High Intensity Chemotherapy Guidelines for Haematology Patients at ASPH Contents: Page No. 1. Overview 2 2. Admission 3 3. Admission Checklist 5 4. Inpatient management during chemotherapy 6 5. Inpatient management after chemotherapy 7 6. Blood product support 8 7. Discharge planning 10 1
OVERVIEW 1. These guidelines cover high intensity in-patient chemotherapy for Acute Myeloid Leukaemia (AML), Mantle Cell Lymphoma (MCL), and Salvage high grade Lymphoma. The purpose is to support junior medical staff and ward nursing staff involved in the care of these patients. We are grateful to Dr Louise Hendry who produced a similar policy for RSCH which formed the basis for this document. 2. Treatment for patients with AML [common regimens include DA, FLAG, FLAG-Ida, High dose Ara-C (Cytarabine)] is administered as an inpatient in one of the side rooms on Aspen Ward except where patients require intensive care support or in other exceptional circumstances. Patients with AML require multiple cycles of chemotherapy each followed by a period of prolonged, severe pancytopenia where close monitoring and support are required. They are usually discharged only for a brief period between cycles. 3. Some elements of the chemotherapy regimens used for patients with lymphoma [including Nordic, ESHAP, R-GemP, and High dose Methotrexate] may be able to be administered on the Haematology Day Unit if the patient is sufficiently stable and well enough to be brought down from the ward. 4. Individual patients receiving chemotherapy that can usually be administered in an outpatient/day unit setting may sometimes require inpatient management either because they are acutely unwell or because they have major complicating comorbidities. 5. Full details of treatment algorithms, chemotherapy regimens, supportive care regimens and consent forms together with the related alliance cytotoxic policy are available at the following link http://stlukescanceralliance.co.uk/haematologychemotherapy/ 6. Additional advice and guidance can be obtained by speaking with the haematology clinical team: during working hours please call either the Haematology Day Unit [ext: 2193/2347] or haematology office [ext: 2120/3432]; out of hours support is available from the duty medical registrar and the site co-ordinator; the duty Haematology Consultant Out Of Hours may be paged by Consultants, SpRs and Haematology SHOs. 2
ADMISSION Admission Routes: Patients may be admitted on to Aspen ward for high-intensity chemotherapy via the following routes; Elective admission: Directly from home or via the Haematology Day Unit; usually for planned first treatments or subsequent cycles of therapy. Emergency admission: Via A&E, MAU, Haematology Day Unit, other hospital wards, or the Haematology out-patients clinic; usually for unwell patients with new diagnoses or severely symptomatic progressive disease. Admission Procedure: 1. All patients require a full clerking on each admission detailing their: Primary haematological diagnosis, planned treatment regimen, course number and consultant Background medical issues and regular medications Previous treatment and dates (if relevant) Previous infective issues (if relevant, including positive microbiology results) Any new issues arising since last review Social history and any anticipated social/care needs Any specific special requirements for blood components (see page 9) and check with the transfusion lab. 2. They should be fully examined, and an up to date height and weight documented. 3. IV access: All patients receiving in-patient high-intensity chemotherapy require central IV access, usually in the form of a PICC- line (Peripherally Inserted Central Catheter). Rarely, some patients may have a Hickman line in the chest wall. Occasionally chemotherapy is started through a small-gauge peripheral cannula whilst central access is being arranged. If a new PICC- line is required, contact Interventional Radiology on extension: 3470, or the Haematology Day Unit on extension: 2193/2347. 4. Supportive and regular medications: Prescribe all the patient s usual medications on the drug chart. Some may need to be omitted during chemotherapy (e.g. anti-platelet agents, anti-hypertensives, diuretics). Refer to the specific chemotherapy regimen the patient is scheduled to receive on http://stlukescanceralliance.co.uk/haematology-chemotherapy/ and prescribe the supportive medications listed (usually a combination of prophylactic anti-microbials, 3
anti-viral agents and anti-emetics, occasionally with GCSF, prophylactic eye drops or TLS prophylaxis). 5. Ensure all anti-microbials are prescribed in the designated antibiotic section of the drug chart. 6. VTE assessment: complete the assessment and document this in the drug chart. Ensure re-assessment at 24 hours is completed. Omit LMWH prophylaxis if bleeding or if/when the platelet count is below 50 x10 9 /L. 7. Investigations: ensure appropriate, up to date blood investigations have been completed by checking the tests required in the chemotherapy protocol, available at http://stlukescanceralliance.co.uk/haematology-chemotherapy/ 8. Chemotherapy is prescribed electronically on the e-prescribing system, Aria. This must be done by Consultants and Haematology Specialty Doctors only. Liaise with pharmacy or the senior on-call Haematologist if you have any concerns about the chemotherapy prescription. The patient s named consultant or the on-call consultant will make any final decision relating to the timing of chemotherapy, and will authorise the prescription on Aria accordingly. 9. Consent Forms: There are regimen-specific chemotherapy consent forms which are completed by the patient and their consultant / specialty doctor prior to treatment, and the signed copies should be available on Evolve. The patient s consent is reconfirmed by the chemotherapy nurses before the treatment is given. Further details and consent forms are available here: http://stlukescanceralliance.co.uk/chemotherapy-consent-forms-for-haematology/. 4
ADMISSION CHECKLIST New Admission Tasks To be completed by: Full clerking Doctor Tick When Complete IV access Doctor/Nurse Drug Chart Doctor Regular medications Supportive medications VTE assessment and prophylaxis Blood investigations Doctor/Nurse Special requirements for blood components Doctor 5
