Transcript Nutritional Support Antineoplastic Therapy

Nutritional Support
Antineoplastic Therapy
Principles of IV Therapy
BSN336
Nutritional Support
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The care of individuals with potential or
known nutritional alterations.
Nutritional Support
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Goals of Parenteral nutrition include:
• Provide all essential nutrients in adequate
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amounts to sustain nutritional balance during
periods when oral or eteral routes of feedings
are not possible or are insufficient to meet the
patient’s caloric needs.
Preserve or restore the body’s protein
metabolism and prevent the development of
protein or caloric malnutrition
Nutritional Support
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Diminish the rate of weight loss and to
maintain or increase body weight.
Promote wound healing
Replace nutritional deficits
Concepts of Nutrition
Nutritional balance depends on 3 things:
 Intake of nutrients (Quantity and Quality)
 Relative need for nutrients
 Ability of the body to use nutrients
Concepts of Nutrition
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Nutritional Deficiency
• Body’s components are used to provide
energy for essential metabolic processes
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Malnutrition
• Nutritional deficit associated with an
increased risk of morbidity and mortality
Concepts of Nutrition
Three types of Malnutrition:
 Marasmus – decrease in the intake of calories
with adequate protein calorie ratio. Gradual
wasting
 Kwashiorkor – adequate intake of calories
along with a poor protein intake.
 Mixed Malnutrition – characterized by aspects
of both Marasmus, and kwashiorkor
Nutritional Assessment
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Mild malnutrition: 85 to 95 % IBW
Moderate malnutrition: 75 to 84% IBW
Severe Malnutrition: less than 75% IBW
Biochemical Assessment:
• Serum Albumin and Transferrin Levels
• Prealbumin and Retinol-Binding protein
• Total Lymphocyte Count
• Serum Electrolytes
Nutritional Requirements
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Carbohydrates: provide energy
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Glucose provides calories in parenteral sol.
Spare body protein
Fats: primary source of heat and energy
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Essential for the structural integrity of all cell
membranes
Fewer problems with glucose homeostasis, carbon
dioxide production is lower, hepatic tolerence may
improve
EFAD – Essential Fatty Acid Deficiency
Nutritional Requirements
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Protein: body-building nutrient, functions
to promote tissue growth and repair and
replacement of body cells.
• Amino Acids are the basic units of protein
• 8 essential Amino Acids needed by adults
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Electrolytes: infused as a component
already contained in the amino acid
solution or as an additive
Nutritional Requirements
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Vitamins: necessary for growth and
maintenance, multiple metabolic
processes
• Both fat and water soluble are needed
• Vitamin K can be given IM
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Trace Elements: Basic requirements are
very small but essential
Parenteral Nutrition Medication
Additives
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Insulin
Heparin
Histamine 2 (H2) Inhibitors
• Cimetidine, Pepsid, Reglan, Zantac
Admixture Complications
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Amounts of Calcium and Phosphorus
added
Phosphate Ions
Line should be flushed: incompatible
components
Lipid emulsion: obscure presence of
precipitates
Admixture Complications
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Filter used for administration: 1.2
micron
Administered with in 24hr after mixing
or removal from the refrigerator
If symptoms of acute respiratory
distress, pulmonary embolus, or
interstitial pneumonitis develop stop
immediately, check for precipitates
Antineoplastic Therapy
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Goal of therapy:
• Curative: given as primary therapy
• Palliative: symptom management
Antineoplastic Therapy
Basic considerations in chemotherapy
treatment:
1. Smaller the tumor burden the easier the
patient is to treat
2. Surgical dubulking decreases the tumor
burden and recruits resting malignant cells
to start dividing, thereby increasing the
sensitivity to chemotherapy.
3. The higher the dose, the better the chance
for response
Antineoplastic Therapy
4. Doses are altered based on the degree of
toxicity the patient experiences
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Therapeutic margin is the difference between
the dose producing the desired benefit and
the dose resulting in unacceptable toxicity.
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The therapeutic margin is narrow compared
with that of other types of drugs
Cell Cycle
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Chemotherapy exerts a cytotoxic action
by interfering with the reproductive cell
cycle
Cancer cells are the intended target, but
cytotoxic action also affects normal cells
Cell Cycle
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Five phases complete the cell growth
cycle: G0, G1, S, G2, and M
G refers to gap phases or the time when
the cell is preparing for a more active
phase of reproduction
Cells can be come resting and
nondividing
Cell Cycle
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G1: the first growth phase characterized
by the production of RNA, enzymes and
proteins, essential to later cycles
S phase: enzymes necessary for DNA
synthesis increase in activity.
