CHEMOTHERAPY ADMINISTRATION IN

PEDIATRIC

An Overview

Dwi Novrianda, Deswita

Faculty of Nursing Universitas Andalas, Padang
Aims of session
 Understand Care of the Pediatric Oncology Patient
 Understand Cell Cycle
 Chemotherapy and the cancer cell
 Components of chemotherapy medication
administration
 Chemotherapy safety standards
 Side effects
 Nursing implications
 Administration & safety
 Nursing interventions
 What are your fears about this
population?
• They can get really sick really fast
• They might die
• Their parents are really intense
• They look sick– bald, frail, always
throwing up
• They are not like other kids
What to Remember
 These kids are just like • Parents will be
any other kids– they love suspicious of you until
to play games, they love you prove yourself or
to do art projects, they until they begin to trust
love to tease the nurses– you– every new HOT
but unlike all other kids, nurse goes through
they get used to being this initiation as well!
sick and usually know Don’t take it
their limits.
personally.
 Sometimes, they even
like being in the hospital–
we make it fun for them!
It becomes part of their
“normal” life.
 Common
Oncology
Common
Myths
Oncology Myths
 Myth: Kids feel the worst when
receiving their chemotherapy.
• Often times, aside from the occasional nausea
and vomiting, kids actually feel okay when they
are getting their chemo. They are usually up,
walking and talking.
• It is not until 7-14 days AFTER their chemo
that kids feel their worst. The chemo wipes out
their marrow (also called myelosuppression)
and leaves them feeling fatigued (low RBCs),
more prone to bleeding (low platelets), and
more prone to infection (low WBCs, or
“neutropenic”).
Myth: Oncology patients are always in
the hospital.
• Treatment protocols dictate how often a child
is scheduled to be here (scheduled chemo
admits, scheduled surgical resections)
• Kids with AML are in the hospital for four cycles of
chemo through chemo administration, dropping
counts and nadir, and count recovery, whereas kids
with ALL receive their induction chemotherapy
inpatient and most of their subsequent therapy
outpatient over the course of two to three years (two
years for girls and three years for boys)
• Unexpected admits are usually due to fevers
or side effects and symptom management
Myth: Oncology patients do not get
better.
• They do get better– kids are far more resilient than
adults; however, cancer is still the leading cause of
death by disease for children between the ages of
one and fourteen years old.
Definition:

Chemotherapy
• The treatment of cancer using specific
chemical agents or drugs that are
destructive to malignant cells and tissues.
The term comes from two words that mean
"chemical" and "treatment."

Cytotoxic
• literally translated means ‘toxic to cells’.
Physiology and Pathophysiology
 Chemotherapy is one of the three traditional
ways of treating cancer. It works systemically,
meaning all rapidly dividing cells are affected,
including those in the bone marrow, mucous
membranes, and hair follicles.
 A chemotherapeutic agent will cause
myelosuppression. Depending on the severity
of the agent, it may actually cause
myeloablation (often times seen in a myriad of
bone marrow transplant protocols), or
complete annihilation of the bone marrow.
The Cell Cycle

The Cell Cycle

Mitosis
Cell Biology: Mitosis

 A cell in mitosis
Normal Cell Characteristics:
 Metabolism. Strictly controlled &
predictable
 Maturation & Specialisation. Occurrs
before dividing. Strictly controlled.
 Reproduction = Cell death
 Contact Inhibition. Mechanism for
switching off division when in contact with
different cells
 Recognition. Like cells stay together.
Cancer Cell Characteristics:

 Unchecked & Uncontrolled Growth

 Loss of contact inhibition
 Loss of capacity to differentiate
 Increased growth fraction
 Chromosomal Instability
 Capacity to metastasise
 Altered biochemical properties
Chemotherapy and Cancer Cells

Cell Cycle specific :

Most active against cells in a specific
phase therefore need prolonged exposure
or repeated doses.

