Nutrition

Cancer chemotherapy via ambulatory infusion pump..AbstractOne hundred twenty-four patients with metastatic malignancy were treated with four different single agent infusion programs by constant intravenous infusion for 30 or more days. Drug was administered via a tunneled subclavian line by a battery-driven peristaltic pump (Cormed model ML6) on an ambulatory basis. This schedule allowed for increased cumulative drug dose for 5-Fu, decreased tolerated dose for vinblastine, and comparable doses for adriamycin and mitomycin-C relative to that delivered with the standard intermittent bolus schedule. Therapeutic effects were observed for three of four drugs studied: 5-Fu 13/31 colorectal cancer; adriamycin 7/29; and vinblastine 4/12, including 2/4 melanoma. Adverse effects were significantly reduced, particularly with regard to gastrointestinal toxicity, but also in adriamycin-associated cardiac effects and hair loss. Phase III comparative trials of intermittent bolus therapy with protracted infusion therapy are in progress for 5-Fu in advanced colorectal cancer and for adriamycin in specific tumors. Ambulatory pump infusion (API) chemotherapy is technically feasible and has improved patient tolerance to chemotherapy while demonstrating similar, if not comparable, antitumor effects.

Normally, your cells grow and die in a controlled way. Cancer cells keep forming without control.

Chemotherapy is drug therapy that can kill these cells or stop them from multiplying. However, it can also

harm healthy cells, which causes side effects.

During chemotherapy you may have no side effects or just a few. The kinds of side effects you have

depend on the type and dose of chemotherapy you get. Side effects vary, but common ones are nausea,

vomiting, tiredness, pain and hair loss. Healthy cells usually recover after chemotherapy, so most side

effects gradually go away.

Your course of therapy will depend on the cancer type, the chemotherapy drugs used, the treatment goal

and how your body responds. You may get treatment every day, every week or every month. You may

have breaks between treatments so that your body has a chance to build new healthy cells. You might

take the drugs by mouth, in a shot or intravenously.

Good nutrition is especially important if you have cancer because both the illness and its treatment can affect your

appetite. Cancer and cancer treatments can also affect your body's ability to tolerate certain foods and use nutrients.

This guide can help you and your loved ones learn about your nutrition needs and cope with treatment side effects

that may affect how well you can eat. Click on the topics below to get started.

Benefits of good nutrition

Good nutrition is especially important if you have cancer because both the illness and its treatments can

change the way you eat. Cancer and cancer treatments can also affect the way your body tolerates

certain foods and uses nutrients.

The nutrient needs of people with cancer vary from person to person. Your doctor, nurses, and a

registered dietitian can help you identify your nutrition goals and plan ways to help you meet them. Eating

well while you are being treated for cancer might help you:

Feel better.

Keep up your strength and energy.

Maintain your weight and your body’s store of nutrients.

Better tolerate treatment-related side effects.

Lower your risk of infection.

Heal and recover faster.

Eating well means eating a variety of foods that will give your body the nutrients needed to help fight

cancer. These nutrients include protein, carbohydrates, fat, water, vitamins, and minerals.

Nutrients

Proteins

We need protein for growth, to repair body tissue, and to keep our immune systems healthy. When your

body doesn’t get enough protein, it might break down muscle for the fuel it needs. This makes it take

longer to recover from illness and can lower resistance to infection. People with cancer often need more

protein than usual. After surgery, chemotherapy, or radiation therapy, extra protein is usually needed to

heal tissues and help fight infection.

Good sources of protein include fish, poultry, lean red meat, eggs, low-fat dairy products, nuts and nut

butters, dried beans, peas and lentils, and soy foods.

Fats

Fats play an important role in nutrition. Fats and oils are made of fatty acids and serve as a rich source of

energy for the body. The body breaks down fats and uses them to store energy, insulate body tissues,

and transport some types of vitamins through the blood.

You may have heard that some fats are better for you than others. When considering the effects of fats on

your heart and cholesterol level, choose monounsaturated and polyunsaturated fats more often than

saturated fats or trans fats.

Monounsaturated fats are found mainly in vegetable oils like olive, canola, and peanut oils.

Polyunsaturated fats are found mainly in vegetable oils like safflower, sunflower, corn, and flaxseed.

They are also the main fats found in seafood.

Saturated fats are mainly found in animal sources like meat and poultry, whole or reduced-fat milk,

cheese, and butter. Some vegetable oils like coconut, palm kernel oil, and palm oil are saturated.

Saturated fats can raise cholesterol and increase your risk for heart disease. Less than 10% of your

calories should come from saturated fat.

Trans-fatty acids are formed when vegetable oils are processed into margarine or shortening. Sources

of trans fats include snack foods and baked goods made with partially hydrogenated vegetable oil or

vegetable shortening. Trans fats also are found naturally in some animal products, like dairy products.

Trans fats can raise bad cholesterol and lower good cholesterol; try to eliminate them from your diet.

Carbohydrates

Carbohydrates are the body’s major source of energy. Carbohydrates give the body the fuel it needs for

physical activity and proper organ function. The best sources of carbohydrates – fruits, vegetables, and

whole grains – also supply needed vitamins and minerals, fiber, and phytonutrients to the body’s cells.

Whole grains or foods made from them contain all the essential parts and naturally occurring nutrients of

the entire grain seed. Whole grains are found in cereals, breads, flours, and crackers. Some whole grains,

such as quinoa, brown rice, or barley, can be used as side dishes or part of an entree. When choosing a

whole-grain product, look for the words “whole grain,” “stone ground,” “whole ground,” “whole-wheat

flour,” “whole-oat flour,” or “whole-rye flour.”

Fiber is the part of plant foods that the body cannot digest. There are 2 types of fiber. Insoluble fiber

helps to move food waste out of the body quickly, and soluble fiber binds with water in the stool to help

keep stool soft.

Other sources of carbohydrates include bread, potatoes, rice, spaghetti, pasta, cereals, corn, peas, and

beans. Sweets (desserts, candy, and drinks with sugar) can supply carbohydrates, but provide very little

in the way of vitamins, minerals, or phytonutrients.

Water

Water and liquids or fluids are vital to health. All body cells need water to function. If you do not take in

enough fluids or if you lose fluids through vomiting or diarrhea, you can become dehydrated (your body

doesn’t have as much fluid as it should). If this happens, the fluids and minerals that help keep your body

working can become dangerously out of balance. You do get some water from the foods you eat, but a

person should drink about eight 8-ounce glasses of liquid each day to be sure that all the body cells get

the fluid they need. You may need extra fluids if you are vomiting or have diarrhea. Keep in mind that all

liquids (soups, milk, even ice cream and gelatin) count toward your fluid goals.

Vitamins and minerals

The body needs small amounts of vitamins and minerals to help it function properly. Most are found

naturally in foods. They are also sold as supplements in pill and liquid form. They help the body use the

energy (calories) found in foods.

A person who eats a balanced diet with enough calories and protein usually gets plenty of vitamins and

minerals. But it can be hard to eat a balanced diet when you are being treated for cancer, especially if you

have treatment side effects that last for a long time. In this case, your doctor or dietitian may suggest a

daily multivitamin and mineral supplement.

If you are thinking of taking a vitamin or supplement, be sure to discuss this with your doctor first. Some

people with cancer take large amounts of vitamins, minerals, and other dietary supplements to try to

boost their immune system or even destroy cancer cells. But some of these substances can be harmful,

especially when taken in large doses. In fact, large doses of some vitamins and minerals may make

chemotherapy and radiation therapy less effective.

If your oncologist says it is OK for you to take a vitamin during treatment, it may be best to choose a

supplement with no more than 100% of the Daily Value (DV) of vitamins and minerals and one without

iron (unless your doctor thinks you need iron).

Antioxidants

Antioxidants include vitamins A, C, and E; selenium, and zinc; and some enzymes that absorb and attach

to free radicals, preventing them from attacking normal cells.

If you want to take in more antioxidants, health experts recommend eating a variety of fruits and

vegetables, which are good sources of antioxidants. Taking large doses of antioxidant supplements or

vitamin-enhanced foods or liquids is usually not recommended while getting chemo or radiation therapy.

Talk with your doctor to find out the best time to take antioxidant supplements.

Phytonutrients

Phytonutrients or phytochemicals are plant compounds like carotenoids, lycopene, resveratrol, and

phytosterols that are thought to have health-protecting qualities. They are found in plant products such as

fruits, vegetables, and teas. Pill or supplement forms of phytochemicals have not been shown to be as

helpful as eating the foods that contain them.

Herbs

Herbs have been used to treat disease for hundreds of years, with mixed results. Today, herbs are found

in many products, like pills, liquid extracts, teas, and ointments. Many of these products are harmless and

safe to use, but others can cause severe and harmful side effects. Some may even interfere with proven

cancer treatments, including chemo, radiation therapy, and recovery from surgery. If you are interested in

using products containing herbs, talk about it with your oncologist or nurse first.

Safety considerations

Many people believe that if they find a pill or supplement in stores, it is safe and it works. The Food and

Drug Administration (FDA) put out rules in 2007 to help ensure that supplements contain what their labels

claim they do, but the supplement’s safety and its effects on the body are not addressed by any FDA

rules. The FDA does not make manufacturers of these products print possible side effects on their labels.

And the FDA cannot pull a dietary supplement or herbal product from the market unless it can prove that

the product is unsafe.

Tell your health care team about any over-the-counter products or supplements you are using or are

thinking about using. Take the bottle(s) to your doctor to talk about the dose, and be sure that the

ingredients do not interfere with your health or cancer treatments. Some other safety tips:

Ask your doctor or nurses for reliable information on dietary supplements.

Check the product labels for both the quantity and concentration of active ingredients contained in each

product.

Stop taking the product and call your doctor right away if you have side effects, like wheezing, itching,

numbness, or tingling in your limbs.

What are Vascular Access Procedures?

A vascular access procedure involves the insertion of a flexible thin plastic tube, or catheter, into a blood vessel to provide an effective method of drawing blood or delivering medications and nutrients into a patient's bloodstream over a period of weeks, months or even years.A simple intravenous (IV) line is effective for short-term use, but is not suitable for long-term use. When an IV line is necessary for a longer period of time and/or a more secure venous access is necessary, a special catheter that is generally longer, called a central access catheter, or a similar device can be used. The catheter can remain in place either temporarily (days) or long-term (weeks to years) so that it can be easily and repeatedly accessed over the necessary period of time without the need for repeat punctures to the patient.In a vascular access procedure, a special catheter is inserted inside a major vein (generally in one of the large veins in the neck, arms or legs) with the tip of catheter positioned into a large central vein that terminates near the heart.

top of page

What are some common uses of the procedure?

View larger with caption

Vascular access procedures are performed when patients need: intravenous antibiotic treatment. chemotherapy , or anti-cancer drugs. long-term intravenous (IV) feeding for nutritional support. repeated drawing of blood samples. hemodialysis , a process used to treat patients whose kidneys are not

working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body.

Access catheters may also be used for: blood transfusions.

patients who have difficulty receiving a simple IV line.

Vascular access procedures are commonly performed in children for similar reasons with similar techniques using appropriately sized devices intended for children. Examples of reasons for vascular access procedures in children include:

intravenous antibiotic treatment. chemotherapy. delivering special heart medications. long term intravenous (IV) feeding for nutritional support. hemodialysis. blood transfusions. patients who have difficulty receiving a simple IV line. repeated drawing of blood samples.

top of page

How should I prepare?

Prior to your procedure, your blood may be tested to determine how well your kidneys are functioning and whether your blood clots normally.You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials containing iodine (sometimes referred to as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners for a specified period of time before your procedure.Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule.Other than medications, you may be instructed to not eat or drink anything for several hours before your procedure.You should plan to have a relative or friend drive you home after your procedure.You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

top of page

What does the equipment look like?

