Refeeding Syndrome in Tongue

Cancer:
A Major Case Study
Kirsten Voss
ISU Dietetic Intern, Class of 2017
Outline and Objectives
Outline
Objectives
1. Basic patient info
Gainbasic understanding of head
2. Head and Neck Cancer
and neck cancers, including MNT
3. Refeeding Syndrome recommendations.
4. Timeline of Care
Understand the causes, risk
5. Review Coordination of Care factors, prevention steps, and
6. Initial Assessment treatment of refeeding
syndrome.
7. Nutrition Follow Ups
Assessnutrition care provided to
8. Discharge Plans
post-hemiglossectomy patient.
9. Reflection
Patient Information
Name: CM
79 YO white male
2daughters; 1 granddaughter
55 (1.651 m)
who assists with care
Admit weight: 136 lbs (61.689 kg)
Drug Use History
BMI 21.6, normal
Based on 130 lbs (58.968 kg) at initial
Former smoker of 2 packs/day x
assessment 2/1 40 years; quit in 2000
Admit 1/31/17 to 4 Ham Surgical Floor Chewed tobacco/snuff in 1950s

Lives Smoked pipes

alone in own home
No alcohol or other drug use
Uses walker
Supplemental O2 at home
Patient Information
Reason for
Admit: Prior Medical History Surgical History
Hyperlipidemia Laser hemiglossectomy
Hypertension 1/31/17 by Dr. Lansford
Atrial fibrillation Hernia repair
COPD Abdominal aortic
Thyroid disease aneurysm repair
Tongue cancer Stented
Previous Caridac catheterization
chemotherapy 4 heart stents
and Cholecystectomy
Hemiglossecto radiation

my
Patient Information
MST 2: unintentional weight
loss of unsure amount
Weight History
10 lb (7.1%) weight loss in 1
year
3 lb (2.3%) weight loss in 6
months
Medications
Simvastatin, Symbicort, Coreg,
Cleocin IV, Digoxin, Pepcid,
Lisinopril, Duragesic patch,
Synthroid, Flomax, Peridex, low
dose aspirin
Warfarin at home; held for
surgery
Head and Neck Cancers
Esophageal, hypopharyngeal, Risk factors
Highest incidence in black males
laryngeal, lip, oral cavity, Tobacco linked to 85% of cases
parathyroid, salivary glands Heavy alcohol use
Tongue cancer = most common Obesity
type of mouth cancer Male
Older than 50 years
3-5% of all cancer cases in US Chronic inflammation from gastric acid
exposure
Metastases to cervical lymph Radiation to head and neck
nodes HPV
Prognostic indicator Sun exposure (lip cancer)
Industrial exposures
Asbestos exposure
Head and Neck Cancers
Medical treatment
Multi-modalities Symptoms with nutritional
Surgery impact
Often with lymph node dissection Anorexia
Radiation Dysphagia
Chemotherapy
Xerostomia
Many patients malnourished Mucositis

before treatment Stomatitis

25-60% of oropharyngeal Poor dentition
cancer patients Dysgeusia

Severe Early satiety

weight loss in 58% of
Poor wound healing
cases
Fistulas
Head and Neck Cancers
Nutrition intervention
Meet needs w/ TF as needed
Transition to full or partial PO
intake
Modify diet for dysphagia
Adequate fluid intake
Prevent/improve deficiencies
Meet nutrition needs
30-35 kcal/kg
1.0-1.5 grams protein/kg
Minimize risk of refeeding
10 kcal/kg per day to start
Pre- and post-op arginine
supplement?
EAL
No significant wt change or body
comp
No impact on immune function
EPA-enhanced medical food
supplement?
EAL
No evidence of decrease in post-op
complications
1 study showed supplement led to
weight gain, but no difference in fat-
free mass or complications
About Refeeding Syndrome
Metabolic
abnormalities associated with rapid initiation of
adequate nutrition after period of prolonged undernourishment
Nutrition support
Usually occurs within 4 days

Rapid CHO intake insulin surge, glucagon plunge rapid

cellular uptake of glucose intracellular electrolytes driven into
cells low serum levels severe complications (cardiac,
pulmonary)
surge decreases renal excretion of Na and water fluid
Insulin
retention
Serum electrolytes may be normal in undernutrition
Contraction of intracellular compartment
About Refeeding Syndrome
Complications High Risk
Heart failure Anorexia nervosa
Arrhythmias Alcoholism

Seizures Chronic underfeeding

Cardiac arrest Hepatic failure

Increased HR, BP Malabsorption from GI damage

High O2 consumption, CO2 Obesity with massive weight

production loss
Fluid overload Oncology patients

Wernickes encephalopathy PEM

Death Prolonged fasting

Respiratory alkalosis
Criteria from the guidelines of the National Institute
for Health and Clinical Excellence for identifying
patients at high risk of refeeding problems:

