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8/10/2019 Complications of Chemotherapeutic Drugs
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Complications ofChemotherapeutic drugs
Tolentino
Sanchez
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1. Infusion site related
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Extravasationis the accidental
leakage of a druginto thesubcutaneoustissue thatcauses pain,necrosis, or
sloughing oftissue
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Definition of Terms
VESICANT-is an agent that can produce a blister,tissue destruction, or both.
IRRITANT- is an agent that can cause aching,tightness and phlebitis at the injection site or alongthe vein line with or without an inflammatory
reaction.
FLARE- is a local allergic reaction without painthat usually is accompanied by red blotches alongthe vein line. This subsides within 30 minutes withor without treatment.
DELAYED EXTRAVASATION-is one in whichsymptoms occur 48 hours or more after the drug isadministered.
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Indications of
Extravasation
Absence of blood return from the IVcatheter
Resistance to flow of IV fluid
Burning, or pain, swelling at the site
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Initial management
STOP THE INFUSION IMMEDIATELY.Do not flush the line, and avoidapplying pressure to theextravasation site.
Disconnect the IV tubing from the IVdevice, but do not remove the IVdevice or noncoring port needle.
Attempt to aspirate residual fluidfrom the IV device using a small (1-3
mL) syringe. (Central line) Remove the peripheral IV device or
port needle.
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Assess the site of the suspected extravasation andnote any symptoms experienced by the patients
Assessment and documentation should includedrug extravasated, dose, volume, position, andsize of any apparent wound, presence of swelling,and extent and spread of erythema and pain.
If possible, digital photographs should be obtainedto help further document the injury and assesschanges over time.
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Notify the physician or advanced practice
nurse. Initiate appropriate management
measures in accordance with professionalpractice guidelines and institutional
policies.
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Management
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1. Cold application
Application of an ice pack to cool the site ofextravasation is recommended for extravasationof:
anthracyclines (doxorubicin, daunorubicin,epirubicin and idarubicin),
alkylating agents(mechloretamine)
antitumor antibiotics(dactinomycin ndmitomycin-C)
taxanes (docetaxcel and paclitaxel)
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2. Heat application
Application of heat is indicated forextravasation of the plantalkaloidssuch as:
Vincristine
Vinblastine
Vindestine
Vinorelbine
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Heat should be applied to the
affected area for 15 to 20 minutes4 times per dayfor the first 24 to48 hours.
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3. Limb elevation
May help with reabsorption of the
extravasated drug and is recommended fothe first 24 to 28 hours wheneverpossible.
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Antidotes and treatments
ANTIDOTE- an agent that is eitherapplied or injected to theextravasated area to counteract theeffects of the infiltrated agent.
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Sodium thiosulfate
Exact mechanism unknown.
Thought to prevent alkylation andreduce subcutaneous tissuedestruction.
Subcutaneous injection using a25-gauge needlearound the
affected area is recommended forextravasation ofMechlorethamine.
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It is supplied as a 10% or 25% solution and shouldbe diluted to a 1/6 molar solution, by mixing 4 mLof the 10% solution with 6 mL of sterile water or1.6 mL of the 25% solution with 8.4 mL of sterile
water. Using 2 mL for each milligram extravasated,
multiple local subcutaneous injections should beadministered as soon as possible after theextravasation, changing the needle for each
injection, followed by ice application for 6 to 12hours.
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Local subcutaneous injection has beenrecommended for extravasation of vinca
alkaloids and can be used in combinationwith heat application.
It is recommended to administer painmedications prior to this procedure.
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Dexrazoxane
Exact mechanism unknown, thetarget of anthracyclinechemotherapy is an enzymeknown as DNA topoisomerase.
Dexrazoxane is thought to inhibitand bind to DNA topoisomerase II,thereby disabling the enzyme so it is
no longer affected by theanthracycline and damage to thecells is averted.
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Administered IV as three 1-2 hourinfusions through a different venousaccess location. FIRST DOSE should begiven within 6 hours of the actual
extravasation, and subsequent dosesadministers as 24 and 48 hours afterextravasation.
The 1stand 2nddoses are 1000 mg/m2and
the 3rd
dose is 500 mg/m2
up to maximumtotal doses of 2000 mg on days 1 and 2and 1000 mg on day 3.
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Surgery
Surgical interventions include
debridementof necrotic tissue, whichcan help minimize subsequent damage,and wide excision or skin grafts if healingis delayed.
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Pain Management
Non-opioid analgesics
Opioid analgesics
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Prevention
Vesicant chemotherapy should never beadministered in peripheral veins involving thehands or the wrist.
For any frequent, or prolonged administration ofantineoplastic vesicants, right atrial silasticcathethers, implanted at venous access devices, orperipherally inserted central cathethers (PICC)should be inserted to promote safety duringmedications administration and reduce problems
with access to the circulatory system.
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Hypersentivity/
Anaphylacticreactions
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Overall incidence of hypersensitivity reactionsis 5%.
Emergency medications and supplies: Injectable aminophylline, diphenhydramine
hydrochloride (Benadryl), dopamine,epinephrine, heparin, hydrocortisone.
Oxygen setup, tubing cannula, or mask andairway device
Suction equipment
IV fluids (isotonic solutions) IV tubings and supplies for venous access.
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Management
Immediately stop the drug infusion
Maintain an IV line with isotonic saline
Position the patient for comfort and topromote perfusion of the vital organs
Notify the physician, nursing agency, oremergency medical services.