Cell Cycle Non-specific:

Most effective against actively dividing
cells but also effective in G0.
Chemotherapy

Chemotherapy may be used

conventionally to:
 Cure patients
 Prolong survival
 Palliative care symptom control
Chemotherapy

Combination Therapy.
Prevents resistance.
Adjuvant Therapy.
Administered after primary therapy
e.g.Surgery
Neo adjuvant Therapy:
Given before surgery to reduce
tumour size.
Chemotherapy
Over 50 different chemotherapy drugs

Administered as an outpatient or inpatient

depending on toxicity

Modes of administration include:

 Oral e.g. Methotrexate, Hydroxyurea
 IV: Canula/Indwelling Central Venous Catheter
 Sub cut
 Intracavity e.g pelvic cavity, bladder
 Intrathecal. Can be fatal if wrong drug administered!
Intrathecal Chemotherapy
Components of Chemotherapy
Challenges in Chemotherapy
 Identification of exact start and stop times for
chemotherapy
 Accuracy of titration rates for chemotherapy agents
 Documentation of reactions to chemotherapy agents
 Consistency in the preparation of chemotherapy
infusions
 Differences in the administration of investigational
agents
 Retrieval of data from the medical record for audits
(Looper, Winchester, Robinson, Price, Martin, Holloway, Rosenberg, Flake, 2015)
Preparation and Administering Ch/

 Wearing protective personal equipment: gowns,

double gloves, face protection utilization.
 Using a closed system or priming of chemotherapy
under the biologic safety cabinet (BSC) --> done in the
pharmacy.
 Intravenous tubing and syringes containing
chemotherapy be primed inside a ventilated cabinet or
chemotherapy tubing be primed with nondrug solution
(normal saline) to prevent exposure to the nursing
staff.
Method to obtain an accurate start time

 Hyper-priming – running the infusion rate at a high rate to clear

the saline from the line.
 Priming the infusion tubing with chemotherapy instead of diluent.
Weakness: delay in the chemoth/ reaching the patient, inaccurate
start and stop times, inaccurate documentation, inaccurate
titration times, potential for inaccurate pharmacokinetic
measurements.
 Recalculate IV infusion times to account for the 20 ml flush –
affect the accuracy of chemoth/ infusions running at very low
rates.
 Still in debate, none of these methods were consistent or reliable
Documentation
 Implementation an electronic medical record
 computerized chemotherapy orders,
electronic nursing and medication
documentation, electronic treatment road map
documentation.
 Using patient armband scanning for time of
chemotherapy medication administration  as
a standard safety practice.
Solution to challenges – Process
Improvement

 Identification of the process improvement –

using circle priming
 Implementation of the process improvement –
incorporate new practice into policy
 Measurement and evaluation of the process
improvement – a quality improvement
approach based on structure, process, and
outcomes
Identification – circle priming
 It is a closed administration system that allows the
nurse to safely prime infusion lines with chemotherapy
to ensure the actual start of the infusion begins with
chemoth/ infusing instead of carrier fluid.
 By using a closed connector at the point of connection
to the patient in order to prevent nurse exposure to the
chemoth/
 Strengthen:
1. Diminishes the risk of exposure
2. Completed on the infusion unit
3. Ensures exact chemoth/ start and stop times
Implementation
 Extensive staff training in a consistent manner; using in-services
and mock simulations; real-time individual training by nurse
champions and nurse educators.
 Revision of the Chemotherapy Administration Policy – how to
prime, administer, and flush chemoth/ using the circle prime
method.
 Using new products like a ChemoClave Needle Free Closed
System Transfer Device and the Alaris pump.
 An SBAR communication – to notify staff of the upcoming
practice changes.
 A quality improvement process tool, the PDSA (plan, do, study,
and act) – to introduce and trial the new product and the change
in workflow for the staff
ChemoClave Needle Free Closed System
Transfer Device
Alaris Pump
Measurement and Evaluation
 Structured
1. Purchased new products, fulfilled the
requirements in NIOSH recommendations,
supported by the evidence-based literature
review
2. Ongoing staff education and support,
continuing to work with the product team –
enhance the safety of the closed system
Measurement and Evaluation
 Process
1. The process change for nursing: preparation of a new
chemoth/ line for each infusion, circle priming each
chemoth/ infusion line, documentation of exact start
and stop times
2. The nursing culture of the institution
3. Chemotherapy safety was made a priority by
leadership, and frontline staff embraced the
importance of this process change for their own safety
Measurement and Evaluation
 Outcomes
1. Compliances with circle priming
2. Using the same method of chemoth/ administration and the
process was consistent
3. Using electronic documentation system and available for the
nurse to chart accurately – start and stop times, timing of
pharmacokinetics studies, titration rates, reactions related to
chemoth/ infusion – IT team builds reports for the clinical
research associates in both clinical trial audits and internal audits
4. Medication barcode scanning for safe patient identification
5. Weekly audits demonstrated over time
Safety Components

