Transcript Acute Myelogenous Leukemia

+
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