MAJOR CASE STUDY: ACUTE LYMPHOBLASTIC LEUKEMIA Jenni Wolf, DI - - PowerPoint PPT Presentation
MAJOR CASE STUDY: ACUTE LYMPHOBLASTIC LEUKEMIA Jenni Wolf, DI Illinois State University UnityPoint Health Methodist March 2018 OUTLINE: I. Patient Introduction II. Review of PMH III. HPI IV. Acute Lymphoblastic Leukemia V.
ACUTE LYMPHOBLASTIC LEUKEMIA
Jenni Wolf, DI Illinois State University UnityPoint Health – Methodist March 2018
I. Patient Introduction
VII.Prognosis VIII.Review and Reflection
Patie tient: t: N.S. Age: e: 75 y.o. F Heig ight: t: 5’1” Weig ight: t: 210 lb (95.3 kg) BMI: : 40 Admit: mit: 01.30.18 Unit: t: Oncology/ICU LOS: S: 18 days Care e team am: : ICU, Oncology, Hematology, Nephrology, Nutrition, SLP, PT, OT, Wound, IV Pharm, Chaplain Dx Dx: : IT chemotherapy tx r/t acute lymphoblastic leukemia (ALL) – relapsed/transformed disease PMH: : CHF, afib, HTN
Nov. . 201 016
Stage IVB DLBCL (marrow only).
Dec.
6 – Apr. . 2017
R-CHOP, 8 cycles
Augus ust t 2017
PET scan. f/u bone marrow biopsy consistent w/ ALL. Began HyperCVAD/IT chemo
■ Acute e – rapid onset and progression ■ Lympho hoblas astic ic – immature white blood cells ■ Leukem kemia ia – bone marrow or blood ■ Rapid creation and proliferation of immature white blood cells (leukemic lymphoblasts) in the blood and bone marrow. ■ Etiology unknown – acquired vs. genetic
– Begins in bone marrow
■ Childhood vs. adult onset ■ Incidence: 6,000 new cases x 1 year ■ Anemia, neutropenia, thrombocytopenia ---> pancytopenia
https://www.cancer.gov/types/leukemia/patient/adult-all-treatment-pdq
https://orthoinfo.aaos.org/en/diseases--conditions/leukemia
■ Symptoms – Fatigue – Weakness – Dizziness – Fever – Chronic infections – Bruising easily – Bleeding at the gums or nose – Night sweats – Wt loss; decreased appetite ■ Treatment – 4 phases
1. Induction therapy 2. Consolidation therapy
3. Maintenance therapy 4. Preventative therapy
■ Chemotherapy or radiation ■ PRBC, platelets ■ MNT
– Neutropenic diet – High-energy, high protein
(1/30 – 1-31) ■ Admitted for final chemo cycle ---> C6 HyperCVAD/IT tx
HyperCVAD: Cyclophophamide Vincristine Sulfate Adriamycin Dexamethasone Methotrexate (MTX) also given intrathecally
■ Thrombocytopenia, hypomagnesemia r/t ALL + chemo ■ Lasix r/t chronic edema ■ Afib controlled with Beta-blocker; no anticoagulation therapy ■ MST 0; tolerating tx well; no new concerns
https://www.cancer.gov/publications/dictionaries/cancer- terms/def/intrathecal-chemotherapy
(2/1 – 2/5) Fever; er; PNA A w/ abx AKI; ; MTX toxicit icity Declining lining PO intake ake Cardia iac + R Renal al Consult lted ed Alter ered mental al status; CT unrem remarkab arkable le RRT r/t ment ntal al status, seizure re- like e activity; ivity; ICU trans ansfer er
■ MTX = essential component of chemo; used to treat a wide range of cancers ■ Interferes with folic acid metabolism – competitive inhibitor ■ Prevents synthesis of thymidine + purines, DNA ---> stops cell division ■ Risk for renal toxicity ■ Pathophysiology : MTX metabolite crystallization
– Blockage of renal tubules – Decreased renal flow, GFR – Reduced ability to clear MTX
■ MTX also associated with hepatotoxicity, neurotoxicity, mucositis
■ Frequent monitoring is essential
– Serum creatine, BUN – Serum MTX – Electrolytes – Urine output
■ Cornerstones of care:
– Hydration (2.5-3 L/day pre-tx) – Urine alkalinization(pH >7) – Leucovorin “rescue” (@ 24-36 hr)
Serum MTX Goals: 24 hr: ≤ 5.0 umol/L 48 hr ≤ 0.5 umol/L 72 hr ≤ 0.1 umol/L
▪ Dose: 12 mg ▪ Hydration: IVFs @ 50 mL/hr ▪ Bicarb infusion ▪ Started on Leucovorin ▪ Elevated BUN, creatine ▪ Low GFR (84 ---> 27) ▪ Nephrology following
7.61 61 umol/L /L x 24 hr hr
2.25 umol
L x 48 hr hr 0.59 9 umol/L /L x 5 d
Serum MTX Goals: 24 hr: ≤ 5.0 umol/L 48 hr ≤ 0.5 umol/L 72 hr ≤ 0.1 umol/L
(2/6-2/7) LOS assessmen ent: : NPO r/t dysphagi agia; a; TPN consult lt MTX toxic icit ity: 0.46 umol/L /L 0.29 umol/L /L Leucovo vorin rin, bicarb arb contin inues es
Thrombo bocytopenia penia
Encep ephalo halopath athy; Mucositis itis
Considerations:
■ No NG tube d/t thrombocytopenia ■ AKI – referred to renal for TPN volume ■ Energy needs: 1350 kcal, 42-48 g pro ■ Risk for refeeding ■ Electrolytes: elevated na+, low k+ ■ Multiple riders given x 24 hr
– 100 mEq KCL – 1 g mg++ – 1 g ca++