 Chemotherapy ordering
 Preparation
 Administration
 Patient management
 Unique safety considerations for
pediatric patients – height, weight, age
Chemotherapy Safety Standards
 Domain 1: creating a safe environment – staffing and general
policy (14 Standards)
1. Training, education and communication in key personal involved
in ordering, preparing, and delivering antineoplastic therapy
2. Staff members must have age-appropriate life support training
and certification
3. Perform and document patient assessment elements on day of
treatment, esp age, height and weight of children at least weekly
4. Information about cancer support services
5. Patient attendance at scheduled visits and/or chemo treatment
Chemotherapy Safety Standards
 Domain 2: Treatment planning, patient
consent, and education (4 Standards)
 Domain 3: Ordering, preparing, dispensing,
and administering chemotherapy (22
Standards)
 Domain 4: Monitoring after chemotherapy is
administered, including adherence, toxicity,
and complications (6 Standards)
(2016 Updated American Society of Clinical Oncology [ASCO] and Oncology Nursing
Society [ONS] Chemotherapy Administration Safety Standards)
Chemotherapy Side Effects

 Chemotherapy targets cells which are

dividing rapidly.
 Chemotherapy cannot distinguish
between normal cells and cancer cells
 Healthy Cells which have a high rate of
growth and multiplication include cells of
the bone marrow, hair, GI mucosa and
skin.
Chemotherapy Side effects contd…

 Side effects may be drug specific e.g.

anthracyclines and cardiotoxicity, vinca
alkaloids and neuropathy/constipation,
bleomycin and pulmonary fibrosis
 Severity of side effects varies between
drugs.
 Side effects often occur 7-14 days post
treatment.
Side Effects: Acute

Tumour Lysis Syndrome.

 A Metabolic Emergency.
 Occurrs due to rapid cell lysis (death) &
large amounts of cell metabolites in
blood.
 If untreated can lead to acute renal
failure, cardiac arrest and death.
Side Effects: Acute

Neutropenic Sepsis:
Occurs due to Bone Marrow Failure and
poor immune response to infection.
Predisposing factors include:
Neutropenia
Underlying disease
Chemotherapy
Venous access devices
Neutropenic Sepsis

 Severe overwhelming infection where

inadequate blood flow to the tissues
results in cellular dysfunction and, if not
reversed, eventual organ failure.
 Most common micro organism is gram
negative
 Mortality rate 40-90%
Side Effects: Acute

Haemorrhage
• Invading tumours e.g gastric MALT
lymphomas
• Haemorrhagic Cystitis related to high
dose Cyclophosphomide

Anaphylactic Reaction
Side Effects:Bone Marrow

Neutropenia:
Increased risk of infection.
Anaemia:
Tiredness, lethargy & breathlessness
Thrombocytopenia:
Increased risk of bleeding
Side Effects: Gastro-Intestinal

 Nausea & Vomiting

 Diarrhoea & constipation
 Loss of appetite
 Taste Changes
 Mucositis
Side Effects

 Example of Grade 4 Mucositis

Side Effects: Body Image

 Hair Loss
 Weight Loss/ Weight Gain
 Long term central venous catheters
 Skin changes (colour, rashes, sensitivity
to sunshine/chlorine, dry)
Side Effects: Other

