Lecture 13 - Hematology & Pediatrics Flashcards
What are the 3 methods of treatment for lymphoma?
Chemotherapy, radiation and stem cell transplant
What is an additional method of treatment for NHL?
Monoclonal antibody therapy
What is the most important concept of cancer care?
Risk of infection related to altered immune function and chemotherapy treatment
What is a major complication of adriamycin?
Cardiotoxicity - there is only a set amount of dose that people can receive in their lifetime
What is the ABVD protocol for HL?
Adriamycin, bleomycin, vinblastine and dacarbazine
What does the ABVD protocol include?
Cell cycle specific and cell cycle non-specific antineoplastics
What is the most common dose-limiting adverse effect of ABVD?
Hematologic toxicities related to myelosuppression resulting in decreased WBC, RBC and PLT
Why is chemotherapy administered via a CVC? (2)
Chemotherapy is very irritating to the vessels and a CVC provides an easy access for taking blood
What method of administration of chemotherapy is preferred for children?
Portacath - it is surgically inserted into the chest wall so kids cannot pull this out
What are some adverse effects of ABVD for Hodgkin’s?
Myelosuppression, infection, bleeding, N/V, diarrhea, constipation, anorexia, abdominal pain, rash, flu-like symptoms, fever, chills, infertility, increase in LFT, myalgia, mucositis and alopecia
What are some adverse effects of ABVD for Hodgkin’s?
Myelosuppression, infection, bleeding, N/V, diarrhea, constipation, anorexia, abdominal pain, rash, flu-like symptoms, fever, chills, infertility, increase in LFT, myalgia, mucositis and alopecia
What should you complete for a patient with infection?
Head-to-toe for possible causes of infection
What should you look for in terms of respiratory for a patient with infection?
Sputum, cough, abnormal breath sounds
What should you look for in terms of CV for a patient with infection?
Warm, flush skin, pounding pulse
What should you look for in terms of GI for a patient with infection?
Abdominal pain, guarding, diarrhea, musocitis
What should you look for in terms of skin and mucous membranes for a patient with infection?
Edema, drainage, exudate, erythema, cream colored lesions in mouth
What should you look for in terms of indwelling devices for a patient with infection?
CVC, drainage, pain, fever,
What should you look for in terms of CNS for a patient with infection?
Change in mental status
What should you look for in terms of CNS for a patient with infection?
Change in mental status
What specimen collection and diagnostic tests can you expect for a patient with infection?
Specimens from blood, sputum, urine, stool, from wounds as well as a CXR
Describe the role of neutrophils
A type of WBC that engulfs and fights infection causing bacteria, develops in bone marrow
What is the lifespan of neutrophils?
7-14 days to develop but lifespan is only 72 hours
What is neutropenia and what is its relationship to chemotherapy?
A decrease in circulating neutrophils - this is the most common dose-limiting side effect of chemotherapy
What is an education piece for patients in terms of lab work?
Instruct patients on what their important blood counts are and to encourage them to track blood counts to understand their responses to treatment
What is FN?
Febrile neutropenia - a medical emergency that has risks for sepsis and death
What are risk factors for FN?
High dose chemotherapy, malnutrition, bone marrow disease, >65 years, advanced cancer, performance status, concurrent/prior radiation and liver or kidney dysfunction
When are WBC levels the lowest for a patient receiving cell cycle specific antineoplastic?
7-10 days
When are the WBC levels the lowest for a patient receiving cell cycle non-specific antineoplastic?
10-14 days
What is an important education piece for patients to monitor for FN?
Teach them when they can expect to see neutorpenia, and to monitor for fever (either single temp of 38.3 or greater than 38 for >1 hr), as well as signs of infection
Who are at highest risk for FN?
Leukemia, lymphoma and treatments that include high dose steroids
Who are at highest risk for FN?
Leukemia, lymphoma and treatments that include high dose steroids
What is the goal of treatment for FN?
Treat infection, optimize hydration, support immune function and prevent secondary infections
What would you do before a pathogen has been isolated with FN?
Administer broad spectrum IV antibiotics and to schedule/ time multiple infusions
What is G-CSF?
