A Case Study: Astrocytoma
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ASTROCYTOMA
Victoria Parry, Dietetic InternJune 9, 2010
Astrocytoma
Astrocytomas normally develop in the cerebrum but can originate in other parts of the brain and spinal cord.
Star-shaped glial cells located in the brain and spinal cord (CNS)
Function: Regulate external chemical environment of neurons; blood flow in brain
Astrocytes
Stages of Astrocytoma
Stage 1: Pilocytic Astrocytoma
Stage 2: Diffuse Astrocytoma
Stage 3: Anaplastic Astrocytoma
Stage 4: Glioblastoma Multiforme (GBM) Gliosarcoma Giant Cell Glioblastoma
(1)
Examples of Astrocytomas
Low-grade Astrocytoma Giant Cell Astrocytoma
(2)
Cause of Astrocytoma
Currently unknown Cell phones Prophylactic Radiation
for Acute Lymphatic Leukemia
Genetics Family history of
astrocytoma Molecular Mutation
(3)
Prevalence
Male predominance 1.18:1 Low-grade 1.87:1 Anaplastic (Grade
III)
Affects all ages 10% less than 20 years 60% 20-45 years 30% 45 years or older
Gender Age
Mortality and MorbidityRace
Affects all races Grade 1: 10 years Grade 2: More than 5 years Grade 3: 2-5 years Grade 4: Less than 1 year
(3)
Symptoms
Altered development or growth (in children)
Double Vision Drowsiness Eyesight Problems Headache Lethargy Mental Status Change Obtuseness Personality Changes Seizures Vomiting
(1,4)
Diagnosis and Treatment
Testing: Neurological Exam
Vision Hearing Balance Coordination
Computed Tomography Scan (CT)
Magnetic Resonance Imaging (MRI)
Angiogram Biopsy
Treatment Options:
Surgery Resection of
tumor Radiation Chemotherapy
Temozolomide
(1, 2, 3, 5)
Case Study Patient Information• Admit Diagnosis: Aspiration Pneumonia,
Dehydration, Sepsis • Sex: Female• Age: 36 Years Old• Weight: 157#• Height: 5’0”• BMI: 31• Ideal Body Weight: 90-110#• Percent Ideal Body Weight: 157%• Adjusted Body Weight: 114#• Home Diet Regimen: G-Tube with Jevity Bolus 5
Cans Daily
Past Medical History
Astrocytoma 1987: Cerebral Astrocytoma
Surgery 1992: Repeat Brain Surgery
Pituitary Insufficiency Post radiation treatment
Seizure Disorder Post brain surgery
Hypothyroidism Pneumonia Gastrostomy Tube Placement
2006
Social History
Resides with mother and other family
Bed bound last 3-4 years
Home Health Care Aide Three times daily
Nonverbal
Relevant Medications
Os-Cal: Calcium supplement. Also used as antacid, phosphate binder, antidiarrheal
Prilosec: Proton Pump Inhibitor. Used to decrease gastric acid secretion and increase gastric pH
Lactinex: Lactobacillus probiotic. Used to aid with GI regulation and antidiarrheal
Zofran: Antiemetic. Used to decrease vomiting
Flagyl: Antibiotic used to treat C. diff. Can cause nausea, diarrhea, anorexia, taste changes
(6)
Laboratory Values
Date Hgb12-18
Hct37-47
MCV82-101
Na+135-155
K+3.5-5.5
Gluc.70-120
BUN8-26
Creat..6-1.3
Ca+8.7-10.2
4/18 16.4 49.2 81.8 141 4.4 86 12 0.9 9.1
4/19 14.2 42.1 80.7 135 3.4 97 10 0.9 8.5
4/20 12.3 35.9 80.9 140 3.8 84 5 0.6 8.2
4/21 N/A N/A N/A 145 2.9 73 1 0.6 8.0
4/22 11.4 33.0 79.5 N/A N/A N/A N/A N/A N/A
4/23 N/A N/A N/A 145 2.9 90 2 0.6 8.0
4/24 12.6 37.0 79.8 141 3.4 102 6 0.6 7.7
4/25 12.3 37.0 81.6 143 3.4 86 8 0.5 7.9
4/26 12.6 37.9 82.3 N/A N/A N/A N/A N/A N/A