In this procedure,  x-ray  and ultrasound equipment, a needle, a guide wire and a vascular access catheter are used.The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room. Fluoroscopy, which converts x-rays into video images, is used to watch and guide progress of the procedure. The video is produced by the x-ray machine and a detector that is suspended over a table on which the patient lies.The x-ray equipment allows the operator to watch the wire and catheter on a live display so they can be advanced safely and the catheter tip positioned accurately to allow the catheter to function best.Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to scan the body.Ultrasound is used to assess and identify a vein that is suitable for catheter placement. It also allows the interventional radiologist the ability to identify appropriate veins that may be larger and deeper than veins that can be seen or felt on the skin surface. Ultrasound gel is used to improve the contact of the transducer to the skin in order to improve image quality. Ultrasound guidance is helpful because it provides real-time or live visualization for the interventional radiologist to advance the needle directly into the vein during the venous puncture (or access) process. This helps improve the likelihood of a successful venous puncture and also helps the interventional radiologist avoid surrounding structures reducing the risk for possible complications such as bleeding.In contrast to the catheter used in a standard intravenous (IV) line, a vascular access catheter is more durable and does not easily become blocked or infected. These catheters are designed in a way that they extend into the largest central vein near the heart.A catheter is a long, thin plastic tube that is the same size or smaller than a pencil.Following are the major types of vascular access catheters: A peripherally inserted central catheter (PICC) is a long catheter that

extends from an arm or leg vein into the largest vein (superior vena cava or inferior vena cava ) near the heart and typically provides central IV access for several weeks, but may remain in place for several months. These catheters are called "midline catheters" when they are placed in a way that the tip of the catheter remains in a relatively large vein, but doesn't extend into the largest central vein. They may have one or two lumens and some may be able to be used for CT contrast injections (manufactured for forceful contrast injections).

A non-tunneled central catheter may be larger caliber than a PICC, and is designed to be placed via a relatively large, more central vein such as the

jugular vein in the neck or the femoral vein in the groin. The skin exit point of a non-tunneled central catheter is in close proximity to the entry point of the vein used.

A tunneled catheter may have a cuff that stimulates tissue growth that will help hold it in place in the body. Examples of the tunneled catheter include HICKMAN® catheters, BROVIAC® catheters and GROSHONG® catheters. There are several different types of dialysis catheters. The tunneled catheter is the best choice when access to the vein is needed for long period of time. It is secure and easy to access. They are more secure and usually work more efficiently than PICCs because of their larger size. The tunnel and cuff on the catheter decrease the risk of catheter infection, allowing these types to remain in place for extended periods of time. This type of catheter has portions that hang outside the skin, and is used by connecting directly to the out side ports of the catheter. The patient's skin is not directly punctured when the catheter is used. This type of catheter must be protected from getting pulled or getting wet. The skin exit point of a tunneled catheter is remote from the actual vein entry point. This tunneled path also helps reduce the risk of infection.

A port catheter, or subcutaneous implantable port, is a permanent device that consists of a catheter attached to a small reservoir, both of which are placed under the skin similar to tunneled catheters. This catheter is placed completely under the skin. The patient's skin is punctured every time the catheter is used, but there are no restrictions on showering or bathing once the incision made for placement heals.

Note: HICKMAN®, BROVIAC® and/or GROSHONG® are registered trademarks of C. R. Bard, Inc. and its related company, BCR, Inc.Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.

top of page

How is the procedure performed?

A midline catheter and some peripherally inserted central catheter (PICC) lines may be inserted at your bedside without image guidance. These are inserted through a vein near the elbow and threaded through a large vein in the upper arm.Other vascular access procedures are most often performed by a specially trained interventional radiologist in an interventional radiologysuite or occasionally in the operating room.These procedures are often performed on an outpatient basis.You will be positioned on your back.A nurse or technologist may insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be givenintravenously. PICC placement usually does not require sedative medications.

The area of your body where the catheter is to be inserted will be shaved (typically the upper chest for tunneled catheters and in the arm for PICCs), sterilized and covered with a surgical drape.Your physician will numb the area with a local anesthetic.A very small nick is made in the skin at the site.PICC: To place a PICC line, the physician or nurse will identify the vein using ultrasound or x-ray guidance and insert a small needle into the arm vein and advance a small guide wire into the large central vein, called the superior vena cava, under x-ray (fluoroscopy). The catheter is then advanced over the guide wire and moved into position. The guide wire is then removed. If this is done without x-ray guidance, a chest x-ray is needed to confirm the catheter position.NON-TUNNELED CENTRAL CATHETER: These catheters are placed via a relatively larger vein such as the jugular vein in the neck or femoral vein in the groin.TUNNELED CATHETER: For a tunneled catheter, the physician will make one small incision in the skin commonly in the lower neck. Using ultrasound guidance, the vein is punctured with a needle (usually the jugular vein at the base of the neck), and a small guide wire is advanced into the large central vein, called the superior vena cava, under x-ray guidance (fluoroscopy). A second small skin incision may be made below the first, and a tunnel under the skin is then created. Using x-ray guidance, the catheter is placed through the tunnel into the vein, and the tip of the catheter is placed into the largest vein, the superior vena cava. The cuff, which is typically made of Dacron®, is located under the skin in the tunneled path of the catheter. Finally, the physician will place stitches at end of the tunnel to help keep the catheter firmly in place. The stitches do not typically need to be removed until the catheter is taken out.PORT-CATHETER: Implanting a subcutaneous port generally requires two incisions (except in the arm where a single incision may suffice). The port reservoir is placed under the skin. A small skin incision slightly longer than the diameter of the device itself is made, and a small pocket for the port is created under the skin. The rest of the procedure is similar to the tunneled central catheter placement. A small, elevated area remains on your body at the site of the reservoir at the conclusion of the procedure. The port, which passes from an access site in a vein of your arm, shoulder or neck, ends in a large central vein in the chest. The reservoir has a silicone covering that can be punctured with a special needle.Incisions are held together by stitches, surgical glue and/or a special tape.An x-ray may be performed after the procedure to ensure the catheter is positioned correctly but is frequently not necessary if x-ray (fluoroscopy) was used during the placement procedure.The implanted vascular access catheter is then ready for use.Your intravenous line will be removed.

For pediatric patients, a smaller catheter or other equipment may be used. X-ray equipment settings will be adjusted to lower the radiation dose used to guide the placement of the catheter.Pediatric procedures are more commonly performed with deeper sedation, possibly with the assistance of an anesthesiologist. Your child may be required to have nothing to eat or drink for up to six hours before the procedure. You will be given detailed instructions depending on the age of your child.Let your physician know about any medication, x-ray dye or latex allergies your child may have, as well as previous responses to sedation. If your child has had previous vascular access devices, previous surgery in the same area, or has unusual anatomy, let your physician know so they can plan the best location for the device. If a PICC line is to be placed in the arm, your child may have a preference for which arm is used. You can discuss this with the physician in advance.

top of page

What will I experience during the procedure?

Devices to monitor your heart rate and blood pressure will be attached to your body.You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.You may feel some pressure or brief discomfort when the needle is placed into the vein and when the tunnel is created. If the arm is used for a PICC line placement, a tourniquet will be positioned on the upper arm. A tourniquet may be used to help dilate the vein and aid with the initial venous puncture.You will have to lay flat for about 30 to 45 minutes during catheter placement.If you are not staying overnight at the hospital, you should rest at home for the remainder of the day following the procedure. You may resume your usual activities the next day, but should avoid lifting heavy objects.After having a tunneled catheter or subcutaneous port placed, you may experience bruising, swelling and tenderness in the chest, neck or shoulder, but these symptoms clear up in a few days. Pain medicine may help during this time.You will receive instructions on how to care for your incision(s) and your particular vascular access device. For the first week, it is especially important to keep the catheter site clean and dry. Some, but not all, physicians will recommend sponge bathing around the catheter site, then cleaning the area

with peroxide, applying an ointment that contains an antibiotic and bandaging the area.You may be allowed to shower after one week, using a piece of plastic wrap over the site where the catheter was inserted. You should not allow the incision to be held under water such as by swimming or soaking in a tub.You may be advised to flush your catheter with a heparin solution to help keep blood clots from forming and blocking the catheter.You should call the physician or nurse if you have any questions about your vascular access device or if: the device malfunctions. there is bleeding at the insertion site. you develop a fever. you notice redness, increased swelling, tenderness, warmth or fluid

drainage at the catheter insertion site.Vascular access catheters are usually removed by a health professional. PICC and non-tunneled central catheters may be removed by nurses or technologists similar to the way an IV would be removed, and the site covered with a Band-Aid. Tunneled catheters and port catheters will be removed by a physician. To remove these catheters, the skin is numbed with local anesthesia. An incision is required to remove the port catheter. Removal takes about 15 minutes and is done as an out-patient procedure. The skin will need to be protected from water until the incision is fully healed after removal.

top of page

Who interprets the results and how do I get them?

Your interventional radiologist will use x-ray imaging during the placement procedure or a chest x-ray taken immediately after the procedure to confirm that your catheter is correctly positioned. Your physician will also check how well your vascular access device is functioning by using a needle and/or syringe and injecting fluid through the catheter.

top of page

What are the benefits vs. risks?

Benefits

A central catheter permits infusion of solutions containing medication or nutritional substances without causing the complications that may occur with an IV, such as local tissue damage when a toxic drug leaks out of the vein.

In many conditions, having this type of tube inserted provides a simple and painless means of drawing blood, or delivering drugs, nutrients or both.

Vascular access devices spare the patient the discomfort and stress of repeated needle sticks.

The vascular access device is an extremely useful solution for patients who—for any reason—require repeated entry into the venous circulation over a long period. A number of different designs are available that are suitable for different circumstances.

Placement of a vascular access device is a great solution for those requiring prolonged treatment such as chemotherapy. They will not need to have an IV line placed for each treatment and their arm veins will not become badly scarred.

A PICC is very helpful when medicines or fluids that are irritating to the wall of the vein are needed. A wide range of products may be given by this route, including antibiotics and blood products. The catheter also may be used for IV feeding and frequent blood sampling.

A vascular access device may be used immediately after placement. Some types will continue functioning well for a year or longer. The devices are easily removed when no longer needed.

A catheter sometimes is the only way of getting access to the circulatory system for hemodialysis in patients with serious kidney disease.

Risks

Two types of risk are associated with vascular access devices: those occurring during or shortly after placement and delayed risks that occur simply because the device is in your body.Following are some of the risks associated with placement of a vascular access device: Any procedure that involves placement of a catheter inside a blood vessel

carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection.

An infection may develop at an incision site shortly after catheter placement. The risk is less if you carefully follow instructions about caring for the incisions as they heal.

Bleeding or hemorrhaging may occur. This risk can be minimized through a blood test in advance to be sure that your blood clots normally. If your blood is too thin, the procedure may be postponed or you may receive medication or blood products to improve blood clotting.

Very rarely a patient may develop a condition called a pneumothorax, a collection of air in the chest that may cause one of the lungs to collapse. This may occur during placement of a catheter or port using a vein in the chest or neck, but not when an arm vein is used. The risk is lessened when catheter placement is guided by ultrasound or fluoroscopy. Placement of these catheters by interventional radiologists using appropriate imaging guidance significantly decreases the risk of pneumothorax.

The normal heart rhythm may be disturbed while the catheter is inserted, but this is usually only temporary. The problem is easily recognized during the procedure and eliminated by adjusting the catheter position.

Rarely, the catheter will enter an artery rather than a vein. If this happens, the catheter will have to be removed. Most often the artery then heals by itself, but occasionally it has to be surgically repaired.

Delayed Risks: Two types of delayed infection may develop: skin infection at the catheter

or port insertion site or bloodstream infection. Infections are least common after placing a port. The risk of delayed infection can be minimized if you and anyone else who will be handling the device wash hands before flushing it or cleaning the insertion site. The site should be carefully inspected each time the dressing is changed. The risk of infection is higher for individuals who have low white blood cell counts.

A hole or break in the catheter may lead to leakage of fluid. Breaks may be avoided by not always clamping the catheter in the same spot and by never using too much force when flushing it. Two important first aid measures: 1) clamp the catheter between the damaged part and the skin insertion site; 2) tape a sterile gauze pad to the skin to cover the break. Catheters rarely fracture inside the body, but if this does happen, a chest x-ray will show the problem. The broken fragment can usually be removed without open surgery.

The catheter may become accidentally dislodged. If the catheter is not secured to the skin appropriately, it may come out. If this happens, you should apply pressure to the incision site using a sterile dressing and call your physician immediately.