INPATIENT MANAGEMENT DURING CHEMOTHERAPY 1. Patients should be reviewed at least daily. Particular attention should be given to whether regimen proceeding well, IV access, nausea and vomiting, hydration, fluid balance, mouth care, sepsis, blood count and coagulation support, as well as dealing with any other issues consequent on chemotherapy, their underlying malignancy or other medical issues. 2. The chemotherapy protocol should be consulted for issues relating to that regimen and how to deal with them e.g.: methotrexate levels, fluids and Folinic acid in High dose methotrexate; fluid overload in ESHAP/ R-GemP. 3. During this period some can be very well, especially during consolidation cycles, and may even be able to go home for short periods between doses. Others, especially patients with active disease, can be very unwell and need a lot of support as per Inpatient management after chemotherapy (page 7). 4. Fevers in the context of a normal WBC should be taken seriously due to impending neutropenia. A source should be sought and the infection treated. PICC / Hickman lines are often a source of infection during this period. 6
INPATIENT MANAGEMENT FOLLOWING CHEMOTHERAPY 1. Patients on certain regimens e.g. salvage regimens for lymphoma can usually be discharged once their regimen is complete. Plans for blood monitoring, GCSF administration and readmission should be arranged prior to discharge. 2. Patients on salvage regimens who develop severe pancytopenia despite GCSF prophylaxis will often need to be readmitted. 3. Patients on AML therapy will all develop severe pancytopenia a few days after treatment. They require protective isolation: Follow instructions on side room door regarding infection control precautions. 4. Avoid risk of introducing infection by avoiding procedures that may provoke infection e.g. rectal examinations and insertion of urinary catheters unless absolutely essential. 5. All required prophylactic drugs should now be taken. 6. Check if GCSF should be started for lymphoma / lymphoid malignancy patients according to treatment protocol. GCSF however is often avoided in AML and other myeloid malignancies and should not be started unless authorised by the duty haematology consultant. 7. Neutropenic sepsis should be treated urgently according to the neutropenic sepsis pathway (refer to Microbiology guidelines). Intravenous antibiotics are continued for 7 days whilst neutropenic. Please document indication and review date on the drug chart. Once the count has recovered then a switch to oral antibiotics after 48hrs can be considered. 8. Patients can become very unwell very quickly at this stage, needing aggressive fluid resuscitation, and sometimes develop severe sepsis requiring ITU input. Contact senior medical/haematology team, Outreach Team and ITU team if there are these complications. 9. Blood test should be checked daily: FBC, U&Es, Mg, LFT, Ca, PO4. Clotting should be checked twice weekly and if abnormal monitored daily until normal. 10. Mouth care is important at this stage and mucositis guidelines should be followed if this becomes significant. 11. Monitor nutrition and weight throughout the admission; consider dietician referral for advice on nutritional support. 7
BLOOD PRODUCT SUPPORT Blood Count Recovery after inpatient chemotherapy: 1. Blood counts are usually low for a variable period post intensive chemotherapy. For AML regimens it is usually 10-21 days post last day of chemotherapy treatment. 2. The first sign of recovery is usually a rising WBC followed by neutrophils. Platelets and RBCs follow later. Usually once a neutrophil count is >0.2 it is the beginning of recovery. 3. Once neutrophils are >0.5 the patient can be considered for discharge, although should still be in protective isolation whilst in hospital. 4. Once neutrophils >1, patient no longer needs protective isolation. Special requirements: CMV negative blood products are not a routine requirement any longer in these patients. Irradiated blood products should be given to patients in the following situations: Have received Fludarabine, Cladribine, Bendamustine, Clofarabine or Pentostatin (deoxycoformycin) chemotherapy Hodgkin s lymphoma diagnosis After bone marrow transplant and during stem cell harvest [d/w haematology] Having ATG/ALG (anti-thymocyte globulin/anti-lymphocyte globulin) Having Campath [Alemtuzumab] Platelet transfusion: Give 1 pool/bag platelets over 30 minutes in the following situations: If platelets < 50 and active bleeding; must also check coagulation screen to rule out other contributory causes of bleeding If platelets <20 and patient septic/febrile If platelets < 10 Pre-procedures like PICC line if <20 and Hickman line insertion or lumbar puncture if <50 If platelets not incrementing do 1hr FBC-post platelet transfusion to confirm the rise in platelet count; if no increment, discuss with the consultant about sending blood to NHSBT for HLA antibodies and possible use of HLA matched platelets. 8
Red Cell Transfusion: Red cell transfusion is usually an individualised plan. Each unit/bag is given over 2-3 hours. RBCs should be given to treat symptomatic anaemia, usually if HB<80 but some patients with associated cardiac problems may need HB maintaining >90-100 [Please note that the Trust transfusion threshold is HB<70] Clotting factor support; Coagulation is not routinely deranged in these patients, unless unwell/septic/dic. If clotting abnormal, especially if PTR and or APTTR >1.5 and bleeding, discuss with Haematology team who will advise on blood product replacement and/or Vitamin K etc. 9
DISCHARGE PLANNING 1. Once patient is well enough for discharge, take home drugs and discharge summaries should be prepared. Ensure GSCF is included where needed. 2. Arrangements need to be made for any blood count monitoring or support needed, and for any investigations whilst at home e.g. bone marrow or imaging to assess response, as well as PICC line care. The Haematology CNS/ Haematology Day Unit will guide the follow up plans. 3. If required re-admission date needs to be agreed and added to the ward diary. 4. Contact numbers for Haematology Day Unit; CNS support etc. should be given to patient and family. 10