING THE TREATMENT OF
GLIOBLASTOMA MULTIFORME (CHAMP ET AL)
R E S U LT S O F K D TOX I C I T Y
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KD was well tolerated in all patients
Constipation occurred in 2 patients upon initiation
All patients experienced alopecia
4 pts experienced grade 2 fatigue (also restricted calorie intake)
Serum glucose levels remained in the normal range except for one
0 episodes of hypoglycemia
0 acute glucose replacement needed
TARGETING METABOLISM WITH A KETOGENEIC DIET
DURING THE TREATMENT OF GLIOBLASTOMA
MULTIFORME (CHAMP ET AL)
R E S U LT S
• 4 of 6 patients were alive after 14 months.
• Mean blood glucose values on standard diet
was 122.
• Mean blood glucose values on KD was 84.
• Larger prospective trials are needed.
POSTEXTUBATION DYSPHAGIA (PED)
• PED - ICU-acquired swallowing dysfunction following extubation
after mechanical ventilation
• True prevalence is unknown, considered relatively common
• ~ 3 – 62%
• Guidelines for routine screening do not exist
• Diagnosis is done with a bedside swallow study
• Mechanisms of action vary
• Macht et al, review of issue
POSTEXTUBATION DYSPHAGIA (MACHT ET AL)
RISK FACTORS
OUTCOMES
• Male sex
• Pneumonia
• Tracheostomy
• Reintubation
• Reintubation
• Longer length of
stay
• Mechanical ventilation
for more than 7 days
• Surgical placement
of feeding tubes
• Death
CASE STUDY TERMINOLOGY
• Intracranial Hemorrhage – Blood vessels rupture
within brain, collection of blood compresses brain
tissue
• Craniotomy – part of the skull (bone flap) is removed
to access brain
CASE STUDY TERMINOLOGY
• Vocal Cord Paralysis – Nerve impulses to your voice
box (larynx) are interrupted. This results in paralysis of
the muscle of the vocal cords.
• Vocal Fold Augmentation – Vocal cord is enlarged by
injecting a filler directly into the vocal fold.
MR. BB’S HOSPITAL COURSE OVERVIEW
• 35 year old
• African American
• Male
• Reason for admit: Tumor resection
• Initial Diagnosis: Right sided glioblastoma multiforme with
acute intracranial hemorrhage post craniotomy
• LOS: 28 days
PATIENT HISTORY
• Married, no kids
• Family history not significant
• Primary medical history – glioblastoma
• Surgical history – Dec 2013 cranial resection for
glioblastoma
• Pt refused chemoradiation after surgery and moved to
Germany
THE SUPPLEMENTS
• Ginseng
• Saw Palmetto
• Yohimbine
“BB was taking natural
remedies that he did not
disclose to us prior to
surgery” - MD
“Discussed with wife in plain terms that I do believe
that these supplements contributed to the bleeding
that we encountered” - MD
HERBAL AND DIETARY SUPPLEMENT DISCLOSURE
TO HEALTH CARE PROVIDERS BY INDIVIDUALS
WITH CHRONIC CONDITIONS (MEHTA ET AL)
BACKGROUND
• Herbal and dietary supplements are the most commonly
used CAM therapy.
• Questions of safety, efficacy, and drug interactions fuel
importance of disclosing use to health care providers.
• Herbal and dietary supplement use is more concerning in
patient’s with chronic diseases.
HERBAL AND DIETARY SUPPLEMENT DISCLOSURE TO
HEALTH CARE PROVIDERS BY INDIVIDUALS WITH
CHRONIC CONDITIONS (MEHTA ET AL)
STUDY AIM & METHODS
• Estimate national rates of herbal supplement use disclosure
in patient’s with chronic medical conditions.
• Data from 2002 National Health Interview Survey used to
obtain data relating to alternative medicine use
• 5,456 respondents reported herbal supplement use
• Disclosure was assessed by asking “Did you let any
conventional medical professionals know of your herb use?”
HERBAL AND DIETARY SUPPLEMENT DISCLOSURE TO
HEALTH CARE PROVIDERS BY INDIVIDUALS WITH
CHRONIC CONDITIONS (MEHTA ET AL)
FINDINGS
• HDS users were more often younger, female, highly educated and
had higher incomes than non HDS users
• Rheumatologic, cardiac, pulmonary and GI conditions were more
likely to use HDS.
