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CMT-dos > Oncology Therapies and blood transfusions > Flashcards

Oncology Therapies and blood transfusions Flashcards

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How do we decide what to use?

A
  • Clinical trials for all cancer types
  • Target specific molecular pathways when possible
  • Old chemotherapy agents can be helpful but also toxic!
  • Initial and acquired drug resistance continues to be challenging!
    Impaired membrane transport of drugs
    Enhanced drug metabolism
    Mutated target proteins
    Blockage of apoptosis due to mutations in cellular proteins
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Antiemetic medications

A
  • 5HT3 receptor antagonists IV/PO/Sublingual
    Ondansetron (Zofran)
    Palonosetron (Aloxi)
    May cause QT prolongation
  • NK1 receptor antagonists (Preventative) IV/PO
    Aprepitant (Emend)
    Given with Dexamethasone to improved immediate and delayed effect

Can’t swallow?
Prochlorperazine (Compazine) rectally

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6
Q

GI Toxicity

Oral mucositis

A

Pretreatment dental care
Ice chips during infusion (5-FU)
Antifungal medication
Antiviral medication
Mouthwashes
Non alcohol rinses (Biotene)
Lidocaine
Pain control!

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7
Q

GI Toxicity

Diarrhea Tx

mild/moderate/severe

A

Diarrhea
Mild-moderate
Loperamide (Imodium)

Severe
IV hydration
Electrolyte replacement
Octreotide (Sandostatin) SC inj. up to TID
Inhibits multiple hormones (growth hormone, glucagon, insulin, LH, and VIP)

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8
Q

Skin toxicity

S/Sx

A

Hyperpigmentation
Alopecia
Photosensitivity
Nail changes
Acral erythema (hand foot syndrome)
Painful palms or soles with erythema progressing to blisters, desquamation, and ulceration

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9
Q

Cardiac toxicity

S/Sx

acute/subacute/delayed

A

Acute: During chemotherapy treatment
Subacute: Days to months after
Delayed: Years after treatment
Possible baseline testing
Echocardiogram to ensure EF > 50%
EKG

Arrhythmias
Cardiac ischemia
Myocarditis
Thrombosis
Heart failure risk
Total dose received
Age > 70
Chest irradiation
Preexisting cardiac disease
Multiple agents at risk for cardiac complications

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10
Q

Cisplatin

Nephrotoxicity

A

IV hydration before, during, and after chemotherapy administration
Monitor Cr+ and electrolytes
May also develop low mg+, K+, and Na+

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11
Q

Miscellaneous toxicity

Hemorrhagic cystitis

A

peeing blood

Drink lots of fluids!
Frequent urination
IV Mesna for prevention

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12
Q

Miscellaneous toxicity

Neuropathy S/Sx

A

Sensory
Motor
Autonomic

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13
Q

If toxicity occurs, what do we do?

A

Hold next cycle until symptoms resolve
Add supportive medications
Drug dose reduction
Palliation vs. cure
Change regimen

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14
Q

Intravesical therapy

general and Sx

A

Deliver medications directly into the bladder via a urethral catheter
Typically post transurethral resection to decrease likelihood of recurrence

Side effects
Irritative voiding symptoms
Hemorrhagic cystitis

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15
Q

targeted agents

most common types

A

Many medications treating many cancer subtypes

Most common
* Monoclonal antibodies
Rituximab (Rituxan)
* Kinase inhibitors
Ibrutinib (Imbruvica)

Side effects differ based on cell receptor acts on

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16
Q

immunotherapy

general and types

4

A

Using own immune system

Types
* Immune checkpoint therapy
Help T cells respond longer
Ipilimumab (Yervoy) for lung cancer
* Adoptive cell therapy
Chimeric antigen cell (CAR) T cell therapy- T cells that are all genetically engineered to find and fight the cancer are infused
Multiple types undergoing clinical trials!
* Cytokine therapy
Interferons and interleukins are infused/injected, trigger an immune response
May be combined with other immunotherapies
IL-2 therapy for renal cancer
* Vaccine therapy
Help the body recognize cancer cells and stimulate the immune system
Sipuleucel-T (Provenge)

