corinne larson lacy sprague, ann belforti, cindy fitteron, liz valente, nowen beebe, rose cretella,...
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Corinne LarsonCorinne Larson
Lacy Sprague, Ann Belforti, Cindy Lacy Sprague, Ann Belforti, Cindy Fitteron, Liz Valente, Nowen Beebe, Fitteron, Liz Valente, Nowen Beebe, Rose Cretella, Kayla Hickerson, Mary Rose Cretella, Kayla Hickerson, Mary
Jennings Jennings
3/3/153/3/15
Introduction to the Patient Background Patient Presentation
Surgical history Reason for admission Patient Assessments Interventions
Ideal Nutritional Management before Discharge Discussion Conclusion References
Overview
68”, 185lbs 10oz Admitted for salvage laryngectomy s/p failed
radiotherapy for laryngeal cancer Left supraglottic cancer, chemoradiation in
2011 Plan: 10 days in SICU for monitoring
PMH: CAD s/p CABG in 2010, COPD, DM, GERD, hx of prostate cancer s/p prostatectomy 2013, hx of throat cancer s/p tracheostomy 2010
Patient Presentation
Epiglottis, vocal cords Symptoms
Sore throat/Painful swallowing
Ear pain Change in voice quality Enlarged neck nodes 1
Chemoradiation therapy 2
Radiation + cisplatin 3
Dysphagia and MBS4
Left Supraglottic Cancer
Performed for recurrent disease 5
Total laryngectomy Separation of airway from esophagus 6
Supraomohyoid Neck dissection Removes lymph nodes 7
Sternocleidomastoid muscle Bilateral muscle flaps 8
Salvage Laryngectomy
HNC – functional GI tract 9
Radiotherapy – risk of xerostomia, dysguesia, odynophagia, dysphagia, anorexia, N/V 10
Laryngectomy – withhold oral feeding ~3 weeks to decrease the rate of fistula formation Swallowing Longer meal times SLP monitoring 6
Salvage Laryngectomy – Nutrition Needs
Tracheostomy 2010 with G tube placement d/t
throat cancer CABG x 4 in 2010 Prostatectomy 2013
Surgical History
~ 4 years s/p chemoradiation for advanced
left supraglottic cancer 12/17
Left otalgia, persistent left sore throat Pre-op dx of malignant neoplasm of
mediastinum Direct laryngoscopy, biopsy Found fibrinous ulceration over left false cord
Biopsy returned with malignant SCC
Surgical history
Timeline
2/6 admitted
Total laryngectomy Neck dissection (I, II, III) 7
Reconstructive surgery of the SCM
Maintain NPO until POD 10 Oral diet transition
Shiley tube placed into stoma
Reason for Admission
Food/Nutrition History
Followed “regular healthy diet” PTA Anthropometrics
Admit weight: 185# 10 oz, 5’8”, BMI = 28.23 kg/m2
Weight history: 190# on 12/17 admit Estimated Needs: 2039kcal, 101-126 g protein,
2039mL Biochemical
BG: 120 – DM H&H: 11.2/32.6 – surgical blood loss
Patient Data
COPD: Albuterol, Budesonide DM: Levemir, Humalog, Metformin HTN: Metoprolol, Olmesartan GERD: Omeprazole (Ca supplement usually
advised)11
HLD: Rosuvastatin Bladder control agent: Solifenacin (may interact
with grapefruit)
Home Medications
Tracheostomy care by RN
SLP visits for use of electrolarynx
ENT physician
Respiratory therapist
LOS Care
Timeline
RN: total laryngectomy NGT in place, team members providing care BG: 227 PES: Inadequate oral intake r/t need to await
return of bowel function s/p laryngectomy AEB pt NPO
Prescription: Once medically able, initiate Glucerna 1.2 at 10mL/hr until 70mL/hr + 1 oz prostat 2116 kcal, 116g pro, 2102mL water
Goal: Tolerate TF within 72 hours Monitor: Labs, weight, TF initiation and
tolerance, PO ability
Assessment 1 – 2/7
Timeline
RN consult: tube feed recs Pt sitting in chair with TFs infusing at 70mL/hr,
diet ordered in EMR at 80mL/hr 2/8: 14% total formula, 2/9: 75% total formula
PES: Inadequate oral intake r/t s/p laryngectomy AEB need for enteral nutrition support
Prescription: Glucerna 1.2 at 70mL/hr, 1 oz prostat
Discussed TF recs with team & were in agreement
Goal: Tolerate goal within 72 hours, met and ongoing
Monitor: Tolerance to TF, bowel function, labs, weight, plan of care
Assessment 2 – 2/10
Timeline
TFs began 2/8/15 at 15:00
Bolus on 2/11
10 cans 2/12 = 119%
Oral Intake
Noted change to bolus feeds without proper
goal reached BG: from 187-221 Called ENT, spoke to nurse, new bolus goal
