CASE STUDY

Jesse Terris
 WHAT IS LYMPHOMA

Lymphoma is a cancer that starts in the lymph system.

There are two categories of lymphoma

• Hodgkin lymphoma
• Those with Hodgkin lymphoma have large cancerous cells called Reed-Sternberg (RS)
cells.
• Non-Hodgkin lymphoma (NHL)
• NHL forms in either B cells or T cells within the immune system and can be fast or slow
growing.
 DIFFUSE LARGE B CELL
LYMPHOMA
• Diffuse Large B cell Lymphoma is the most aggressive type of Non-
Hodgkin Lymphoma.
• B cells are what your bodies immune system relies on to make
antibodies.
• It is fast growing and is caused by abnormal B cells in the blood.
• It affects the body’s white blood cells and its ability to fight
infections.
 CHEMOTHERAPY
• Prior to admission the pt was receiving chemotherapy which can cause side effects that
affect nutritional intake.
• Mouth sores
• Loss of appetite *
• Nausea
• Vomiting
• Constipation *
• Change in taste
• Metallic taste in mouth *
 THE PATIENT

• 68-year-old male • Past medical history

• Height: 5’10” • Alcoholism
• Cancer: Non-Hodgkin lymphoma
• Weight: 155 lb (70.4 kg)
• COPD
• BMI: 22.36 • GERD
• Hypertension
 ADMISSION
• Pt presented to ED with hyper calcium and
bilirubin levels. Pt experiencing shortness of
breath and has been “peeing blood”
Lab 3/10/22 3/11/22
• Pt has relapsed Diffuse Large B cell lymphoma
and has been receiving chemotherapy. Calcium 14.6 13.3
• Pt receiving IV NaCl and is on Decadron.
Bilirubin 5.9 3.4
 INITIAL VISIT 3/11
• Patient was sitting up in bed, good spirited and was able to answer questions
• RN Admission Nutrition screen positive for weight loss 24-33 lb and decreased appetite. –
RD consulted.
• Decreased appetite for 2.5 months (since NFPE
starting Chemotherapy) Subcutaneous Fat loss
- Orbital: moderate/severe
• Weight loss of 10 lb in last 2.5 months - Triceps: mild
(6.0% weight loss, significant) Muscle wasting
- Temple: mild
• Drinks Oreo premier protein once a day at - Clavicle: moderate
home - Shoulder: moderate
- Interosseous: moderate
• Willing to try strawberry or vanilla ensure Edema
while here. - bilateral trace pitting
 ENERGY NEEDS

• Energy Needs:
• 1760- 2100 kcals
• Based on 30-35 kcal/kg for repletion
• Protein needs:
• 84-105 gm
• Based on 1.2-1.5 gm /kg for cancer
• Fluid needs:
• 1760-2100 ml
• Based on 1 ml per kcal
 INTERVENTIONS MONITORING
- Food and supplement intake
1. Meals and snacks: NPO, diet advancement per
GI. - Weight and weight changes

2. Medical food supplements: trial Strawberry and - Diet advancement/tolerance

Vanilla Ensure Enlive.
- Labs/medical tests/procedures

NUTRITION DIAGNOSIS
1. Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by NPO.

2. Non-severe malnutrition in the context of chronic illness related to inadequate oral intake as evidenced by
<75% intake x 2 months, 4.3% weight loss x 2 months, and moderate/severe subcutaneous fat loss in orbitals
and moderate muscle wasting in clavicle, shoulder, and interosseous regions.
3/12
- Diet advanced to Cardiac diet: 3-4 gm 3/14
Na; Low fat - Pt has had increased needs for oxygen
- Pt started experiencing hallucinations and and course crackles noted
requested to have medications to help - Now NPO due to concerns for aspiration,
him sleep. pending swallow evaluation
- Pt became aggressive with staff and was
placed in restraints
- GEM team now following.
 • Moved to ICU and intubated due to increased oxygen demands,
respiratory distress, and inability to follow demands.
• OG tube placed in stomach, verified per KUB.

FOLLOW UP • RD consulted for vent protocols

• IV medication
3/15 • Propofol at 18 ml/hr (provides 491 kcal)
• Dextrose 5% at 125 ml/hr (provides 510 kcal)
• Labs: Mg 1.2 – placed on replacement.

ENERGY NEEDS for
critical care
Kcal: 1685-1830
- Based on 23-25 kcal/kg
Protein: 85-145 gm
- Based on 1.2-2 g/kg
Fluid: 1685-1830 ml
- Based on 1ml/kcal
INTERVENTIONS
1. Enteral Nutrition:
- Vital AF 1.2 at goal rate
50ml/hr if off Propofol Increase to 65
ml/hr.
- This provides 1716 kcal, 107
gm protein, and 1158 ml free water.
- Recommend 100 ml flush every
4 hrs when IV fluids discontinue.
2. Monitor BM: Last BM 3/10. Colace
and Senokot ordered.

PT STILL NPO AT THIS TIME

 FOLLOW UP 3/18

• 3/17
• Oncology spoke with the family about poor prognosis for any
meaningful recovery.
• Palliative care following
• Still NPO – No TF started.
• BM 3/16 – still receiving Colace and Senokot BID per NG tube
• IV Medications
• Dextrose 125 ml/hr (provides 510 kcal)
• Propofol 18 ml/hr (provides 491 kcal)
• Labs: Na 135, low. Ca 6.8, low
• 3/21
• Family visit with palliative care
• Progressive metastatic lymphoma
• Not a candidate for disease directed therapy
• Family decided comfort care and liberated from life support 3/22
• Labs: Na 133, low. Ca 6.3, low
• 3/22
• Patient passed away.
 CONCLUSION
• This is a perfect example of just how quickly people can decline.
• Although as dietitians we did everything, we could to ensure the patient could receive
nutrition, his body was too weak to support it.
 CITATIONS
• Sehn LH, Author AffiliationsFrom the BC Cancer Centre for Lymphoid Cancer and the University of British
Columbia. Diffuse large B-cell lymphoma: Nejm. New England Journal of Medicine.
https://www.nejm.org/doi/full/10.1056/NEJMra2027612. Published June 10, 2021. Accessed April 12, 2022.
• Schmitz R, Al. E, Author AffiliationsFrom the Lymphoid Malignancies Branch (R.S., et al. Küppers R. The
biology of Hodgkin's Lymphoma. Nature News. https://www.nature.com/articles/nrc2542. Published December
11, 2008. Accessed April 12, 2022.
• New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1801445. Published August
2, 2018. Accessed April 12, 2022.