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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

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Acute Myelogenous Leukemia

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  1. Acute Myelogenous Leukemia Olivia Wagner

  2. Patient Hx. Diagnosis Etiology AML Treatment Plan Medical/Surgical Nutrition Therapy Patient Response to Tx. Patient Prognosis Questions

  3. 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

  4. 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

  5. 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

  6. Tx Plan - Bone Marrow Transplant • AllogeneicBone Marrow Transplant • Day 0 • HLA-matched sibling bone marrow • graft versus tumor effect: stem cells develop into immune cells and identify the leukemia cells as invaders • Primary goal: replace destroyed bone marrow with healthy bone marrow stem cells • Engraftment: the process of transplanted cells reproducing new cells • Monitor:weight, electrolyte levels, energy needs

  7. 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

  8. 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

  9. 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

  10. Parenteral Nutrition • tube feeding is not successful due to severity of N/V, mucositis, delayed gastric emptying, and diarrhea. • AML pt have low platelet count that increases risk of bleeding with enteral • PICC • Two-in-one • Flexibility • Precipitate • Needs • Energy: 30-35 Kcal/kg • Protein: 1.5 grams/kg • Branchamin Nutrition Therapy

  11. Pt. Response to Tx. •  Day +16 • 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. • Day +20 • 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

  12. 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

  13. 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

  14. Questions?

  15. What is the purpose of high dose chemotherapy and total body irradiation (TBI) treatment before bone marrow transplant (BMT) in patients with AML?

  16. What are the required protein needs for an individual receiving a BMT?

  17. 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/leukemia-acute-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/digestive-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://medical-dictionary.thefreedictionary.com/engraftment

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