Oncology - care of the oncology patient admitted to PICU - general principles
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- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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
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.
- Dexamethasone (if not AML or pre diagnostic BMA/LP)
- 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.
- 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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- 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
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