• HDS users more likely to use prescription drugs
• <50% of subjects with a chronic condition stated they disclosed
their HDS use, 1 in 3 adults
• 39% of prescription drug users reported HDS use
BB’S INITIAL HOSPITAL PLAN OF ACTION
• Chemical coma for 48 hrs to decrease
metabolic demands of brain
• Decadron therapy
• Central line of mannitol
ANTHROPOMETRICS
• Height: 69 inches
• Weight: 75 kg
• BMI: 24
• Classification: Normal
• IBW: 70 kg
• % IBW: 107 %
MEDICATIONS & FLUIDS
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NS @ 100ml/hr
Dexamethasone
Protonix
Zofran
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Vanomycin
Humalog
Heparin
Docusate
BIOCHEMICAL DATA – 1ST DAY
Lab
BB Range
Normal
Glucose
156 H
70-90
BUN
8L
Albumin
3.0 L
• Glucose remained elevated
3.5 – 5.5
BB’S OVERALL NUTRITION CARE
• 6 overall visits with BB (Assumed pt care at 2nd visit)
• 5 Follow Ups
• 1 Nutrition Education
ENN FOR BB – POSTEXTUBATION
• Caloric Range: 2250 - 2625 kcal/kg (30-35 kcal/kg)
• Protein: 112-150g (1.5-2g)
• Fluid Needs: 2250-2625 mL (1mL/kcal)
VISIT # 2 – TUBE FEED FOLLOW UP
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Moderate encephalopathy, postextubation dysphagia, failed bedside swallow
study
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CDO: Glucerna 1.2 @ 80ml via NGT
•
Current Regimen Provides: 2304 kcal and 115g of protein
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Tolerating
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Last BM: 8 days ago
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Labs: Glucose 131 H
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PES: Altered nutrition related lab values related to current condition as evidenced
by blood glucose value of 131
•
Recommendations: Continue TF regimen, last bowel movement 8 days ago –
noted docusate, consider laxative if medically appropriate
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Goals: Preserve lean body mass, maintain skin integrity
VISIT # 3 – TUBE FEED FOLLOW UP
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Barium swallow study to be conducted, out of ICU
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CDO: Glucerna 1.2 @ 80ml via NGT
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Current Regimen Provides: 2304 kcal and 115g of protein
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Tolerating
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Last BM: Yesterday
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Labs: Glucose 125 H
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PES: Previous PES Remains
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Recommendations: Continue TF regimen, Continue bowel regimen to promote
regular bowel moves.
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Goals: Preserve lean body mass, maintain skin integrity
VISIT # 4 – TUBE FEED FOLLOW UP / CONSULT
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Vocal cord dysfunction related to paralysis, possible discharge on PEG
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CDO: Glucerna 1.2 @ 80ml via NGT
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Current Regimen Provides: 2304 kcal and 115g of protein
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Tolerating
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Last BM: 6 days ago
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Labs: No abnormal labs, glucose at 102
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PES: Swallowing difficulty related to current condition as evidenced by enteral
intake
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Recommendations: Continue current regimen, revaluate bowel regimen – noted
docusate and lactulose
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Goals: Preserve lean body mass, maintain skin integrity
CONSULT WITH PATIENT
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Reviewed tube feed formula selection
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Discussed ingredients
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Discouraged use of at home foods in PEG
Water, Sodium Caseinate, Corn Maltodextrin, High Oleic Safflower Oil, Isomaltulose, Canola Oil,
Fructose, Soy Protein Isolate, Sucromalt, Short-Chain Fructooligosaccharides, Glycerine, Milk Protein
Concentrate, Oat Fiber, Soy Lecithin, Soy Fiber, Potassium Citrate, Marine Oil (May Contain One or More
of the Following: Anchovy, Menhaden, Salmon, Sardine, Tuna), Magnesium Phosphate, Natural &
Artificial Flavor, Potassium Chloride, m-Inositol, Calcium Carbonate, Calcium Citrate, Sodium Citrate,
Ascorbic Acid, Choline Chloride, Salt, L-Carnitine, Taurine, Carrageenan, Ferrous Sulfate, dl-AlphaTocopheryl Acetate, Zinc Sulfate, Niacinamide, Calcium Pantothenate, Manganese Sulfate, Cupric
Sulfate, Vitamin A Palmitate, Thiamine Chloride Hydrochloride, Pyridoxine Hydrochloride, Beta-Carotene,
Riboflavin, Chromium Picolinate, Folic Acid, Biotin, Sodium Molybdate, Sodium Selenate, Potassium Iodide,
Phylloquinone, Cyanocobalamin, and Vitamin D3.
Allergens: Contains milk and soy ingredients.
VISIT # 5 – FOLLOW UP
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Status post vocal cord augmentation, dysphagia resolved, NGT removed, poor
intake
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CDO: Regular Diet
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Tolerating
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Last BM: Yesterday
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Labs: No abnormal labs
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PES: Inadequate energy intake related to decreased appetite, current condition
as evidenced by intake record
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Recommendations: Will send glucerna TID to help meet ENN, encourage PO
intake, monitor glycemic control to assess need for diabetic restriction
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Goals: Preserve lean body mass, maintain skin integrity, >75% PO intake
VISIT # 6 – FOLLOW UP
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Moved to ICU, developed second intracranial hemorrhage, SLP to reevaluate
patient, wife reports poor intake up until this point
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CDO: NPO, NPO x 1
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Last BM: 3 days previous
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Labs: Potassium: 5.1 H, Chloride: 97 L
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PES: Inadequate energy intake related to current condition as evidenced by NPO
diet
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Recommendations: Advance diet as tolerated, if EN necessary recommend
Glucerna 1.2 @ 80ml/hr. Continue bowel regimen
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Goals: Preserve lean body mass, maintain skin integrity, >75% PO intake
SUMMARY
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RIP, Patient BB.
KEY POINTS
• Many patient’s underreport herbal supplement use
• Postextubation dysphagia is under recognized and associated
with longer durations of mechanical ventilation
• Evidence that a ketogeneic diet could be useful in treating
patient’s with glioblastoma multiforme, more research is needed