confirmed and agreed upon Prescription: Glucerna 1.2 = 480ml bolus at
8a, 12p, 4, & 240ml at 8p
Assessment 3 – 2/13
Timeline
*Nasogastric tube removed*
Pt with NG tube removed, mouthing words,
nodding BG: 233, Wt: 178 lbs 8 oz New needs: 2000 kcal, 97-121g pro, 2000 mL PES: Inadequate oral intake r/t s/p laryngectomy
AEB enteral feeds x 9 days, clear liquid diet prescription
Prescription: Continue diabetic clears, advance to CCD with textures per SLP
Goals: Advance in 1-3 days, consume 75% of meals and supplements
Monitor: Weight, labs, oral intake, I/O, diet tolerance, medical course
Assessment 4 – 2/16
Feb 17th – discharged
On dental soft diet BG: 339 Start taking tramadol – opioid Sent to STR facility
Prognosis Careful surveillance and monitoring by SLP Fistula complication 12,13,14
Study by Yeun et. al, 21% patients with recurrence had TL. 14
Discharge
Keep TFs at rate until SLP seen
Begin clear liquid diet Discontinue TFs when 60% energy and 100%
fluid needs are met Slow diet progression 15
Check for dysphagia
An Ideal Diet Progression
Cancer: nutrition related symptoms, make
recommendations Laryngectomy: meet needs with alternate
nutrition, monitor symptoms Work alongside ENT and SLP
Pt with TF experience, long hospital stay LOS 10 days – was ready to leave Pt and ENT pushing for discharge
Discussion – RDs
Laryngeal Cancer – decreased oral intake,
tolerance
Laryngectomy – need with failed chemoradiation therapy, need for enteral nutrition
Critical care, close monitoring – multiple team members following
Ideal setting – follow nutrition guidelines
Conclusions/Summary
1. National Cancer Institute. Laryngeal Cancer Treatment: General Information about Laryngeal Cancer. National Cancer Institute at the National Institutes of Health Website. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/laryngeal/HealthProfessional/page1. Published July 31, 2014. Accessed February 20, 2015.2. Bataini JP, Ennuyer A, Poncet P, Ghossein NA. Treatment of supraglottic cancer by radical high dose radiotherapy. Cancer. 1974;33(5):1253-1262. 3. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, Glisson B, Trotti A, Ridge JA, Chao C, Peters G, Lee DJ, Leaf A, Ensley J, Cooper J. Concurrent chemotherapy and radiotherapy for organ preservation in advance laryngeal cancer. The New England Journal of Medicine. 2003;349:2091-2098.4. Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. Journal of Clinical Oncology. 2006;24(17):2636-2643.5. Li M, Lorenz RR, Khan MJ, Burkey BB, Adelstein DJ, Greskovich Jr JF, Koyfman SA, Sharpf J. Salvage laryngectomy in patients with recurrent laryngeal cancer in the setting of nonoperative treatment failure. Otolaryngology Head and Neck Surgery. 2013;149(2):245-251.6. Landera MA, Lundy DS, Sullivan PA. Dysphagia after total laryngectomy. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2010;19:39-44.7. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head & Neck. 1989;11(2):111-122.8. Conley J, Gullane PJ. The sternocleidomastoid muscle flap. Head & Neck Surgery. 1980;2(4):308-311.9. Raykher A, Russo L, Schattner M, Schwarts L, Scott B, Shike M. Enteral nutrition support of head and neck cancer patients. Nutrition in Clinical Practice. 2007;22(1):68-73.10. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head & Neck. 2005;27(8):659-668.11. Pronsky ZM, Crowe JP. Food-Medication Interactions. 17th ed. Birchrunville, PA: Food-Medication Interactions; 2012.12. Eustaquio M, Medina JE, Krempl GA, Hales N. Early oral feeding after salvage laryngectomy. Head & Neck. 2009;31(10):1341-1345.13. Gooi Z, Richmon J. Long-term oral intake through a salivary bypass tube with chronic pharyngocutaneous fistula. American Journal of Otolaryngology. 2012;33(6):762-763.14. Yeun APW, Ho CM, Wei WI, Lam LK. Prognosis of recurrent laryngeal carcinoma after laryngectomy. Head & Neck, 1995;17(6):526-530.15. Compass Group. Manual of Clinical Nutrition Management. Morrison, Inc; 2014.
References
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