Complications of Chemotherapeutic Drugs

8/10/2019 Complications of Chemotherapeutic Drugs

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Complications ofChemotherapeutic drugs

Tolentino

Sanchez


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1. Infusion site related


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Extravasationis the accidental

leakage of a druginto thesubcutaneoustissue thatcauses pain,necrosis, or

sloughing oftissue


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Definition of Terms

VESICANT-is an agent that can produce a blister,tissue destruction, or both.

IRRITANT- is an agent that can cause aching,tightness and phlebitis at the injection site or alongthe vein line with or without an inflammatory

reaction.

FLARE- is a local allergic reaction without painthat usually is accompanied by red blotches alongthe vein line. This subsides within 30 minutes withor without treatment.

DELAYED EXTRAVASATION-is one in whichsymptoms occur 48 hours or more after the drug isadministered.


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Indications of

Extravasation

Absence of blood return from the IVcatheter

Resistance to flow of IV fluid

Burning, or pain, swelling at the site


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Initial management

STOP THE INFUSION IMMEDIATELY.Do not flush the line, and avoidapplying pressure to theextravasation site.

Disconnect the IV tubing from the IVdevice, but do not remove the IVdevice or noncoring port needle.

Attempt to aspirate residual fluidfrom the IV device using a small (1-3

mL) syringe. (Central line) Remove the peripheral IV device or

port needle.


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Assess the site of the suspected extravasation andnote any symptoms experienced by the patients

Assessment and documentation should includedrug extravasated, dose, volume, position, andsize of any apparent wound, presence of swelling,and extent and spread of erythema and pain.

If possible, digital photographs should be obtainedto help further document the injury and assesschanges over time.


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Notify the physician or advanced practice

nurse. Initiate appropriate management

measures in accordance with professionalpractice guidelines and institutional

policies.


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Management


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1. Cold application

Application of an ice pack to cool the site ofextravasation is recommended for extravasationof:

anthracyclines (doxorubicin, daunorubicin,epirubicin and idarubicin),

alkylating agents(mechloretamine)

antitumor antibiotics(dactinomycin ndmitomycin-C)

taxanes (docetaxcel and paclitaxel)


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2. Heat application

Application of heat is indicated forextravasation of the plantalkaloidssuch as:

Vincristine

Vinblastine

Vindestine

Vinorelbine


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Heat should be applied to the

affected area for 15 to 20 minutes4 times per dayfor the first 24 to48 hours.


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3. Limb elevation

May help with reabsorption of the

extravasated drug and is recommended fothe first 24 to 28 hours wheneverpossible.


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Antidotes and treatments

ANTIDOTE- an agent that is eitherapplied or injected to theextravasated area to counteract theeffects of the infiltrated agent.


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Sodium thiosulfate

Exact mechanism unknown.

Thought to prevent alkylation andreduce subcutaneous tissuedestruction.

Subcutaneous injection using a25-gauge needlearound the

affected area is recommended forextravasation ofMechlorethamine.


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It is supplied as a 10% or 25% solution and shouldbe diluted to a 1/6 molar solution, by mixing 4 mLof the 10% solution with 6 mL of sterile water or1.6 mL of the 25% solution with 8.4 mL of sterile

water. Using 2 mL for each milligram extravasated,

multiple local subcutaneous injections should beadministered as soon as possible after theextravasation, changing the needle for each

injection, followed by ice application for 6 to 12hours.


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Local subcutaneous injection has beenrecommended for extravasation of vinca

alkaloids and can be used in combinationwith heat application.

It is recommended to administer painmedications prior to this procedure.


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Dexrazoxane

Exact mechanism unknown, thetarget of anthracyclinechemotherapy is an enzymeknown as DNA topoisomerase.

Dexrazoxane is thought to inhibitand bind to DNA topoisomerase II,thereby disabling the enzyme so it is

no longer affected by theanthracycline and damage to thecells is averted.


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Administered IV as three 1-2 hourinfusions through a different venousaccess location. FIRST DOSE should begiven within 6 hours of the actual

extravasation, and subsequent dosesadministers as 24 and 48 hours afterextravasation.

