Leukemia

 

Supportive care


 

Total dose acceptable : (for Life) 

 

Vincristine :   25 mgs /M2

CCNU :        1100/m2

BCNU :          1500 mgs/M2

Donorubicine : 550 Mg\m2

Doxorubicine  :550 Mg/m2.

Mitoxantrone :140 mg\m2

Bleomycine  :250/m2

Mitomycine : 60 mg/m2

Epirubicine : 1000 Mg\m

Etoposide: 6000 Mg/m2

 

Blood Products

Optimal and Up to date use of blood products in Leukemia lymphoma patients :

In patients who will require use of blood products on a regular basis, a full phenotype should be obtained before transfusion. Young patients with negative serology for CMV, who may be candidates for bone marrow transplantation, should receive CMV negative blood products.
 

Irradiated Blood and CMV Negative Blood

The following groups of patients should receive irradiated blood products:

1) Any previous progenitor cell or bone marrow transplant recipient, even if off all immunosuppression
2) Patients with acute leukaemia having induction/consolidation chemotherapy
3) High grade lymphomas and Hodgkin's disease
4) Dedicated blood from family members
5) Premature babies or sick neonates
6) Intrauterine transfusions
7) Other organ transplant recipients (other than cornea)

White Cell Filters
Packed cells and platelet transfusions are all administered through white cell filters (Immuguard, Sephacel or Pal) to reduce leucocyte antigen sensitisation.



CMV Negative Blood Products:

1) All patients who have received any form of allogeneic transplant  (bone marrow, liver, kidney, heart).
2) Patients with acute leukaemia, high grade lymphomas, Hodgkin's disease who are potential allogeneic transplantation candidates, until CMV serology has been performed. If the patient is positive, CMV positive blood may be used.
3) Neonates and children under the age of 10.
4) Pregnant women.



Thrombocytopenia and Platelet Transfusions:

(References: Red Cross recommendations; Beutler E. Blood 1993; 81:1411-3)

In remission induction chemotherapy for leukaemia or lymphoma, give platelet transfusions to maintain platelet count >10 X10^9/l.
A higher threshold is appropriate if bleeding, sepsis, coagulopathy or patient receiving L-asparaginase or ATG.

In other situations, the current Red Cross criteria for platelet transfusions are:
prophylactic <15 X 10^9/l
pre-surgery <70
active bleeding <100
The average platelet transfusion is six single donor bags. These may be put up individually, or pooled [only if all of the same blood group]. If platelets of different groups are being given, change the giving set with each lot of a different group.
Platelets may be collected by apheresis from a screened volunteer or family member. A single donor pletelet apheresis collection will usually give the same yield as 6-10 random Iranian Blodd  Transfusion units.
Platelets are transfused through a White cell filter.


Platelet Transfusion Reactions:

  1. Premedication is given to patients with a history of reactions or patients who have been heavily pretransfused:
  2. ;Hydrocortisone 100 mg IVI stat.
    plus
  3. Promethazine (Phenergan) 12.5 mg IVI stat [flush in between with saline to avoid precipitate]


Platelet refractory patients:
HLA matched donors may sometimes be identified through National Transfusion Centers. (send 20 ml of clotted blood). To document platelet survival, measure platelet count 1 hour after platelet transfusion. Intravenous immunoglobulin may be useful in patients with platelet refractoriness and bleeding, after consultation with the Red Cross.


Mouth Care

Patients with acute leukaemia should be given prophylactic mouth care, as well as patients with lymphoma being given high dose methotrexate containing regimens.

Give one of a) followed by one of b) :
a) chlorhexidine mouthwashes 10 ml Q4H gargle and spit out
OR
normal saline mouth washes


b) Nistatin 1 ml gargle and swallow Q4H
OR
amphotericin (Fungizon) lozenges i Q4H suck and swallow.

c) A soft toothbrush should be used to clean the teeth and gums gently TDS.

 

Antiemetics

a) standard: like drug like Vincristine
With chemotherapy, give:

  1. Methoclopromide 20 mg IVI
  2. Lorazepam 1-2.5 mg PO stat (depending on size and condition)
  3. Dexamethasone 10 mg IVI

Following chemotherapy give metoclopromide 10 mg q4h prn IVI or PO

b) in patients refractory to "MAD" or highly emetogenic regimens (Nitrogen Mustard,Procarbazine ,Streptozocin,Dactinomycin  DTIC, cis-platinum, high dose cyclophosphamide etc):

  1. Granisetron (Kytril) 3 mg IV , with chemotherapy,
    Then 1 mg  PO q 8 hours for 24 hours or Tropisetron 5 mgs IV with chemotherapy  then 5 mgs po q 8 hours for 48 hours.
    or Ondansetron 8 mgs IV slow in 15 minutes and then  8  mg PO daily x3-5 days.

Intravenous Lines

Lines used for chemotherapy should be sited immediately before use. With vesicant agents (especially doxorubicin, daunorubicin, vinca alkaloids, mustine) severe ulceration and soft tissue loss may result from extravasation. Avoid placement of lines where dislodgement is easy, and where tendon and nerve loss are most likely, especially the antecubital fossa and the dorsum of the hand.
Where extended chemotherapy is likely or access is a problem, insert a Long IV cathater (lymphoma, chronic leukaemias, myeloma) or a double lumen Hickman catheter (acute leukaemia). Hickman catheters are more appropriate for induction chemotherqpy for acute leukaemia, because higher volumes (blood products, antibiotics, IVI fluid) are more easily given.

