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