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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

C O N C E R N S

• Poor intake

• Wt loss and wasting

• Malnutrition

• Alterations in metabolism

N U T R I T I O N G O A L S

• 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)

B A C K G R O U N D

• 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)

S T U D Y A I M & M E T H O D S

• 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 T O X I C I T Y

• 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)

R I S K F A C T O R S

• Male sex

• Tracheostomy

• Reintubation

• Mechanical ventilation for more than 7 days

O U T C O M E S

• Pneumonia

• Reintubation

• Longer length of stay

• 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.

PATI

ENT

BB

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

• Ginseng• Saw

Palmetto• Yohimbine

“BB was taking natural remedies that he did not disclose to us prior to surgery” - MD

THE SUPPLEMENTS

“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)

B A C K G R O U N D

• 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)

S T U D Y A I M & M E T H O D S

• 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)

F I N D I N G S

• 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 %

• NS @ 100ml/hr

• Dexamethasone

• Protonix• Zofran

• Vanomycin• Humalog• Heparin• Docusate

MEDICATIONS & FLUIDS

• Glucose remained elevated

BIOCHEMICAL DATA – 1ST DAY

Lab BB Range Normal

Glucose 156 H 70-90

BUN 8 L

Albumin 3.0 L 3.5 – 5.5

NUTRIT

ION C

ARE

PROCESS

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

• Moderate encephalopathy, postextubation dysphagia, failed bedside swallow study

• CDO: Glucerna 1.2 @ 80ml via NGT

• Current Regimen Provides: 2304 kcal and 115g of protein

• Tolerating

• Last BM: 8 days ago

• Labs: Glucose 131 H

• 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

• Goals: Preserve lean body mass, maintain skin integrity

VISIT # 3 – TUBE FEED FOLLOW UP

• Barium swallow study to be conducted, out of ICU

• CDO: Glucerna 1.2 @ 80ml via NGT

• Current Regimen Provides: 2304 kcal and 115g of protein

• Tolerating

• Last BM: Yesterday

• Labs: Glucose 125 H

• PES: Previous PES Remains

• Recommendations: Continue TF regimen, Continue bowel regimen to promote regular bowel moves.

• Goals: Preserve lean body mass, maintain skin integrity

VISIT # 4 – TUBE FEED FOLLOW UP / CONSULT• Vocal cord dysfunction related to paralysis, possible discharge

on PEG

• CDO: Glucerna 1.2 @ 80ml via NGT

• Current Regimen Provides: 2304 kcal and 115g of protein

• Tolerating

• Last BM: 6 days ago

• Labs: No abnormal labs, glucose at 102

• PES: Swallowing difficulty related to current condition as evidenced by enteral intake

• Recommendations: Continue current regimen, revaluate bowel regimen – noted docusate and lactulose

• Goals: Preserve lean body mass, maintain skin integrity

CONSULT WITH PATIENT

• Reviewed tube feed formula selection

• Discussed ingredients

• 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 ProteinConcentrate, Oat Fiber, Soy Lecithin, Soy Fiber, Potassium Citrate, Marine Oil (May Contain One or Moreof 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-Alpha-Tocopheryl Acetate, Zinc Sulfate, Niacinamide, Calcium Pantothenate, Manganese Sulfate, CupricSulfate, 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

• Status post vocal cord augmentation, dysphagia resolved, NGT removed, poor intake

• CDO: Regular Diet

• Tolerating

• Last BM: Yesterday

• Labs: No abnormal labs

• PES: Inadequate energy intake related to decreased appetite, current condition as evidenced by intake record

• Recommendations: Will send glucerna TID to help meet ENN, encourage PO intake, monitor glycemic control to assess need for diabetic restriction

• Goals: Preserve lean body mass, maintain skin integrity, >75% PO intake

VISIT # 6 – FOLLOW UP

• Moved to ICU, developed second intracranial hemorrhage, SLP to reevaluate patient, wife reports poor intake up until this point

• CDO: NPO, NPO x 1

• Last BM: 3 days previous

• Labs: Potassium: 5.1 H, Chloride: 97 L

• PES: Inadequate energy intake related to current condition as evidenced by NPO diet

• Recommendations: Advance diet as tolerated, if EN necessary recommend Glucerna 1.2 @ 80ml/hr. Continue bowel regimen

• Goals: Preserve lean body mass, maintain skin integrity, >75% PO intake

SUMMARY

• 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

THANK YO

U!

Questio

ns?

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