Brain Tumor & Complication_ Dr_Shymaa Shehata.pptx

A case suffering from Glioblastoma (GBM) and had a post-operative complication which is 2ry Adrenal Insufficiency and the challenge of the diagnosis, follow-up, long-term goals, discharge medication, and patient education

1. Brain Tumor & Complication Dr. Shymaa Shehata Harvard CSRT Batch A Head of the Scientific Research Department at MIH Pharm D, BCPS, TOT & Clinical Pharmacotherapy Specialist at MIH 

2. 03 TABLE OF CONTENTS About The Disease 01 Pre-operative Preparation SOAP Analysis 02 Post-operative Complication 04 Patient Education 06 Interventions 05

3. ABOUT THE DISEASE

4. Brain Tumor ( GBM) Glioblastoma (GBM), also referred to as a grade IV astrocytoma , is a fast-growing and aggressive brain tumor . It invades the nearby brain tissue, but generally does not spread to distant organs.

5. GBM & Complications GBM is a devastating brain cancer that can result in death in six months or less GBM Left side hemiplegia U.L. = G1 flickers L.L. = G0 Monoplegia 2ry Brain Insult Glucocorticoids are very effective in ameliorating the vasogenic edema BUT HCP changes need rapid onset of mannitol Vasogenic edema & HCP changes

6. ABOUT THE DISEASE GBM The mainstay of treatment for GBMs is surgery, followed by radiation and chemotherapy. The primary objective of surgery is to remove as much of the tumor as possible without injuring the surrounding normal brain tissue Vasogenic edema & HCP changes Dexamethasone is the preferred agent due to its very low mineralocorticoid activity. The usual initial dose is 10 mg intravenously or by mouth, followed by 4 mg every 6 hours. 2ry Brain Insult S hould take DVT prophylaxis

7. SOAP Analysis

8. Subjective

9. Subjective Inability to walk & Disorientation 2 days ago History of present illness (HPI) Seizure then decrease of conscious level at 23- 11-2023 Chief complaint (CC) L. I. , 50 years old female , 80 Kg Demographics Hypertension ( Concor 2.5 mg at every morning) History of endocrine problem (thyroid gland) Past M edical & Medication History (PMH)

10. Objective

11. GCS = 10 ( E 2 V 3 M 5) Seizure – post ictal No vomit Left Side Hemiplegia U.L. = G1 flickers L.L. = G0 Monoplegia A review of systems (ROS) on admission

12. Vital signs on admission 23/11 24/11 25/11 26/11 28/11 29/11 B.p 156/90 110/85 109/65 (MAP=) 110/85 (MAP=) H.R 90 95 120 — Temp 37 37.3 37 37.1 R.R 18 17 22 15 SaO2 98 ( On room air) Normal Abn ormal

13. ABG on admission 23/11 24/12 25/12 26/12 PH 7.42 7.35 : 7.45 — — PsO2 96 80 : 100 120 — PCo2 36 35 : 45 37 — HCO3 26 — — Normal Abn ormal

14. NORMAL RANGE 24/11 23/11 TEST 4.5-11 x10 9 /L 7.9 8.2 WBC 12-16 g/dl 11.6 12.2 HGB 150-450 x10 9 /L 282 288 Platelet 0.6-1.2 mg/dl 0.6 0.7 Sr.Cr . Below 3 5 U/L 23 ALT Below 3 5 U/L 26 AST Below 1.1 1.1 INR 3.4 to 5.4 g/dL 3.7 S. Albumin 110 - 140 mg/dL 110 112 RBGs Electrolytes NORMAL 24/11 23/11 135-145 mEq /L 140 142 Na 3.5-5.5 mEq /L 4.2 4.3 K Lab tests

15. Imaging & Radiology MRI with Contrast requested Right Parietal SOL (GBM) with vasogenic edema & HCP changes

16. Assessment

17. Assessment (Problem list ) Decrease ICP & Brain Relaxation (Preoperative preparation) Right Parietal GBM with vasogenic edema & HCP changes 2ry Adrenal Insufficiency after S uegery complication Post Operative Complication U.L. = G1 flickers L.L. = G0 Monoplegia Left Side Hemiplegia

18. Plan

19. 19

20. Right Parietal GBM with vasogenic edema & HCP changes

21. Pre-operative Preparation Brain Relaxation should be occur Before Neurosurgery

22. 22 Goal - Indication DOC Regimen Monitoring Decrease ICP and Prevention  of  secondary  brain injury as soon as possible Brain relaxation pre operative (8,9) Mannitol for rapid onset And Dexamethasone for vasogenic edema Mannitol 20%: 0.25 – 1g / kg per dose / 6hr Dexamethasone IV (10 mg then 4mg / 6hr) Effect: improve in sign of high ICP Side Effect: Bl.P ., electrolyte, fluid balance ,blood glucose

