NUTRITION SUPPORT FOR

HYPOPHARYNGEAL CANCER
Kirsten Voss
ISU Dietetic Intern, Class of 2017
Patient Information
Initial assessment 4/3/17
Initials: JP
47 YOM
Admitted to MMC 4/3/17
Chief Complaint: trach bleed
OSH with blood per laryngeal stoma cuffed ETT placed transferred to
SJH MMC
On full support during transport
No active bleeding during transport

G-Tube at home for long-term nutrition

Per wife, supposed to do 6 boluses/day of 1 can chocolate Ensure Plus each
Actually does 4-5 boluses per day
5 cans of Ensure Plus per day provides 1750 kcal, 65 grams protein
Patient Information
PMH: hypopharyngeal cancer, dysphagia, esophageal stenosis,
tracheoesophageal fistula
Surgical Hx: narrow field laryngectomy, esophagoscopy with
dilations, multiple reconstructive surgeries
Oral Concerns: endotracheal tube, tracheostomy
Skin concerns: abrasion L shoulder
GI Concerns: dysphagia, tracheoesophageal fistula
Lines, Tubes, Drains: G-tube, PIV (multiple), CIV, urinary cath
Patient Information
CT Scan Results:
hyperdensity at L thyroidectomy bed near
stoma which may represent acute blood
small branch of L thyrocervical trunk may be
bleeding source
pneumonia of L lung
Laryngectomy Research
Retrospective case-control study, 2015
N= 71; 36 early oral feeding (3-5 days), 30 late oral feeding (7-10 days)
Patients without reconstructive with tissue transfer
Early PO feeding after total laryngectomy did not experience increased
complications and had shorter hospital stay

Serbanescu-Kele, C.M.C., Halmos, G.B, Wedman, J., van der Laan, B.F.A.M., & Plaat, B.E.C. (2015). Early
feeding after total laryngectomy results in shorter hospital stay without increased risk of complications: a
retrospective case-control study. Clinical Otolaryngology, 40, 587-592.
Relevant Surgical History
12/2010: narrow field laryngectomy with tracheostomy
4/2012: PEG placement
6/2014: segmental pharyngeal resection, tracheal resection, stoma revision
9/2015: stoma revision with removal of granulation tissue
Labs Medications
4/3/17 Scheduled
BUN 8 mg/dl Fluoxetine (Prozac)
Crea 0.8 mg/dl Chlorhexidine oral rinse
GFR 89 mg/dl Famotidine (Pepcid)
Na 136 mmol/L Levothryoxine (Synthroid)
K 4.3 mmol/L Mirtazapine (Remeron)
Cl 107 mmol/L
Continuous Infusions
Ca 8.0 mg/dl (L) Lactated Ringers at 70 mL/hr
Mg 1.9 mg/dl Norepinephrine (Levophed)
Phos 2.5 mg/dl Not infusing at time of visit
POC Glu 73-96 mg/dl Propofol (Diprivan) at 9.2 mL/hr
CO2 23 mmol/L (L) 243 kcal from lipids
Anthropometrics
Ht: 170 cm (57)
Admit wt: 96.4 kg (212 lbs)
BMI: 33.4 (obese)
IBW: 67.3 kg (148 lbs)
% IBW: 143%
ABW: 74.5 kg (164 lbs)
Estimated Nutrition Needs
Calories: 1933 kcal
Based on Penn State equation for ventilated patients
Max temp: 36.9 C
Wt: 96.4 kg
Ht: 170 cm
Age: 47 years
Average of last 6 recorded mechanical vent total minute volume (Ve): 8.3 L

Protein: 101-114 grams

Based on 1.5-1.8 g/kg IBW of 74.5 kg

Fluids
ICU team to manage
Nutrition Diagnosis
Swallowing difficulty related to history of hypopharyngeal cancer with multiple
surgeries as evidenced by diagnosed dysphagia and long-term dependence on
G-tube for nutrition.
Practice Guidelines
Continuous pump-assisted infusion preferred for feeding critically ill patients
Avoid bolus feedings for patients at high risk of aspiration
Critically ill patients
Patients with impaired swallowing

