+ Acute Myelogenous Leukemia Olivia Wagner •Patient Hx. •Diagnosis •Etiology AML •Treatment Plan + •Medical/Surgical •Nutrition Therapy •Patient Response to Tx. •Patient Prognosis •Questions + 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 + 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 + 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 + Tx Plan - Bone Marrow Transplant Allogeneic Bone Marrow Transplant Day 0 HLA-matched sibling bone marrow Primary goal: replace destroyed bone marrow with healthy bone marrow stem cells graft versus tumor effect: stem cells develop into immune cells and identify the leukemia cells as invaders Engraftment: the process of transplanted cells reproducing new cells Monitor: weight, electrolyte levels, energy needs + 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 + 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 + 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 + Nutrition Therapy Parenteral Nutrition tube feeding is not successful due to severity of N/V, mucositis, delayed gastric emptying, and diarrhea. 4% amino acid Carbohydrate 16% dextrose 3% lipid 1700 mL 50 mEq 50 mEq 10 mEq 20 mmol 10 mL/day Fat PICC Potassium Two-in-one Sodium Flexibility Calcium Precipitate Phosphorus Energy: 30-35 Kcal/kg Protein: 1.5 grams/kg Fluids Needs Branchamin Mrs. Dean’s Needs Protein AML pt have low platelet count that increases risk of bleeding with enteral Nutrients Adult Multivitamin Adult Multimineral 1 mL/day + Pt. Response to Tx. Day +16 Day +20 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. 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 + 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 + 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 Questions? + + What is the purpose of high dose chemotherapy and total body irradiation (TBI) treatment before bone marrow transplant (BMT) in patients with AML? What are the required + protein needs for an individual receiving a BMT? 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/leukemiaacute-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/digestiv e-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://medicaldictionary.thefreedictionary.com/engraftment