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NUTR 424 Cancer > HPN in Advanced Cancer > Flashcards

HPN in Advanced Cancer Flashcards

1
Q

How might multmodal treatment look?

A

Multiple Care Providers and a journey spanning months
* Chemotherapy
* Radiation therapy
* Surgery
* Multimodal therapy: CT/RT; Surgery/CRT; CRT/Surgery/Palliation

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2
Q

What is typically the adequacy of energy and protein via oral route?

A
  • energy: 77%
  • protein: 69%
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3
Q

What are strong reccomendations from the ESPEN guidelines?

A
  • Screening
  • Assessment: to include objective markers, nutrition impact symptoms, function, body comp
  • Nutrient Provision: Energy: 25-30kcal/kg, Protein: 1-1.5 gm/kg, Vitamins: RDA (not Excess esp. vit E)
  • Refeeding Syndrome
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4
Q

Efficacy of nutrition intervention from ESPEN

A
  • Use Supplements if needed
  • avoid harmful diets
  • EN or PN if oral intake is insufficient
  • Pursue ERAS strategies which are specific approach to surgery to to avoid fasting and initiate feeding soon after
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5
Q

ESPEN nutrition in advanced cancer

A
  • Assessment indicated
  • Consider EN or PN if therapy has the potential to impact survival and Quality of Life
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6
Q

ESPEN definition of intestinal failure

A

the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth.

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7
Q

intestinal insufficiency

A

reduction of gut absorptive function that doesn’t require intravenous supplementation to maintain health and/or growth

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8
Q

ESPEN classification of intestinal failure in adults

A

Intestinal failure can be classified into five major pathophysiological conditions, which may originate from various gastrointestinal or systemic diseases:
1. short bowel
2. intestinal fistula
3. intestinal dysmotility (snipped vagus nerve)
4. mechanical obstruction
5. extensive small bowel mucosal disease

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9
Q

What is indicated by this graph?

A

HPN has gotten a lot safer

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10
Q

Survival and PN Dependence in Adults With SBS/IF

A

After 2 yrs probability of permanent intestinal failure is 94%
* Survival (2, 5 yrs): 86%, 75%
* PN Dependence (2, 5 yrs): 49%, 45%
* Basically dont really get off of PN

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11
Q

Mortality of intestinal failure

A

Death is related to:
* underlying disease
* TPN related liver disease (15% long term TPN)
* Sepsis (catheter related), related to residual bowel length
* malnutrition

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12
Q

Use of HPN in advanced cancer care

A

Addresses the malnutrition associated with IF
* reduction in food intake
* Metabolic Derangement: Insulin resistance, lipolysis
* Systemic Inflammation driving catabolism
* Muscle Protein Depletion – results in reduction in quality of life, treatment intolerance, reduction in physical function

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13
Q

Ethical considerations in feeding patients with advanced cancer

A
  • Respect for the religious, cultural and ethnic background of patients
  • Consideration of social, emotional and existential aspects
  • The risks and detriments as well as the possible futility of artificial nutrition must be weighed against possible physiologic and or psychological benefits, for a given patient and family.
  • As a general rule, the risks of PN are regarded to outweigh its benefits for patients with a prognosis of less than 2 months. However, in some cultures, active feeding in any form is regarded as essential.
  • Withdrawal of artificial feeding or deciding not to initiate artificial feeding in a patient who is unable to consume food is usually considered only in an end-of-life setting.
  • Potential Benefits: Survival, QOL
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14
Q

What outcomes does HPN impact?

A
  • mortality
  • survival
  • QoL
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15
Q

Prognosis of incurable cachectic cancer patients on HPN

A
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16
Q

Karnofsky performance scores

A
17
Q

Daily life with HPN for intestinal failure

A
  • PN duration can be up to 10-12 hrs per night
  • Pump alarms activate on average 13-14 times per night
  • Constant need to urinate due to the amount of PS volume
  • Taking part in evening events is usually not possible or takes enormous changes in your PS routine
18
Q

Impact of HPN on caregiver burden

A

Basal level of strain was relatively high but did not increase after 2 weeks of home care. Nourishment (HPN) has a cultural and symbolic value and is experienced by the family caregiver as an expression of love and care for the severely ill relative. Physicians tend to see nourishment as a medical treatment aimed at achieving physiological objectives.
* no difference in the nutritional status and quality of life of the patients.
* No increase in caregiver burden despite advancing Cancer
* salient positive features of HPN: a sense of relief and security - nutritional needs were met, both patients and family members reported the experience as having a direct and positive effect on QoL.

19
Q

What needs to be considered with HPN?

A
  • Parenteral nutrition formulation: amount, composition.
  • Intestinal rehabilitation strategy-Medical Short Bowel Treatment
  • Optimizing Catheter function: reduce CRBSI, prevent thrombosis
  • Strategies to reduce PNALD
  • Inform patients of the potential role of growth factor treatments; the GPL2-analog, teduglutide/revestive, is the first choice
  • Intestinal transplantation: recommend HPN as the primary treatment and the early referral of patients to intestinal rehabilitation centers with expertise
20
Q

Venous access for HPN

A
  • Short term: PICC
  • Long-term: Tunneled catheter (broviac, Hickman) catheter
  • Avoid Femoral Lines
  • Avoid portacaths (best for chemo meds, can get infected easily with nutrient rick fluid)
  • Apply best care practices to reduce CRBSI, thrombosis
21
Q

Northern Alberta approach to HPN

A
  • Doc to Doc Consult – do not establish the expectation that HPN will be provided
  • Identify the patient who will benefit
  • Palliative Homecare consult required
  • Risk of refeeding syndrome assessed and addressed
  • Consider “premix” PN
  • Rationale for and plan
22
Q

Who might benefit from HPN?

A
  • estimated survival > 2 months
  • KPS >60
  • supportive family or home environment
  • reasonable symptom control
  • reasonable narcotic use, minimal edema
  • appropriate IV access
23
Q

Northern Alberta HPN Program Goals in Advanced Cancer

A
  • Improve quality and quantity of life for patients suffering with advanced cancer and intestinal failure as a consequence
  • Do not add to burden of care
  • Continuously reevaluate care

NUTR 424 Cancer (19 decks)

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