4 - Procedural Skills Flashcards
What is a bone marrow examination and how is the procedure carried out?
- Bone marrow aspiration (fluid bone marrow) for cytology
- plus Bone marrow biopsy (solid bone marrow) for histology with trephine
- Collected from the posterior iliac crest after being given local anaesthetic
What are some complications with a bone marrow examination?
- Excessive bleeding, particularly in people with low platelets
- Infection
- Long-lasting discomfort at the bone marrow exam site
What are some indications for a bone marrow biopsy?
- Chronic microcytic anaemia
- Diagnosis of leukaemias
- See if lymphoma has bone marrow involvement
- Multiple myeloma and monoclonal gammopathy of undetermined significance
- Autoimmune thrombocytopenic purpura
- Check if treatment is working
What is a thoracentesis and how is it done?
US guided drainage of pleural effusions for therapeutic and diagnostic purposes
Need to stop any NSAIDs and anticoagulants a few days before and check the platelets
What are the risks with a thoracentesis?
- Collapsed lung
- Bleeding
- Bruising
- Infection
- Liver injury (rare)
- Spleen injury (rare)
What tests are pleural fluid sent off for?
- Cytology
- MC+S
- Inflammatory markers
- Levels of glucose, protein or other chemicals
Only drain max of 0.5 L at a time (max 1.5L in 24h)
After a chest drain insertion what needs to be done to check it is in the right position?
- CXR
- Check the drain is swinging
What are some indications for chest drain insertion?
- Pneumothorax
- Pleural effusion especially if malignant
- Peri-operative eg. thoracotomy, oesophageal surgery, cardiothoracic surgery
Where is the chest drain inserted?
The 5th intercostal space in the mid-axillary line (safety triangle)
What is done on a daily check for a chest drain?
- Check it is swinging with respiration and no bubbling
- Daily dressing change
- Change bottle if full
- Check adequate analgesia as breathing with chest drain is painful
What is a paracentesis and how is it done?
Drainage of ascites
Needle and drain placed for up to 6 hours
Send fluid off for cytology
What are the complications with paracentesis?
Common
Lethargy
Pain
Leakage (up to 72 hours)
Rare
Infection
Bleeding
Organ perforation
What is a Hickman line and what are some indications for this?
Central venous catheter
Tunnelled under the skin
Indications: TPN, chemotherapy, blood transfusions, antibiotics and intravenous fluids
What are the complications with a Hickman line?
- Infection
- Bruising
- VTE
- Vein stenosis
- Pneumothorax
Always have CXR after procedure to check in right place and no pneumothorax
What is the care needed for a Hickman line?
- Change dressing weekly and don’t get wet
- Weekly flush with heparinised saline to keep patent
- Keep needle free cap on at all times
- Remove entry site stitch after 1 week and exit site stitch after 3-4 weeks
What is a venous portocath?
Same as Hickman but completely tunnelled under the skin, no part out
What are some risks with a Port a Cath and how should it be cared for?
- Infection
- Thrombosis
- Blocked port
- Only use Hueber needles
- Flush every 4-6 weeks
- Wash hands before handling
What is a PICC line?
Peripheral Venous Catheter
Put into one of the large veins of the arm, above elbow joint. It is then threaded into the vein until the tip is in a large vein just above the heart.
Sometimes it divides into two or three lines which allow you to have different treatments and medications at the same time.
What is Apheresis?
Removing whole blood and separating the blood into individual components so that one particular component can be removed
Used for the collection of donor blood components (such a platelets or plasma) as well as for the treatment for certain medical conditions in which a part of the blood that contains disease-provoking elements is removed
Also used for the collection of stem cells from peripheral blood
What are some complications of aphaeresis?
Bleeding and a tendency to bleed
Clotting factors are removed
Infection and a tendency toward infection
Antibodies are removed
Low blood pressure
As fluids are removed
Muscle cramping
Low blood calcium can occur
What diseases can be treated with aphaeresis?
- Clogging of blood vessels (leukostasis) due to elevated WBC in leukemia
- Severely elevated platelet counts in leukemia or myeloproliferative disorders
- Myasthenia gravis,
- HELLP syndrome of pregnancy
What is looked at on a blood film?
- Erythrocytes
- Leucocytes
- Platelets
- Cancerous cells
Looking at number of them, the morphology, any inclusions
What are the advantages of a central venous catheter?
- More than 1 drug at a time (multi-lumen)
- Continuous infusion
- Can give nutrition
- Less invasive for frequent treatment
- Home treatment
- Long term therapy
- Reduced risk of extravasation
What are the disadvantages of a central venous catheter?
- Risk of PTX during insertion
- Infection
- Bleeding during insertion
- Thrombosis of line
- Misplacement of line, CXR to check and USS when inserting
Undergoing chemotherapy patients can become infertile, can undergo premature menopause and they should not become pregnant. How can all of these risks be managed?
Pre-Chemotherapy
- If starting chemotherapy can be delayed, women can be offered oocyte or embryo collection
- Men can be referred for sperm storage
- Norhisterone is used in women to stop menstruation
Peri-Chemotherapy
- Use contraception to avoid pregnancy
What are some prophylactic medications given before chemotherapy and stem cell transplant for leukaemias?
- Mouth care – chlorhexidine mouthwash
- Prophylactic anti-fungal medication – fluconazole/posaconazole
- Prophylactic co-trimoxazole (prevent Pneumocystis jiroveci)
- Prophylactic antiviral – aciclovir
- Prophylactic antibiotics
Which cancer patients would you give LMWH for a VTE over the recommended DOACs?
GI malignancy due to risk of bleeding
What are the different stages of chemotherapy induced nausea and vomiting?
How is the severity of chemotherapy induced nausea and vomiting graded?
How can mucositis be managed?
Chemotherapy induced diarrhoea can be life threatening. How is this managed?
- If capecitabine/5-FU-related: likely to need chemo withheld if ≥ grade 2, consider DPD deficiency
- Loperamide and Codeine if not settling
- Consider Octreotide and or Budesonide
How is extravasation of chemotherapy managed?
How long after treatment can immunotherapy side effects occur?
YEARS later
What class of drugs are most immunotherapy agents?
Checkpoint inhibitors
