Oncology patient care in PICU
This guideline has been developed to guide the care of oncology patients admitted to the Paediatric Intensive Care Unit at Starship Child Health
- Airway
- Breathing
- Circulation
- Neurological
- Gastrointestinal (GI) / Genitourinary (GU)
- Skin/ Positioning
- Patient Isolation
- Febrile Neutropenia
- Blood testing and Blood Product Transfusion
- Specific Transfusion Parameters
- Post Stem Cell or Bone Marrow Transplant
- Central Venous Catheter (CVC) Management
- Medications
- Chemotherapy
- Related Information
- Document Control
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
ANDNeutropenia: 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