Maintain the airway, and anticipate theneed for CPR
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Monitor vital signs
Administer appropriate medications withan approved physicians order
Follow the nursing agencys protocol forfollow-up care.
Document the incident in the patientsmedical record.
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Complications of
Chemotherapy
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SHORT TERM
Fever
Nausea
Infusional reactions
Oral complications
Diarrhea
Anemia Neuropathy
Alopecia
Rash, Extravasation
Emotional
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FEBRILE NEUTROPENIA
On Chemotherapy, 7 to 14 days postchemo
WBC nadir, NEUTROPHILS are 1stline of
DEFENCE Temperature great than or equal to 38.3
degrees centigrade
Absolute Neutrophil count (ANC) less than
1.0
One of the few Oncologic EMERGENCIES
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MANAGEMENT
Broad Spectrum antibiotics
If well, hemodynamically stable
CIPRO and CLAVULIN PO and home
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IF UNWELLADMIT WITH BROAD SPECTRUM IV
ANTIOBIOTICS I/E TAZOCIN ORIMIPENEM OR AMP AND GENT
WITH NEUPOGEN SUPPORT(300mcg sc daily until anc >1.0), IVFLUIDS ETC.
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Usually fever lasts less than 48 hours
If fever longer than 48 hrs, patient needsIV antibiotics, consider antifungals
Usually bacterial or viral infections butfungal infections becoming more of anissue
As WBC and ANC recover, patient usually
improves
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2. NAUSEA
Most chemotherapeutic agents causenausea. Why?
systemically as drug makes its way tonausea centre of brain (chemotherapeutictrigger zone)
Sight and smell of drug
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Types of Nausea
Anticipatoryconditioned reflex tosight and smell of chemotherapy area
Acute
within 24hrs and related tochemotherapeutic agents
Delayedmore than 24 hrs. postchemotherapy--specific agents
cisplatin, cyclophosphamide, adriamycin
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Worst offenders:
Cisplatin
High dose cyclophosphamide
Doxorubicin, eprirubicin, carboplatinalso have a high incidence of nausea
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NAUSEA TREATMENT
Medications:
Prochlorperazine (stemetil)
Metoclopramide (maxeran)
Ondansetron (Zofran)5HT3 antagonists
Dexamethasone
Lorazepam, Haloperidol
Aprepitant
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INFUSIONAL REACTIONS
Very common with new MONOCLONAL ANTIBODYagents i/e RITUXIMAB
Infusion of these agents may take several hours
Fever, hypotension, asthmatic like reactions, pain
Premedicate or treat with Dexamethasone,Benadryl, Tylenol
May have to stop infusion temporarily
If serious, may have to discontinue agent
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Oral Complications
Occurs in approx. 40% of patientsreceiving chemotherapy
Team approach using nutritionist, nursing,
dentist, pain management team
Oral hygiene important-soft tooth brushes,floss
Source of bacteremia
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loss of taste
Affects appetite, nutrition
Which in turn affects healing
In this situation, we advisepatients to think of eating as a job
Sometimes, oral complicationsrequire nutrition supplements oralternatives
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MUCOSITIS
Chemotherapy is intended to injure rapidlydividing cells such as the MUCOSA
Presents with mouth sores, inflammation,sometimes sloughing of mucosa anywherein the GASTROINTESTINAL TRACT, RESPTRACT
Usually occurs in the mouth
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SIMPLE ORAL MUCOSITISTREATED WITH MOUTH RINSE
MAGIC MOUTHWASH
SALT WATER GARGLES
TOPICAL ANALGESIA i/e Xylocaineviscous, tantum
Systemic analgesia
NYSTATIN
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Upper GI tract
Heartburn
Very common
Antacid, Ranitidine, Pantoloc
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MANAGEMENT
Hydrationpo, IV if more SERIOUS
Dietfluids, BRAT (Bananas, Rice, Apples,
Toast)
Loperamide (immediately if on Irinotecan)
4mg followed by 2mg Q4H or until formed stool.Up to 16 mg per day
Usually rule out CDIFF first
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If severe, Ocreotide (Sandostatin)
Decreases fluid output from bowel
100mcg sc TIDGrowth hormone analogue-decreases
all salivary gland secretions
And Antibiotics may be consideredespec. if CDIFF positive
oral metronidazole or oralvancomycin
oral CIPRO
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ANEMIA
Bone marrow suppression fromchemotherapeutic agents
Secondary to malignancy
Anemia work-up
Chemotherapy induced anemia
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Erythropoietin, Aranesp
Stimulate marrow to produce
RBCsUsed while on chemotherapy only
Additional iron: po vs. iv
Sc injection
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Adverse effects ofErythropoietin
Flu-like illnessRashes
Diarrhea
HeadacheBone pain
Liver, kidney
Dosage: Eprex 40,000 units scqweekly Aranesp: 150mcg scqweeklyto 7 days)
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NEUROPATHY
Very common with vincristine, vinblastine,cisplatin
Usually temporary.
Sometimes leads to dose alterations orstopping of some drugs
Most commonly, we see numbness andtingling in fingers and toes
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MANAGEMENT:
May need to alter chemotherapeuticagents or doses thereof
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LONG TERM
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Cardiac Complications
Adriamycin or other anthracyclines
450mg per m2 dose lifetime
Strong treatment for breast cancerand hematologic malignancies
Affects myocardium longterm above
maximum dose
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Secondary Malignancies
Skin cancers
Breast cancers
Hematologic Malignancies
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Fatigue
Thorough history, physical exam
and ancillary tests
Fatigue workshop
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Arthropathy
Treated in usual fashion withNSAIDs, prednisone