Case study presented during the dietetic internship at Reid Hospital

1. ASTROCYTOMA
June 9, 2010 Victoria Parry, Dietetic Intern

2. Astrocytoma
Astrocytoma
s normally
develop in
the
cerebrum
but can
originate in
other parts
of the brain
and spinal
cord.

3. Astrocytes
Star-shaped glial cells located in the brain and spinal cord (CNS)
Function: Regulate external chemical environment of neurons; blood flow
in brain

4. Stages of Astrocytoma
 Stage 1: Pilocytic Astrocytoma
 Stage 2: Diffuse Astrocytoma
 Stage 3: Anaplastic Astrocytoma
 Stage 4: Glioblastoma Multiforme (GBM)
 Gliosarcoma
 Giant Cell Glioblastoma
(1)

5. Examples of Astrocytomas
Low-grade Astrocytoma Giant Cell Astrocytoma
(2)

6. Cause of Astrocytoma
 Currently unknown
 Cell phones
 Prophylactic Radiation
for Acute Lymphatic
Leukemia
 Genetics
 Family history of
astrocytoma
 Molecular Mutation
(3)

7. Prevalence
Gender Age
 Male predominance  Affects all ages
 10% less than 20 years
 1.18:1 Low-grade
 60% 20-45 years
 1.87:1 Anaplastic (Grade  30% 45 years or older
III)
Race Mortality and Morbidity
 Affects all races  Grade 1: 10 years
 Grade 2: More than 5
years
 Grade 3: 2-5 years
 Grade 4: Less than 1 year
(3)

8. Symptoms
 Altered development or
growth (in children)
 Double Vision
 Drowsiness
 Eyesight Problems
 Headache
 Lethargy
 Mental Status Change
 Obtuseness
 Personality Changes
 Seizures
 Vomiting
(1,4

9. Diagnosis and Treatment
Testing: Treatment Options:
 Neurological Exam
 Surgery
 Vision
 Resection of tumor
 Hearing
 Balance  Radiation
 Coordination
 Chemotherapy
 Computed Tomography
 Temozolomide
Scan (CT)
 Magnetic Resonance
Imaging (MRI)
 Angiogram
 Biopsy (1, 2, 3, 5)

10. Case Study Patient Information
• Admit Diagnosis: Aspiration
Pneumonia, Dehydration, Sepsis
• Sex: Female
• Age: 36 Years Old
• Weight: 157#
• Height: 5’0”
• BMI: 31
• Ideal Body Weight: 90-110#
• Percent Ideal Body Weight: 157%
• Adjusted Body Weight: 114#
• Home Diet Regimen: G-Tube with Jevity Bolus 5 Cans
Daily

11. Past Medical History
 Astrocytoma
 1987: Cerebral Astrocytoma
Surgery
 1992: Repeat Brain Surgery
 Pituitary Insufficiency
 Post radiation treatment
 Seizure Disorder
 Post brain surgery
 Hypothyroidism
 Pneumonia
 Gastrostomy Tube Placement
 2006

12. Social History
 Resides with mother and
other family
 Bed bound last 3-4 years
 Home Health Care Aide
 Three times daily
 Nonverbal

13. Relevant Medications
 Os-Cal: Calcium supplement. Also
used as antacid, phosphate binder,
antidiarrheal
 Prilosec: Proton Pump Inhibitor. Used
to decrease gastric acid secretion and
increase gastric pH
 Lactinex: Lactobacillus probiotic.
Used to aid with GI regulation and
antidiarrheal
 Zofran: Antiemetic. Used to decrease
vomiting
 Flagyl: Antibiotic used to treat C. diff. (6)
Can cause nausea, diarrhea, anorexia,

14. Laboratory Values
Date Hgb Hct MCV Na+ K+ Gluc. BUN Creat. Ca+
12-18 37-47 82-101 135-155 3.5-5.5 70-120 8-26 .6-1.3 8.7-10.2
4/18 16.4 49.2 81.8 141 4.4 86 12 0.9 9.1
4/19 14.2 42.1 80.7 135 3.4 97 10 0.9 8.5
4/20 12.3 35.9 80.9 140 3.8 84 5 0.6 8.2
4/21 N/A N/A N/A 145 2.9 73 1 0.6 8.0
4/22 11.4 33.0 79.5 N/A N/A N/A N/A N/A N/A
4/23 N/A N/A N/A 145 2.9 90 2 0.6 8.0
4/24 12.6 37.0 79.8 141 3.4 102 6 0.6 7.7
4/25 12.3 37.0 81.6 143 3.4 86 8 0.5 7.9
4/26 12.6 37.9 82.3 N/A N/A N/A N/A N/A N/A