Either the patient has one or
more of the following:
Body
mass index (kg/m2) <16
Unintentionalweight loss >15% in
the past three to six months
Little or no nutritional intake for >10
days
Lowlevels of potassium, phosphate,
or magnesium before feeding
Or the patient has two or more
of the following:
Body mass index <18.5
Unintentional weight loss >10% in the
past three to six months
Little or no nutritional intake for >5
days
Historyof alcohol misuse or drugs,
including insulin, chemotherapy,
antacids, or diuretics
Refeeding Syndrome Intervention &
Prevention
Start nutrition support slowly
15-20 kcal/kg first 3 days
Protein 1.2 g/kg, work up to 1.5 Electrolyte correction
g/kg IV replacements
150-200 g CHO Mg, Phos, K
May need fluid restriction 800- Correct before feeding
1000 mL Insulin for hyperglycemia
Work up to goal rate by day 7
Low infusion rates Thiamine boluses
Timeline Summary
Date
1/31/1 Pt admitted, laser hemiglossectomy completed by Dr. Lansford
7
2/1/17 Initial assessment; TF trickle feeds initiated via NGT; goal rate 32 mL/hr
2/2/17 PEG tube placed; work up to continuous goal rate of 32 mL/hr
2/3/17 MD consult to increase TF rate and transition to bolus feeds; goal rate of 32
mL/hr
2/4/17 Weekend: seen by Tracy Anderson, RD; Phos rider given
2/5/17 Weekend: seen by Tracy Anderson, RD; increased goal rate to 38 mL/hr
2/6/17 Increased goal rate to 45 mL/hr
2/7/17 MD increased goal rate to 55 mL/hr; switched to bolus feeds with increased
formula volume
2/8/17 Continued bolus feeds
2/9/17 Met with Pt and granddaughter about home plan; Pt D/C in afternoon
3/1/17 Follow up phone call to granddaughter and Option Health
Coordination of Care
RD Team: Tracy Anderson, Kim Kelley, Tracy
Trebian
RN Team: Britney, Abby, Misty, Sally
Case Manager: Susan
MD Team: Dr. Lansford, Dr. Geraughty,
Dr. Gootee, Dr. Reddivari
Option Health home infusion services:
Tammie
Family Support: granddaughter
Initial Assessment: 2/1/17
RD consult to start trickle tube feeding (TF) via nasogastric tube (NGT)
Diet order: NPO except sips with meds
IVF D5 0.45% NaCl w/ KCl 20 mEq at 100 mL/hr
Labs: BUN 22, GLU 103
Pt interview:
Usual body weight: 131 lbs
Hardly ate at all 1 month PTA due to tongue pain , <50% of usual intake
Felt like lost weight, unsure of amount or time period
No oral supplements at home

TF held midnight 2/2/17 for upcoming G-tube placement

Nutrition
Diagnosis: Inadequate oral intake related to tongue cancer as
evidenced by patient report of <50% of usual PO intake during past month and
recent hemiglossectomy.
Initial Assessment: 2/1/17
Calorie, Protein, Fluid Needs based on 58.968 kg actual wt
Calories: 18-20 kcal/kg short term goal for refeeding risk
1061-1179 kcal/day
Calories: 30-35 kcal/kg long term goal rate for nutritional adequacy
1769-2064 kcal/day
Protein: 1.0-1.3 g/kg
59-77 gm protein/day
Fluids: 25-30 mL/kg
1474-1769 mL/day
Initial Assessment: 2/1/17
Intervention:
Trickle feeds of Jevity 1.5 via NGT at rate of 10 mL/hr. Continue trickle
feed until NPO order with holding of TF goes into effect at midnight 2/2.
When TF restarted, initiate at rate of 10 mL/hr. Advance gradually to
short term goal rate of 32 mL/hr x 23 hours per MD approval. Short
term goal rate to provide 736 mL formula, 1104 kcal, 47 gm protein,
559 mL free water. (18.7 kcal/kg, 0.8 gm pro/kg)
Taper off D5 as TF increased
D5 at 100 mL/hr providing 408 kcal
Add flushes if IVF tapered off or D/C
Follow Up 1: 2/2/17
PEG tube placed in AM
Trickle feeds restarted at 10 mL/hr
IVF 0.9% NaCl at 75 mL/hr
D5 D/C 2/1 PM
No new labs; labs ordered
Non-pitting edema RLE, LLE
RD
goal rate of 32 mL/hr x 23 hrs vs
MD goal rate of 65 mL/hr x 23 hrs
Discussed with RN
Continued with 32 mL/hr x 23 hrs
Follow Up 2: 2/3/17
TF follow up and MD consult to increase TF rate and transition to bolus feeds
Unclear when 32 mL/hr rate achieved, estimated 6:00AM
Labs drawn 6:13 AM
Phos: 2.1, low
Labs not indicative of TF tolerance at goal
Synthroid via PEG hold TF 1 hr before and after feeding
Goal TF rate x 22 hours
IVF 0.9% NaCl at 75 mL/hr
Intervention: continue feeds of Jevity 1.5 via PEG tube at rate of 32 mL/hr x 22
hours
17.9 kcal/kg
0.76 gm pro/kg
Follow Up 3: 2/4/17 (weekend)
Phos 1.6, low
Tracy Anderson, RD requested Phos rider
10 mmol NaPhos given in PM
Delaying advancing TF rate until Phos WDL
Continuing with goal rate of 32 mL/hr x 22 hrs
Follow Up 4: 2/5/17 (weekend)
Phos 2.3, low
Increase TF rate to 38 mL/hr x 22 hours
21.3 kcal/kg
0.9 gm pro/kg

