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Oncology - care of the oncology patient admitted to PICU - general principles

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General Points

  • Oncology patients admitted to PICU are usually severely ill.
  • When patients present to PICU without a confirmed diagnosis stabilising the patient is more important than confirming a diagnosis with invasive tests.
  • Close communication between PICU and Oncology is vital.
  • PICU consultants expect the Oncology consultant to liaise with them directly regarding management decisions as well as discussing the patient careplan with nurses.

Airway

  • These patients can have major cardiovascular decompensation with intubation drugs.
  • Always discuss with PICU Consultant on call before embarking upon intubation and always have resuscitation drugs and fluids drawn up. It may be appropriate to commence inotropes and give a fluid bolus before giving drugs for intubation
  • Use an oral ET tube if platelets < 20 or there is coagulopathy.

Breathing

  • Try non-invasive ventilation using High Flow or CPAP/BiPAP via mask. Bubble CPAP is an option in infants less than 6 kgs.
  • If no improvement or not tolerated then intubate.
  • Ventilate as per usual except in cases of air trapping where a long expiratory time is required.

Circulation

  • Support the circulation as per PICU guidelines with iv fluids and inotropes
  • Do not give excessive amounts of iv fluids to patients with compromised respiratory function.
  • Obtain central access as required.

Neurological

  • Regular PICU assessment.
  • Morphine is first line of treatment as to not mask a fever.
  • If giving paracetamol please take temperature before hand.
  • DO NOT give Tramadol or Ibuprofen as they can effect platelet count.
  • When pts receiving chemotherapy they may have mucositis which is quite painful.
  • If pts has neurological disease component and the pt has persistent pain please consider gabapentin.
  • Please consult pain team if pts pain persists past three days.

GI/GU

  • NO suppositories or PR medications
  • Normal PICU fluids UNLESS
    • Patient is receiving specific hydration for chemotherapy
    • Patient is newly diagnosed or recently relapsed (see tumour lysis protocol)
      • DO NOT add any K to IV fluids
  • If patient is receiving carboplatin, cisplatin, cyclophosphomide, Ifosfamide or methotrexate see chemotherapy hydration page
  • Commence bowel protocol day 3 if BNO (but NO suppositories)
  • If receiving Vincristine please start bowel protocol on day prior to Vincristine.
  • Treat hyperglycemia as per PICU protocol

Feeding

  • If patient not eating/or absorbing feeds consider TPN
  • Low pathogen diet when neutrophils < 1.0 x 109/L
  • Vitamin K 300ug/kg IV weekly from day +1 until tolerating oral feeds then 300ug/kg orally once/weekly
  • TPN if weight loss >5-10% admission weight; ensure daily break off TPN (2-4 hours);
  • Vitamin E orally daily when on TPN
  • Consider ursodeoxycholic acid (UDCA) 10mg/kg three times a day orally to improve bile excretion

Nausea/Vomiting

If the patient is receiving chemotherapy, or has had chemotherapy in the last 5 days please administer antiemetics regularly.

If patient is experiencing nausea please move down the following antiemetics cascade.

  • Ondansetron
  • Dexamethasone (if not AML or pre diagnostic BMA/LP)
  • Omeprazole
  • Cyclizine
  • Lorazepam
  • Dimenhydrinate
  • Metoclopramide
  • Domperidone

Skin/Positioning

  • All oncology children should receive antimicrobial mouth cares 4 hourly and an assessment of mucosal membranes every shift.
  • Any patient post bone marrow transplant should also be on nilstat 6 hourly.
  • If patient has mediastinal mass sit patient up at a 45 degree angle.

Patient Isolation

  • ALL patients require isolation in a positive pressure room unless their neutrophil count is greater than 0.5 x 109/L AND they haven't received chemotherapy in the last two weeks.
    • Newly diagnosed or newly relapsed pts should be isolated despite WCC as they could have artificially high and not functioning white cells.
  • All patients post stem cell/bone marrow transplant require protective isolation (gown and glove).
    • This is not the policy on 27B, but as there is a greater variety of patients in PICU and a greater number of health care professionals in and out of the room. It is in the patient's best interest to protect them from PICU bugs.

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Document Control

  • Date last published: 10 June 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Fiona Miles
  • Editor: John Beca
  • Review frequency: 2 years