Nutritional Support Antineoplastic Therapy

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Nutritional Support Antineoplastic Therapy

• Principles of IV Therapy
• BSN336

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Nutritional Support

• The care of individuals with potential or known
  nutritional alterations.

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Nutritional Support

• Goals of Parenteral nutrition include
• Provide all essential nutrients in adequate
  amounts to sustain nutritional balance during
  periods when oral or eteral routes of feedings
  are not possible or are insufficient to meet the
  patients caloric needs.
• Preserve or restore the bodys protein metabolism
  and prevent the development of protein or caloric
  malnutrition

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Nutritional Support

• Diminish the rate of weight loss and to maintain
  or increase body weight.
• Promote wound healing
• Replace nutritional deficits

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Concepts of Nutrition

• Nutritional balance depends on 3 things
• Intake of nutrients (Quantity and Quality)
• Relative need for nutrients
• Ability of the body to use nutrients

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Concepts of Nutrition

• Nutritional Deficiency
• Bodys components are used to provide energy for
  essential metabolic processes
• Malnutrition
• Nutritional deficit associated with an increased
  risk of morbidity and mortality

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Concepts of Nutrition

• Three types of Malnutrition
• Marasmus decrease in the intake of calories
  with adequate protein calorie ratio. Gradual
  wasting
• Kwashiorkor adequate intake of calories along
  with a poor protein intake.
• Mixed Malnutrition characterized by aspects of
  both Marasmus, and kwashiorkor

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Nutritional Assessment

• Mild malnutrition 85 to 95 IBW
• Moderate malnutrition 75 to 84 IBW
• Severe Malnutrition less than 75 IBW
• Biochemical Assessment
• Serum Albumin and Transferrin Levels
• Prealbumin and Retinol-Binding protein
• Total Lymphocyte Count
• Serum Electrolytes

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Nutritional Requirements

• Carbohydrates provide energy
• Glucose provides calories in parenteral sol.
• Spare body protein
• Fats primary source of heat and energy
• Essential for the structural integrity of all
  cell membranes
• Fewer problems with glucose homeostasis, carbon
  dioxide production is lower, hepatic tolerence
  may improve
• EFAD Essential Fatty Acid Deficiency

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Nutritional Requirements

• Protein body-building nutrient, functions to
  promote tissue growth and repair and replacement
  of body cells.
• Amino Acids are the basic units of protein
• 8 essential Amino Acids needed by adults
• Electrolytes infused as a component already
  contained in the amino acid solution or as an
  additive

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Nutritional Requirements

• Vitamins necessary for growth and maintenance,
  multiple metabolic processes
• Both fat and water soluble are needed
• Vitamin K can be given IM
• Trace Elements Basic requirements are very small
  but essential

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Parenteral Nutrition Medication Additives

• Insulin
• Heparin
• Histamine 2 (H2) Inhibitors
• Cimetidine, Pepsid, Reglan, Zantac

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Admixture Complications

• Amounts of Calcium and Phosphorus added
• Phosphate Ions
• Line should be flushed incompatible components
• Lipid emulsion obscure presence of precipitates

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Admixture Complications

1. Filter used for administration 1.2 micron
2. Administered with in 24hr after mixing or removal
   from the refrigerator
3. If symptoms of acute respiratory distress,
   pulmonary embolus, or interstitial pneumonitis
   develop stop immediately, check for precipitates

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Antineoplastic Therapy

• Goal of therapy
• Curative given as primary therapy
• Palliative symptom management

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Antineoplastic Therapy

• Basic considerations in chemotherapy treatment
• Smaller the tumor burden the easier the patient
  is to treat
• Surgical dubulking decreases the tumor burden and
  recruits resting malignant cells to start
  dividing, thereby increasing the sensitivity to
  chemotherapy.
• The higher the dose, the better the chance for
  response

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Antineoplastic Therapy

• 4. Doses are altered based on the degree of
  toxicity the patient experiences
• Therapeutic margin is the difference between the
  dose producing the desired benefit and the dose
  resulting in unacceptable toxicity.
• The therapeutic margin is narrow compared with
  that of other types of drugs

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Cell Cycle

• Chemotherapy exerts a cytotoxic action by
  interfering with the reproductive cell cycle
• Cancer cells are the intended target, but
  cytotoxic action also affects normal cells

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Cell Cycle

• Five phases complete the cell growth cycle G0,
  G1, S, G2, and M
• G refers to gap phases or the time when the cell
  is preparing for a more active phase of
  reproduction
• Cells can be come resting and nondividing

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Cell Cycle

• G1 the first growth phase characterized by the
  production of RNA, enzymes and proteins,
  essential to later cycles
• S phase enzymes necessary for DNA synthesis
  increase in activity. Predominant event is the
  production of DNA, the genetic code of all
  information needed for cell life.

