P R E S E N T E D BY M E G A N F U E TT E R E R

CANCER W/ EMPHASIS ON HOME TUBE FEEDING

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

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

WEIGHT DECLINE OVER PAST YEAR

3/22/1

24/6

/12

4/21/1

25/6

/12

5/21/1

26/5

/12

6/20/1

27/5

/12

7/20/1

28/4

/12

8/19/1

29/3

/12

9/18/1

2

10/3/

12

10/18

/12

11/2/

12

11/17

/12

12/2/

12

12/17

/121/1

/13

1/16/1

3

1/31/1

3

2/15/1

33/2

/1330

32

34

36

38

40

42

44

46

48

50

WEIGHT (kg)

Date

Wei

ght

(kg)

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

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

PHYSICAL EXAM

PHYSICAL EXAM

PHYSICAL EXAM

PHYSICAL EXAM

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

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

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

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

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

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)

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

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

LAB VALUES AFTER TF INITIATION

Date Lab Value Reference Range

3/18/13 K 3.9 3.5 - 5.1 mmol/L

Glucose 111 74 - 106 mg/dL

PO4 2.8 2.5 - 4.9 mg/dL

Magnesium 1.8 1.8 - 2.4 mg/dL

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

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

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

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 Acad Nutr Diet. 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. Exp Ther 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. Nutr Clin Pract. 2007;22:68-73.

• A.S.P.E.N. Board of Directors. Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579-590.

• A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr OnlineFirst. 2009:1-19.

• Nourish Nutrition Support Program. Medicare Guidelines: Medicare Part B. Apria Healthcare, Inc., 2011.