Predominant event is the production of
DNA, the genetic code of all information
needed for cell life.
Cell Cycle
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G2: another resting phase, Tna and protein
necessary for mitosis are synthesized.
M phase: last phase, mitosis takes place, lasts
about ½ hour to 1 hour.
The phases of the cell cycle are correlated to
the efficacy of the antineoplastic agents for
specific types of cancer
Most agents kill only cells that are actively
reproducing,
Tumor Kinetics
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Cycling cells: cells that are dividing
continuously
Nondividing cells: cells that divide for a time
and then complete their life cycle with out
dividing again
G0 or resting cells: further divided into
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Stem cells: replenish the stem cell pool
Nonstem cells: differentiate and enter the maturing
groups of cells
Growth Fraction
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Cell cycle time: amount of time required
to move from one mitosis to another
Growth fraction: percentage of cycling
cells in the entire cell population
Total number of cells
Rate of cell loss or the number of cells
that die or leave the cell population
Doubling Time
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As the tissue mass increases in size, the
doubling time slows
Decrease in nutrition available for each
cell as the total mass increases and
blood supply is outgrown
Tumor cells may die spontaneously
Cell Kill Hypothesis
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Certain drugs doses destroy a constant
fraction of tumor cells in the body, rather
than a constant number of cells
Cell kill caused by antineoplastic drugs is
related to the relative growth fraction of
the tumor at the time of treatment
Drug Resistance
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Cell resistance to drug therapy can be
natural or aquired.
Antineoplastic Agents
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Classifications: classified according to
the cell life cycle
• Cell cycle phase-specific (CCS) agents
• Cell cycle phase-nonspecific (CCNS) agents
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Combination Chemotherapy: Drugs
given in specific combinations to work at
different phases of the cell cycle
Antineoplastic Agents
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Reductive Therapy: debulking,
decreases the body burden of cancer
cells
Adjuvant Chemotherapy:
administration of chemotherapy to
destroy micrometastasis and to prevent
secondary tumors
Antineoplastic Agents
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Intermittent Therapy: Intermittent highdose (pulse) therapy with CCS and
CCNs agents gives better therapeutic
results with fewer toxic side effect than
more frequent divided doses. Yields
better cell kill.
Antineoplastic Agents
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Chemotherapy Dosing:
• Dose calculations using Body Surface Area
(BSA)
• Formula: BSA x mg/m2 = total dose
• Dose Calculation using the Calvert Formula
• Attempts to individualize the does so that optimal
therapeutic response is achieved without toxic
effects
Classes of Drugs
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Alkylating Agents: mustard Gas
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Effect the DNA thereby blocking replication
CCNS act at any stage
Antimetabolites: Low molecular weight
compounds that exert their effect because of
similarity to naturally occurring metabolites
involved in nucleic acid synthesis
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Folic acid antagonists, pyrimidine antagonists, purine
antagonists, and immunosuppresant azathioprine
(Imuran)
Classes of Drugs
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Mitotic Inhibitors: Natural products, modes of
action are different
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Cytotoxic Antibiotics: produced by the mold
streptomyces
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Vinblastine, vincristine, etoposide, taxol,
Bleomycin, Dactinomycin, Mitomycin
Topoisomerase-1 Inhibitors: activity against a
broad range of tumors
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Inhibit the enzyme topoisomerase-1 causing reversible
single strand DNA breaks
Classes of Drugs
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Miscellaneous:
• Altretamine
• L-Asparaginase
• Cladribine
• Hydroxyurea
• Mitotane
• Hormonal agents
Classes of Drugs
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Hormones and Hormone Antagonists:
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Steroidal estrogens, progestins, androgens,
corticosteroids and synthetic derivatives
Biotherapy: six categories
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Cytokines
Monoclonal antibodies,
Differentiation agents
Cellular therapies
Immunostimulants
Gene thereapy
Short term Complications
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Venous Fragility
Alopecia
Diarrhea
Constipation
Altered Nutritional Status
Anorexia and Alteration in Taste
Fatigue
Acute Reactions
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Hypersensitivity and Anaphylaxis
Extravasation
Stomatitis and Mucositis
Nausea and Vomiting
Myelosupression
Neutropenia
Thrombocytopenia
Anemia
Toxicities
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Neurotoxicity
Cardiac Toxicity
Pulmonary Toxicity
Renal Toxicity
Routes of Administration
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Intravenous
Intrathecal
Regional
Intra-arterial
Intraperitoneal
Cerebrospinal Fluid Reservoirs
Infusion Pumps