Acute Care Case
Presentation:
Stage IV Lung Cancer
and Malnutrition
Alivia Oney
Presented to the Emergency room (11/13) with SOB, chest pain
Very confused, family indicated patient is alcohol dependent and
has a history of Wernicke’s encephalopathy.
Korsakoff dementia?
Patient Consulted for BMI <19 (14.98)
Presentation DTI to coccyx, and multiple to back
Diagnoses during stay: STEMI, pneumonia, acute respiratory failure
with hypoxia, septic shock, possible Korsakoff dementia, stage IV
lung cancer, malnutrition
HT: 5’7” BP: 97/65
Anthropometrics
and Vitals WT: 94# RR: 22
BMI: 14.98* TEMP: 97.8
PMH: COPD, CAD, PAD, A-fib, Wernicke’s encephalopathy,
possible liver cirrhosis
Patient
Medical Hx, FMH:
Family Medical Mother- DM, MI
Father- unexpected early death
Hx, and Social
Hx Social history: lives with brother, performs most ADLs, chronic
alcohol dependence, lifelong smoker
• Zithromax • Phenobarbital
• Rocephin • Ativan
• Zosyn • Valium
• Vancomycin
• Pulmozyme
• Versed
• Precedex • Iron sucrose
• Fentanyl • Senna and Colace
• Oxycodone
• Steroid inhaler
• Nitroglycerin • Albuterol
• Heparin
• Isoptin • NaCl 0.9% saline
• Digoxin • Thiamine injections
• Lovenox • Mg sulfate in D5
• Midodrine • Levophed
• Ticagrelor • Potassium bicarb
• Metoprolol • KCl tablets
• Cardizem
Medications
Patient Clinical Course:
Initial Assessment
Stable, not yet in ICU
S/p chest tube placement and still confused, slow and incoherent
responses
Per RN- poor intakes
Day 2 (first Visible severe muscle wasting and fat loss
assessment, WT hx? Patient family reported poor appetite/intakes and weight
loss for the past 2 months along with worsening cough and SOB
11/14)
Relevant labs: Initial intervention:
• Ca: 13.8 • ONS: Ensure Enlive and CIB milkshake
• Na: 134 at every meal
• K: 3.6
• Mg: 1.7
Patient moved to ICU today
Dietitian consulted for PPN order and management (no central
access)
High nutrition risk, expecting withdrawals, dx of malnutrition
Severe chronic disease related malnutrition
Day 3 (11/15) Labs:
• Ca: 12.4
• K: 2.9
• Na remained stable
• Mg: 1.6
Emergency intubation overnight
Mechanically ventilated, OG in place
CVC placed, consulted for TPN
Needs calculated with Penn St 2003b (vent pts), 1.5-1.8 g/kg CBW
Day 4 (11/16) Trying to wean pressors
Clinimix 4.25/10 @ 42 mL/hr without electrolytes + 20% fat
emulsion daily in 250 mL.
Goal of 84 mL provides 1520 kcal, 85 g PRO, 2250 mL
found Ca + D3 supplement
Weaned off Levophed, but extubated (OG pulled)
TPN continued with no changes
Still hypercalcemic, recommended replacement of individual lytes
NEW DX OF STAGE IV SQUAMOUS CELL LUNG CANCER
Explains the persistent hypercalcemia
Day 5 (11/17)
Labs today
Ca: 12.2
K: 3.3
Phos: 1.1
Na: WNL
Mg- 1.7
Epidemiology:
NSCLC accounts for 84% of lung cancers
Squamous cell- 25-30% all lung cancers
Second most common cancer, 1st in cancer related deaths
2020- 2.2 million new cases, 1.8 million deaths
More common in men than women
SQUAMOUS Etiology:
CELL LUNG Smoking (#1 cause)
Second-hand smoke
CANCER Occupational carcinogens (chemicals)
Radon, asbestos, arsenic, etc.
(NSCLC): Clinical manifestations:
Persistent and bloody cough, pneumonia/bronchitis, weight
loss, SOB, hypercalcemia
Typical medical care:
Early stages: surgery, chemotherapy, radiation therapy
Late stages: palliative care
PATHOPHYSIOLOGY OF CONDITION
Transformation of normal cells by DNA point mutations
Inactivation of tumor suppressor genes (p53) and activation of oncogenes (EGFR)
Causes damaged cells to go unchecked, progress through cell cycle (proliferate), and evade apoptosis
Activation of telomerase.
Angiogenesis:
Tumor cells produce vascular endothelial growth factor- causes creation of new blood vessels from
existing vasculature to perfuse the area and allow cells to remain.
Hallmark:
Cavitary lesions in the central part of the lung
Keratin pearls
*PTHrP leads to hypercalcemia by stimulating calcium resorption from bone and
reabsorption in the kidneys.
• Prescribe increased energy and increased protein diet to meet
energy and protein needs.
• 25-35 kcal/kg/d
• 1.0-2.5 g/kg/d
• Prescribe oral nutrition supplements to meet energy and protein
needs.
MNT for • Recommend enteral nutrition for patients who are malnourished
Patients with and unable to tolerate adequate oral diet.
Cancer • Recommend parenteral nutrition support for patients with
moderate to severe malnutrition who have inadequate enteral
nutrition or oral intake over a prolonged period.
• Provide education on malnutrition prevention and/or treatment and
its impact on overall outcomes.
• Provide education on dietary interventions to manage disease and
treatment-related side effects.
Intubated again, OG placed
and tube feeds initiated
New needs calculated, Penn
St 2003b, 1.5-1.8 g/kg CBW,
1 mL/kcal/d fluid
Vital AF 1.2 at a goal rate of
50 ml/hr, 25 ml/hr flushes
Day 6 Provides: 1440 kcal, 90 g
PRO, 1573 ml fluid
(11/18)
Labs today
Still hypercalcemic
K and phos still low,
replacing
All other labs WNL
Failed extubations x2
Discussions for hospice/palliate care/terminal extubation
Started receiving Pamidronate, brings down calcium levels
Regimen cont’d with no change
Day 7-Day 11
(11/19-11/22)
Developed hypernatremia and
hyperosmolality
Increased water flushes
Switched to lower Na fluids
Day 12-20 Labs improved, remained stable since
(11/23-12-1) Family decided against comfort care
Long-term decisions made, trach (11/29)
and PEG placement (12/1)
New needs calculated, no change to
regimen
Patient being transferred to LTAC
CIB milkshake
Oral Nutrition Supplements
Ensure Enlive
Nutrition support (ventilated,
Interventions
TPN and EN
unable to eat, malnourished)
Provided
During Stay: Fluid/electrolyte Ca, K, Phos,
monitoring/management Mg, Na
Clinical judgement decisions
NCM, Oncology General Guidance
The Clinical Guide to Oncology Nutrition, 2006
NIH National Library of Medicine- Squamous Cell Lung Cancer
Medscape- Non-Small Cell Lung Cancer (NSCLC)
References JAMA Oncology- Update of Incidence, Prevalence, Survival, and
Initial Treatment in Patients With Non-Small Cell Lung Cancer in
the US
YouTube- Lung Cancer / Pathology - Squamous cell carcinoma (Dr.
G Bhanu Prakash Animated Medical Videos