A large amount of air in the catheter may create an emergency that causes chest pain or shortness of breath. If you develop chest pain or shortness of breath related to air being pushed into the vein through the catheter, you should clamp the catheter right away, lie on your left side and call 9-1-1. This problem can be avoided by always clamping the catheter before and after inserting a syringe, and by making sure that the catheter cap is screwed on tightly.

Any type of vascular access catheter may become obstructed by clotted blood or fibrin sheath. You can minimize the risk by carefully following instructions about flushing the catheter. Once a catheter occludes, or becomes closed off, it sometimes can be cleared by injecting medication but at other times must be removed or exchanged for a new catheter. Occasionally the catheter can be stripped by a simple interventional procedure.

If the vein in which the catheter lies becomes occluded (closed off) the arm, shoulder, neck or head may develop swelling. If this occurs, call your physician immediately. The clot may be treated by a blood-thinning medication, but occasionally the catheter will have to be removed.

Rarely, patients experience a sensation of skipped or irregular heartbeat that may be related to the catheter. Call your physician if this occurs. The catheter tip may need to be readjusted slightly to relieve this.

top of page

What are the limitations of Vascular Access Procedures?

Although some types of central venous catheter may remain in place for months or even years, most catheters require replacement after certain time frame because of poor function. The reservoir septum of most types of implanted ports has a useful lifetime of about 1,000 punctures and so is not suitable for patients who require IV access on a daily basis.Some patients have very poor veins that are not well suited for catheter placement. This usually happens when these access veins have been used for a long period of time (years of intravenous feeding, etc.). It may be very difficult to find a suitable vein to place a catheter in these patients, and may require unusual venous entry sites (e.g., through the back or through the liver).

Peripherally inserted central catheter - flushingEmail this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version

You have a peripherally inserted central catheter (PICC). This is a tube that goes into a vein in your arm.

It will help carry nutrients and medicine into your body. It will also be used to take blood when you need to

have blood tests.

These catheters are used when people need intravenous (IV) medical treatment or routine blood drawing

over a long period of time.

You will need to rinse out your catheter after every use. This is called "flushing." Sometimes you will also

need to flush it between uses.

After some practice, flushing your catheter will get easier. A friend, family member, caregiver, or your

doctor may be able to help you.

Your doctor will give you a prescription for the supplies you will need.

You can buy these at a medical supply store. It will be helpful to know the name of your catheter

and what company made it. Write this information down, and keep it handy.

How to Flush Your Catheter

To flush your catheter, you will need:

Clean paper towels

Saline syringes (clear), and maybe heparin syringes (yellow)

Alcohol or chlorhexidine wipes

Sterile gloves

“Sharps” container. This is a special container for used syringes and needles.

Before starting, check the labels on the saline syringes, heparin syringes, or medicine syringes. Make

sure it is the right strength and dose. Check the expiration date. If the syringe is not prefilled, draw up the

correct amount.

You will flush your catheter in a sterile (very clean) way. This will help protect you from infection. Follow

these guidelines:

1. Wash your hands for 30 seconds with soap and water. Be sure to wash between your fingers and

under your nails.

2. Dry with a clean paper towel.

3. Set up your supplies on a clean surface on a new paper towel.

4. Put on a pair of sterile gloves.

5. Remove the cap on the saline syringe and set the cap down on the paper towel. Do NOT let the

uncapped end of the syringe touch the paper towel or anything else.

6. Unclip the clamp on the end of the catheter and wipe the end of the catheter with an alcohol or

chlorhexidine wipe.

7. Screw the saline syringe to the catheter to attach it.

8. Inject the saline slowly into the catheter by gently pushing on the plunger. Do a little, then stop,

then do some more. Inject all the saline into the catheter. Do not force it. Call your doctor if it is

not working.

9. When you are done, unscrew the syringe and put it in your sharps container.

10. Clean the end of your catheter again with a new wipe.

11. Put the clamp on the catheter if you are done.

Ask your doctor if you also need to flush your catheter with heparin. Heparin is a medicine that helps

prevent blood clots.

Follow these steps to flush your catheter with heparin:

1. Attach the heparin syringe to your catheter, the same way you attached the saline syringe.

2. Flush slowly by injecting a little at a time, the same way you did the saline.

3. Unscrew the heparin syringe from your catheter. Put it in your sharps container.

4. Clean the end of your catheter with a new alcohol wipe.

5. Put the clamp back on the catheter.

Other Care

Keep all of the clamps on your catheter closed at all times. It is a good idea to change the caps at the end

of your catheter (called the “claves”) when you change your dressing and after blood is drawn.

It is okay to take showers and baths 7 - 10 days after your catheter was put in place. When you do, make

sure the dressings are secure and your catheter site is staying dry. Do not let the catheter site go under

water if you are soaking in the bathtub.

When to Call the Doctor

Call your doctor or nurse if you:

Have bleeding, redness or swelling at the site

Develop swelling in the arm downstream of where the catheter is

Notice leaking, or the catheter is cut or cracked

Have pain near the site, or in your neck, face, chest, or arm

Have signs of infection (fever, chills)

Are short of breath

Feel dizzy

Are having trouble flushing your catheter or changing your dressings

Also call your doctor if your catheter:

Is coming out of your vein

Seems blocked

Alternate Names

PICC - flushing

Central venous catheter - flushingEmail this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version

You have a central venous catheter. This is a tube that goes into a vein in your chest. It will help carry

nutrients and medicine into your body. It will also be used to take blood when you need to have blood

tests.

These catheters are used when people need medical treatment over a long period of time.

You may need antibiotics or other medicines for weeks to months.

You may need extra nutrition because your bowels are not working correctly.

You may be receiving kidney dialysis.

You will need to make sure the skin where the catheter is placed stays healthy. This will help protect you

from infection. You will need to check the skin and change the special bandages (dressings) around the

site about once a week. See also: Central venous catheter-dressing change

You will also need to rinse out the catheter after every use. This is called “flushing.” Sometimes you will

also need to flush it between uses. A friend, family member, caregiver, or your doctor may be able to help

you.

It is okay to take showers and baths 7 to10 days after your catheter was put in place. When you do, make

sure the dressings are secure and your catheter site is staying dry. Do not let the catheter site go under

water if you are soaking in the bathtub.

Supplies You Will Need

Your doctor will give you a prescription for the supplies you will need. You can buy these at a medical

supply store. It will be helpful to know the name of your catheter and what company made it. Write this

information down and keep it handy.

To flush your catheter, you will need:

Clean paper towels

Saline syringes (clear), and maybe heparin syringes (yellow)

Alcohol wipes

Sterile gloves

“Sharps” container. This is a special container used for syringes and needles.

How to Flush Your Catheter

You will flush your catheter in a sterile (very clean) way. Follow these steps:

1. Wash your hands for 30 seconds with soap and water. Be sure to wash between your fingers and

under your nails.

2. Dry with a clean paper towel.

3. Set up your supplies on a clean surface on a new paper towel.

4. Put on a pair of sterile gloves.

5. Remove the cap on the saline syringe and set the cap down on the paper towel. Do not let the

uncapped end of the syringe touch the paper towel or anything else.

6. Unclip the clamp on the end of the catheter and wipe the end of the catheter with an alcohol wipe.

7. Screw the saline syringe to the catheter to attach it.

8. Inject the saline slowly into the catheter by gently pushing on the plunger. Do a little, then stop,

then do some more. Inject all the saline into the catheter. Do not force it. Call your doctor or nurse

if it is not working.

9. When you are done, unscrew the syringe and put it in your sharps container.

10. Clean the end of the catheter again with another alcohol wipe.

11. Put the clamp on the catheter if you are done.

Ask your doctor if you also need to flush your catheter with heparin. Heparin is a medicine that helps

prevent blood clots. Follow these steps if you do:

1. Screw the heparin syringe to your catheter, the same way you attached the saline syringe.

2. Flush slowly by pushing on the plunger and injecting a little at a time, the same way you did the

saline.

3. Unscrew the heparin syringe from your catheter. Put it in your “sharps” container.

4. Clean the end of your catheter with a new alcohol wipe.

5. Put the clamp back on your catheter.

Other Care

Keep all the clamps on your catheter closed at all times. It is a good idea to change the caps at the end of

your catheter (called the “claves”) when you change your catheter dressing and after you have blood

taken.

When to Call the Doctor

Call your doctor or nurse if you:

Are having trouble flushing your catheter

Have bleeding, redness, or swelling at the catheter site

Notice leaking, or the catheter is cut or cracked

Have pain near the site or in your neck, face, chest, or arm

Have signs of infection (fever, chills)

Are short of breath

Feel dizzy

Also call your doctor if your catheter:

Is coming out of your vein

Seems blocked

Alternate Names

Central venous access device - care; CVAD - care

Central venous catheter - dressing changeEmail this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version

You have a central venous catheter. This is a tube that goes into a vein in your chest. It will help carry

nutrients and medicine into your body. It will also be used to take blood when you need to have blood

tests.

These catheters are used when people need medical treatment over a long period of time.

You may need antibiotics or other medicines for weeks to months.

You may need extra nutrition because your bowels are not working correctly.

You may be receiving kidney dialysis.

You may be receiving cancer drugs.

Dressings are special bandages that block germs and keep your catheter site dry and clean. You will

learn how to change your dressing. You should change the dressing about once a week. You will need to

change it sooner if it becomes loose or gets wet or dirty. After some practice, it will get easier. A friend,

family member, caregiver, or your doctor may be able to help you.

It is okay to take showers and baths 7 -10 days after your catheter was put in place. When you do, make

sure the dressings are secure and your catheter site is staying dry. Do not let the catheter site go under

water if you are soaking in the bathtub.

See also: Central venous catheter - flushing

Supplies You Will Need

Your doctor will give you a prescription for the supplies you will need. You can buy these at a medical

supply store. It will be helpful to know the name of your catheter and what company made it. Write this

information down and keep it handy.

When your catheter is put in place, the nurse will give you a label that tells you the make of the catheter.

Keep this for when you buy your supplies.

To change your dressings, you will need:

Sterile gloves

Cleaning solution

A special sponge

A special patch, called a Biopatch

A clear barrier bandage, either Tegaderm or Covaderm

Changing Your Dressings

You will change your dressings in a sterile (very clean) way. Follow these steps:

1. Wash your hands for 30 seconds with soap and water. Be sure to wash between your fingers and

under your nails.

2. Remove all jewelry from your fingers before you wash your hands.

3. Dry with a clean paper towel.

4. Set up your supplies on a clean surface on a new paper towel.

5. Put on a pair of clean gloves.

6. Gently peel off the old dressing and Biopatch. Throw away the old dressing and gloves.

7. Put on a pair of sterile gloves.

8. Check your skin for redness, swelling, or any bleeding or other drainage around the catheter.

9. Clean the skin with the sponge and cleaning solution. Air dry after cleaning.

10. Place a new Biopatch over the area where the catheter enters your skin. Keep the grid side up

and the split ends touching.

11. Peel the backing from the clear plastic bandage (Tegaderm or Covaderm) and place it over the

catheter.

12. Write down the date you changed your dressing.

13. Remove the gloves and wash your hands when you are done.

14. Always throw your used supplies away in a separate container, not your home garbage.

Other Care

Keep all the clamps on your catheter closed at all times. It is a good idea to change the caps at the end of

your catheter (called the “claves”) when you change your dressing.

When to Call your Doctor

Call your doctor or nurse if you:

Are having trouble changing your dressings

Have bleeding, redness or swelling at the site

Notice leaking, or the catheter is cut or cracked

Have pain near the site or in your neck, face, chest, or arm

Have signs of infection (fever, chills)

Are short of breath

Feel dizzy

Also call the doctor if your catheter:

Is coming out of your vein

Seems blocked, or you are not able to flush it

Central venous catheters - portsEmail this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version

A central venous catheter is a tube that goes into a vein in your chest and ends at your heart. Sometimes

this type of catheter is attached to a device called a port that will be under your skin. The port and

catheter are put in place in a minor surgery.

The catheter helps carry nutrients and medicine into your body. It will also be used to take blood when

you need to have blood tests. Having a port attached to your catheter will causeless wear and tear on

your veins than just having the catheter.

Why Do I Need a Central Venous Catheter and Port?