Hickman Catheters :

  1. Arrange for insertion via surgical team.
  2. Give platelets immediately preoperatively if platelet count < 75.
  3. Prophylactic vancomycin 1 g IVI over one hour immediately preoperatively, and Q12H X 2 doses post-operatively (if renal function is normal).

Ideally insert 12F double lumen Hickman catheter  with internal lumens 1.6 mm.
If not technically possible (insertion via a small cephalic vein) a 10F double lumen catheter (internal lumens 1.3 & 1.0 mm) is acceptable.

Dressing of Hickman catheter:
Clean work area with methylated spirits. Wash hands throroughly. Using a minor dressing pack, open onto the sterile field gauze swabs, airstrip and gallipot. Pour into the gallipot some methylated spirits.
Open betadine swab sticks onto sterile plastic container. Remove old dressing and inspect for inflammation.
Wash hands thoroughly again.
Pick up a gauze swab by the corners, dip into methylated spirits and commence cleaning around the catheter site in a circular motion, working out from the exit site. Repeat once more and clean down the tube.
Repeat the same pattern of cleaning using a Betadine swabstick.
Clean 2-3 cm around exit site. Repeat with a second Betadine swabstick and clean 2-3 cm down the tube.
Using another gauze swab, pat the area dry, but do not wipe the area dry.
Carefully place an air strip over the exit site.
Coil the catheter comfortably on the chest wall, and tape firmly.



Heparin Flushing of Catheters:

Set up as described above: include in addition 5 ml of heparinised saline (50 units in 5 ml), a 5 ml syringe, 19 G needle, and syringes, tubes appropiate for collecting blood). Using a sterile dressing pack and sterile gloves, thoroughly swab the distal end of the catheter and cap with Betadine and methylated spirits. Clamp the catheter to avoid air embolism. Remove the cap or IVI giving set and connect the syringe with heparin-saline. Release the clamp and flush. Do not flush forcefully, as catheter rupture may occur. As the last of the heparin-saline is being given, reclamp the catheter.
Flush Hickman catheters  with 5 ml heparinised saline (50 units heparin/5 ml) after completion of any infusion. When not in use, Hickman catheters should be flushed weekly .
Blocked Catheter: Flush gently with heparin-saline. DO NOT USE FORCE. Try aspirating. In patients who do not have thrombocytopenia or coagulopathy, with a persistent blockage, a local infusion of Streptokinase 5,000 units may be tried .
Split Catheter: Clamp immediately between the split and the exit site. The catheter may be able to be repaired using the Hickman catheter repair kit.
Infected Catheter:See section 2

Pain Relief

Mild to moderate pain may be relieved by paracetamol i-ii tab Q4H prn.
Bone pain often responds well to the addition of NSAIDs e.g. Naproxen  1 tab tid.

Avoid NSAIDs in patients with thrombocytopenia, renal impairment or on methotrexate or warfarin.
For stronger pain, the use of opiate analgesics is appropriate:
Morphine mixture: start at 5 mg Q4H prn and increase prn OR
Subcutaneous morphine: start at 5 mg Q4H prn and increase as required.

N.B.

  1. All patients on narcotic analgesics require a laxative e.g. Bisacodyl or Milk of magnesia + lactulose  daily prn, to prevent severe constipation.
  2. In the presence of renal failure, accumulation of active narcotic metabolites may occur.
  3. Patients with severe pain of terminal malignancy should be encouraged to take a regular rather than prn dose, to prevent re-emergence of pain.

Sedation for Bone Marrow Biopsy & Other Procedures

Sedation is not given for routine bone marrow biopsy procedures. Where patient anxiety or preference dictates, consider sedation with Diazepam  5-15 mg low IV. Give an initial dose to 15 mg in a young fit adult and 5 mg in a frail elderly patient. Titrate with further increments of 1-2 mg IVI until drowsy. Monitor pulse and oxygen saturation. Have resuscitation equipment  available.


The Adminstration Of Cytotoxics

(Reference: Clinical Oncological Society of Australia. Guidelines & recommendations for the safe handling of antineoplastic agents. Med J Aust 1983; 1: 425+)

Check instructions for individual drugs as to how best given. Vesicant drugs should be injected into the side arm of a fast running drip, with frequent drawing back of the syringe, to check for the free return of blood up the tubing. Cannulas used for vesicant drugs should be freshly placed at a secure site. IF ANY PAIN OCCURS DURING ADMINISTRATION, DISCONTINUE IMMEDIATELY. Where possible, avoid giving vesicant drugs into cannulas placed in the elbow, wrist and back of hand. Extravasation is at greater risk of causing extensive damage of nerves and tendons.
Give cyclophosphamide in the morning, because of its potential for haemorrhagic cystitis and late onset bladder cancer. When giving IVI, give extra fluid. Advise patient to drink copious oral fluids, and to void frequently. Furesemide( Lasix) may be given with fluids to produce a diuresis.

Allopurinol

All patients commencing chemotherapy should be covered with allopurinol to avoid hyperuricaemia.
Exceptions include patients receiving 6-mercaptopurine and azathioprine .

 

Management of new patient with Acute Leukemia

Acute Myeloid Leukemia

Acute Lymphoblastic Leukemia