CANCER PT 4

Hematological Impacts of Myelosuppression

  • Definition of Myelosuppression: This refers to the depression of the bone marrow. The bone marrow is responsible for producing white blood cells (WBCs), red blood cells (RBCs), and all components of a white blood cell differential, including lymphocytes and monocytes.

  • Leukopenia: A condition characterized by a decreased white blood cell count. This is a common side effect of chemotherapy and radiation which depletes these cells.

  • Infection Risk: When a patient's white blood cell count reaches zero, they become extremely prone to infection. In such cases, cancer treatment is usually suspended for a period of time to allow recovery.

  • Thrombocytopenia: A decrease in the platelet count as a result of bone marrow depression.

    • Spontaneous Bleeding Threshold: Whenever a platelet count reaches 15,00015,000, spontaneous bleeding can occur.

    • Clinical Interventions: For patients with low platelet counts, medical professionals must implement bleeding precautions. This includes avoiding IM (intramuscular) injections and applying pressure on IV sites.

    • Contraindications: Anticoagulants should generally be avoided, though a specific condition called disseminated intravascular coagulation (DIC) involves spontaneous bleeding where Heparin may be used (noted as an exception).

  • Anemia: A decrease in red blood cells resulting from myelosuppression.

  • Cellular Susceptibility: Side effects like alopecia (hair loss), nausea, vomiting, and neutropenia occur because skin, blood, hair, and GI cells are the fastest reproducing and dividing cells in the body, making them primary targets for chemotherapy.

Neutropenia and Leukopenia Precautions

  • Purpose: To protect immunocompromised patients from external infection risks.

  • Personal Protective Equipment (PPE): Health care providers and family members must wear masks and gloves.

  • Screening: Anyone entering the room who possesses a "culture" (signs of illness) should not be allowed in.

  • Dietary Restrictions: No fresh fruits or vegetables are permitted in the patient's room because they can carry bacteria.

  • Environmental Restrictions: Real flowers are prohibited; plastic flowers are recommended instead.

Mucositis and Gastrointestinal Care

  • Mucositis: This is the inflammation of the mucosal lining of the gastrointestinal (GI) and respiratory tracts.

  • Anatomy: The GI tract is defined as the alimentary canal extending from the mouth to the anus.

  • Oral Care Protocol:

    • Avoid alcohol in the mouth (specifically alcohol-based mouthwashes).

    • Avoid very cold drinks and food; the recommendation is to consume items at room temperature.

    • Use a neutral mouthwash. Oncologists often order a specific preparation known as "chemo mouthwash" to treat and prevent inflammation.

  • Nausea and Nutrition: Excessive nausea and vomiting can lead to dehydration, which is one of the worst associated side effects.

    • Treatment usually requires IV fluids when a patient can no longer tolerate PO (oral) fluids.

    • Maintain small, frequent meals throughout the day.

    • Fluid intake should be increased to above and beyond a minimum of 3,000 mL3,000\,mL.

Radiation Safety Principles

  • Radiation Source: In cases of internal radiation or systemic treatments (such as Radioactive Iodine-131131), the patient themselves becomes a source of radiation.

  • Three Pillars of Safety:

    1. Time (Length of Exposure): Providers must be efficient and practice "cluster care"—having everything ready before entering the room to minimize time spent near the patient.

    2. Distance: The further away a person is from the source, the less radiation exposure they receive.

    3. Shielding: Facilities use lead-lined walls, doors, and lead aprons (similar to those used in radiology) to contain radiation.

  • Unit Design Example: The 7th floor in Hendrick (P7) was formerly the oncology unit. It featured four specific rooms at the ends of halls equipped with lead-lined walls and doors specifically for shielding.

  • Contaminated Articles: Patient excreta (stool and urine) must be treated as a biohazard. Protocols include double flushing the toilet, wearing gloves, and disposing of tubing in appropriate chemotherapy disposal kits or biohazard containers.

Chemotherapy Side Effects and Specific Medications

  • Uric Acid Management: Chemotherapy can increase uric acid levels, which are derived from purines. High levels of uric acid are toxic to the kidneys and can cause gout.

    • Allopurinol: This xanthine oxidation inhibitor is frequently ordered for chemotherapy patients as an anti-gout medication to prevent uric acid buildup.

  • Metabolic and Neurologic Effects:

    • Cachexia: Indicated by excessive weight loss.

    • Metabolic Encephalopathy: This can lead to changes in the patient's level of consciousness.

    • Paresthesia: Defined as numbness and tingling of the extremities (spelled: P-A-R-A-E-S-T-H-E-S-I-A).

  • Vesicants: Certain chemotherapy drugs are vesicants that cause harm if they come into contact with the skin. Proper precautions, such as wearing chemo-rated gloves, must be taken.

  • Adriamycin: Known for causing the patient's urine to turn red.

  • Vincristine: A specific agent known to cause paresthesia.

  • Colony Stimulating Drugs: These treat low white blood cell counts and encourage the bone marrow to produce more cells. They are expensive, costing approximately $1,000\$1,000 per injection.

    • Neulasta (n-e-u-l-a-s-t-a): Specifically increases neutrophils.

    • Epogen (e-p-o-g-e-n): Increases red blood cells.

Questions & Discussion

  • Question regarding WBC transfusions: "Can you get a white blood cell transfusion? Like, can I give you more?"

    • Response: It is technically a type of replacement, but the focus in this context remained on colony-stimulating factors.

  • Question regarding IV swelling: "If the IV site is swollen, what do you do? Just discontinue the IV? Or do you withdraw as much of the medication as you can first?"

    • Response: It depends on the medication. However, if a site is swollen, it might be due to leakage, fluid, or trauma from the insertion. It is recommended to get a second opinion before discontinuing if possible, as some patients are very difficult to stick for new IV access, though usually swelling indicates bleeding or infiltration.