Oncology III Flashcards

1
Q

What the patient tells us

A
  • About themselves
  • About there mental state
  • Co-morbidities
  • Medication
  • Support
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2
Q

Toxicity the questions we should be asking

A
  • Duration vs Severity
  • Single vs Multiple
  • Visible vs Invisible
  • Preventable vs Manageable
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3
Q

Signs and symptoms of anaphylaxis

A
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4
Q

Anaphylactic reaction pathway

A
  • ABCDE (Airway Breathing Circulation Disability Exposure) =>
  • Diagnosis: Acute onset of illness, life-threatening airway/breathing/circulation problems =>
  • Call for help: Lie patient flat, raise patient legs =>
  • Adernaline =>
  • When skills and equipment available
    • Establish airway, high O2 flow, IV fluid challenge, Chlorphenamine, hydrocortisone
    • MONITOR: Pulse, ECG, BP
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5
Q

Extravasation is

A
  • The leakage of one drug from its intended compartment of delivery into one or more adjacent compartments
  • It has a number of euphemisms- infiltration, tissuing, displacement- but at the end of the day they are all the same injury
  • It is a complex interaction of factors
  • It is a whole spectrum of reactions from a pre-extravasation syndrome to a complete necrotic breakdown of tissue
  • It is an oncological parenteral therapy emergency
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6
Q

Difficult to diagnose, varied and unpredictable development & outcome

A
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7
Q

Factors known to be involved

A
  • Patient
  • Practical
  • Personnel
  • Pharmacological
  • An individual extravasation injury will be a mix of all of the above
  • Some factors are causative of injuries whilst others are contributory too it
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8
Q

Basis of treatment

A
  • ALWAYS
    • Aspirate
    • Palliate the immediate symptoms
  • THEN
    • Localise and Neutralise- followed by
    • Dilute and spread
  • For established or missed extravasations
    • treat as for other ulcerated tissue- de-bride and granulate
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9
Q

There should be a national protocol for the treatment of extravasation, and a standard approach to antidotes

A
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10
Q

Chemotherapy-induced N&V (CINV)

A
  • Can lead to serious complications
    • Dehydration
    • Malnutrition
    • Electrolyte disturbance
  • May result in delay, dose reduction or discontinuation of SACT
  • Effective management is an important part of patient care
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11
Q

Risk factors

A
  • Gender
  • Age
  • Chemotherapy (previous treatments)
  • History of lifestyle
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12
Q

Emetogenic risk with SACT

A
  • CINV is complex
  • Main risk factors
  • SACT emetogenic potential
  • SACT categorised for emetic risk
    • Minimal (0-10%)
    • Low (10-30%)
    • Moderate (>30-90%)
    • High (90%)
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13
Q

Types of N+V associated with chemotherapy

A
  • Acute vomiting
    • Occurs within 24 hrs of SACT, peaks after 5-6 hours
  • Delayed N&V
    • >24hrs post SACT, lasts 3-7 days
  • Anticipatory N&V
    • Conditioned response; associated poor control previously
  • Breakthrough N&V
    • CINV despite prophylaxis
  • Refractory vomiting
    • CINV despite interventions, recurs in subsequent cycles
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14
Q

Antiemetic prophylaxis for chemotherapy-induced N&V

A
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15
Q

Emetic reflex

Neurotransmitters: targeting key pathways

A
  • DA
  • Histamine
  • 5-HT
  • Endorphins
  • Substance P
  • GABA
  • Cannabinoids
  • ACh
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16
Q

CINV classification & examples of anti-emetics

A
  • Acute- 5-HT3 receptor anatagonist, metoclopramide, dexamethasone
  • Delayed- dexamethasone, NK1-blocker
  • Breakthrough- Metoclopramide, cyclizine
  • Anticipatory- lorazepam
  • Refractory- Levomepromazine, NK1-blocker, nabilone
17
Q