Catheters are used when you need medical treatment over a long period of time. For example, you may need:

Antibiotics or other medicines for weeks to months

Extra nutrition because your bowels are not working correctly

Or you may be receiving:

Kidney dialysis several times a week

Cancer drugs often

Your doctor will talk with you about other methods for receiving medicine and fluids into a vein and will

help you decide which one is best for you. Other methods are:

Peripherally inserted central catheter

Central venous catheter

How Is the Port Placed?

A port is placed under your skin in a minor surgery. Most ports are placed in the chest, but they may also

be placed in the arm.

You may be placed into a deep sleep so you do not feel pain during surgery.

You may stay awake and receive medicines to help you relax and numb the area so that you do

not feel pain.

You can go home after your port is in place.

You will be able to feel and see a quarter-sized bump under your skin where your port is.

You may be a little sore for a few days after surgery.

Once you have healed, your port should not hurt.

Taking Care of and Using Your Port

Your port has 3 parts:

Portal or reservoir -- a pouch that is made of hard metal or plastic

Rubber top -- where a needle is inserted into the portal

Tube or catheter -- carries medicine or blood from the portal to a large vein and into the heart

To get medicine or nutrition through your port, a trained nurse or doctor will stick a special needle through

your skin and the rubber top and into the portal. A numbing cream can be used on your skin to decrease

the pain of the needle stick.

Your port may be used in your home, in a clinic, or in the hospital.

A sterile dressing (bandage) will be placed around your port when it is used to protect you against

infection.

When your port is not being used, you can bathe or swim, as long as your doctor says you are ready for

activity. Check with your doctor if you plan to do any contact sports, such as soccer and football.

Nothing will stick out of your skin when your port is not being used. This decreases your chance of

infection.

About once a month, you will need to have your port flushed to help prevent clots. To do this, your health

care provider will use a special solution.

Ports can be used for a long time. When you no longer need your port, your health care provider will

remove it.

When to Call our Doctor

If you notice any of these signs of infection, tell your doctor or nurse right away:

Your port seems to have moved.

Your port site is red or there are red streaks around the site.

Your port site is swollen or warm.

Yellow or green drainage is coming from your port site.

You have pain or discomfort at the site.

You have a feverover 100.5 oF (38.0 oC).

Alternate Names

Central venous catheter - subcutaneous; Port-a-Cath; InfusaPort, PasPort; Subclavian port; Medi - port;

Central venous line - port

Enteral nutrition - child - managing problemsEmail this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version

Enteral feeding is a way to feed your child using a feeding tube. Enteral feedings will become easier for

you to do with practice. Your nurse will go over all of the steps you should follow to deliver the feedings.

You will learn how to care for the tube and the skin, flush the tube, and set up the bolus or pump feedings.

Sometimes a feeding does not go as planned, and you may have a minor problem. Your nurse will go

over all of the things that can happen and what you should do.

What Should I Watch For?

Follow your doctor or nurse’s instructions on how to solve problems if they come up. Below are some

general guidelines.

If the tube is clogged or plugged:

Flush the tube with warm water.

If you have a nasogastric tube, remove and replace the tube (you will need to measure again).

Use a special lubricant (ClogZapper) if your nurse or doctor has told you to use one.

Make sure any medications are crushed properly to prevent clogging.

If the child coughs or gags when you insert the nasogastric tube:

Pinch the tube, and pull it out.

Comfort your child, and then try again.

Make sure you are inserting the tube the right way.

Make sure your child is sitting up.

Check the tube placement.

If your child has diarrhea and cramping:

Make sure the formula is mixed properly and warm.

Do not use formula that has been hanging for feeding for more than 4 hours.

Slow the feeding rate, or take a short break. (Make sure you flush the tube with warm water in

between breaks.)

Check with your doctor about antibiotics or other medications that may be causing it.

Start feeding when your child feels better.

If your child has an upset stomach or is vomiting:

Make sure the formula is mixed properly and warm.

Make sure your child is sitting up during feedings.

Do not use formula that has been hanging for feeding for more than 4 hours.

Slow the feeding rate, or take a short break. (Make sure you flush the tube with warm water in

between breaks.)

Start feeding when your child feels better.

If your child is constipated:

Take a break from feeding.

Check with your doctor about choice of formula and adding more fiber.

If your child is dried out (dehydrated), ask your doctor about changing formula or adding additional water.

If your child is losing weight, ask your doctor about changing formula or adding more feedings.

If your child has a nasograstric tube and the skin is irritated:

Keep the area around the nose clean and dry.

Tape down over the nose, not up.

Switch nostrils at each feeding.

Ask your doctor about a smaller tube.

If your child’s Corpak feeding tube falls out, call your child’s nurse or doctor. Do not replace it yourself.

When to Call the Doctor

Call your doctor if you notice your child has:

Fever

Diarrhea, cramping, or bloating that does not go away

Excessive crying, and your child is hard to console

Nausea or vomits frequently

Weight loss

Constipation

Skin irritation

The delivery of cancer chemotherapy by constant venous infusion. Ambulatory management of venous access and portable pump.Lokich J, Bothe A Jr, Fine N, Perri J.

AbstractFifty chemotherapy trials with 5-fluorouracil; mitomycin C; vinblastine; Adriamycin; and cis-platinol were initiated employing constant (24-hour) intravenous infusion for protracted periods (14-94 days). The use of the tunneled subclavian line for greater than 2200 patient days was associated with minimal complications and no instances of thrombosis or infection were observed. The use of an ambulatory infusion pump was associated with a pump efficiency of greater than 85% in 38 of 39 evaluable trials. Only four of 50 trials were associated with excess drug infusion and in no instance was a drug complication encountered. Constant infusion cancer chemotherapy is feasible, reliable, and safe. Objective tumor regression is observed but the superiority of this drug schedule over the standard intermittent bolus schedule is yet to be determined. Nonetheless, drug toxicity patterns are altered substantially and, in particular, gastrointestinal side effects of chemotherapeutic drugs may be eliminated without compromising cumulative dose.

Administrative and technical support of ambulatory infusional cancer chemotherapy (ICC).Moore C, Strong D.

Source

Cancer Center of Boston, Massachussetts, USA.

AbstractThe term "infusion" is generally equated with the parental administration of drugs in a continuous mode of delivery over some unspecified length of time. However, in terms of applicability to this paper, ICC will imply a minimum of a 24-hour delivery schedule and may include four to 7-day schedules up to protracted infusions covering many weeks. Infusional Cancer Chemotherapy programs may employ a single drug used with or without concomitant radiation therapy or admixtures of two and three drugs. Sequential alternating infusions of drug admixtures are a common mode of treatment which allow maximization of dose with minimal side effects and toxicities. The ICC model is based on the tenet that the quality of the program is directly related to the safety, efficiency, and continuity of the care provided. The supporting structures of an ICC program are rooted in four administrative and technical requisites. Strategies for program support include: 1) a team to carry out the treatment approach and to provide instructional and physical care support; 2) pre-established guidelines, protocols, policies, and procedures by which to administer the program; 3) achievement of a safe and reliable means of venous access which promotes the outpatient status; 4) a source for an accurate and reliable ambulatory infusion device and delivery system. A referral base may encompass a wide geographical area, and the patient population may be varied as to ethnicity, intellectual capacity, age, level of activity, family support and life style, thus it is important to develop a program to support the majority of patients as opposed to the carefully selected few.

Application of ambulatory infusion devices in infusional cancer chemotherapy: a model for nursing management.Moore C, Herbst S, Lawson M.

Source

Cancer Center of Boston, Framingham, MA, USA.

AbstractOptimal support of the patient receiving infusional cancer chemotherapy (ICC) in the home setting is partially dependent on the provision of an infusional device that offers minimal complexity and maximal reliability and safety. The selection of the appropriate device is vital to positive patient outcomes and to the comfort level of both patient and care providers. This article presents issues and considerations in the selection of infusion devices and the nursing role in the management of patients utilizing such devices. Aspects of nursing management are presented from the perspective of The Cancer Center of Boston (TCC) model.

[Infusion pumps and subcutaneously implantable catheter systems as an aid in the ambulatory care of tumor patients].[Article in German]

Ludwig CU, Obrecht JP.

AbstractTotally implantable catheters have greatly improved therapy and supportive care of tumor patients. Venous catheters can reduce the problem of maintaining reliable vascular access and the risk of cytotoxic drug extravasation. In addition, epidural or intrathecal catheter systems can result in an improved pain relief and in reduced side effect incidences in many patients suffering from severe cancer pain. The intraarterial and intraperitoneal catheters facilitate loco-regional chemotherapy. If used by an experienced team, most of these systems have a relatively low complication rate. The combination of such catheters with portable pumps does further facilitate the management of ambulatory tumor patients and will improve their quality of life.

Evaluation of a totally implanted venous access port and portable pump in a continuous chemotherapy infusion schedule on an outpatient basis.Greidanus J, de Vries EG, Nieweg MB, de Langen ZJ, Willemse PH.

Source

Department of Internal Medicine, University Hospital Groningen, The Netherlands.

AbstractIn this study we evaluated the feasibility of a totally implanted vascular access port (VAP) and portable infusion pump for cytostatic drug administration on an outpatient basis, in a 21-day continuous infusion schedule with 4-epidoxorubicin (phase I and phase II study) and mitoxantrone (phase I study). Patients were instructed to dissolve their own drugs at home. Fifty patients were treated with 114 cycles (2394 infusion days). Thecomplication rate was low. In one patient thrombosis of the subclavian and superior caval vein resulted in the termination of treatment. One patient developed pulmonary embolism during

treatment. Needle dislocation was observed in two patients. No septicaemia and no irreversible catheter occlusion were seen. Pump functioning was efficient and pump arrest (9 X) never lasted longer than 24 h. We conclude that a VAP and portable pump are a safe and reliable route of administration for cytostatic drugs on an outpatient basis and that patients are capable of preparing their own drugs at home without increase of complications.

Cancer and cancer treatment affect nutritionWhen you are healthy, eating enough food to get the nutrients and calories you need is not usually a problem. In fact, most nutrition guidelines stress eating lots of vegetables, fruits, and whole-grain products; limiting the amount of red meat you eat, especially those that are processed or high in fat; cutting back on fat, sugar, alcohol, and salt; and staying at a healthy weight. But when you are being treated for cancer, these things can be hard to do, especially if you have side effects or just don’t feel well. So, you might need to change your diet to help build up your strength and withstand the effects of your cancer and its treatment. This may mean eating things that are not normally recommended when you are in good health. For instance, you may need high-fat, high-calorie foods to keep up your weight, or thick, cool foods like ice cream or milk shakes because sores in your mouth and throat are making it hard to eat anything. The type of cancer, your treatment, and any side effects you have must be considered when you are trying to figure out the best ways to get the nutrition your body needs.

When your cancer was first diagnosed, your doctor talked with you about a treatment plan. This may have meant surgery, radiation therapy, chemotherapy, hormone therapy, biologic therapy (immunotherapy), or some combination of treatments. All of these treatments kill cancer cells. But in the process some healthy cells are also damaged. This damage is what causes cancer treatment side effects. Some of the more common side effects that can affect your ability to eat are:

Loss of appetite (anorexia) Sore mouth or throat Dry mouth Dental and gum problems Changes in taste or smell Nausea Vomiting Diarrhea Constipation Feeling very tired all the time (fatigue) Depression

You might or might not have any of these side effects. Many factors determine whether you will have any side effects and how bad they will be. These factors include the type of cancer you have, the part of the body affected, the type and length of your treatment, and the dose of treatment.

Many side effects can be controlled, and most go away over time after treatment ends. Talk with your doctor or nurse about your chances of having side effects and what can be done to help control them. After your treatment starts, tell your cancer care team about any side effects that are not being controlled. Let them know if the medicines they have given you to control side effects do not work, so that others can be used.

Good nutrition is important for cancer patients.

Nutrition is a process in which food is taken in and used by the body for growth, to keep the body healthy, and to replace tissue. Good nutrition is important for good health. Eating the right kinds of foods before, during, and after cancer treatment can help the patient feel better and stay stronger. A healthy diet includes eating and drinking enough of the foods and liquids that have the important nutrients (vitamins, minerals, protein, carbohydrates, fat, and water) the body needs.