23. Left Side Hemiplegia

24. 24 Goal - Indication DOC Regimen Monitoring Deep vein thrombosis (DVT) prophylaxis in high risk period (6,7) Enoxaparin during hospitalization AND Rivaroxban when discharge Clexane S.C ( 40 U/24hr ) all hospitalization period Then Rivaroxban oral 10 mg / 24 hrs. For at least 3- 8 weeks Effect: redness, swelling and or hotness of the left leg Side Effect: P lt., Sr,Cr ., sign of bleeding

25. General Pharmaceutical Care FAST HUGS BID

26. 26 F A S T H Fluid & Feeding Analgesics Sedatives Thromboembolic Prophylaxis Head of bed Maintenance fluid Fluid Resuscitation (30ml/kg) with N.S 0.9% . Feeding should be started within (24-48hrs) after stabilization. This pt. should take analgesics as ( paracetamol I.V ) IV oral switch when it is possible Not indicated This pt. should take pharmacological ttt as : ( Enoxaparin ) (6,7) As there is no risk of bleeding . The head of bed should be raised ( 45• )

27. 27 U G Ulcer prophylaxis Glycemic control Acc. to ESUP recommendations (1) : Initially patient has 2 non-major Risk Anticoagulant and on high dose Corticosteroids 250 mg HCs (16 mg dexa . = 426mg HCs) then patient was 1 Major Risk (Major surgery 4hrs) Finally patient has 2 non-major Risk Shocked and on high dose Corticosteroids 250 mg HCs She is on the target ( 140 – 180 ).

28. 28 I D Indwelling catheter De-escalation of Antibiotics- Delirium A catheter should be present for this patient Initially during dehydrating measures then As she is shocked and we need to follow U.O. FINALLY after stabilization should be removed Central line – Fluid balance Should be done 24 hrs., max after surgery Stop dexamethasone when decrease ICP S B Supplement O2 Bowel movement Not indicated Bowel (ileus/gastroparesis/distension/ bowel movement) It is necessary to make sure that the stomach is moving because this will affect respiration .

29. Follow-up

30. Vital signs 23/11 24/11 25/11 26/11 28/11 29/11 B.p 156/90 110/85 100/60 (MAP= 73) 75/50 (MAP=58) CVP = 5 113/65 (MAP=81) CVP = 11 130/85 H.R 90 95 110 122 102 107 Temp 37 37.3 37 37.1 37.1 37.2 R.R 18 17 22 15 14 13 Normal Abn ormal

31. Fluid Balance 23/11 24/11 25/11 26/11 28/11 29/11 Input 3500 3100 3000 4500 2600 2800 Output 3000 2900 2500 2500 2200 2300 Balance 500 200 500 Resus. 400 500 Normal Abn ormal

32. ABG 23/11 24/12 25/12 26/12 PH 7.42 7.41 7.39 7.4 PsO2 96 96 96 97 PCo2 36 39 40 40 HCO3 26 24 25 26 Normal Abn ormal

33. NORMAL RANGE 27/11 26 /11 24/11 23/11 TEST 4.5-11 x10 9 /L 4.5 5.5 7.9 8.2 WBC 12-16 g/dl 11.4 11.5 11.6 12.2 HGB 150-450 x10 9 /L 280 283 282 288 Platelet 0.6-1.2 mg/dl 0.6 0.7 0.6 0.7 Sr.Cr . Below 3 5 U/L 23 ALT Below 3 5 U/L 26 AST Below 1.1 1.02 1.1 INR 3.4 to 5.4 g/dL 3.7 S. Albumin 110 - 140 mg/dL 111 75 110 112 RBGs Electrolytes NORMAL 27/11 26 /11 24/11 23/11 135-145 mEq /L 135 139 140 142 Na 3.5-5.5 mEq /L 3.8 4 4.2 4.3 K Lab tests

34. Post-operative Complication

35. The primary objective of surgery is to remove as much of the tumor as possible without injuring the surrounding normal brain tissue . at 25- 11 -2023

36. Post Operative Complication 2ry Adrenal Insufficiency Neurosurgical stress (due to Insufficient cortisol production) is not an all or nothing phenomenon. Patient-specific, surgical, and anesthetic procedures are factors that determine the level of surgical Stress. And degree of brain tissue damage H ypotension and shock Reductions in vascular tone lead to orthostatic hypotension followed by supine hypotension and finally shock, which will be fatal if not rapidly corrected.