Protein needs elevated in critically ill

1.2-2.0 g/kg
No specific level of protein intake shown to decrease mortality, infectious complications
or LOS (AND EAL)
Plan
Recs to MD: if TF initiated via G-tube, recommend initiating TF of Jevity 1.2 at 40 mL/hr
and advance by 10 mL/hr Q4H to goal rate of 67 mL/hr + 2 packets of Beneprotein BID to
provide
2031 kcal
INCLUDES 243 kcal from propofol
9.2 mL/hr x 24 hrs x 1.1 kcal/mL = 243 kcal from lipids in propofol
102 grams protein
1375 mL free water

If TF initiated and propofol discontinued, recommend TF of Jevity 1.2 at 75 mL/hr + 3

packets Beneprotein to provide
1965 kcal
105 grams protein
1451 mL free water
Nutrition Goals RD Intervention
Meet nutrient needs Monitor nutritional parameters for
Fluid/electrolyte balance nutrition initiation

Maintain lean body mass Discuss home TF regimen with pt and

wife prior to discharge
Stable weight Ensure Plus vs standard formulary
Glycemic control
Provided TF recs
Advance to TF as tolerated RD not yet officially consulted for recs
to begin TF
Prevent skin breakdown
Resume TF if no plans for surgery
Optimal organ function
Full follow up by RD in 3 days (4/6/17)
Regular bowel movements
Labs
4/3/17 4/4/17
BUN 8 mg/dl BUN 5 mg/dl (L)
Crea 0.8 mg/dl Crea 0.8 mg/dl
GFR 89 mg/dl GFR 104 mg/dl
Na 136 mmol/L Na 136 mmol/L
K 4.3 mmol/L K 3.7 mmol/L
Cl 107 mmol/L Cl 107 mmol/L
Ca 8.0 mg/dl (L) Ca 7.9 mg/dl (L)
Mg 1.9 mg/dl Mg 1.8 mg/dl
Phos 2.5 mg/dl Phos 2.0 mg/dl (L)
POC Glu 73-96 mg/dl POC Glu not taken
CO2 23 mmol/L (L) CO2 20 mmol/L (L)
Follow Up 4/4/17
Off propofol since 7:30 am LR at 70 mL/hr
Switch to TF only for fluids?
Ventilated with ETT
Planning extubation K, Phos, Mg repleted overnight
Pt alert and calm, pain controlled TF started 10am 4/4
Initiated at 20 mL/hr
No active bleeding
Embolization of inferior thyroid artery MDs wanting to switch TF to home
and distal branches off thyrocervical regimen next day
trunk by IR Bolus recs:
Suspected source of bleed 315 mL x 5 bolus feeds / day of Jevity 1.2
Pt tolerated 3 packets Beneprotein / day
Possible wean of IV meds, switch to meds
via G-tube
References
Academy of Nutrition and Dietetics Evidence Analysis Library. (2007). Critical illness:
protein needs. Evidence Analysis Library.
Boullta, J.I., Carrera, A.L., Harvey, L., Hudson, L., McGinnis, C., Wessel, J.J., . . . Bajpai, S.
(2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral
Nutrition, 41 (1), 62-63.
Mueller, C.M., Kovacevich, D.S., McClave, S.A., Miller, S.J., & Schwartz, D.B. (2012). The
A.S.P.E.N. adult nutrition support core curriculum 2nd edition. Silver Spring, MD: American
Society for Parenteral and Enteral Nutrition.
Serbanescu-Kele, C.M.C., Halmos, G.B, Wedman, J., van der Laan, B.F.A.M., & Plaat, B.E.C.
(2015). Early feeding after total laryngectomy results in shorter hospital stay without
increased risk of complications: a retrospective case-control study. Clinical Otolaryngology,
40, 587-592.