When the body does not get or cannot absorb the nutrients needed for health, it causes a condition called malnutrition or malnourishment.

This summary is about nutrition in adults with cancer.

Healthy eating habits are important during cancer treatment.

Nutrition therapy is used to help cancer patients get the nutrients they need to keep up their body weight and strength, keep body tissue healthy, and fight infection. Eating habits that are good for cancer patients can be very different from the usual healthy eating guidelines.

Healthy eating habits and good nutrition can help patients deal with the effects of cancer and its treatment. Some cancer treatments work better when the patient is well nourished and gets enough calories and protein in the diet. Patients who are well nourished may have a better prognosis (chance of recovery) and quality of life.

Cancer can change the way the body uses food.

Some tumors make chemicals that change the way the body uses certain nutrients. The body's use of protein, carbohydrates, and fat may be affected, especially by tumors of the stomach or intestines. A patient may seem to be eating enough, but the body may not be able to absorb all the nutrients from the food.

Cancer and cancer treatments may affect nutrition.

For many patients, the effects of cancer and cancer treatments make it hard to eat well. Cancer treatments that affect nutrition include:

Surgery . Chemotherapy . Radiation therapy .

Immunotherapy . Stem cell transplant .

When the head, neck, esophagus, stomach, or intestines are affected by the cancer treatment, it is very hard to take in enough nutrients to stay healthy.

The side effects of cancer and cancer treatment that can affect eating include:

Anorexia (loss of appetite). Mouth sores. Dry mouth. Trouble swallowing. Nausea . Vomiting . Diarrhea . Constipation . Pain. Depression . Anxiety .

Cancer and cancer treatments may affect taste, smell, appetite, and the ability to eat enough food or absorb the nutrients from food. This can cause malnutrition (a condition caused by a lack of key nutrients). Malnutrition can cause the patient to be weak, tired, and unable to fight infections or get through cancer treatment. Malnutrition may be made worse if the cancer grows or spreads. Eating too little protein and calories is a very common problem for cancer patients. Having enough protein and calories is important for healing, fighting infection, and having enough energy.

Anorexia and cachexia are common causes of malnutrition in cancer patients.

Anorexia (the loss of appetite or desire to eat) is a common symptom in people with cancer. Anorexia may occur early in the disease or later, if the cancer grows or spreads. Some patients already have anorexia when they are diagnosed with cancer. Almost all patients who have advanced cancer will have anorexia. Anorexia is the most common cause of malnutrition in cancer patients.

Cachexia is a condition marked by a loss of appetite, weight loss, muscle loss, and general weakness. It is common in patients with tumors of the lung, pancreas, and upper gastrointestinal tract. It is important to watch for and treat cachexia early in cancer treatment because it is hard to correct.

Cancer patients may have anorexia and cachexia at the same time. Weight loss can be caused by eating fewer calories, using more calories, or both.

It is important to treat weight loss caused by cancer and its treatment.

It is important that cancer symptoms and side effects that affect eating and cause weight loss are treated early. Both nutrition therapy and medicine can help the patient stay at a healthy weight. Medicine may be used for the following:

To help increase appetite. To help digest food. To help the muscles of the stomach and intestines contract (to keep food moving along). To prevent or treat nausea and vomiting. To prevent or treat diarrhea. To prevent or treat constipation. To prevent and treat mouth problems (such as dry mouth, infection, pain, and sores). To prevent and treat pain.

Types of Nutrition Care

Key Points for This Section

Nutrition support gives nutrition to patients who cannot eat or digest normally. Nutrition support for patients who cannot eat can be given in different ways. Enteral Nutrition

o Enteral nutrition is also called tube feeding. o Enteral nutrition may continue after the patient leaves the hospital.

Parenteral Nutrition o Parenteral nutrition carries nutrients directly into the blood stream. o The catheter may be placed into a vein in the chest or in the arm. o Parenteral nutrition support may continue after the patient leaves the hospital. o Ending parenteral nutrition support must be done under medical supervision.

Nutrition support gives nutrition to patients who cannot eat or digest normally.

It is best to take in food by mouth whenever possible. Some patients may not be able to take in enough food by mouth because of problems from cancer or cancer treatment. Medicine to increase appetite may be used.

Nutrition support for patients who cannot eat can be given in different ways.

A patient who is not able to take in enough food by mouth may be fed using enteral nutrition (through a tube inserted into the stomach or intestines) or parenteral nutrition (infused into the bloodstream). The nutrients are given in liquid formulas that have water, protein, fats, carbohydrates, vitamins, and/or minerals.

Nutrition support can improve a patient's quality of life during cancer treatment, but there are harms that should be considered before making the decision to use it. The patient and health care providers should discuss the harms and benefits of each type of nutrition support. (See the Nutrition in Advanced Cancer section below for more information on deciding whether to use nutrition support.)

Enteral Nutrition

Enteral nutrition is also called tube feeding.

Enteral nutrition is giving the patient nutrients in liquid form (formula) through a tube that is placed into the stomach or small intestine. The following types of feeding tubes may be used:

A nasogastric tube is inserted through the nose and down the throat into the stomach or small intestine. This kind of tube is used when enteral nutrition is only needed for a few weeks.

A gastrostomy tube is inserted into the stomach or a jejunostomy tube is inserted into the small intestine through an opening made on the outside of the abdomen. This kind of tube is usually used for long-term enteral feeding or for patients who cannot use a tube in the nose and throat.

The type of formula used is based on the specific needs of the patient. There are formulas for patients who have special health conditions, such as diabetes. Formula may be given through the tube as a constant drip (continuous feeding) or 1 to 2 cups of formula can be given 3 to 6 times a day (bolus feeding).

Enteral nutrition is sometimes used when the patient is able to eat small amounts by mouth, but cannot eat enough for health. Nutrients given through a tube feeding add the calories and nutrients needed for health.

Enteral nutrition may continue after the patient leaves the hospital.

If enteral nutrition is to be part of the patient's care after leaving the hospital, the patient and caregiver will be trained to do the nutrition support care at home.

Parenteral Nutrition

Parenteral nutrition carries nutrients directly into the blood stream.

Parenteral nutrition is used when the patient cannot take food by mouth or by enteral feeding. Parenteral feeding does not use the stomach or intestines to digest food. Nutrients are given to the patient directly into the blood, through a catheter (thin tube) inserted into a vein. These nutrients include proteins, fats, vitamins, and minerals.

Parenteral nutrition is used only in patients who need nutrition support for five days or more.

The catheter may be placed into a vein in the chest or in the arm.

A central venous catheter is placed beneath the skin and into a large vein in the upper chest. The catheter is put in place by a surgeon. This type of catheter is used for long-term parenteral feeding.

A peripheral venous catheter is placed into a vein in the arm. A peripheral venous catheter is put in place by trained medical staff. This type of catheter is usually used for short-term parenteral feeding.

The patient is checked often for infection or bleeding at the place where the catheter enters the body.

Parenteral nutrition support may continue after the patient leaves the hospital.

If parenteral nutrition is to be part of the patient's care after leaving the hospital, the patient and caregiver will be trained to do the nutrition support care at home.

Ending parenteral nutrition support must be done under medical supervision.

Going off parenteral nutrition support needs to be done slowly and is supervised by a medical team. The parenteral feedings are decreased by small amounts over time until they can be stopped, or as the patient is changed over to enteral or oral feeding.

Following certain dietary guidelines may help prevent cancer.

The American Cancer Society and the American Institute for Cancer Research both have dietary guidelines that may help prevent cancer. Their guidelines are a lot alike and include the following:

Eat a plant-based diet, with at least 5 servings of fruit and vegetables a day. Have several servings a day of beans and grain products (such as cereals, breads, and pasta). Eat less meat.

Eat foods low in fat. Eat foods low in salt. Get to and stay at a healthy weight. Be active for 30 minutes on most days of the week. Drink few alcoholic drinks or don't drink at all. Prepare and store food safely. Do not use tobacco in any form.

The effect of soy on breast cancer and breast cancer prevention is being studied.

Study results include the following:

Some studies show that eating soy may decrease the risk of having breast cancer. Taking soy supplements in the form of powders or pills has not been shown to prevent

breast cancer.

Adding soy foods to the diet after being diagnosed with breast cancer has not been shown to keep the breast cancer from coming back.

Soy has substances in it that act like estrogen in the body. Studies were done to find out how soy affects breast cancer in patients who have tumors that need estrogen to grow. Some studies have shown that soy foods are safe for women with breast cancer when eaten in moderate amounts as part of a healthy diet.

If you are a breast cancer survivor be sure to check the most up-to-date information when deciding whether to include soy in your diet.

Palliative care helps relieve symptoms that bother the patient and helps improve the patient's quality of life.

The goal of palliative care is to improve the quality of life of patients who have a serious or life-threatening disease. Palliative care is meant to prevent or treat symptoms, side effects, and psychological, social, and spiritual problems caused by a disease or its treatment.

Palliative care for patients with advanced cancer includes nutrition therapy (see the Treatment of Symptoms section) and/or drug therapy.

Nutrition needs are different for patients with advanced cancer.

It is common for patients with advanced cancer to want less food. Patients usually prefer soft foods and clear liquids. Those who have problems swallowing may do better with thick liquids than with thin liquids. Patients often do not feel much hunger at all and may need very little food.

In patients with advanced cancer, most foods are allowed. During this time, eating can be focused on pleasure rather than getting enough nutrients. Patients usually cannot eat enough of any food that might cause a problem. However, some patients may need to stay on a special diet. For example, patients with cancer that affects the abdomen may need a soft diet to keep the bowel from getting blocked.

The benefits and harms of nutrition support are different for each patient.

Answering the following questions may help to make decisions about using nutrition support:

What are the wishes and needs of the patient and family? Will the patient's quality of life be improved? Do the possible benefits outweigh the risks and costs? Is there an advance directive? An advance directive is a legal document that states the

treatment or care a person wishes to receive or not receive if he or she becomes unable to make medical decisions. One type of advance directive is a living will.

Cancer patients and their caregivers have the right to make informed decisions. The healthcare team and a registered dietitian can explain the benefits and risks of using nutrition support for

patients with advanced cancer. In most cases, there are more harms than benefits, especially with parenteral nutrition support. However, for someone who still has good quality of life but is unable to get enough food and water by mouth, enteral feedings may be best. The benefits and risks of enteral nutrition during advanced cancer include the following:

Benefits

May make the patient more alert. May be a comfort to the family. May relieve nausea. May make the patient feel more hopeful.

Harms

Surgery may be needed to place a tube through the abdomen. May increase the amount of saliva in the mouth and throat. This may cause choking or

pneumonia. May cause diarrhea or constipation. May cause nausea. May cause infection. Makes patient care harder for caregiver.

Nutrition Therapy in Cancer Care

Screening and assessment are done before cancer treatment begins, and assessment continues during treatment.

Screening is used to look for nutrition risks in a patient who has no symptoms. This can help find out if the patient is likely to become malnourished, so that steps can be taken to prevent it.

Assessment checks the nutritional health of the patient and helps to decide if nutrition therapy is needed to correct a problem.

Screening and assessment may include questions about the following:

Weight changes over the past year. Changes in the amount and type of food eaten compared to what is usual for the patient. Problems that have affected eating, such as loss of appetite, nausea, vomiting, diarrhea,

constipation, mouth sores, dry mouth, changes in taste and smell, or pain. Ability to walk and do other activities of daily living (dressing, getting into or out of a bed or

chair, taking a bath or shower, and using the toilet).

A physical exam is also done to check the body for general health and signs of disease. The doctor will look for loss of weight, fat, and muscle, and for fluid buildup in the body.

Finding and treating nutrition problems early may improve the patient's prognosis (chance of recovery).

Early nutrition screening and assessment help find problems that may affect how well the patient's body can deal with the effects of cancer treatment. Patients who are underweight or malnourished may not be able to get through treatment as well as a well-nourished patient. Finding and treating nutrition problems early can help the patient gain weight or prevent weight loss, decrease problems with the treatment, and help recovery.

A healthcare team of nutrition specialists will continue to watch for nutrition problems.

A nutrition support team will check the patient's nutritional health often during cancer treatment and recovery. The team may include the following specialists:

Physician . Nurse . Registered dietitian . Social worker . Psychologist .