Laboratory ValuesDate Alb
3.4-5.0Alk Phos50-136
SGOT7-47
PO42.5-4.9
RBC4.2-5.4
WBC4-10.5
Cl-96-107
4/18 N/A N/A N/A N/A 6.01 16.2 100
4/19 2.4 339 43 3.2 5.21 18.4 102
4/20 N/A N/A N/A N/A 4.44 12.4 107
4/21 N/A N/A N/A N/A N/A N/A 108
4/22 2.2 232 63 N/A 4.16 7.7 N/A
4/23 2.5 257 58 N/A N/A N/A 107
4/24 2.3 189 32 N/A 4.63 16.7 106
4/25 2.2 187 18 N/A 4.53 14.7 109
4/26 N/A N/A N/A N/A 4.60 13.4 N/A
Dietary Trigger
Dietary Consult for Tube Feeding Recommendation
Moderately Depleted Albumin Level of 2.4 and Pre-albumin Level of 11.6
PES Statements
(NC-1.1) Swallowing difficulty related to dysphagia and past medical history as evidenced by patient needing Gastrostomy Tube for main nutrition and hydration support.
(NI-5.1) Increased protein needs related to increased demand for protein as evidenced by moderately depleted albumin level of 2.4 and pre-albumin level of 11.6. (7)
Interventions
Await restart of tube feedings
Recommend necessary adjustments to tube feeding rate and fluids
Monitor tolerance of tube feeding
Energy, Protein, and Fluid Needs*
Estimated Energy Needs: 1266 (BEE) x 1.2 x 1.1= 1,671 kcals
Estimated Protein Needs: 1.2-1.3g/kg= 62-68g
Estimated Fluid Needs: 35mL/kg= 1,820mL
*All needs based on Adjusted Body Weight of 114#
Tube Feeding Recommendations
Jevity 1.5 at 30cc/hr
Provides: 1,080 kcals 46g protein 16g fiber 547cc free water
IV Fluid 100cc/hr
Jevity 1.5 at 50cc/hr Provides:
1,800 kcals 77g protein 26g fiber 912cc free water 100% RDI’s vitamins and
minerals IV Fluid KVO Water Flushes 200cc QID
Initial MD Order RD Recommended Order*
*RD recommendation based on Adjusted Body Weight of 114#
Tests and Procedures
Chest X-Ray
Kidney, Ureters, Bladder X-ray (KUB)
Abdominal Ultrasound
Conversion G-Tube to G-J Tube
Abdominal CT Scan with Contrast
Diet Orders
Tube Feeding via G-Tube Jevity 1.5 at 30cc/hr Held due to projectile vomit
Gatorade via G-Tube 30cc/hr Held for testing
Tube Feeding via G-J Tube Jevity 1.5 at 40cc/hr
Discharge Notes
April 26, 2010
Approximate 15# Weight Gain Positive Fluid Balance
Discharge to home Continue with Home Health Care
Medical follow ups in two-three weeks
Resume Jevity bolus of 5 cans daily
Questions?
Works Cited
1. Astrocytoma. Astrocytoma. 2007. Available at: http://www.astrocytoma.org/. Accessed June 1, 2010.
2. Glioma. Mayo Clinic. April 2010. Available at: http://www.mayoclinic.org/glioma/. Accessed June 1, 2010.
3. Kennedy B, Bruce JN. Astrocytoma. eMedicine Oncology. January 23, 2009. Available at: http://emedicine.medscape.com/article/283453-overview. Accessed June 2, 2010.
4. Brain tumor-primary-adults. Medline Plus Medical Encyclopedia. May 7, 2010. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/007222.htm. Accessed June 5, 2010
5. Adult brain tumor treatment. National Cancer Institute. October 13, 2009. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/adultbrain/HealthProfessional/page7. Accessed June 4, 2010.
6. Pronsky ZM. Food Medication Interactions. 15th Ed. Birchrunville, PA: Food-Medication Interactions; 2008.
7. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd Ed. Chicago, IL: American Dietetic Association; 2009.
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