Residuals <15 mL
Follow Up 5: 2/6/17
Phos 2.8, WDL OptionHealth home infusion
Trending up after weekend Phos rider services
Residuals <15 mL Intervention:
increase TF rate to 45
8.4 lb (3.8 kg) wt increase mL/hr x 22 hrs
Fluid retention? 25 kcal/kg
Non-pitting edema RLE, LLE 1.07 gm pro/kg

SOB and a-fib overnight Intervention:additional flushes

Treated w/ med adjustments, Lasix dose, needed due to IVF D/C
IVF D/C 160 mL flushes 4x daily to
Back on Warfarin, Lasix started provide additional 640 mL
Manual flushes + flush protocol
1x Ativan given extreme drowsiness
+ formula fluid = 1512 mL
Follow Up 6: 2/7/17
Phos 2.8 WDL
Residuals <5 mL
Non-pitting edema RLE, LLE
AM order from MD to increase rate to 55 mL/hr x 22 hours
Discussed switch to bolus feeds with RN and MD
Confirmed switch to bolus instead of establishing 55 mL/hr rate

Intervention: Bolus feed/flush recs

240 mL 5x daily staggered by 3-4 hours
30.5 kcal/kg
1.3 gm pro/kg
30 mL flushes before and after each bolus
75 mL flushes 4x daily between bolus feeds
Follow Up 7: 2/8/17
Phos 3.2 WDL RN discussion
Tolerating bolus w/ residuals <10 mL Tube clogged AM after meds
Non-pitting
Concern about Flomax
edema RLE, LLE
Switch to 150 mL flushes 2x
RNteaching Pt and granddaughter
day?
how to flush tube and give bolus
feeds Total
daily bolus feeds: 1200
Pt interview mL Jevity 1.5 (5 cans/day)
Normally takes synthroid immediately
after waking up Total daily flushes: 600 mL
Waits >1 hr to eat after Flushes + formula = 1512 mL
Feelings of fullness after boluses fluid daily
not too bad
Follow Up 8: 2/9/17
Pt continuing to learn and practice giving bolus feeds and flushes
Spoke with Pt and granddaughter before D/C
Reviewed suggested feeding and flush schedule
Nutrition Focused Physical
Assessment
Visible orbital fat pads
Ample fat pinched on triceps
Visible and palpable temporal scooping
Clavicle protruding, indentations surrounding
Acromion process protruding
Shoulder squared off
Edges of scapula visible
Moderate depression of interosseous region on back of hand
Indications: moderate muscle loss in temporalis, trapezius, interosseous, clavicle,
pectoralis major.
Poor nutrition status indicated from NFPA being addressed with current TF recs
calculated to meet Pts caloric and protein needs
Discharge Plan
D/C to home Hopeful return to oral
Ptto give own bolus feedings intakes
with 30 mL flushes before/after Phonecall follow up 3
Granddaughter to give meds weeks after D/C
and flushes in AM and PM Concern about weight loss,
128 lbs
OptionHealth home infusion 2 lb lower than initial
services assessment (130 lb)
Post-surgical
follow up 9 lb lower than D/C (137 lb)
appointments with MD Tongue healing
Worn out with SOB
SLP therapy at home 1x/week
All else alright
Speech first, swallow later
Reflection
Learned?
TF initiation and advancement
Transition from continuous bolus for at home
Care coordination

Challenges?
Completed care during Weeks 4-5
MDs wanting to ramp up TF too quickly

Done differently?
Completed NFPA during initial assessment
Diagnosed malnutrition
Ordered complete labs sooner
Should have ordered Phos, Mg on 2/1, instead of 2/2
Correct hypophosphatemia before feeding
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