A patient whose religion doesn't allow eating certain foods may want to talk with a religious advisor about allowing those foods during cancer treatment and recovery.

There are three main goals of nutrition therapy for cancer patients in active treatment and recovery.

The main goals of nutrition therapy for patients in active treatment and recovery are to provide nutrients that are missing, maintain nutritional health, and prevent problems. The health care team will use nutrition therapy to do the following:

Prevent or treat nutrition problems, including preventing muscle and bone loss. Decrease side effects of cancer treatment and problems that affect nutrition. Keep up the patient's strength and energy. Help the immune system fight infection. Help the body recover and heal. Keep up or improve the patient's quality of life.

Good nutrition continues to be important for patients who are in remission or whose cancer has been cured.

The goal of nutrition therapy for patients who have advanced cancer is to help with the patient's quality of life.

The goals of nutrition therapy for patients who have advanced cancer include the following:

Control side effects. Lower the risk of infection.

Keep up strength and energy. Improve or maintain quality of life.

Nutrition Screening and Assessment

Nutrition in cancer care embodies prevention of disease, treatment, cure, or supportive palliation. Caution should be exercised when considering alternative or unproven nutritional therapies during all phases of cancer treatment and supportive palliation, as these diets may prove harmful. Patient nutritional status plays an integral role in determining not only risk of developing cancer but also risk of therapy-related toxicity and medical outcomes. Whether the goal of cancer treatment is cure or palliation, early detection of nutritional problems and prompt intervention are essential.

The original principles of nutrition care for people diagnosed with cancer were developed in 1979 [1] and are still very relevant today. Proactive nutritional care can prevent or reduce the complications typically associated with the treatment of cancer.[1]

Many nutritional problems stem from local effects of the tumor. Tumors in the gastrointestinal tract, for example, can cause obstruction, nausea, vomiting, impaired digestion, and/or malabsorption. In addition to the effects of the tumor, marked alterations in normal metabolism of carbohydrates, protein, and/or fats can occur.[2]

The nutritional prognostic indicators most recognized as being predictive of poor outcome include weight loss, wasting, and malnutrition. In addition, significant weight loss at the time of diagnosis has been associated with decreased survival and reduced response to surgery, radiation therapy, and/or chemotherapy.[3]

Malnutrition and accompanying weight loss can be part of an individual’s presentation or can be caused or aggravated by treatments for the disease. Identification of nutrition problems and treatment of nutrition-related symptoms have been shown to stabilize or reverse weight loss in 50% to 88% of oncology patients.[4]

Screening and nutrition assessment should be interdisciplinary; the healthcare team (e.g., physicians, nurses, registered dietitians, social workers, psychologists) should all be involved in nutritional management throughout the continuum of cancer care.[5]

A number of screening and assessment tools are currently available for use in nutritional assessment. Examples of these tools include the Prognostic Nutrition Index,[6,7] delayed hypersensitivity skin testing, institution-specific guidelines, and anthropometrics. Each of these tools can help identify persons at nutritional risk; unfortunately, the values obtained using such tools can be altered by the hydration status and the immune compromise frequently found in individuals diagnosed with cancer. In addition, each of these objective measures can carry a cost in terms of laboratory or practitioner time. One author has provided a useful overview of assessment procedures for advanced cancer patients.[8]

Another example of a screening and assessment procedure is the Patient-Generated Subjective Global Assessment (PG-SGA). Based on earlier work on a protocol called Subjective Global Assessment (SGA),[9] the PG-SGA is an easy-to-use and inexpensive approach in identifying individuals at nutritional risk and in triaging for subsequent medical nutritional therapy in a variety of clinical settings.[10,11] The individual and/or caretaker complete sections on weight history, food intake, symptoms, and function. A member of the healthcare team evaluates weight loss, disease, and metabolic stress and performs a nutrition-related physical examination. A score is generated from the information collected. The need for nutrition intervention is determined according to the score.

Bioelectrical impedance analysis (BIA) is also used to assess nutritional status, as determined by body composition.[12] The BIA measures electrical resistance on the basis of lean body mass and body fat composition. Single BIA measures show body cell mass, extracellular tissue, and fat as a percent of ideal, whereas sequential measurements can be used to show body composition changes over time. Because of cost and accessibility, BIA is currently in limited use and often unavailable in most ambulatory settings.

Taste and smell defects are common in cancer patients and may affect nutritional status. The relative importance of chemosensory changes to the etiology of malnutrition was assessed in 66 patients with advanced cancer. Some degree of chemosensory abnormality was reported by 86% of patients; approximately one-half of patients reported interference with enjoying favorite foods. Poor appetite, nausea, early satiety, and chemosensory abnormalities presented concurrently. These findings were significantly related to decreased energy intake. Further research is required to design nutritional interventions for these chemosensory problems.[13]

Because nutritional status can quickly become compromised from illness and decreased dietary intake, and because nutritional well-being plays an important role in treatment and recovery from cancer, early screening and intervention as well as close monitoring and evaluation throughout all phases of cancer treatment and recovery are imperative in the pursuit of health for the individual with cancer.

Goals of Nutrition Therapy

Optimal nutritional status is an important goal in the management of individuals diagnosed with cancer. Although nutrition therapy recommendations may vary throughout the continuum of care, maintenance of adequate intake is important. Therefore, a waiver from most dietary restrictions observed during religious holidays is granted for those undergoing active treatment. Individuals with cancer are encouraged to speak to their religious leaders regarding this matter before a holiday.

Whether patients are undergoing active therapy, recovering from cancer therapy, or in remission and striving to avoid cancer recurrence, the benefit of optimal caloric and nutrient intake is well documented.[14-16]

The goals of nutrition therapy are to accomplish the following:

Prevent or reverse nutrient deficiencies. Preserve lean body mass. Help patients better tolerate treatments. Minimize nutrition-related side effects and complications. Maintain strength and energy. Protect immune function, decreasing the risk of infection. Aid in recovery and healing. Maximize quality of life.

Patients with advanced cancer can receive nutritional support even when nutrition therapy can do little for weight gain.[17,18] Such support may help accomplish the following:

Lessen side effects. Reduce risk of infection (if given enterally). Reduce asthenia. Improve well-being.

In individuals with advanced cancer, the goal of nutrition therapy should not be weight gain or reversal of malnutrition, but rather comfort and symptom relief.[19]

Nutrition continues to play an integral role for individuals whose cancer has been cured or who are in remission.[20] A healthy diet helps prevent or control comorbidities such as heart disease, diabetes, and hypertension. Following a healthful nutrition program might help prevent another malignancy from developing.

Methods of Nutrition Care

As outlined above, individuals diagnosed with cancer are at risk for malnutrition resulting from the disease itself; from anticancer therapy such as surgery, radiation, or pharmacologic therapy; and/or from anorexia due to emotional turmoil. The following sections highlight the benefits, contraindications, methods of administration, and home care issues for all forms of nutrition support—oral, enteral, and parenteral.

The preferred method of nutrition support is via the oral route, with the use of dietary modifications to reduce the symptoms associated with cancer treatments. Enteral nutrition is indicated when the gastrointestinal (GI) tract is functional but oral intake is insufficient to meet nutritional requirements. Common situations in which enteral nutrition may be needed include malignancies of the head and neck regions, esophagus, and stomach. When the GI tract is dysfunctional, total parenteral nutrition (TPN) or enteral nutrition may be indicated; however, the widespread use of TPN is controversial because little evidence of improved survival has been demonstrated in patients with advanced cancer.[21] Parenteral nutrition has been shown to be beneficial in only a small group of patients—specifically, postoperative patients who are being aggressively treated and who have demonstrated a positive response rate. One study [22] reported that patients with GI cancer benefited from perioperative support with TPN, with one-third fewer complications and decreased mortality.

Oral nourishment

Optimal nutrition can improve the clinical course, outcome, and quality of life of patients undergoing treatment for cancer.[23] Virtually every cancer patient could benefit from consultation with a registered dietitian or physician to formulate a plan for nutrition and to begin meal planning. Oral nutrition, or eating by mouth, is the preferred method of feeding and should be used whenever possible. Appetite stimulants may be used to enhance the enjoyment of foods and to facilitate weight gain in the presence of significant anorexia.[24]

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

At-risk individuals who may benefit from nutritional support might have one or more of the following characteristics:[26]

Low body weight, as defined by less than 80% of ideal weight or recently experienced unintentional weight loss of more than 10% of usual weight.

Malabsorption of nutrients due to disease, short bowel syndrome, or anticancer therapy. Fistulas or draining abscesses. Inability to eat or drink for more than 5 days. Moderate or high nutritional risk status as determined by screening or an assessment tool. The ability to demonstrate competencies for discharge planning on nutritional support

(both individual and caregiver).

Although the many benefits of achieving good nutritional status via nutritional support can clearly be detailed, the disadvantages or questionable benefits of nutritional support must also be considered. The debate regarding the effect of nutritional support on tumor growth has not been settled;[27] though quality of life is usually improved with better nutritional status, the actual impact of nutritional support on longevity has yet to be definitively determined.[27]

Once the degree of malnutrition has been assessed, the decision to offer nutritional support and which form of support to utilize must be determined by the healthcare professional and other parties involved. Enteral and parenteral nutritional support offers viable options to reduce the risk of debilitating malnutrition and interruptions in anticancer therapy that may influence outcome. Each form of nutritional support has advantages and disadvantages. It is critical to thoroughly evaluate the diagnosis, prognosis, degree of malnutrition, function of the gut, and ease of delivery before embarking on the plan of nutritional support. Caution must also be exercised to avoid refeeding syndrome, the metabolic complication that is caused by rapid repletion of potassium, phosphorous, and magnesium in a severely malnourished or cachectic patient.[26]

The following sections highlight the benefits, contraindications, methods of administration, formulas, and home care issues for both enteral and parenteral nutrition.

Enteral nutrition

The benefits of enteral nutrition, or tube feeding, are that it continues to use the gut, has fewer complications such as infection and organ malfunction, is often easier to administer, and is cheaper than parenteral nutrition.[26-29] In addition, nutrients are metabolized and utilized more efficiently by the body.

Specific disease and condition-related indications for use consist of a diagnosis of a cancer of the alimentary canal (in particular, head and neck, esophageal, gastric, or pancreatic cancers) and severe complications/side effects from chemotherapy and/or radiation that are seriously jeopardizing the treatment plan of an individual already suffering from malnutrition.[26]

Contraindications for enteral nutritional support include a malfunctioning gastrointestinal tract, malabsorptive conditions, mechanical obstructions, severe bleeding, severe diarrhea, intractable vomiting, gastrointestinal fistulas in locations difficult to bypass with an enteral tube, inflammatory bowel processes such as prolonged ileus and severe enterocolitis, and/or an overall health prognosis not consistent with aggressive nutrition therapy.[26] Thrombocytopenia and general pancytopenic conditions following anticancer treatments may also prevent placement of an enteral tube.

Prospective Assessment

Several effective methods for the delivery of enteral nutritional support or tube feedings exist. An approximation of how long nutritional support will be needed is critical, however, to determine the most appropriate delivery route. Nasogastric, nasoduodenal, or nasojejunal methods are best for short-term support (<2 weeks).[29] The endpoint of delivery—the stomach, the duodenum, or jejunum—is determined by the risk of aspiration, with nasojejunal feeds recommended for individuals with aspiration risk. If the person with cancer is at very high risk for aspiration, enteral nutritional support may be contraindicated and parenteral nutrition should be considered. Also, immune-compromised individuals with mucositis, esophagitis, and/or herpetic, fungal, or candidiasis lesions in the mouth or throat may not be able to tolerate the presence of a nasogastrointestinal tube.

Tubes are constructed from silicone or polyurethane and can vary in length from 30 to 43 inches, with the shorter tubes used for nasogastric feedings. The diameters range from 5F to 16F catheters. Tubes may have weighted tips to help passage through the gut.