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17
Q

Blood Transfusions

Blood Types

A

Four Major Groups
A
B
AB
O

Blood types are inherited
Antigen is present on the RBC
Typing is done w/rbc

Antibody is present in the plasma
Antibody screening done on plasma

43% of population are O, 42% A, 12% B and 3% AB

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Blood Types

O negative

A

Universal donor
It carries no antigen

20
Q

Blood types

AB positive

A

Universal recipient
It carries no antibodies in the plasma

21
Q

Rh Factor

general

A

Found on the surface of an RBC
Can be phenotypically positive or negative
Positive is dominant over negative

Rh negative patients form antibodies against the Rh factor if they are exposed to Rh positive blood

Blood transfusion between incompatible groups causes an immune response against the cells carrying the antigen Resulting in transfusion reaction

22
Q

Rh Incompatibility in Pregnancy

A

Occur when the mother is Rh- and the baby is Rh+
Treatment:
Give a series ofRhoGAMshots during pregnancy to all Rh- mothers
1st shot: around the 28th week of pregnancy
2nd shot: just after birth

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24
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RBC Transfusion

Indications

A

Acute Blood Loss
Symptomatic Anemia
Volume: 300mL
1 unit UP Hgb 1 g/dL
Consider transfusion for Hgb < 7g/dL

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26
Q

indications for whole, packed RBCs, and autologous

A

Whole blood
Used for cardiac surgery or massive hemorrhage (>10 units of blood are needed in 24-hours)

Packed red blood cells
Most commonly used
Recommended transfusion “trigger” - hemoglobin is 7-8 g/dL

Autologous red blood cells
Donate own blood for an elective procedure

27
Q

Platelet Transfusions

indications and how much will it increase platelet count?

A

Risk of spontaneous bleeding
Platelet count < 80,000/mcL

Risk of life-threatening bleeding
Platelet count < 5,000/mcL

6 pack or 1 unit pheresed platelets

1 pheresed unit will increase count by 50,000-60,000/mcL
Lasts 2-3 days

28
Q

Platelet Transfusion Goals

A
29
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Fresh Frozen Plasma

A

200-250 ml of plasma containing
All clotting factors (1 unit/mL of each)
AT-III
Protein C & S

Indications:
Correct factor deficiencies
Thrombotic microangiopathies- TTP
Correct/prevent coagulopathy with massive transfusions- 1:2 FFP:PRBC

30
Q

Cryoprecipitate

A

Cryoprecipitated antihemophilic factor (AHF)
Thaw FFP and precipitate refrozen

15-20 ml per unit (bag)
Fibrinogen >150 mg
Factor VIII > 80 IU
Factor XIII at least 50-75 IU
Von Willebrand Factor at least 100-150 IU

Indications
Acute DIC
Low fibrinogen with bleeding/risk

1 unit INCREASE fibrinogen 8mg/dL

31
Q

Transfusion Complications

A

Volume overload
Transfusion reactions
Iron overload
Infections
Hyperkalemia
Massive transfusions
CKD

32
Q

Transfusion Rxns

A
33
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Acute Transfusion Reactions

minor and critical

A

Complication that occurs during or after a blood product is given
Range from clinically benign to life-threatening

Minor
Urticarial (simple allergic) transfusion reaction
Febrile non-hemolytic transfusion reaction

Critical
Transfusion-associated circulatory overload (TACO)
Transfusion-related acute lung injury (TRALI)
Acute hemolytic transfusion reaction (AHTR)
Transfusion-associated sepsis
Anaphylactic transfusion reaction
q

34
Q

Minor transfusion rxn

Urticarial transfusion reaction (UTR)

A

Common reaction
Occurs during or up to 2 hours after the transfusion
Commonly due to an antigen-antibody interaction that occurs between the patient and the product given
Clinical features:
Hives or pruritus
Management:
Mild reaction – continue the transfusion
Antihistamines (H1 and H2 blockers)

