Paediatric Haematology & Oncology: Supportive Care …

1 Paediatric Haematology &. oncology : Supportive care Protocols Version: 4th Edition version (2018). Summary of Changes for Date: 19th October 2018. Previous editions First edition: 2003. Second edition: 2007. Third edition: 2011 ( Supportive care protocol version August 2011). 4th edition : 2014. A collaborative publication from Great Ormond Street Hospital for Children NHS Foundation Trust The Royal Marsden NHS Foundation Trust University College London Hospitals NHS Foundation Trust Jump to Contents Summary of Changes Abbreviations Quick search: hover cursor over selection in Contents, and click the link to jump to correct page, this will facilitate your search. Any text in blue is also clickable. Table of Contents TABLE OF CONTENTS .. 2. TELEPHONE / FAX NUMBERS AND EMAIL ADRESSES .. 7. GREAT ORMOND STREET CHILDREN'S HOSPITAL .. 7. THE ROYAL MARSDEN 10. UCLH CHILDREN AND YOUNG PEOPLE'S CANCER SERVICES .. 11. ABBREVIATIONS ..13. LEAD AUTHORS AND CONTRIBUTORS.

2 14. 1. FORWARD & SUMMARY OF SIGNIFICANT CHANGES ..18. SUMMARY OF SIGNIFICANT CHANGE BETWEEN SCP 4TH EDITION AND (WHERE POSSIBLE CHANGES ARE HIGHLIGHTED IN. YELLOW IN BODY OF protocol ).. 20. SUMMARY OF SIGNIFICANT CHANGE BETWEEN SCP 4TH EDITION AND PREVIOUS 3RD EDITION ( Supportive care protocol . VERSION AUGUST 2011) .. 24. 2. USE OF BLOOD COMPONENTS AND HAEMATOPOIETIC GENERAL 27. SPECIAL 28. Irradiated blood components .. 28. CMV negative components .. 29. INDIVIDUAL BLOOD COMPONENTS .. 30. Red blood cells .. 30. Platelets .. 31. Platelet Transfusion Guidelines .. 32. Fresh Frozen Plasma (FFP) .. 33. Octaplas .. 33. Cryoprecipitate .. 34. Fibrinogen concentrate .. 34. Major haemorrhage .. 35. Granulocytes .. 35. HAEMATOPOIETIC 36. Granulocyte Colony Stimulating Factor (GCSF).. 36. Thrombopoietin Receptor Agonists (TPO-RA) .. 36. Erythropoietin .. 36. 3. NEUTROPENIC SEPSIS / FEBRILE INTRODUCTION .. 38. DEFINITION OF NEUTROPENIC SEPSIS.

3 38. DEFINITION OF RISK: TABLE 1: CRITERIA EXCLUDING PATIENTS FROM LOW RISK protocol .. 39. FLOW DIAGRAM / SUMMARY OF THE EMERGENCY MANAGEMENT .. 40. TABLE 2: ASSESSMENT OF PATIENTS WITH NEUTROPENIC SEPSIS .. 41. EMPIRICAL ANTIBIOTIC TREATMENT OF NEUTROPENIC SEPSIS .. 42. All patients (empirical antibiotics) .. 42. Patients with suspected Gram positive infection .. 43. Patients at risk of renal impairment .. 44. GOSH PATIENTS ONLY (NOT UCLH / RMH) WITH MITOCHRONDRIAL A1555G MUTATION OR WHERE RESULT UNKNOWN .. 45. ONGOING MANAGEMENT (48 HOURS ASSESSMENT) .. 46. Low Risk Neutropenic Sepsis: .. 46. Management of low risk patients after 48 hours intravenous antibiotic treatment .. 46. Follow up for patients discharged on oral antibiotics after 48 hours .. 46. Standard risk neutropenic sepsis: .. 47. ONGOING MANAGEMENT (STANDARD RISK PATIENTS AFTER 96 HR INTRAVENOUS ANTIBIOTIC TREATMENT IF PERSISTENT FEVER) .. 48. Fungal 48. Standard risk patients with persistent fever (> 7 days).

