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Transcript of + Acute Myelogenous Leukemia Olivia Wagner. + Patient Hx. Diagnosis Etiology AML Treatment Plan...
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Acute Myelogenous Leukemia Olivia Wagner
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•Patient Hx.•Diagnosis•Etiology AML•Treatment Plan
•Medical/Surgical•Nutrition Therapy
•Patient Response to Tx.•Patient Prognosis•Questions
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+Patient Hx: Name: Rachel Dean
Chemical Engineer Married Age: 25 Sex: Female Wt: 115 (46.8 kg) Ht: 5’3” (1.6 m) BMI: 20.3 Not a smoker Family hx: maternal CAD
Diagnosis of Acute Myelogenous Leukemia (AML) Sinus infection symptoms >3 months Chemistry panel and CBC revealed elevated WBC and blasts
Onset of disease: 4 months PTA
Induction Chemotherapy cytarabine and idarubicin 1st CR achieved
Dx: Acute Leukemia in CR. Admitted for bone marrow transplant
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+Acute Myelogenous Leukemia (AML)
Cancer of the blood and bone marrow affecting the myeloid cells
“Acute”due to rapid progression
Shortage of RBC when leukemia cells crowd around the blood making cells of the bone marrow
Symptoms Recurring infections, weight
loss, fatigue, fever, night sweats, and loss of appetite
Dx: based on lab measurements
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+Tx. Plan – Preparative Regimen Cyclophosphamide
Days -6, day -5
Total body irradiation (TBI) Days -3, -2, -1
Primary goal: completely destroy any residual leukemia cells to make room for the new stem cells after transplant
Nutrition Related Side Effects: Mucositis, N/V, infections, suppressed immune system, dehydration
Monitor: weight, electrolyte levels, energy needs, increased nutrient needs NI-5.1
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+Tx Plan - Bone Marrow Transplant Allogeneic Bone Marrow Transplant
Day 0 HLA-matched sibling bone marrow
graft versus tumor effect: stem cells develop into immune cells and identify the leukemia cells as invaders
Primary goal: replace destroyed bone marrow with healthy bone marrow stem cells Engraftment: the process of transplanted cells reproducing
new cells
Monitor: weight, electrolyte levels, energy needs
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+Tx. Plan Intravenous cyclosporine
Instituted day-2 until day +180 Prophylaxis Graft versus host disease (GVHD)
Common side effect of BMT when transplanted immune cells attack the patients
body Side Effects: hyperkalemia, hyperlipidemia,
hypomagnesemia, hyperlipidemia Monitor: metabolic state, magnesium level- take regular
labs
Methotrexate Days +1, +3, +6,+11 Side Effects: mucositis, nitrogen catabolism, hypertension,
hyperglycemia, suppressed immune system Monitor: metabolic state glucose levels and weight-
increase energy needs
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+Tx. Plan
Prophylactics for infection Fluconazole (Antifungal)
Day +1 Acyclovir (Antiviral) Day
+1
Antibiotics administered with onset of fever
IV morphine: pain management
Antiemetic Lorazepam Ondansteron
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+Pt. Response to Tx.
Post BMT- Day 7 Severe mucositis- ice chips and
jell-o are intolerable diarrhea (650 cc/day), weight
dropped to 107lb Labs indicate malnutrition low
blood counts
Intervention place on TPN Increase energy and protein
Monitor Pt body weight and chemistry
and CBC labs to evaluate tolerance to TPN
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+ Nutrition Therapy
Nutrients Mrs. Dean’s Needs
Protein 4% amino acid
Carbohydrate 16% dextroseFat 3% lipidFluids 1700 mLPotassium 50 mEqSodium 50 mEqCalcium 10 mEqPhosphorus 20 mmolAdult Multivitamin
10 mL/day
Adult Multimineral
1 mL/day
Parenteral Nutrition tube feeding is not
successful due to severity of N/V, mucositis, delayed gastric emptying, and diarrhea.
AML pt have low platelet count that increases risk of bleeding with enteral
PICC Two-in-one
Flexibility Precipitate
Needs Energy: 30-35 Kcal/kg Protein: 1.5 grams/kg
Branchamin
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+Pt. Response to Tx.
Day +16 Dx: stage I/II aGVHD
maculopapular rash on palms and trunk, bilirubin elevated (2.1mg/dL), stool output increased to 1200cc/24 hours
Intervention: Corticosteroid therapy Side Effects: anorexia, weight loss, elevated energy and protein
needs, hyperglycemia , nitrogen catabolism, hypertension, and sodium retention.
Day +20 blood glucose averaging 350 mg/dL
Onset of hyperglycemia due to use of corticosteroid therapy with treatment of I/II aGVHD
PN Intervention : start 1 unit insulin for every 10g dextrose Monitor: glucose levels, sodium, potassium, and fluids
Responded well to corticosteroid therapy stool output decreased to less than 150 cc/dy Bilirubin stabilized and rash diminished
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+Nutrition Therapy - TPN transition Clear liquid diet ( 3 days)
Total bowel rest Use of PN until diarrhea subsides
GVHD diet Introducing lactose free, residue free, fiber free, and low fat
foods TPN weaned and discontinued by day +32
Intervention Stage II GVHD diet
low lactose, low fiber until day +100
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+Pt. Prognosis Recurrent Leukemia is main concern
Long term effects of AML treatment (CT, TBI, GVHD,BMT) Growth retardation, infertility, organ dysfunction, delayed
gastric emptying, catabolism, osteoporosis, growth suppression, poor wound healing, immunosuppression, infection
Monitor albumin levels
Take precautions to prevent infection
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Questions?
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+What is the purpose of high dose chemotherapy and total body irradiation (TBI) treatment before bone marrow transplant (BMT) in patients with AML?
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What are the required protein needs for an individual receiving a BMT?
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References Mahan, L. K., Escott-Stump, S., & Raymond, J. (2012). Krause\'s food & the nutrition care process. (13 ed., Vol. 1). St. Louis: W B Saunders Co. Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (2011). Nutrition therapy & pathophysiology. (2nd ed. ed.). Belmont, CA: Wadsworth, Cengage Learning.
Leukemia--acute myeloid (myelogenous). (2012). Retrieved from http://www.cancer.org/cancer/leukemia-acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-diagnosed Acute myeloid leukemia treatment. . (Master's thesis, University of California )Retrieved from http://www.ucsfhealth.org/conditions/acute_myeloid_leukemia/treatment.html Parrish, C. (2006, July). The hitchikers guide to parenteral nutrition management for adult patients. Retrieved from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/MadsenArticle.pdf The leukemia/bone marrow transplant program of bc. (2011). Retrieved from http://www.leukemiabmtprogram.org Acute myelogenous leukemia. (n.d.). Retrieved from http://www.mayoclinic.com/health/acute-myelogenous-leukemia/DS00548 Engraftment. In The Free Dictionary. Farlex. Retrieved from http://medical-dictionary.thefreedictionary.com/engraftment