 Fatigue: Often multi-factorial

 Peripheral neuropathy
 Altered Kidney Function
 Changes in hearing (high dose Cisplatin)
 Cardiac Toxicity (Doxorubicin/ Idarubicin)
 Late Effects: Infertility, secondary
malignancy, growth retardation.
How can nurses help.
 Information and Education.
 What to do if unwell. Infection is a big risk!
 Advice on Symptom Control
 Timely administration of drugs
 Regular assessment of side effects and
effectiveness of interventions e.g anti emetics,
analgesia etc
 Nutritional assessment and intervention
How can nurses help
 Psychological Care: Body Image, Diagnosis of
life threatening disease, Fear of dying
 Involve Family members, talking to children
about parents diagnosis etc
 Consider Sexual advice needed
 Consider financial implications
 Direct to supportive services in their area eg
support groups, complementary therapies etc.
 Refer to Community Team if support at home
needed
Points about Administration: Staff

 Must be administered by chemotherapy

trained nurses only
 Safe handling is essential. Cytotoxic drugs are
carcinogenic, mutagenic and teratogenic.
 Potential exposure occurs during: preparation,
administration and changing lines, handling of
body fluids e.g urine, handling of chemo
waste products e.g lines, medication bottles,
spillage / leakage of chemotherapy.
 ALWAYS TAKE UNIVERSAL
PRECAUTIONS
Key Points:
 Chemotherapy is a major treatment in
curing or prolonging survival in cancer
patients
 It has a wide range of side effects
depending on the drugs given.
 Nurses have a key role to play in caring
for a patient receiving chemotherapy
 Safety issues are paramount in
administration.
Summary:

The potential benefit to the patient

of treatment as an option must
always outweigh the toxic effects.
 Nursing
Interventions
• Anemia
• Monitor VS
• Clinical exam (pallor, fatigue, headache, etc.)
• Monitor for blood loss
• Administer products as needed (CMV negative)
• CHW Oncology guidelines are to give
PRBCs for symptoms, not for a lab value,
due to chronic iron overload problems that
have shown up in recent research.
 Nursing
Interventions
• Thrombocytopenia
• Physical exam (bruising, petechiae)
• Monitor labs
• Transfuse (lab value lower than 10, pre-
procedure,
PRN)
 Nursing
Interventions
• Neutropenia
• Risk for infection – most dangerous time!
• Close monitoring of changes in clinical status
(VS)
• Monitor changes in mucosa (GI tract)
• Prophylactic medications (Viral, Fungal,
Bacterial)
 Neutropeni
a
• Neutropenia is defined as an absolute neutrophil
count (ANC) of less than 1,000. A neutrophil is a type
of WBC that specifically functions to fight infections. It
is the first line of defense.
• Severe neutropenia is characterized as an ANC of
less than 500.
• In the oncology population, a person may be
neutropenic:
• Upon diagnosis
• 7-14 days after chemotherapy
• With an infection
• After radiation
 Bottom
Line…
• Remember, chemotherapy works
systemically, so it damages rapidly
dividing cells (both malignant and
nonmalignant cells).
• Bottom line: Neutropenia is often acquired
after cytotoxic agents, therefore the focus
is not on eradicating it, but rather on
monitoring and managing it.
 Nadi
r
• WBCs continue to drift down within the 7-14
days immediately following chemotherapy.
When a WBC reaches a significant low, it is
referred to as the
patient’s nadir. Nadir commonly refers to the
lowest point that an individual's blood cell
count.
 Calculating the
ANC

• (Segs + Bands) x WBC

x 10
 Calculating the
ANC

• (56 + 1) x 1.9 x 10 =
1083
Calculating the
ANC

• (17 + 2) x 0.7 x 10 =
133
 ANC Calculation
Errors
• Most common errors when calculating
the ANC:
• Do not accidentally use the lymphocyte count
in place of the band count– it will most likely
be a falsely elevated value.
 ANC Calculation
Errors
• Most common errors when calculating the
ANC:
• Even if the patient has a WBC count of 2.0, but
they do not have neutrophils (segs + bands = 0),
then the ANC is still 0.