MRHA advice- domperidone, metoclopramide, ondansetron

A
  • Domperidone (May 2014): cardiac side effects inc. QT prolongation
    • Lowest effective dose (30mg) for the shortest possible time (max 48hrs)
  • Metoclopramide (Aug 2013): neurological effects
    • Maximum 30mg/24 hours (or o.5mg/kg)
    • Short term use; upto 5-days; IV slow over >3mins
  • Onsansetron (July 2013); QT prolongation, cardiac arrhythmia
    • Max dose restrictions for CINV
      • <75yrs 16mg
      • >75yrs 8mg
    • 15 minute infusion
    • Repeat doses (at least 4hr intervals)
18
Q

Overview of guidelines for acute N&V

A
19
Q

Risking factors- summary

Oral mucositis

A
20
Q

Effect of radiation on oral mucositis

A
21
Q

Treatment of oral mucositis

A
22
Q

Why do we give chemotherapy every 3 weeks

Neutropenia

A
23
Q

Predisposing factors

A
  • Infectious complications are a major cause of morbidity and mortality in cancer patients
    • 8% mortality in patients admitted with febrile neutropenic episodes
  • Predisposing factors include
    • Neutropenia
    • Loss of cell-mediated and humoral immunity
    • Disruption of skin or mucosal barriers
24
Q

Predisposing factors- neutropenia

A
25
Q

Prevention of infection

A
  • Protective isolation
  • Good oral hygiene
  • Antimicrobial prophylaxis
    • Anti-bacterial (inc gut decontamination)
    • Anti-fungal
    • Anti-viral- surveillance of viral load
  • Neutropenic diet
26
Q

Diagnosis of febrile neutropenia

A
  • Definition vary
  • Temp >38’C
  • Neut- <0.5 x109/L or <1x109/L and falling
  • Usual inflammatory signs of infection often absent due to lack of neutrophils
  • Caution- patients in septicaemic shock may present with tachycardia, hypotension and no fever
27
Q

Management of febrile neutropenia

A
  • Investigations
    • Take history
    • Clinical examination
    • Peripheral and Hickman line blood cultures
    • FBC, U&E
    • Sputum, MSU, Stool, swab sites of infection
    • Chest X-ray and nasopharyngeal aspirate if necessary
  • Most crucial factor is prompt initiation of antibiotics
28
Q

Treatment schedule

A
  • Tazocin monotherapy unless significant hypotension (diastolic BP <60 mmHg) or septic shock- then add gentamycin
  • Vancomycin only if obvious line infection and/or severe mucositis
  • Reassess at 48 hours, if significant isolate amend therapy
29
Q

Antibiotic prophylaxis- quinolones

A
  • Two large trials and a meta-analysis published in 2005
    • Gafter-Gvilli A et al. Ann Intern med 2005; 142: 979-95
    • Bucaneve G et al
    • Cullen M et al
  • Meta-analysis: Decrease mortality risk cf placebo or no treatment
  • Both studies included solid tumour & lymphoma patients
    • Bucaneve et al: higher risk group (inc autos, acute leukaemia)
  • Cullen: decrease febrile episodes, probable infection, hospitalisation
  • Bucaneve: decrease clinically significant bacterial infections, including G-ve rod bacteraemias
30
Q

Effect of antimicrobial prophylaxis on the rate of and time of infection

A
31
Q

Antibiotic prophylaxis- other

A
  • Co-trimoxazole (960mg M/W/F0 recommended as prophylaxis if significant T-cell immunosuppression
    • E.g. fludarabine, cladribine, alemtuzumab, ciclosporin, corticosteroids
  • Dapsone
  • Penicillin V (500mg BD) post-transplant
32
Q

Antifungal prophylaxis

A
33
Q

Antiviral prophylaxis

A
  • Low risk patients do not require aciclovir prophylaxis (unless prior HSV)
  • Aciclovir prophylaxis for intermediate/high risk patients (HSV)
    • Historically, high dose aciclovir used in high risk patients to prevent VZV/CMV, alternatives ganciclovir, foscarnet or cidofovir
    • HSV- Herpes Simplex Virus
    • VZV- Vermicelli-Zoster Virus
    • CMV- CytoMegaloVirus
34
Q
A