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Oncology patient care in PICU

Date last published:

This guideline has been developed to guide the care of oncology patients admitted to the Paediatric Intensive Care Unit at Starship Child Health

This document is only valid for the day on which it is accessed. Please read our .
Paediatric intensive care
  • Oncology patients admitted to PICU are often severely ill

  • When patients present to PICU without a confirmed diagnosis, stabilising the patient is more important than confirming a diagnosis with invasive tests

  • Close communication between PICU and Oncology is essential

  • PICU Consultants expect the Oncology Consultant to liaise with them directly regarding management of the patient and daily plans of care. Therefore, always contact the PICU Registrar or Consultant when the Oncology team are reviewing the patient

Airway

  • Oncology patients are at high risk of major cardiovascular decompensation with the administration of intubation medications

  • Always discuss with the PICU Consultant on-call, before embarking upon intubation

  • Have resuscitation medications and fluids drawn up at the bedside. It may also be appropriate to commence inotropes and give a fluid bolus before administering intubation medications

  • Use an oral ET tube if platelets are <20 x 10⁹/L or there is coagulopathy

Breathing

  • Try non-invasive ventilation using High Flow or CPAP/BiPAP via mask first. Bubble CPAP is an option in infants less than 6 kgs

  • If there is no improvement in the patient’s respiratory status or non-invasive ventilation is not tolerated, then intubate

Circulation

  • Support circulation as per PICU guidelines with IV fluids/boluses and inotropes

  • Use IV fluids with caution in patients with compromised respiratory function

  • IV fluid management can be complicated, especially when the patient requires hyper-hydration. Always discuss with Oncology to check if the patient requires specific fluid management for chemotherapy

  • The management of children with compromised respiratory function who require specific hydration management based on their chemotherapy treatment regimen should be discussed between the PICU and Oncology Consultants

  • Newly diagnosed or recently relapsed patients should not have potassium added in their IV fluids. Refer to the tumour lysis syndrome guideline when caring for these patients
  • If patients do not require specific hydration and are not at risk of tumour lysis syndrome, normal PICU fluids for IV fluid management should be used

Neurological

  • Assess neurology as per normal PICU assessment

  • Morphine should be used as the first line of treatment for pain, so as to not mask a fever

  • If giving Paracetamol, always take the patient’s temperature beforehand

  • Do not give Ibuprofen to any Oncology patient, as this medication can affect the platelets

  • Patients receiving chemotherapy often develop mucositis, which can be very painful. Treatment often requires regular analgesia, including analgesia infusions

  • If there is a neurological component to the disease, the patient may experience persistent pain. In such cases, gabapentin may be considered (Consult with Oncology & the Pain Service prior to prescribing)

  • If a patient’s pain persists for more than 3 days, consult the Pain Service for advice

Gastrointestinal (GI) / Genitourinary (GU)

  • Follow the PICU bowel protocol if BNO day 3

  • NO suppositories or PR medications should ever be given to Oncology patients

  • Vincristine is a chemotherapy that often causes or worsens constipation. Therefore, monitor closely and consider early constipation management in consultation with the Oncology team

  • If the patient is hyperglycaemic, refer to the PICU Hyperglycaemia protocol

  • Ensure all Oncology patients are on a Low Risk, High Energy diet, ordered through Trendcare

  • If the patient’s oral intake is inadequate, or they have a weight loss of > 5% usual body weight, consider nasogastric feeding

  • If the patient is not absorbing feeds, consider post pyloric feeding or intravenous nutrition in consultation with the Oncology team and PICU dietician(s)

  • Daily weights if possible

  • Administer regular anti-emetics, even when intubated and refer to the nausea and vomiting protocol if the patient is receiving chemotherapy, or has had chemotherapy in the last 5 days

  • Always discuss with the Oncologist which anti-emetics the patient is allowed prior to prescribing. This is especially important when considering steroids or Aprepitant, as some patients are NOT allowed these medications due to their diagnosis and/or treatment protocol

Skin/ Positioning

  • Patients require different levels of mouth care depending on the mucositis potential of therapy

  • As mucositis occurs, then additional therapies should be added

  • All Oncology children should receive basic mouth cares

  • If the patient’s neutrophils are <1.0, commence an oral assessment guide

  • Patients post stem cell/bone marrow transplant should receive Nilstat 6 hourly

  • If a patient has a mediastinal mass, keep the patient in a sitting up position at a 45 degree angle

Patient Isolation

  • All patients require isolation in a positive pressure room unless their neutrophil count is greater than 0.5 x10⁹/L AND they have not received chemotherapy in the last two weeks

  • Newly diagnosed or recently relapsed patients should always be isolated despite their white cell count, as this could be artificially high and the cells could not be functioning effectively

  • All patients, including those post stem cell/bone marrow transplant require protective isolation (gown and gloves)

  • Although it is not the policy on 27B to routinely gown and glove, there is a greater variety of patients in PICU and a greater number of health care professionals including the nurse runner, transport nurse, medical registrars and PICU consultants that may be entering the room. Therefore, it is in the patient’s best interest to be protected from all other PICU bugs