4 49. SCPs - 4th Edition Version (2018) Table of Contents Oct 2018 PAGE 2. Jump to Contents Summary of Changes Abbreviations Quick search: hover cursor over selection in Contents, and click the link to jump to correct page, this will facilitate your search. Any text in blue is also clickable. Standard risk patients - duration of intravenous antibiotic therapy .. 49. Discharge of Standard risk patients .. 49. FEBRILE NON-NEUTROPENIA protocol : TREATMENT OF FEVER IN PATIENTS WITHOUT NEUTROPENIA .. 50. APPENDIX: NEUTROPENIA SEPSIS: EMPIRICAL ANTIMICROBIAL CHOICES .. 52. REFERENCES .. 53. 4. PREVENTION AND TREATMENT OF SPECIFIC INFECTIONS AND VACCINATIONS IN PATIENTS WHO HAVE RECEIVED. CHEMOTHERAPY OR HAEMATOPOIETIC STEM CELL TRANSPLANT (HSCT) ..55. VARICELLA-ZOSTER .. 55. Vaccination of siblings/household contacts .. 55. VZV Post-exposure prophylaxis (PEP) .. 55. Definition of significant exposure to VZV .. 55. Special circumstances which may increase risk of VZV infection.

5 56. Rationale for guideline .. 56. Figure 1: Management of patients with malignant disease until at least 6 months after end of treatment .. 57. Choice of VZV prophylaxis (Oral aciclovir or oral valaciclovir) .. 58. VZIG and contraindication to aciclovir/valaciclovir .. 59. Post autologous or allogenic HCST patients .. 60. Information to parents after aciclovir / valaciclovir prophylaxis or VZIG .. 60. Treatment of Clinical Varicella/ Herpes Zoster .. 60. Supportive care with intravenous (IV) aciclovir .. 60. References for VZV section .. 61. MEASLES .. 62. PNEUMOCYSTIS JIROVECII PNEUMONIA (PCP) AND OTHER INTERSTITIAL PNEUMONIAE .. 63. PREVENTION OF INFECTION AND VACCINATION POLICIES IN HAEMATOPOIETIC STEM CELL TRANSPLANT RECIPIENTS .. 64. VACCINATIONS FOR Paediatric PATIENTS TREATED WITH STANDARD-DOSE 64. 5. DRUGS USED IN THE TREATMENT OF INFECTIONS (REMOVED) ..65. 6. ONCOLOGICAL EMERGENCIES ..67. 67. ECTHYMA GANGRENOSUM/NECROTISING FASCIITIS.

6 67. TUMOUR LYSIS 67. Figure 1. Tumour lysis syndrome flow chart 1: Prior to starting treatment/chemotherapy .. 68. Figure 2. Tumour lysis syndrome flow chart 2: After starting appropriate treatment/chemotherapy .. 69. Initial management = Prevention ( .. 71. Established tumour lysis .. 72. LEUKOSTASIS AND HYPERLEUKOCYTOSIS .. 73. ANTERIOR MEDIASTINAL MASSES & SUPERIOR VENA CAVA (SVC) 75. SPINAL CORD COMPRESSION (SCC) .. 77. Suggested dose of Dexamethaone intravenously or orally for raised ICP & spinal cord compression is 10mg/m2/day in divided doses.. 78. RAISED INTRACRANIAL PRESSURE .. 79. Suggested dose of Dexamethaone intravenously or orally for raised ICP & spinal cord compression is 10mg/m2/day in divided doses.. 79. SEIZURES AND STATUS EPILEPTICUS .. 80. ACUTE HYPERTENSION AND HYPERTENSIVE ENCEPHALOPATHY .. 80. INTESTINAL OBSTRUCTION AND TYPHLITIS .. 80. TYPHLITIS .. 81. PANCREATITIS .. 82. COAGULOPATHY/DIC .. 83. CARDIAC DYSFUNCTION & 84.)

7 VENO-OCCLUSIVE DISEASE .. 86. EXTRAVASATION .. 86. 7. care OF CENTRAL VENOUS ACCESS DEVICES ..88. SUMMARY OF care OF CENTRAL VENOUS ACCESS DEVICES .. 88. ASEPTIC NON-TOUCH TECHNIQUE (ANTT).. 88. SCPs - 4th Edition Version (2018) Table of Contents Oct 2018 PAGE 3. Jump to Contents Summary of Changes Abbreviations Quick search: hover cursor over selection in Contents, and click the link to jump to correct page, this will facilitate your search. Any text in blue is also clickable. care OF TUNNELLED AND NON-TUNNELLED CVAD'S .. 90. care OF IMPLANTABLE PORTS .. 91. Accessing the 92. care OF PICC'S (PERIPHERALLY INSERTED CENTRAL CATHETERS / TUNNELLED NON-CUFFED CVC'S TNC-CVC) .. 94. TUNNELLED OR NON-TUNNELLED DIALYSIS CATHETERS - (PERMCATH OR VASCATH) .. 95. NEEDLE-FREE ACCESS DEVICES .. 96. GENERAL PRINCIPLES OF care .. 96. The importance of syringe size .. 97. Exit Site care .. 98. Dressing Selection .. 99. Antimicrobial 99. Bathing, Showering and Swimming.