15. Laboratory Values
Date Alb Alk Phos SGOT PO4 RBC WBC Cl-
3.4-5.0 50-136 7-47 2.5-4.9 4.2-5.4 4-10.5 96-107
4/18 N/A N/A N/A N/A 6.01 16.2 100
4/19 2.4 339 43 3.2 5.21 18.4 102
4/20 N/A N/A N/A N/A 4.44 12.4 107
4/21 N/A N/A N/A N/A N/A N/A 108
4/22 2.2 232 63 N/A 4.16 7.7 N/A
4/23 2.5 257 58 N/A N/A N/A 107
4/24 2.3 189 32 N/A 4.63 16.7 106
4/25 2.2 187 18 N/A 4.53 14.7 109
4/26 N/A N/A N/A N/A 4.60 13.4 N/A

16. Dietary Trigger
 Dietary Consult for Tube Feeding
Recommendation
 Moderately Depleted Albumin Level of 2.4 and
Pre-albumin Level of 11.6

17. PES Statements
 (NC-1.1) Swallowing difficulty related to
dysphagia and past medical history as
evidenced by patient needing Gastrostomy
Tube for main nutrition and hydration support.
 (NI-5.1) Increased protein needs related to
increased demand for protein as evidenced by
moderately depleted albumin level of 2.4 and
pre-albumin level of 11.6.
(7)

18. Interventions
 Await restart of tube feedings
 Recommend necessary adjustments to tube
feeding rate and fluids
 Monitor tolerance of tube feeding

19. Energy, Protein, and Fluid
Needs*
 Estimated Energy Needs:
 1266 (BEE) x 1.2 x 1.1= 1,671 kcals
 Estimated Protein Needs:
 1.2-1.3g/kg= 62-68g
 Estimated Fluid Needs:
 35mL/kg= 1,820mL
*All needs based on Adjusted Body Weight of 114#

20. Tube Feeding
Recommendations
Initial MD Order RD Recommended Order*
 Jevity 1.5 at 30cc/hr  Jevity 1.5 at 50cc/hr
 Provides:
 Provides:  1,800 kcals
 1,080 kcals  77g protein
 26g fiber
 46g protein
 912cc free water
 16g fiber  100% RDI’s vitamins and
minerals
 547cc free water
 IV Fluid KVO
 IV Fluid 100cc/hr  Water Flushes 200cc QID
*RD recommendation based on Adjusted Body Weight of
114#

21. Tests and Procedures
 Chest X-Ray
 Kidney, Ureters, Bladder X-ray (KUB)
 Abdominal Ultrasound
 Conversion G-Tube to G-J Tube
 Abdominal CT Scan with Contrast

22. Diet Orders
 Tube Feeding via G-Tube
 Jevity1.5 at 30cc/hr
 Held due to projectile vomit
 Gatorade via G-Tube
 30cc/hr
 Held for testing
 Tube Feeding via G-J Tube
 Jevity 1.5 at 40cc/hr

23. Discharge Notes
 April 26, 2010
 Approximate 15# Weight Gain
 Positive Fluid Balance
 Discharge to home
 Continue with Home Health Care
 Medical follow ups in two-three weeks
 Resume Jevity bolus of 5 cans daily

24. Questions?

25. Works Cited
 1. Astrocytoma. Astrocytoma. 2007. Available at: http://www.astrocytoma.org/. Accessed June 1, 2010.
 2. Glioma. Mayo Clinic. April 2010. Available at: http://www.mayoclinic.org/glioma/. Accessed June 1,
2010.
 3. Kennedy B, Bruce JN. Astrocytoma. eMedicine Oncology. January 23, 2009. Available at:
http://emedicine.medscape.com/article/283453-overview. Accessed June 2, 2010.
 4. Brain tumor-primary-adults. Medline Plus Medical Encyclopedia. May 7, 2010. Available at:
http://www.nlm.nih.gov/medlineplus/ency/article/007222.htm. Accessed June 5, 2010
 5. Adult brain tumor treatment. National Cancer Institute. October 13, 2009. Available at:
http://www.cancer.gov/cancertopics/pdq/treatment/adultbrain/HealthProfessional/page7. Accessed
June 4, 2010.
 6. Pronsky ZM. Food Medication Interactions. 15th Ed. Birchrunville, PA: Food-Medication Interactions;
2008.
 7. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd
Ed. Chicago, IL: American Dietetic Association; 2009.