Febrile Neutropenia

  • Always refer to the Starship Clinical Guidelines when caring for a child with febrile neutropenia

  • Fever: ≥38 deg C on two consecutive occasions ≥1 hour apart OR ≥38.5 deg C on one occasion
    AND

  • Neutropenia: a neutrophil count of <0.5 x 10⁹/L OR recent intensive chemotherapy where neutropenia is expected

  • Remember to check when the patient last had chemotherapy

  • Always culture all central lumen lines prior to administration of antibiotics

  • Antibiotic therapy to be commenced within 1 hour of presentation (or new fever spike, if inpatient)

Blood testing and Blood Product Transfusion

  • Patients should receive irradiated and leukocyte depleted blood products

  • Patients post stem cell/bone marrow transplant should receive irradiated, leukocyte depleted and CMV negative blood products (unless the patient is known to be CMV positive)

  • Post chemotherapy patients will generally become cytopenic day 8 to 14 post chemotherapy

  • Ensure a differential is done daily on the full blood count, especially for patients receiving Filgrastim (G-CSF)

  • All blood tests to be done as per PICU

  • Newly diagnosed or relapsed patients may be at risk of tumour lysis syndrome and may require more frequent and specific blood tests

Specific Transfusion Parameters

Always take into account the patient’s age and clinical state.

General guidelines are

  • Transfuse if haemoglobin below 70g/L or if patient is symptomatic

  • Transfuse if platelets less than 10 x 10⁹/L or if patient is symptomatic OR febrile

  • Transfuse platelets to get above 50 x 10⁹/L pre procedure or when patient bleeding

  • Pre LP/BMA, ensure platelets are greater than 70 x 10⁹/L. Consider transfusing platelets during procedure if concerned about risk of bleeding

  • Transfuse all other blood products including Fresh Frozen Plasma, Cryoprecipitate, Albumin (4% or 20%) and IVIG as per PICU

Post Stem Cell or Bone Marrow Transplant

  • Daily full blood count, urea and creatinine

  • Weekly (Monday) CMV PCR. (Twice weekly if CMV positive)

  • EBV and Adenovirus PCR as clinically indicated (Discuss with Oncology team)

  • Cyclosporin level Monday, Wednesday, Friday

    • IV administration: take level at 0600hr, then give dose

    • Oral or NG administration: take level at 0900hr, then give dose

     

Central Venous Catheter (CVC) Management

  • Central line care for oncology patients is the same as it is for all patients in PICU and should follow the insertion and maintenance bundles outlined in the Starship central venous catheter guideline

  • All dressing and needless connector changes are to be completed using Aseptic Non-Touch Technique

  • Always use a clear dressing for all long-term CVCs so the site is visible and can be routinely assessed for infection. If patients have a long-term surgically implanted CVC in place they do not require a CLAB dressing

  • Subcutaneous port-a-cath needles need to be changed every 7 days. If you are not trained or confident in changing the needle, please contact a staff nurse on Ward 27A/B for assistance

  • For routine CVC heparin management refer to the Starship central venous catheter guideline

  • If the line is blocked, consider alteplase and refer to the Starship central venous catheter guideline

Medications

  • No oncology patients should receive steroids unless the Oncology team has approved it

  • When receiving chemotherapy or radiation, give all anti-emetics regularly and continue for at least 5 days after treatment

  • All patients should receive PCP prophylaxis

  • Newly diagnosed or relapsed patients may require either allopurinol or rasburicase based on their risk of tumour lysis syndrome

  • Refer to the Oncology Outliers in PICU folder for more information about supportive nursing cares and medications

  • Refer to the National Child Cancer Network for more information about specific medications and national guidelines for the supportive care and management of children with cancer in New Zealand

Chemotherapy

  • When a patient is receiving chemotherapy, refer to the Safe Administration of Chemotherapy Checklist located in the Oncology Outliers in PICU folder and on the PICU ‘L’ drive

  • For one week post chemotherapy, ensure you always wear personal protective equipment, including a purple gown and gloves, when touching any body fluids

  • Body fluids include blood, stool, vomit, saliva, sweat, bile, and secretions

  • When suctioning or flushing the nasogastric tube, always wear a mask and goggles

  • Dispose of blood, nappies, or any chemotherapy lines in a purple cytotoxic bin or bag

  • Emesis, urine from an indwelling catheter and stool can be flushed down the toilet while wearing appropriate personal protective equipment

  • When there is a chemotherapy spill, contact a chemotherapy trained professional for assistance, get the chemotherapy spill kit and refer to the Cytotoxic & Hazardous - Spillage policy and procedure

  • If an extravasation occurs, refer to the Cytotoxic & Hazardous - Extravasation policy and procedure and contact a chemotherapy trained professional for assistance

  • Prolonged exposure to small amounts of chemotherapy can cause cancer

  • If pregnant, it is up to the individual health care provider if they would like to care for the patient

  • If family members are educated about the side effects of contact with cytotoxic material, it is their choice to wear gloves or not

 

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