37. 37 Goal - Indication DOC Regimen Monitoring Reverse shock (stop NE) and exclude that it is 1ry adrenal insufficiency (2,4) H ydrocorisone 1 ST Then Prednisolone IV-ORAL switch H ydrocorisone I.V 200 ml continuous infusion Then Solupred 5mg oral 2 tab 8 AM 1tab 4 pm for a month and reassess Effect: Bl.P . Side Effect: blood glucose, K+

38. NORMAL RANGE 26/11 24/11 TEST 0.4 to 4.0 mIU/L  ----- 1.24 TSH 60 to 180 ng/dL ----- 132 TOTAL T3 5.0 to 12.0 μ g/dL ----- - 9.11 TOTAL T4 15 to 65  pg /mL ----- 35.4 PTH   5 to 25 mcg/dL  1.4 ----- CORTISOL 8 AM 10-60 pg /ml 3.2 ----- ACTH 8 AM Specific Lab tests

39. The cut-off values of serum cortisol levels may change according to the method used for evaluation. (3) # Cut-off value < 9,0 µg/dL (3) Hormonal investigation of secondary adrenal insufficiency (SAI)

40. Medication Sheet

41. Medication Sheet 42 Mannitol I.V ( 300 ml) then 150 ml /8 hr levetiracetam I.V 500 mg /12 hrs. Clexane S.C ( 40 U/24hr ) Dexamethasone I.V (10 mg then 4mg / 6hr) Protofix I.V ( 40mg/24hr ) Lasix I.V 10mg with mannitol 500 ml N.S 0.9 % + amp. KCL ( 80 ml/hrs.) 2700 ml I.V maintenance fluid 2311 24 /11 25 /11 Surgery day

42. Medication Sheet Cont. 43 Paramol Oral 1g / 8hrs. PK merz I.V 500 ml / 24 hrs. Cefazoline 2gm I.V 30 min. preop (redosing every 4hrs intraoperative ) to max 24 hrs. post operative (2g / 24 hrs.) Fortamind I.V 2 amp /12 hrs. Amiparin I.V 500 ml / 24 hrs. Cerebrolysin I.V 2 amp /12 hrs. Perfelgan I.V 1g / 8 hrs. 2311 24 /11 25 /11 Surgery day

43. Medication Sheet Cont. 44 Nor adr . ( 5ml/hr ) 2amp. In 50ml Glu.5% I.V H ydrocorisone I.V 100 m g bolus then 50 mg / 6 hrs. Midodrin 2tab / 4hrs. Pantoprazol 40mg IV / 24hrs. 500 ml N.S 0.9 % + amp. KCL ( 80 ml/hrs. ) I.V maintenance fluid 26 /11 27/1 1 28 /1 1 2000 ml N.S 0.9 % I.V bolus Potassium syp 10 ml oral / 24hrs.

44. Medication Sheet Cont. 45 Levetiracetam oral 500 mg /12 hrs. Pantoprazol 40mg oral / 24 hrs. Calcium supplement 2 tab oral / 24 hrs. Clexane S.C ( 40 U/24hr ) levetiracetam I.V 500 mg /12 hrs. 26 /11 27/1 1 28 /1 1 Solupred 5mg oral 2 tab 8 AM 1tab 4 pm

45. Clinical Pharmacist Interventions

46. Discharge Medication For at least 6 months Long life 47 Not indicated Long life Concor oral 5 mg / 24 hrs. ( HX. medication ) Calcium and vit D supplement 2 tab oral / 24 hrs. Away from any other drugs Rivaroxban oral 10 mg / 24 hrs. Pantoprazol 40mg oral / 24 hrs. Solupred 5mg oral 2 tab 8 AM 1tab 4 pm 28 /1 1 Levetiracetam oral 500 mg /12 hrs. Duration For at least 3- 8 weeks

47. RECOMMENDATIONS Stop Cerebrolysin , Citicoline, PK Merz Stop Midodrine Stop PPI on discharge (5) Dexa . + Lasix+ Mannitol DEXA may enhance the potassium wasting effect of Lasix. Add Potassium syp 10 ml oral / 24hrs. IV oral switch when increase GCS Solupred 5mg oral 2 tab 8 AM 1tab 4 pm For 1 month and reassess MRI with Contrast preparation Stop Cefazoline after 24 hrs. Request cortisol 8 am level and Stop Dexamethasone before doing it Continuous monitor of K+ Medication without indication Drug interaction Inappropriate drug regimen Monitoring I ndication without m edication

48. Patient Education The goal of tapering is to use a rate of change that will prevent both recurrent activity of the underlying disease and symptoms of cortisol deficiency due to persistent HPA suppression 2.5 mg/day every 2-3 weeks at prednisone doses between 20 and 10 mg/day. TAPERING REGIMEN (do not stop suddenly) Bl.p, blood gucose, cramps M onitoring Banana , Ca & Vit D supplement Should take

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50. ANY QUESTIONS? THANKS [email protected]