35
Q

Minor transfusion rxn

Febrile non-hemolytic transfusion reaction (FNHTR)

A

Febrile non-hemolytic transfusion reaction (FNHTR)
Occurs during and up to 4 hours after transfusion
Accumulation of cytokines in the donor blood → immune reaction
Type II hypersensitivity reaction in which the host antibodies target donor leukocytes
Prevention by giving leukoreduced blood products

Clinical features:
Low-grade fever with chills
Headache
Malaise

Management:
Hold the transfusion for 30 minutes (often can restart)
Acetaminophen for fever
Check CBC and bilirubin to rule out hemolytic reaction

36
Q

critical transfusion rxn

Transfusion-associated circulatory overload (TACO)

A

Transfusion-associated circulatory overload (TACO)
Occurs during or within 6 hours after transfusion
Patient develops pulmonary edema due to volume overload or circulatory overload
< 1% of patients

At risk patients:
Receive a large volume of a transfused product over a short period of time
H/O renal or cardiovascular disease

Clinical features:
Sudden tachycardia
Hypertension
Overload symptoms: increased jugular venous pressure
CXR: bilateral infiltrates (pulmonary edema)

Management:
Stop the transfusion
Diuresis – furosemide (Lasix)
Supplemental oxygen or assisted ventilation

37
Q

critical transfusion rxn

Transfusion-related acute lung injury (TRALI)

A

Transfusion-related acute lung injury
Occurs during or up to 6 hours after transfusion
Patients develop acute lung injury
HLA antibodies in the donor blood triggers the neutrophils and pulmonary endothelial cells of the recipient
Neutrophils secrete proteolytic enzymes that lead to tissue damage → hypoxemia
1 in 5,000 transfusions

Clinical features:
Fever and/or chills
Respiratory distress (tachypnea, frothy pink sputum)
Hypotension
CXR: bilateral infiltrates (pulmonary edema)

Management:
Stop the infusion
Assisted ventilation or oxygen administration
IV steroids to aid with inflammation
No diuresis

38
Q

critical transfusion rxn

Acute hemolytic transfusion reaction (AHTR)

General

A

Acute hemolytic transfusion reaction (AHTR)
True EMERGENCY
Occurs during or within 1 hour after transfusion
Acute intravascular hemolysis of transfused RBCs
Usually due to ABO incompatibility
Mislabeling and administering to wrong person
1:76,000 transfusions

39
Q

Acute hemolytic transfusion reaction (AHTR)

Clin man

A

High grade fever
Flank pain, hematuria
Tachycardia, Tachypnea, Hypotension
Oozing from the IV site (DIC)
Chills
Headache
Anxiety
Cardiovascular collapse

40
Q

Response to Suspected Hemolytic Reaction

A

Stop Transfusion
Aggressive intravenous hydration
urine output to be 100-200 cc/hr
Prevent acute tubular necrosis
Confirm correct transfusion was initiated
Return blood, bag, tubing, labels, transfusion record to the blood bank
Retype and crossmatch
Check Coombs test → should be positive
Coagulation studies (PT, PTT, Fibrinogen)- Risk of DIC
DIC: Administer FFP and platelets

41
Q

Transfusion-associated sepsis

A

Rare reaction
Usually occurs within 1 hour of transfusion
Bacterial infection from a transfusion product that contains a microorganism

Clinical features:
Fever and/or chills
Hypotension

Management:
Stop the infusion
Culture the recipient’s blood and the donor’s blood
Broad-spectrum antibiotics

42
Q

Anaphylactic transfusion reaction

clin man and Tx

A

Usually occurs right after the start of the transfusion; can be delayed up to 4 hours

Clinical features:
Angioedema
Wheezing, respiratory distress (bronchospasm)
Hypotension
Nausea and/or vomiting
Cardiac arrest or shock

Management:
Stop the transfusion
Hemodynamic stabilization (IV fluids, vasopressors)
Airway management
Epinephrine, steroids, antihistamines

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