Percutaneous endoscopic gastrostomy tubes (PEGs) and percutaneous endoscopic jejunostomy tubes (PEJs) are generally used for long-term enteral feedings (>2 weeks).[29] The placement further down in the gastrointestinal tract has a number of advantages: the diameter of the tube is larger (15F-24F catheters), which allows easier and faster passage of formulas and medications; the risk for aspiration is lower because of the decreased chance of migration of the tube up into the esophagus; the risk for sinusitis or nasoesophageal erosion is lower; and this route is more convenient and aesthetically pleasing to the individual because of the ability to conceal the tube.[29] People anticipating long-term support may also consider a skin-level button gastrostomy or jejunostomy.

Assessment of need and ease of delivery are best done early. If the malnourished individual requires surgery for an unrelated event, a PEG or PEJ may be placed at that time to avoid an additional procedure.

Infusion Methods and Formulas

Enteral nutrition or tube feedings can be delivered at various rates. When possible, the bolus method is preferable because it mimics normal feeding, requires less time and equipment, and offers greater flexibility to the patient.[29] The following is a summary of infusion possibilities:[29]

Continuous or cyclic drip feeding

Caloric/nutrient and free-water requirements need to be determined first to plan rate and time recommendations.

Enteral feeding pumps provide reliable, constant infusion rates and decrease the risk of gastric retention.

Assuming that no compounding factors are present, feeding into the stomach (25–30 cc/h) can start at a higher rate than feeding into the jejunum (10 cc/h); rates can be increased, with tolerance, every 4 to 6 hours until the rate reaches that needed to deliver the required caloric/nutrient needs.

Continuous feeds can be cycled to run at night to allow greater flexibility and comfort. If it is physically possible, these nocturnal feeds can allow daytime oral or bolus feedings to meet nutritional goals and provide a more normal lifestyle.

Bolus and intermittent feeding

Caloric/nutrient and free-water requirements need to be determined to plan the feeding schedule.

Bolus feedings can be offered several times (3–6 times) each day; as much as 250 to 500 cc can be given over 10 to 15 minutes.

Bolus feeding should be used ONLY when the endpoint of the tube is in the stomach; it should NEVER be used when feedings are delivered into the duodenum or jejunum. This precaution protects against gastric distention and dumping.

A gravity drip from a bag or syringe with a slow push can be used to administer the formula.

Diarrhea is a common side effect of this infusion method but can be controlled with a change in formula, additions to the formula, and a change in the amount of formula given over a finite period of time.

After the infusion method has been determined, a formula needs to be selected. There are many formulas on the market, ranging from elemental preparations of predigested nutrients to more complete and complex formulas that mimic oral nutrition intake. Specialized formulas are available for specific health conditions such as diabetes mellitus and compromised renal function. Modular formulas that are not nutritionally complete but add specific nutrients such as

protein, fat, and carbohydrate are also available. These preparations can be added to an existing formula to provide additional benefit.

Glutamine, an amino acid, is a key energy source for the gut and has been shown to help maintain gut health and integrity and to protect the gut from damage from radiation and chemotherapy.[29,30] The use of supplemental glutamine in tube feedings in addition to L-arginine and omega-3 fatty acids is gaining popularity. These potentially beneficial nutrients are now available in formulas and as oral supplements. More research needs to be done, however, to thoroughly evaluate the benefits and possible disadvantages.

When a formula is being chosen, the institution nutrition formulary for available preparations, modular formulas, and additions such as glutamine or fiber should be considered. Consideration should also be given to the patient’s medical condition, gastrointestinal function, and financial resources.

Transition to Home

A significant number of patients using enteral nutritional support in the hospital are discharged to home while still on therapy. This can be done successfully and requires that the following conditions are met:[29]

The patient and/or caregiver is given enough time for education and is proficient in the use of the tubes, site care, and the use of the pump.

The patient is discharged to a safe and clean environment. Regular medical follow-up is arranged to ensure appropriate function of the feeding tube

and optimization of the nutrition plan.

Parenteral nutrition

Parenteral nutrition may be indicated in select individuals who are unable to use the oral or enteral route (i.e., those who have a nonfunctioning gut), such as those with obstruction, intractable nausea and/or vomiting, short-bowel syndrome, or ileus. Additional inclusive conditions common in the cancer population are severe diarrhea/malabsorption, severe mucositis or esophagitis, high-output gastrointestinal fistulas that cannot be bypassed by enteral intubation, and/or severe preoperative malnutrition.[27,29]

Contraindications for use of parenteral nutrition are a functioning gut, a need for nutritional support for a duration less than 5 days, an inability to obtain intravenous (IV) access, and poor prognosis not warranting aggressive nutritional support.[27,29] Additional conditions that should cause hesitation are the following: patient or caregiver does not want parenteral nutrition, patient is hemodynamically unstable or has profound metabolic and/or electrolyte disturbances, and/or patient is anuric without dialysis.[27,29]

Prospective Assessment

If parenteral nutrition is determined to be beneficial, the two venous access sites are central and peripheral. Cancer patients usually have central IV catheters to accommodate multiple IV therapies. If this is not the case, a peripheral catheter can be placed, although care must be taken to avoid overuse of the peripheral accesses with nutritional support and anticancer therapies. Numerous peripheral infusions and venesections can result in vessel sclerosis. The following discussion highlights both types of access:[27,29]

Central venous catheters

May utilize single-, double-, or triple-lumen catheters for delivery of medication, blood and blood products, and parenteral nutrition without interruption.

Placement of lines should be done by an experienced surgical team to minimize risk of pneumothorax, hemothorax, hematuria, aneurysms, venous or nerve damage, and microbial contamination. Evaluation of catheter tip location and site care is critically important.

Short-term support can be provided via Cordis or Swan Ganz catheters; long-term support can be provided via Hickman or Broviac catheters.

Peripheral venous catheters

A short canula is placed in the arm (either the percutaneous subclavian vein in adults or the arteriovenous fistulas are used as access sites).

Catheters must be located in peripheral vessels with high blood flow to facilitate rapid dilution of the formula; access may be alternated to avoid thrombophlebitis.

Peripherally inserted central catheters (PICC lines) are used for long-term support; the tip of the catheter must be placed in a central vein such as the superior or inferior vena cava to decrease risk of infection and thrombosis.

Solutions

Parenteral nutrition formulas are tailored to individual clinical status and nutritional needs. The formulas contain a combination of amino acids, dextrose, lipids, vitamins, minerals and trace elements, fluids, electrolytes, and, possibly, additives such as insulin, heparin, and antacids.

Solutions running through peripherally placed lines must be altered by reducing the percentage of calories from carbohydrates (hypertonic) and increasing the percentage from lipids (isotonic). Peripheral solutions with a final dextrose concentration lower than 10% and an osmolarity lower than 900 mOsm/kg are generally well tolerated.[27] The mandatory alteration in macronutrients can present problems with delivery of recommended calories/nutrients.

Central infusions are not limited by osmolarity because they use a large vein; this feature makes central venous access a good choice for severely stressed, hypermetabolic individuals and/or individuals requiring a fluids restriction.[27]

Many drugs and compounds are not compatible with parenteral solutions and should not be added to the solutions or even run through parenteral solution-designated lines to avoid the

chance of interaction or precipitation. Pharmacists should be consulted in the preparation of parenteral nutrition solutions and before any additional medications or compounds are added.

Complications

Incompatibility with drugs is just one of a number of possible complications associated with parenteral nutrition administration. Complications can be categorized as mechanical (vein thrombosis, pneumothorax, and catheter tip misplacement) or metabolic (hyperglycemia/hypoglycemia, hypokalemia, and elevated liver function tests).[27] Because of the precision that is required to order, administer, and maintain this type of support, trained and experienced medical personnel should be involved. Many facilities have dedicated nutritional support multidisciplinary teams.

Transition to Home

Cancer is one of the most common diagnoses among home parenteral nutrition recipients. The following criteria should be used when assessing the appropriateness of discharge to home on parenteral feeds. The individual must meet the following conditions:[27]

Be medically and emotionally stable. Have a relatively long life expectancy (>6 months). Be educated and able to perform the requisite tasks to maintain a sterile access site in a

safe and clean environment. Have a long-term access in place and be stable on the formula before being discharged. Have a medical follow-up and support system in place for questions and complications.

Tapering off parenteral nutritional support requires coordination between the medical staff and the patient. Because parenteral support is given continuously, the taper involves a gradual reduction in rate and time. Parenteral nutritional support cannot be abruptly discontinued.

When transitioning to enteral feeds, parenteral support can be decreased to 50% when enteral feeds reach 33% to 50% of the goal rate; it can be discontinued when enteral feeds reach 75% of goal and are tolerated.[27]

When transitioning to oral nutrition, parenteral solutions can be decreased to 50% when the patient is tolerating a full liquid diet or beyond and can be discontinued once solid foods are tolerated in addition to the consumption of adequate fluids.[27]

Both enteral and parenteral nutritional support can be safe and effectively used to help reverse the effects of malnutrition in individuals with cancer. However, nutritional support, particularly parenteral support, is still controversial when used as routine adjuvant therapy to anticancer therapies or when there is an absence of efficacious cancer treatment.[31] Every measure should be employed to sustain an individual and improve his or her condition through oral intake before consideration is given to nutritional support.

Nutritional Suggestions for Symptom Management

Side effects of cancer treatments vary from patient to patient, depending on the type, length, and dose of treatments as well as the type of cancer being treated. This section offers practical suggestions for managing the common symptoms affecting nutrition intake.

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

Anorexia

Loss of appetite or poor appetite is one of the most common problems that occurs with cancer and its treatment.[32] The cause of anorexia may be multifactorial. Treatment modality, the cancer itself, and psychosocial factors may all play a role in appetite.[32] Eating frequent meals and snacks that are easy to prepare may be helpful. Liquid supplements may improve total energy intake and body function [33] and may work well when eating solids is difficult. Other liquids that contain energy may also help, such as juices, soups, milk, shakes, and fruit smoothies. Eating in a calm, comfortable environment and exercising regularly may also improve appetite.[32]

Suggestions for appetite improvement include the following:[34-36]

Plan a daily menu in advance. Eat small, frequent, high-calorie meals (every 2 hours). Arrange for help in preparing meals. Add extra protein and calories to food. Prepare and store small portions of favorite foods. Consume one third of daily protein and calorie requirements at breakfast. Snack between meals. Seek foods that appeal to the sense of smell. Be creative with desserts. Experiment with different foods. Perform frequent mouth care to relieve symptoms and decrease aftertastes.

What types of foods are usually recommended?

Cheese and crackers. Muffins. Puddings. Nutritional supplements. Milkshakes. Yogurt. Ice cream. Powdered milk added to foods such as pudding, milkshakes, or any recipe using milk.

Finger foods (handy for snacking) such as deviled eggs, cream cheese or peanut butter on crackers or celery, or deviled ham on crackers.

Chocolate.

See the National Cancer Institute (NCI) Web site [32] for recipes such as Lactose-Free Double Chocolate Pudding Recipe to Help with Lactose Intolerance, Banana Milkshake Recipe to Help with Appetite Loss, and Fruit and Cream Recipe to Help with a Sore Mouth. For a free copy of this booklet, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

Alterations of taste and smell

Alterations in taste can be related to unknown effects of cancer, radiation treatment, dental problems, mucositis and infection (thrush), or medications. Cancer patients undergoing chemotherapy frequently report changes in their sense of taste, specifically a bitter taste sensation during administration of the cytotoxic drugs.[37] One study measured the taste thresholds among cancer patients under chemotherapy compared with controls.[38] In this study, 62% of patients complained of taste disorders associated with the chemotherapy medications. Taste dysfunction can result in food avoidance, inducing weight loss and anorexia, all of which can have significant consequences on patients' quality of life. Simply changing the types of foods eaten as well as adding additional spices or flavorings to foods may help. Citrus may be tolerated well if no mouth sores or mucositis is present. Rinsing the mouth before eating may help improve the taste of food.[32]

While undergoing cancer therapy, patients may experience taste changes or develop sudden dislikes for certain foods. Their sense of taste may return partially or completely, but it may be a year after therapy ends before their sense of taste is normal again. A randomized clinical trial found that zinc sulfate during treatment may be helpful in expediting the return of taste after head and neck irradiation.[39][Level of evidence: I]

Suggestions for helping cancer patients manage taste changes include the following:

Eat small, frequent meals and healthy snacks. Be flexible. Eat meals when hungry rather than at set mealtimes. Use plastic utensils if foods taste metallic. Try favorite foods. Plan to eat with family and friends. Have others prepare the meal. Try new foods when feeling best. Substitute poultry, fish, eggs, and cheese for red meat. A vegetarian or Chinese cookbook can provide useful nonmeat, high-protein recipes. Use sugar-free lemon drops, gum, or mints when experiencing a metallic or bitter taste in

the mouth. Add spices and sauces to foods. Eat meat with something sweet, such as cranberry sauce, jelly, or applesauce.

