Pediatric hematology-oncology-ward-officer-handbook

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<ul><li> 1. Paediatric Haematology/Oncology Ward Officers HandbookTexas Childrens Cancer Center &amp; Hematology ServiceInternational ProgramEditor: Parth S. Mehta, MD Assistant Professor of PediatricsBaylor International Pediatric AIDS Initiative at Texas Childrens Hospital Baylor College of Medicine Texas Childrens HospitalHouston, Texas USA Baylor College of Medicine 2010</li></ul><p> 2. Paediatric Haematology/Oncology Ward Officers Handbook Baylor College of Medicine 2010 2 3. Paediatric Haematology/Oncology Ward Officers HandbookGeneral41. Pain control42. Blood transfusion therapy 43. Transfusion reactions 74. Intravenous fluids, central lines &amp; useful formulas 8Oncology 91. Neutropenia 92. Fever &amp; neutropenia103. Anti-Fungal Therapy124. Antiviral Therapy145. Pneumocystis jerovecii (PCP) Prophylaxis 146. Anti-emetic Medications167. Anaphylaxis Precautions189. Oncologic Emergencies2110. Immunizations in Oncology Patients2411. Constipation24Hematology261. Sickle cell disease262. Sickle cell disease with fever 273. Sickle cell vaso-occlusive crisis284. Pre-operative preparation of sickle cell patients295. Transfusion therapy in sickle cell disease 307. Treatment of bleeding in patients with Hemophilia A318. Treatment of bleeding in patients with Hemophilia B339. Von Willebrands Disease 3510. Immune Thrombocytopenic Purpura (ITP) 36References40 Baylor College of Medicine 2010 3 4. Paediatric Haematology/Oncology Ward Officers HandbookGeneral1. Pain control Intravenous medications Morphine sulfate 0.1 - 0.2 mg/kg/dose every 2-4 hrs (Max single dose 15 mg) Oral medications Ibuprofen 10 mg/kg/dose every 6-8 hours (Max single dose 800 mg, 2400mg/day) Avoid this medication in patients with thrombocytopenia GastrointestinaI prophylaxis with ranitidine recommended Ranitidine 2-4 mg/kg/dose twice daily Oral morphine sulfate 0.3 to 0.6 mg/kg/dose every 4-6 hrs Intravenous (IV) to oral (PO) dosing conversion is 1:3; 1 mg IV is equivalent to 3 mg PO Different formulations exist including sustained release &amp; immediate re- lease; refer to prescribing information contained within medication packag- ing2. Blood transfusion therapy Infection risk of blood transfusion estimates National transfusion centers ought to have more accurate incidence figures for each setting Incidence estimates taken from Transfusion 2002; 42:975-79 HIV 1:2,135,000 Hepatitis B 1:220,000 Hepatitis C 1:1,935,000 Bacterial contamination 1:2,000 platelet units General Guidelines for Transfusion Therapy Prior to initial transfusion, HIV &amp; Hepatitis B &amp; C screening is recommended Premedication Baylor College of Medicine 20104 5. Paediatric Haematology/Oncology Ward Officers Handbook Used in patients with a history of prior allergic or febrile transfusion reaction One or more of these medications can be used: Paracetomol 15 mg/kg PO (Max dose 1000 mg) Diphenhydramine 0.5 mg/kg (Max dose 50 mg) Hydrocortisone 2 mg/kg (Max dose 100 mg) Packed Red Blood Cell (pRBC) transfusion Transfuse 10-15 ml/kg pRBC over 2-4 hours Response varies depending on concentration of unit, but expect 2-3 g/dL rise in hemoglobin for each 10-15 ml/kg transfusion given Patients with long-standing anemia due to iron deficiency can often be ma- naged without transfusion therapy Pre- &amp; post-transfusion diuretic therapy with furosemide is not routinely recommended and should be given only if the clinical condition warrants it (e.g. cardiac dysfunction) Whole blood is frequently used where pRBC are not available. To achieve asimilar rise as noted above in hemoglobin, transfuse 20 ml/kg whole blood over2-4 hours Platelet transfusion Dosing of transfusion volume &lt; 8 kg - give one unit (5 ml/kg) &gt; 8 kg - give one random unit/10 kg body weight Maximum - 6 random donor units or 1 pheresis unit (where available) 1 single pheresis unit is equivalent to 6 random donor units3 Expect increase in platelet count by 50,000/mm with above guidelines If there is concern for poor response check platelet count from 10-60 mi- nutes post-transfusion to assess response Cautions Contraindicated in patients with Thrombotic Thrombocytopenic Purpura(TTP) and Heparin-Induced Thrombocytopenia (HIT) No benefit in patients with Idiopathic thrombocytopenia purpura (ITP)unless there is life-threatening bleeding Baylor College of Medicine 20105 6. Paediatric Haematology/Oncology Ward Officers HandbookPlatelet count (/mm3)Transfusion Strategy&lt; 10,000High risk for bleeding; transfusion likely indi-cated except in ITP without life-threateningbleeding (see ITP section)10,000 - 20,000 Transfusion likely needed if patient has infec-tion, coagulopathy, splenomegaly, or bleeding20,000 - 50,000 Transfusion for active bleeding, patients withbrain tumor, or for invasive procedures. Stablepatients rarely ever require transfusion&gt; 50,000Transfusion only if there is an underlying plate-let dysfunction or there is significant bleeding Baylor College of Medicine 20106 7. Paediatric Haematology/Oncology Ward Officers Handbook Plasma Transfusion Indications for Fresh Frozen Plasma (FFP) use: Massive transfusion of pRBC (greater than one blood volume within 24 hours) Active bleeding or surgery in patient with prolonged Prothrombin Time (PT) and/or activated partial thromboplastin time (aPTT) secondary to factor deficiency for which specific factor replacement is not available Dosing of Plasma 1 unit contains 200-250 ml FFP contains 1 unit/mL of coagulation factors 10-15 ml/kg will result in 15-20% rise in factor level Factor V &amp; Factor VII may be exceptions as the former is labile &amp; thelatter has a short half-life3. Transfusion reactions Signs &amp; symptoms of transfusion reactions are varied, and can include any or all of the following: Chills &amp; fever Hemoglobinuria Urticaria Chest/spine pain Shortness of breath Anxiety or restlessness Hypotension Management of transfusion reaction Stop transfusion, change IV tubing, flush line &amp; start normal saline (NS) at 1600ml/m2/day If febrile or urticarial reaction give: Diphenhydramine 1 mg/kg PO (Max dose 50 mg) Paracetomol 15 mg/kg PO (Max dose 1000 mg) Hydrocortisone 2 mg/kg IV (Max dose 100 mg) In patients with anaphylaxis adrenaline should be given: Adrenaline 1:1000, give 0.01 mL/kg IV Adrenaline 1:10,000, give 0.1 mL/kg IV Once patient is stable, consider transfusion of additional products unless pa-tient experienced hemolytic reaction, in such a case, discuss with specialist first Baylor College of Medicine 2010 7 8. Paediatric Haematology/Oncology Ward Officers Handbook Patients with a history of transfusion reactions can be given pre-medication withdiphenhydramine, paracetomol, and hydrocortisone - doses noted above If patient experiences only mild urticaria, give diphenhydramine &amp; if symptomsresolve, continue transfusion slowly4. Intravenous fluids, central lines &amp; useful formulas2 Maintenance IV fluid rate - 1600 ml/m /day Body surface area forumla: square root (weight [kg] x height [cm] / 3600 Total Blood Volume (TBV) Premature neonate:100 ml/kg Term neonate: 85 ml/kg 1 - 4 months age: 75 ml/kg &gt; 4 months age: 70 ml/kg Plama Volume (PV) TBV x (1-Hct) Factor VIII Replacement 1 unit/kg raises level by 2% In anemic patients: dose Factor VIII = (desired level - current level) x PV Factor IX Replacement 1 unit/kg raises level by 1% In anemic patients: dose Factor IX = (desired level - current level) x PV x 2 Central Lines: while frequently unavailable in the resource-limited setting, these do come into use at times &amp; sterile technique must be used in handling them Hickman/Broviac Flush lumens daily Heparin 300 units in 5 ml NS Dressing change twice per week Port-a-Cath Flush once per month Heparin 500 units in 5 ml NS Change dressing twice weekly while in use Baylor College of Medicine 2010 8 9. Paediatric Haematology/Oncology Ward Officers Handbook When central lines are in use, it is imperative to have anti-pseudomonal anti-biotics such as piperacillin/tazobactam or ceftazidime if these patients are toreceive chemotherapy as pseudomonal line infections are more common &amp; life-threatening. These antibiotics also provide coverage of S. viridans, and there-fore ciprofloxacin, while providing Pseudomonas coverage is not a suitablesubstitute. Central lines should only be used if adequate skill in caring for them is availa-ble, otherwise they present a greater risk than benefitOncology1. NeutropeniaNeutropenia is defined as a decrease in Absolute Neutrophil Count (ANC): ANC &lt; 1500Mild Neutropenia ANC &lt; 1000Moderate Neutropenia ANC &lt; 500 Severe Neutropenia ANC = total WBC * (% neutrophils + % bands)Patients with neutropenia are at higher risk for serious infection and therefore: No suppositories or enemas with oncologist approval No rectal temperature or exam No incision &amp; drainage of lesions without oncologist approval No NG tube, urine catheter, or LP without oncologist approval Prior to blood work or IV, area should be prepped with betadine Baylor College of Medicine 2010 9 10. Paediatric Haematology/Oncology Ward Officers Handbook2. Fever &amp; neutropenia1. Assessment Patients should be assessed immediately upon arrival to the clin-ic/emergency center, and antibiotic therapy instituted immediately afterobtaining blood work.2. Work Up Complete physical exam including visual perianal exam rememberingthat physical signs of infection may be subtle in the neutropenic patient. Full Blood Count (FBC), Blood Culture Obtain according to the presence of symptoms other than fever:Renal Function Tests (RFT), urinalysis (UA), urine culture, Chest x-ray (CXR), stool, and throat cultures3. Therapy Monotherapy: Patients meeting the following criteria may be placed onmonotherapy with cefotaxime: All patients EXCEPT those with infant Acute lymphocytic leuke- mia (ALL), acute mylogenous leukemia (AML), aplastic anemia and bone marrow transplant Normal vital signs No chills No localizing symptoms or findings on physical exam Cefotaxime dosing: 1 month 12 years: 50 mg/kg/dose IV q 8 hoursadults: 1-2 gm IV q 8 hours(Max. Dose: 2 gm/dose) Baylor College of Medicine 2010 10 11. Paediatric Haematology/Oncology Ward Officers Handbook Multiagent therapy: Patients not eligible for monotherapy should be started on one of the following drug combinations: If isolated fever and neutropenia without evidence of cardiovascu- lar compromise or specific PE findings, and patient not allergic to the drugs:Gentamicin: infants/children: 2-2.5 mg/kg/dose IV q 8 hrs (Max Initial Dose: 120 mg/dose)Cefotaxime: 1 month 12 years: 75 mg/kg/dose every 8 hrsadults: 2 gm IV q6 hours Vancomycin can be added where clinically indicated (e.g. persistent fever despite 48 hrs antibiotics)Vancomycin dosing: children: 10-15 mg/kg/dose IV q6 hrs(Max Dose: 500 mg/dose) adults: 1 gm IVq 12 hrs or 750 mg IV q 8 hrs (Max Dose: 2 gm/day)4. Other Considerations: When using aminoglycosides and/or vancomycin monitor BUN, Cr at init-iation then twice weekly as these agents are nephrotoxic. Where availa-ble, drugs levels can be obtained in therapy will continue for more than 3days with either agent. All toxic appearing patients should be treated with a three-drug combi-nation