ANC =
0
 Nursing
Interventions
• When a patient has an ANC of less than
500, follow the CHW Policies and
Procedures.
• Institute “Immunocompromised Precautions”
• No flowers
• No fans
• No sick contacts (ever for this population, but
especially when neutropenic)
 Neutropenic
Precautions
Immunocompromised High Risk
Precautions
•Indications for Immunocompromised
High Risk Precautions.
• Recommended only for allogeneic
hematopoietic stem cell transplant
(HSCT) patients or patients with a
predictive ANC <100 for more than 5
days since they require a Protective
Environment room to reduce exposure
to environmental fungi (e.g., Aspergillus
sp).
 Neutropenic
Precautions
• Do not allow fresh or dried flowers, or
potted plants in patient-care areas for
immunosuppressed patients (i.e.,
oncology, transplant, burn).
• **Note: Fans are prohibited in the
following situations:
Immunosuppressed patients.
 Visiting
Policy
VISITORS
•If signs and symptoms of infection are
noted in a visitor, visitation should be
discouraged. If necessary, appropriate
barrier precautions will be utilized. Visiting
children should be screened for recent
exposure or symptoms of highly contagious
infectious diseases.
 What does this mean for
you?
• It is your responsibility as an employee,
whether nurse, care partner, provider,
HUC, or ancillary staff, that you prohibit
anyone with cold or flu symptoms, from
entering these
patients’ rooms. This includes parents!
• HOT parents are usually pretty good
about this hard rule. When they are sick,
they stay home.
Nursing
Management
Fevers
Nausea /
Vomiting
Mucositis
 Our Oncology
Exceptions
• No rectal temps.
• No ibuprofen or acetaminophen without
permission by an oncology provider.
• Fevers are considered a temperature of
38.3 C or greater for oncology kids.
• Fevers mean cultures from every lumen!
Cultures mean antibiotics.
 When your patient has a
fever…
• Patients, especially when febrile, should
receive antibiotics within one hour of
ordering so alert pharmacy.
• Cefepime is most commonly given antibiotic-
our frontline broad spectrum drug of choice.
• Complete vital signs every 5 minutes with
the start of antibiotics (this is best practice–
blood VS are what we typically are doing on
HOT).
• **The start of antibiotics is a common
time for patients to go septic!!!!
 When your patient has a
fever…
• Patient should also be on a continuous
pulse ox monitor with continuous HRs. The
BP may drop with an increase in HR. If BP
is falling, fluid boluses are given, PRBCs
may be transfused, and/or patient may be
transferred to PICU.
• Cultures are drawn from all lumens for
each culture and done q 24 hours for
T>=38.3. Know when cultures were last
drawn and pass it on in report.
 Side Effect
Management
• Management of Nausea/Vomiting: Anti-
emetics
• Antiemetics are considered pre-meds for
chemo!
• Ondansetron (Zofran)-gold standard
• Hydroxyzine (Vistaril) typically second line of
defense, alternate with Zofran)
• Since Hydroxyzine and Diphenhydramine (Benadryl)
are in the same medication class, do not give them
both within less than 4 hours of one another.
Oftentimes, Benadryl may be a pre-med for blood, so
keeping its last administration on your radar is
important if patient has Hydroxyzine ordered
• Prevention is best management—stay ahead
 Side Effect
Management
• Management of Mucositis:
• Chemo kills rapidly-dividing cells, including
those epithelial cells that make up the
mucous membranes that line the GI tract
from mouth down through anus. When
these cells are killed by chemo, they slough
off, causing intense pain.
• Management: hydration, nutrition, pain
control
• These kids are normally on PCAs for acute
pain management and may be started on
TPN
• Prevention- daily oral hygiene, Biotene QID
 Interdisciplinary
Management
• Interdisciplinary collaboration of physicians,
nurses, pharmacists, Child Life specialists,
chaplains, social workers, case managers,
care partners, and art and music therapists for
these patients