Radiation Therapy: Nutritional Strategies to Improve Outcomes
Nutritional Support Antineoplastic Therapy Principles of IV Therapy BSN336.
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Transcript of Nutritional Support Antineoplastic Therapy Principles of IV Therapy BSN336.
Nutritional Support Antineoplastic Therapy
Principles of IV Therapy
BSN336
Nutritional Support
The care of individuals with potential or known nutritional alterations.
Nutritional Support
Goals of Parenteral nutrition include:• Provide all essential nutrients in adequate
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
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
Nutritional Deficiency• Body’s components are used to provide
energy for essential metabolic processes
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
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
Carbohydrates: provide energy• Glucose provides calories in parenteral sol.
• Spare body protein
Fats: primary source of heat and energy• 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
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
Electrolytes: infused as a component already contained in the amino acid solution or as an additive
Nutritional Requirements
Vitamins: necessary for growth and maintenance, multiple metabolic processes• Both fat and water soluble are needed
• Vitamin K can be given IM
Trace Elements: Basic requirements are very small but essential
Parenteral Nutrition Medication Additives
Insulin Heparin Histamine 2 (H2) Inhibitors
• Cimetidine, Pepsid, Reglan, Zantac
Admixture Complications
1. Amounts of Calcium and Phosphorus added
2. Phosphate Ions
3. Line should be flushed: incompatible components
4. Lipid emulsion: obscure presence of precipitates
Admixture Complications
5. Filter used for administration: 1.2 micron
6. Administered with in 24hr after mixing or removal from the refrigerator
7. If symptoms of acute respiratory distress, pulmonary embolus, or interstitial pneumonitis develop stop immediately, check for precipitates
Antineoplastic Therapy
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 treat2. 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
5. Therapeutic margin is the difference between the dose producing the desired benefit and the dose resulting in unacceptable toxicity.
6. The therapeutic margin is narrow compared with that of other types of drugs
Cell Cycle
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
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
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
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
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 • Stem cells: replenish the stem cell pool
• Nonstem cells: differentiate and enter the maturing groups of cells
Growth Fraction
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
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
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
Cell resistance to drug therapy can be natural or aquired.
Antineoplastic Agents
Classifications: classified according to the cell life cycle• Cell cycle phase-specific (CCS) agents
• Cell cycle phase-nonspecific (CCNS) agents
Combination Chemotherapy: Drugs given in specific combinations to work at different phases of the cell cycle
Antineoplastic Agents
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
Intermittent Therapy: Intermittent high-dose (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
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
Alkylating Agents: mustard Gas• 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• Folic acid antagonists, pyrimidine antagonists, purine
antagonists, and immunosuppresant azathioprine (Imuran)
Classes of Drugs
Mitotic Inhibitors: Natural products, modes of action are different• Vinblastine, vincristine, etoposide, taxol,
Cytotoxic Antibiotics: produced by the mold streptomyces• Bleomycin, Dactinomycin, Mitomycin
Topoisomerase-1 Inhibitors: activity against a broad range of tumors• Inhibit the enzyme topoisomerase-1 causing reversible
single strand DNA breaks
Classes of Drugs
Miscellaneous:• Altretamine
• L-Asparaginase
• Cladribine
• Hydroxyurea
• Mitotane
• Hormonal agents
Classes of Drugs
Hormones and Hormone Antagonists:• Steroidal estrogens, progestins, androgens,
corticosteroids and synthetic derivatives Biotherapy: six categories
• Cytokines
• Monoclonal antibodies,
• Differentiation agents
• Cellular therapies
• Immunostimulants
• Gene thereapy
Short term Complications
Venous Fragility Alopecia Diarrhea Constipation Altered Nutritional Status Anorexia and Alteration in Taste Fatigue
Acute Reactions
Hypersensitivity and Anaphylaxis Extravasation Stomatitis and Mucositis Nausea and Vomiting Myelosupression Neutropenia Thrombocytopenia Anemia
Toxicities
Neurotoxicity Cardiac Toxicity Pulmonary Toxicity Renal Toxicity
Routes of Administration
Intravenous Intrathecal Regional Intra-arterial Intraperitoneal Cerebrospinal Fluid Reservoirs Infusion Pumps