such as vancomycin, cefotaxime and gentamicin. Patients with specific infectious concerns such as interstitial pneumonitisor acute abdomen should have antibiotic selections modified as the clini-cal situation warrants. If the patient has a positive blood culture, daily cultures should be or-dered and continued until negative x 3. Orders should also state to rotatelumens for antibiotic infusion in patients with central lines. Baylor College of Medicine 2010 11 12. Paediatric Haematology/Oncology Ward Officers Handbook Where indwelling central lines (e.g. Broviac or Port-a-Cath) are available &amp; used, ready access to anti-pseudomonal antibiotics must be assured. These agents include piperacillin/tazobactam, ticarcillin/clavulanic acid, and ceftazidime. Without these medications, surgically placed central lines should be used only with due regard to the risk incurred.3. Anti-Fungal Therapy Consider in the persistently febrile patient with negative cultures, or the patientwith fever who has been neutropenic for greater than five days. Nystatin used for thrush infants 1 mL applied to each side of the mouth four times per day children and adults 5 mL PO four times per day swish and swallow Fluconazole used for prophylaxis in AML and for the treatment of candidiasis monitor liver function tests (AST/ALT q 2-3 weeks) Children (&gt;14 days): Prophylatic and treatment doses: 6 mg/kg/dayMax. Prophylactic Dose=200 mg/dayMax. Treatment Dose=400 mg/day Baylor College of Medicine 2010 12 13. Paediatric Haematology/Oncology Ward Officers Handbook Fluconazole IndicationDay One Daily TherapyMinimum DurationOropharyngeal Candidiasis 6 mg/kg3 mg/kg 14 daysEsophageal Candidiasis6 mg/kg3 - 12 mg/kg21 daysSystemic Candidiasis6 - 12 mg/kg 28 days Amphotericin B follow BUN/Cr daily initially until full dose reached, then 3 x per week follow serum K+ daily Dosing: 0.25 mg/kg/day for the first dose Escalate up to 0.5-1 mg/kg/day as indicated by the clinical situation Follow Mg twice/wk ; more frequently if hypokalemia or hypomagnesemia May bolus NS 10 mL/kg (Max. 500 ml IV) over 1-2 hours prior ampho BMinimizes renal toxicityTubuloglomerular feedback system regulates renal blood flow To prevent a drug reaction may use as premedication: Paracetomol 15 mg/kg dose (Max. Dose: 4000 mg/day; 1 gm/dose) Diphenhydramine (or Chlorpheniramine) 1 mg/kg IV/PO (Max. Dose: 50 mg) Hydrocortisone 2 mg/kg IV (Max. Dose: 100 mg) To treat rigors with chills: Meperidine (Pethidine) 0.5 mg/kg (Max. Dose: 25 mg) may use this dose topremedicate in the future. Baylor College of Medicine 2010 13 14. Paediatric Haematology/Oncology Ward Officers Handbook4. Antiviral Therapy Diagnosis made using cultures or polymerase chain reaction (PCR), or antigene- mia where available, otherwise herpes simplex virus (HSV) and varicella zoster vi- rus (VZV) can be diagnosed clinically. Acyclovir: Baseline chemistries prior to therapy, then monitor BUN/Cr 2x week Maintain adequate hydration: High-dose acyclovir IV, use 2400 mL/m2/day Standard-dose, use maintenance IV Fluid rate Adjust dose for renal impairment In immuno-compromised patients with varicella zoster (shingles) who are afe-brile and stable, may use oral dosing. If febrile institute IV therapy. In immuno-compromised patients with chicken pox institute IV therapy Patients with herpes simplex may be treated using the oral acyclovirIntravenous HSV (sick/toxic patient): 20 mg/kg/dose q 8 hours HSV (well-appearing): 10 mg/kg/dose q8 hours Varicella: 20 mg/kg/dose q 8 hours (Max. Dose: None)Oral HSV or shingles: 250-600 mg/m2/dose 4-5 x/day (Max. Dose: 800mg/dose)5. Pneumocystis jerovecii (PCP) ProphylaxisAll patients on chemotherapy should receive PCP prophylaxis that continues until 6months after completion...</p>