Granulocyte colony-stimulating factor
What does G-CSF do?
Promote proliferation, differentiation and activation of cells to make granulocytes
What is the indication of G-CSF?
Prevention and treatment of FN
What is the indication of G-CSF?
Prevention and treatment of FN
What is the most common side effect of G-CSF?
Bone pain
How can you implement infection protection in the pediatric focus?
Hand hygiene, aseptic technique, assess for potential sites of infection, optimize nutrition, animal safety, protect from injury and no live vaccines
What is leukemia?
Neoplastic proliferation of leukocytes in bone marrow that results in decreased WBC, RBC and PLT as well as weaken the bone which results in possible fractures
What are the 4 steps of chemotherapy for ALL?
1) Induction - 4 weeks until remission
2) CNS prophylaxis - prevent leukemic cells from entering CNS
3) Intensification - eradicate residual leukemic cells
4) Maintenance - maintain remission phase, lower dose treatment
What are the 2 steps of chemotherapy for AML?
Induction and post-remission as maintenance is not recommended
What are the 2 treatments involved in leukemia?
Cranial radiation +/- intrathecal chemotherapy and radiationto testicles in case of spread
What is an important consideration for treating lymphoma?
Consider the radiation field, what the dose is, amount of time, what tissue is involved and what shielding is required
What is an important consideration for treating lymphoma?
Consider the radiation field, what the dose is, amount of time, what tissue is involved and what shielding is required
What are methods of supportive care for reducing the risk of bleeding with leukemia?
Ensure blood bank has up-to-date record of type and cross, have transfusion history available, CVC for access to blood and CBC with differential
What are some bleeding precautions to be mindful of for a patient with leukemia?
Assess for blood in urine and stool, assess for changes in petechiae, bruising, epistaxis, don’t give IM, avoid rectal suppositories, fall prevention, stool softeners and laxatives to avoid constipation
What is mucositis?
Painful inflammation and ulceration of the mucosal lining of the GI tract that is common with chemotherapy. It affects ability to eat and can be painful. It can be dose-limiting
What are some interventions for mucositis?
Avoid alcohol based mouth rinse, use toothettes, frequent mouth rinse with sodium bicarbonate, soft liquid foods high in calories and protein, encourage oral fluid intake, schedule analgesics before meals, keep lips moist, swabs for bacteria, antibiotics as prescribed, dietary supplements and not using topical anesthetics for children
Why don’t you use topical anesthetics for children?
With children, do not use topical analgesics because it can be a choking hazard as you numb the mouth and they may aspirate
What is tumor lysis?
An oncologic emergency that is a metabolic imbalance that occurs because of rapid lysis of malignant cells
What major complications does tumor lysis have?
Fatal renal, cardiac and neurologic complications
What is tumor lysis syndrome?
Cell kill leading to dumping of cellular contents into bloodstream. There’s increased K, phosphate, uric acid and Ca that if the kidneys cannot excrete, it can be life-threatening.
What is an important diagnostic test for tumor lysis syndrome?
Urine pH, serum potassium, phosphate, calcium and BUN
What are the signs of tumor lysis syndrome?
N/V, diarrhea, muscle weakness, cramping, convulsions and cardiac arrest
How can you prevent tumor lysis syndrome?
Pre-chemo hydration 24-48 hours before and continue 72 hours after treatment
What 3 medications would you administer for tumor lysis syndrome as preventative measures?
1) Diuretics to promote excretion of phosphate and uric acid
2) Allopurinol to prevent uric acid formation
3) Sodium bicarbonate to keep urine pH alkaline and prevent uric acid from crystallizing
What 3 medications would you administer for tumor lysis syndrome as preventative measures?
1) Diuretics to promote excretion of phosphate and uric acid
2) Allopurinol to prevent uric acid formation
3) Sodium bicarbonate to keep urine pH alkaline and prevent uric acid from crystallizing
How would you treat a patient with tumor lysis syndrome that has onset?
Diuretics to prevent fluid overload, kayexlate to bind with potassium, insulin-glucose therapy to shift potassium back into ICF, calcium gluconate to correct hypocalcemia and dialysis as last resort