8 99. TROUBLESHOOTING .. 100. 100. protocol FOR UROKINASE ADMINISTRATION .. 101. protocol FOR ALTEPLASE ADMINISTRATION (USED AT GOSH) .. 102. PORT POCKET 103. PORT EROSION .. 103. CATHETER DAMAGE .. 104. FLUID LEAKAGE FROM CATHETER EXIT SITE .. 104. FLUSHING TABLE: FLUSHING GUIDELINES FOR CENTRAL VENOUS ACCESS DEVICES .. 105. 109. 8. EXTRAVASATION ..112. WHAT IS EXTRAVASATION? .. 112. Infiltration .. 112. VESICANT DRUGS AND SOLUTIONS REPORTED TO CAUSE EXTRAVASATION INJURY: .. 114. RISK FACTORS FOR INFILTRATION AND EXTRAVASATION .. 115. RECOGNITION OF INFILTRATION / EXTRAVASATION .. 116. PREVENTION OF INFILTRATION/EXTRAVASATION .. 117. NURSING RESPONSIBILITIES WHEN ADMINISTERING INTRAVENOUS MEDICINES .. 117. Monitoring of the infusion .. 118. MANAGEMENT OF INFILTRATION AND EXTRAVASATION .. 118. The recommended immediate management is .. 118. Extravasation Kit .. 120. Saline washouts (Flush out Technique) .. 120. REFERENCES/BIBLIOGRAPHY.

9 121. 9. NUTRITION INTERVENTION IN Paediatric oncology & Haematology PATIENTS ..124. THE AIMS OF NUTRITIONAL SUPPORT IN Paediatric oncology PATIENTS ARE .. 124. CAUSES OF NUTRITIONAL PROBLEMS IN oncology PATIENTS .. 124. Nutritional screening and referral .. 124. Children identified as being at risk .. 124. NUTRITIONAL STRATEGIES .. 125. Oral Intake .. 125. Nutritional Supplements & Sip feeds .. 125. Table 1. Examples of nutritional supplements (prescription only) * .. 125. Alternative /Complimentary diets .. 126. ENTERAL FEEDING .. 126. Table 2. Types of Enteral Feeds*.. 127. Table 3. Semi elemental/ elemental/peptide-based feeds* .. 127. Parenteral Nutrition .. 128. HEALTHY 128. EXCESSIVE WEIGHT GAIN AND POOR EATING HABITS .. 128. 128. 10. MOUTH care protocol AND MUCOSITIS ..130. ORAL AND DENTAL ASSESSMENT .. 131. SCPs - 4th Edition Version (2018) Table of Contents Oct 2018 PAGE 4. Jump to Contents Summary of Changes Abbreviations Quick search: hover cursor over selection in Contents, and click the link to jump to correct page, this will facilitate your search.

10 Any text in blue is also clickable. Implementation .. 131. Toothbrushes: .. 131. Basic oral care : .. 132. Analgesia: .. 132. WHO analgesic ladder .. 132. Supportive THERAPIES .. 132. GelclairTM .. 132. REFERENCES: .. 133. 11. HYPERTENSION ..135. MEASUREMENT OF BLOOD PRESSURE .. 135. CLASSIFICATION OF NORMAL AND ABNORMAL BLOOD PRESSURE IN CHILDREN AND 135. MEDICAL MANAGEMENT OF HYPERTENSION .. 135. Mild to Severe Standard Hypertension .. 135. Catecholamine Excess 136. HYPERTENSIVE CRISIS/ACUTE HYPERTENSIVE ENCEPHALOPATHY .. 136. TABLE 4. BLOOD PRESSURE LEVELS FOR THE 90TH AND 95TH PERCENTILES OF BLOOD PRESSURE FOR BOYS AGE 1 TO 17 YEARS BY PERCENTILES. OF HEIGHT.. 137. TABLE 5. BLOOD PRESSURE LEVELS FOR THE 90TH AND 95TH PERCENTILES OF BLOOD PRESSURE FOR GIRLS AGE 1 TO 17 YEARS BY PERCENTILES. OF HEIGHT.. 138. TABLE 6. DRUGS USED IN THE TREATMENT OF HYPERTENSION (REFER TO BNFC FOR DOSES) .. 139. 12. BASIC PRINCIPLES OF SYMPTOM MANAGEMENT.