■ Monitor electrolytes , weight, plan of care Nutrit ritio ion n dx: Inadequate energy intake r/t ALL, chemo , dysphagia, encephalopathy as evidenced by NPO status, lab values. TPN Bag #1: 45/175/0 /0 775 kcal 12.9 kcal/k al/kg, g, 0.75 g/kg pro
(2/8-2/10) TPN continues inues; ; Pureed reed + nectar ar-thick ick MTX levels els @ goal Encep ephalo halopath athy impro roved ved at times es
■ Increased volume per Nephrology
– 730 mL --> 1030 mL --> 2000 mL
■ na+ remains elevated, despite minimum na+ given ■ k+, mg++, phos WNL ■ CMP, mg++, phos labs ordered TPN Bag #2: 45/175/50 875 kcal 14.6 kcal/kg, 0.75 g/kg pro TPN Bag #3 -#5: 45/180/100 992 kcal 16.5 kcal/kg, 0.75 g/kg pro
(2/11-2/14) NPO; TPN bags #5-#7 #7 RRT r/t hypoxemia, emia, lethar hargy gy BiPAP; PRBC C + P PLT trans ansfusio ion Pleural al effusio ion n via CXR
D5 @ 50 mL/hr hr
Fever; er; encephalop halopath athy
■ Increased protein needs – GFR improving ■ No riders given x 24 hr ■ Electrolyte trends:
– Na+ & phos trending towards high
– K+ high 2/11, low 2/14
■ D5 providing 204 kcal/d ■ TG lab ordered TPN Bag #6: 45/180/100 1086 kcal 18.1 kcal/kg, 0.83 g/kg pro TPN Bag #7: 55/190/150 1166 kcal 19.4 kcal/kg, 0.92 g/kg pro TPN Bag #8: 55/205/180 1277 kcal 21.3 kcal/kg, 0.92 g/kg pro
(2/15-2/16) Comfo fort rt care re measures res TPN d/c Trans nsfer fer to 7H Oncology gy
Phospho horu rus
Phospho horu rus Potas assiu ium
Phospho horu rus Potas assiu ium Magnes nesiu ium
Phospho horu rus Potas assiu ium GFR
■ Continued need for research
– AKI common with chemotherapy tx
Syndrome
■ Better prevention, prophylaxis
■ I feel the appropriate approach to MNT was taken with this patient: NPO ---> TPN ---> Puree + TPN ---> TPN ■ Opportunity to apply field knowledge in context of larger medical picture ■ Was able to gain interdisciplinary and ICU experience ■ Appreciated the opportunity to follow and work on a TPN for a length of time – Improved knowledge + confidence
Academy of Nutrition and Dietetics. (2013). Evidence analysis library: Oncology. Retrieved from https://www.andeal.org/topic.cfm?menu=5291 Dana-Farber Cancer Institute. (2018). Acute lymphoblastic leukemia (ALL). Retrieved from http://www.dana-farber.org/acute- lymphoblastic-leukemia-all/about/ Freeman, T. R. (2017). Leukemia. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/leukemia Howard, S.C., McCormick, J., Pui, C., Buddington, R.K., & Harvey, R.D. (2016). Preventing and managing toxicities of high-dose methotrexate. The Oncologist. http://dx.doi.org/10.1634/theoncologist.2015-0164 LaCasce, A.S. (2018). Therapeutic use and toxicity of high-dose methotrexate. Retrieved from https://www.uptodate.com/contents/therapeutic-use-and-toxicity-of-high- dose-methotrexate?csi=1bd7b7e6-4f10-4b7b-a7a8-7efb769704dd&source=contentShare May, J., Carlson, K.R., Butler, S., Liu, W., Bartlett, N.L., & Wagner-Johnson, N.D. (2014). High incidence of methotrexate associated renal toxicity in patients with lymphoma: A retrospective analysis. LeukLymphoma, 55, 6, 1345-1349. doi:10.3109/10428194.2013.840780 Mayo Clinic. (2017). Acute lymphocytic leukemia. Retrieved from https://www.mayoclinic.org/diseases-conditions/acute-lymphocytic- leukemia/symptoms-causes/syc- 20369077 PDQ Adult Treatment Editorial Board (2018). PDQ adult acute lymphoblastic leukemia treatment. Retrieved from https://www.cancer.gov/types/leukemia/patient/adult- all-treatment-pdq Raetz, E. (2018). Acute lymphoblastic leukemia. Retrieved from http://www.lls.org/leukemia/acute-lymphoblastic-leukemia The American Cancer Society Medical and Editorial Content Team. (2016). What is acute lymphocytic leukemia? Retrieved from https://www.cancer.org/cancer/acute- lymphocytic-leukemia/about/what-is-all.html The American Cancer Society Medical and Editorial Content Team. (2018). Key statistics for acute lymphocytic leukemia. Retrieved from https://www.cancer.org/cancer/acute- lymphocytic-leukemia/about/key-statistics.html Windpessl, M., Mayrbaeurl, B., Baldinger, C., Tiefenthaller, G., Prischl, F. C., Wallner, M., & Thaler, J. (2017). Refeeding syndrome in oncology: Report of four cases. World J Oncol, 8, 1, 25-29. https://doi.org/10.14740/wjon1007w
Special thanks to the UPHM RDs for a wonderful experience and for the opportunity to build my clinical care skills.