Xerostomia

Xerostomia (dry mouth) is most commonly caused by radiation therapy that is directed at the head and neck.[35] A number of medications may also induce xerostomia. Dry mouth may affect speech, taste sensation, ability to swallow, and use of oral prostheses. There is also an increased risk of cavities and periodontal disease because less saliva is produced to cleanse the teeth and gums.

A primary method of coping with xerostomia is to drink plenty of liquids (25–30 mL/kg per day) and eat moist foods with extra sauces, gravies, butter, or margarine.[25,36,40] In addition, hard candy, frozen desserts such as frozen grapes, chewing gum, flavored ice pops, and ice chips may be helpful.[32] Oral care is very important to help prevent infections. Irradiation to the head and neck of a patient who has permanent dry mouth symptoms may result in reduced intake of energy, iron, zinc, selenium, and other key nutrients.[41][Level of evidence: II] Special efforts should be made to help tailor meals and snacks for individuals with xerostomia.

Suggestions for lessening or alleviating dry mouth include the following:[36]

Perform oral hygiene at least 4 times per day (after each meal and before bedtime). (Refer to the Routine Oral Hygiene Care section of the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.)

Brush and rinse dentures after each meal. Keep water handy at all times to moisten the mouth. Avoid rinses containing alcohol. Consume very sweet or tart foods and beverages, which may stimulate saliva. Drink fruit nectar instead of juice. Use a straw to drink liquids.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on xerostomia.)

Mucositis/stomatitis

Stomatitis, or a sore mouth, can occur when cells inside the mouth, which grow and divide rapidly, are damaged by treatment such as bone marrow transplantation, chemotherapy, and radiation therapy. These treatments may also affect rapidly dividing cells in the bone marrow, which may make patients more susceptible to infection and bleeding in their mouth. By carefully choosing foods and by taking good care of their mouths, patients can usually make eating easier.[42-44] Individuals who have mucositis, mouth sores, or tender gums should eat foods that are soft, easy to chew and swallow, and nonirritating.[32] Some conditions may require processing foods in a blender. Irritants may include acidic, spicy, salty, and coarse-textured foods. A pilot study found that oral glutamine swishes might be helpful in reducing the duration and severity of mucositis.[45][Level of evidence: I] Glutamine may also reduce the duration and severity of stomatitis during cytotoxic chemotherapy.[45,46][Level of evidence: I]

Suggestions for people with cancer who are experiencing stomatitis include the following:

Eat soft foods that are easy to chew and swallow, including bananas and other soft fruits; applesauce; peach, pear, and apricot nectars; watermelon; cottage cheese; mashed potatoes; macaroni and cheese; custards; puddings; gelatin; milkshakes; scrambled eggs; oatmeal or other cooked cereals; pureed or mashed vegetables such as peas and carrots; and pureed meats.

Avoid foods that irritate the mouth, including citrus fruits and juices such as orange, grapefruit, or tangerine; spicy or salty foods; and rough, coarse, or dry foods, including raw vegetables, granola, toast, and crackers.

Cook foods until soft and tender. Cut foods into small pieces. Use a straw to drink liquids. Eat foods cold or at room temperature; hot and warm foods

can irritate a tender mouth. Practice good mouth care, which is very important because of the absence of the

antimicrobial effects of saliva. Increase the fluid content of foods by adding gravy, broth, or sauces. Supplement meals with high-calorie, high-protein drinks. Numb the mouth with ice chips or flavored ice pops.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on mucositis.)

Nausea

Nausea can affect the amount and types of food eaten during treatment. Eating before treatment is important, as well as finding foods that do not trigger nausea. Frequent triggers for nausea include spicy foods, greasy foods, or foods that have strong odors.[32] Once again, frequent eating, and slowly sipping on fluids throughout the day may help.

Additional eating suggestions include the following:[19]

Eat dry foods such as crackers, breadsticks, or toast, throughout the day. Sit up or recline with a raised head for 1 hour after eating. Eat bland, soft, easy-to-digest foods rather than heavy meals. Avoid eating in a room that has cooking odors or is overly warm; keep the living space

comfortable but well ventilated. Rinse out the mouth before and after eating. Suck on hard candies such as peppermints or lemon drops if the mouth has a bad taste.

(Refer to the PDQ summary on Nausea and Vomiting for further information.)

Diarrhea

Radiation, chemotherapy, gastrointestinal surgery, or emotional distress can result in diarrhea. Avoiding hyponatremia, hypokalemia, and dehydration during episodes of diarrhea requires the intake of additional oral fluids and electrolytes. Broth, soups, sports drinks, bananas, and canned fruits may be helpful for the replenishment of electrolytes. Diarrhea may worsen with greasy

foods, hot or cold liquids, or caffeine.[32] In the presence of radiation enteritis, fibrous foods—especially dried beans and cruciferous vegetables—may contribute to frequent stools.[47] Meal planning should be individualized to meet nutritional needs and tolerances. Oral glutamine may also help prevent intestinal toxicity from fluorouracil.[48][Level of evidence: I]

Additional suggestions include the following:[19]

Drink plenty of fluids through the day; room-temperature fluids may be better tolerated. Limit milk to 2 cups or eliminate milk and milk products until the source of the problem

is determined. Limit gas-forming foods and beverages such as soda, cruciferous vegetables, legumes

and lentils, and chewing gum. Limit the use of sugar-free candies or gum made with sugar alcohol (sorbitol). Drink at least 1 cup of liquid after each loose bowel movement. (Refer to the Impaction

section of the PDQ summary on Gastrointestinal Complications for more information.)

(Refer to the PDQ summary on Gastrointestinal Complications for more information on diarrhea.)

Neutropenia

People with cancer may have a low white blood cell count for a variety of reasons, some of which include radiation therapy, chemotherapy, or the cancer itself. Patients who have a low white blood cell count are at an increased risk for developing an infection.[49] Suggestions for helping people prevent infections related to neutropenia include the following:

Check expiration dates on food and do not buy or use if the food is out of date. Do not buy or use food in cans that are swollen, dented, or damaged. Thaw foods in the refrigerator or microwave—never thaw foods at room temperature. Cook foods immediately after thawing. Refrigerate all leftovers within 2 hours of cooking and eat them within 24 hours. Keep hot foods hot and cold foods cold. Avoid old, moldy, or damaged fruits and vegetables. Avoid tofu in open bins or containers. Cook all meat, poultry, and fish thoroughly; avoid raw eggs or raw fish. Buy individually packaged foods, which are better than larger portions that result in

leftovers. Use caution when eating out—avoid salad bars and buffets. Limit exposure to large groups of people and people who have infections. Wash hands frequently to prevent the spread of bacteria.

This list may be modified after chemotherapy or when blood count returns to normal.

Hydration and dehydration

Adequate hydration is critically important for health maintenance. There are several common scenarios found in cancer treatment that may lead to altered hydration status and electrolyte imbalance. Hydration status can become compromised with prolonged disease or treatment-related diarrhea and/or episodes of nausea and vomiting.[50] Acute and chronic pain can also adversely affect the appetite and hence the desire to eat and drink. Fatigue, an all-too-common complaint of people with cancer, can be one of the first signs of dehydration.[51] Once the underlying cause for altered hydration is appropriately managed, some suggestions to promote adequate hydration include the following:[32,52,53]

Drink 8 to 12 cups of liquids a day; take a water bottle whenever leaving home. It is important to drink even if not thirsty, as the thirst sensation is not a good indicator of fluid needs.

Add food to the diet that contains a significant portion of fluid, such as soup, flavored ice pops, flavored ices, and gelatins.

Limit consumption of caffeine-containing products, including colas and other caffeinated sodas, coffee, and tea (both hot and cold); these foods may not be as nourishing as noncaffeinated beverages.

Drink most liquids after and/or between meals to increase overall consumption of both liquids and solids.

Use antiemetics for relief from nausea and vomiting; antiemetic use can be very helpful and may prevent hospital admissions from dehydration. The classes of available antiemetics include anticholinergics, phenothiazines, antihistamines, butyrophenones, benzamides, and serotonin receptor antagonists. Of note, all of these antiemetics have side effects that many individuals would consider less problematic than nausea and vomiting.

Constipation

Constipation is defined as fewer than three bowel movements per week.[54] It is a very common problem among individuals with cancer and may result from lack of adequate fluids or dehydration, lack of fiber in the diet, physical inactivity or immobility, anticancer therapies such as chemotherapy, and medications used in the treatment of side effects of anticancer therapy such as antiemetics and opioids.[54,55][Level of evidence: I] In addition, commonly used pharmacologic agents such as minerals (calcium, iron), nonsteroidal anti-inflammatory drugs, and antihypertensives can cause constipation.[54]

An effective bowel regimen should be in place before the problem of constipation occurs. Preventive measures should be common practice, and special attention should be paid to the possibility of constipation as a side effect of certain therapies. Suggestions include the following:[52,54]

Eat more fiber-containing foods on a regular basis. The recommended fiber intake is 25 to 35 grams per day. Fiber should be gradually added to the diet, and adequate fluids must be consumed at the same time (see list below).

Drink 8 to 10 cups of fluid each day; beverages such as water, prune juice and warm juices, decaffeinated teas, and lemonade can be particularly helpful.

Take walks and exercise regularly (proper footwear is important).

If prevention does not work and constipation is a problem, the application of a three-pronged approach for treatment is suggested: diet (fiber and fluids), physical activity, and over-the-counter or prescription medication. The use of biofeedback or surgery may also be considered.[56]

Suggestions are as follows:[15,52,54,56,57]

Continue to eat high-fiber foods and drink adequate fluids. Try adding wheat bran to the diet; begin with 2 heaping tbsp each day for 3 days, then increase by 1 tbsp each day until constipation is relieved. DO NOT EXCEED 6 TBSP PER DAY.

Maintain physical activity. Include over-the-counter treatments if necessary. This refers to bulk-forming products

(e.g., psyllium, methylcellulose [Citrucel], psyllium hydrophilic mucilloid [Metamucil (if adequate hydration is tolerated), Fiberall], calcium polycarbophil [FiberCon, Fiber-Lax]); stimulants (e.g., bisacodyl [Dulcolax] tablets or suppositories, glycerin suppositories, and calcium salts of sennosides [Senokot]); stool softeners (e.g., docusate sodium [Colace] and docusate calcium [Surfak]); and osmotics (e.g., milk of magnesia, lactulose, and magnesium sulfate/Epsom salts). Cottonseed and aerosol enemas can also help relieve the problem. Lubricants such as mineral oil would be included in this group but are NOT recommended because of the potential for binding and preventing absorption of essential nutrients.

Good sources of fiber include the following:[19,52]

4+ grams per ½ cup cooked serving.o Legumes.*

Kidney beans. Navy beans. Garbanzo beans. Lima beans. Split peas. Pinto beans. Lentils.

4+ grams per designated unit.o Corn (½ cup).o Pears with skin (medium piece of fruit).o Popcorn (3 cups popped).

4+ grams per 1 oz serving.o Whole-grain cereals (cold).o Bran cereals (cold).

4+ grams per 1/3 cup serving, dry.o Oatmeal.o Oat bran.o Grits.

2+ grams per ½ cup cooked or 1 cup raw serving.o Asparagus.o Green beans.o Broccoli.*o Cabbage.*o Carrots.o Cauliflower.o Greens.o Onions.o Peas.o Spinach.o Squash.o Green peppers.o Celery.o Canned tomatoes.

2+ grams per ½ cup serving or medium piece of fruit.o Apples with the skin.o Bananas.o Oranges.o Strawberries.o Peaches.o Blueberries.

2 grams per slice or designated serving size.o Whole wheat bread.o Whole grain bagel.o Pita (½ portion).o Whole-grain crackers.