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Cell Cycle

• G2 another resting phase, Tna and protein
  necessary for mitosis are synthesized.
• M phase last phase, mitosis takes place, lasts
  about ½ hour to 1 hour.
• The phases of the cell cycle are correlated to
  the efficacy of the antineoplastic agents for
  specific types of cancer
• Most agents kill only cells that are actively
  reproducing,

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Tumor Kinetics

• Cycling cells cells that are dividing
  continuously
• Nondividing cells cells that divide for a time
  and then complete their life cycle with out
  dividing again
• G0 or resting cells further divided into
• Stem cells replenish the stem cell pool
• Nonstem cells differentiate and enter the
  maturing groups of cells

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Growth Fraction

• Cell cycle time amount of time required to move
  from one mitosis to another
• Growth fraction percentage of cycling cells in
  the entire cell population
• Total number of cells
• Rate of cell loss or the number of cells that die
  or leave the cell population

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Doubling Time

• As the tissue mass increases in size, the
  doubling time slows
• Decrease in nutrition available for each cell as
  the total mass increases and blood supply is
  outgrown
• Tumor cells may die spontaneously

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Cell Kill Hypothesis

• Certain drugs doses destroy a constant fraction
  of tumor cells in the body, rather than a
  constant number of cells
• Cell kill caused by antineoplastic drugs is
  related to the relative growth fraction of the
  tumor at the time of treatment

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Drug Resistance

• Cell resistance to drug therapy can be natural or
  aquired.

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Antineoplastic Agents

• Classifications classified according to the cell
  life cycle
• Cell cycle phase-specific (CCS) agents
• Cell cycle phase-nonspecific (CCNS) agents
• Combination Chemotherapy Drugs given in specific
  combinations to work at different phases of the
  cell cycle

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Antineoplastic Agents

• Reductive Therapy debulking, decreases the body
  burden of cancer cells
• Adjuvant Chemotherapy administration of
  chemotherapy to destroy micrometastasis and to
  prevent secondary tumors

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Antineoplastic Agents

• Intermittent Therapy Intermittent high-dose
  (pulse) therapy with CCS and CCNs agents gives
  better therapeutic results with fewer toxic side
  effect than more frequent divided doses. Yields
  better cell kill.

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Antineoplastic Agents

• Chemotherapy Dosing
• Dose calculations using Body Surface Area (BSA)
• Formula BSA x mg/m2 total dose
• Dose Calculation using the Calvert Formula
• Attempts to individualize the does so that
  optimal therapeutic response is achieved without
  toxic effects

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Classes of Drugs

• Alkylating Agents mustard Gas
• Effect the DNA thereby blocking replication
• CCNS act at any stage
• Antimetabolites Low molecular weight compounds
  that exert their effect because of similarity to
  naturally occurring metabolites involved in
  nucleic acid synthesis
• Folic acid antagonists, pyrimidine antagonists,
  purine antagonists, and immunosuppresant
  azathioprine (Imuran)

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Classes of Drugs

• Mitotic Inhibitors Natural products, modes of
  action are different
• Vinblastine, vincristine, etoposide, taxol,
• Cytotoxic Antibiotics produced by the mold
  streptomyces
• Bleomycin, Dactinomycin, Mitomycin
• Topoisomerase-1 Inhibitors activity against a
  broad range of tumors
• Inhibit the enzyme topoisomerase-1 causing
  reversible single strand DNA breaks

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Classes of Drugs

• Miscellaneous
• Altretamine
• L-Asparaginase
• Cladribine
• Hydroxyurea
• Mitotane
• Hormonal agents

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Classes of Drugs

• Hormones and Hormone Antagonists
• Steroidal estrogens, progestins, androgens,
  corticosteroids and synthetic derivatives
• Biotherapy six categories
• Cytokines
• Monoclonal antibodies,
• Differentiation agents
• Cellular therapies
• Immunostimulants
• Gene thereapy

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Short term Complications

• Venous Fragility
• Alopecia
• Diarrhea
• Constipation
• Altered Nutritional Status
• Anorexia and Alteration in Taste
• Fatigue

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Acute Reactions

• Hypersensitivity and Anaphylaxis
• Extravasation
• Stomatitis and Mucositis
• Nausea and Vomiting
• Myelosupression
• Neutropenia
• Thrombocytopenia
• Anemia

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Toxicities

• Neurotoxicity
• Cardiac Toxicity
• Pulmonary Toxicity
• Renal Toxicity

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Routes of Administration

• Intravenous
• Intrathecal
• Regional
• Intra-arterial
• Intraperitoneal
• Cerebrospinal Fluid Reservoirs
• Infusion Pumps