The 1stand 2nddoses are 1000 mg/m2and

the 3rd

dose is 500 mg/m2

up to maximumtotal doses of 2000 mg on days 1 and 2and 1000 mg on day 3.


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Surgery

Surgical interventions include

debridementof necrotic tissue, whichcan help minimize subsequent damage,and wide excision or skin grafts if healingis delayed.


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Pain Management

Non-opioid analgesics

Opioid analgesics


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Prevention

Vesicant chemotherapy should never beadministered in peripheral veins involving thehands or the wrist.

For any frequent, or prolonged administration ofantineoplastic vesicants, right atrial silasticcathethers, implanted at venous access devices, orperipherally inserted central cathethers (PICC)should be inserted to promote safety duringmedications administration and reduce problems

with access to the circulatory system.


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Hypersentivity/

Anaphylacticreactions


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Overall incidence of hypersensitivity reactionsis 5%.

Emergency medications and supplies: Injectable aminophylline, diphenhydramine

hydrochloride (Benadryl), dopamine,epinephrine, heparin, hydrocortisone.

Oxygen setup, tubing cannula, or mask andairway device

Suction equipment

IV fluids (isotonic solutions) IV tubings and supplies for venous access.


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Management

Immediately stop the drug infusion

Maintain an IV line with isotonic saline

Position the patient for comfort and topromote perfusion of the vital organs

Notify the physician, nursing agency, oremergency medical services.

Maintain the airway, and anticipate theneed for CPR


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Monitor vital signs

Administer appropriate medications withan approved physicians order

Follow the nursing agencys protocol forfollow-up care.

Document the incident in the patientsmedical record.


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Complications of

Chemotherapy


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SHORT TERM

Fever

Nausea

Infusional reactions

Oral complications

Diarrhea

Anemia Neuropathy

Alopecia

Rash, Extravasation

Emotional


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FEBRILE NEUTROPENIA

On Chemotherapy, 7 to 14 days postchemo

WBC nadir, NEUTROPHILS are 1stline of

DEFENCE Temperature great than or equal to 38.3

degrees centigrade

Absolute Neutrophil count (ANC) less than

1.0

One of the few Oncologic EMERGENCIES


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MANAGEMENT

Broad Spectrum antibiotics

If well, hemodynamically stable

CIPRO and CLAVULIN PO and home


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IF UNWELLADMIT WITH BROAD SPECTRUM IV

ANTIOBIOTICS I/E TAZOCIN ORIMIPENEM OR AMP AND GENT

WITH NEUPOGEN SUPPORT(300mcg sc daily until anc >1.0), IVFLUIDS ETC.


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Usually fever lasts less than 48 hours

If fever longer than 48 hrs, patient needsIV antibiotics, consider antifungals

Usually bacterial or viral infections butfungal infections becoming more of anissue

As WBC and ANC recover, patient usually

improves


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2. NAUSEA

Most chemotherapeutic agents causenausea. Why?

systemically as drug makes its way tonausea centre of brain (chemotherapeutictrigger zone)

Sight and smell of drug


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Types of Nausea

Anticipatoryconditioned reflex tosight and smell of chemotherapy area

Acute

within 24hrs and related tochemotherapeutic agents

Delayedmore than 24 hrs. postchemotherapy--specific agents

cisplatin, cyclophosphamide, adriamycin


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Worst offenders:

Cisplatin

High dose cyclophosphamide

Doxorubicin, eprirubicin, carboplatinalso have a high incidence of nausea


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NAUSEA TREATMENT

Medications:

Prochlorperazine (stemetil)

Metoclopramide (maxeran)

Ondansetron (Zofran)5HT3 antagonists

Dexamethasone

Lorazepam, Haloperidol

Aprepitant


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INFUSIONAL REACTIONS

Very common with new MONOCLONAL ANTIBODYagents i/e RITUXIMAB

Infusion of these agents may take several hours

Fever, hypotension, asthmatic like reactions, pain

Premedicate or treat with Dexamethasone,Benadryl, Tylenol

May have to stop infusion temporarily

If serious, may have to discontinue agent


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Oral Complications

Occurs in approx. 40% of patientsreceiving chemotherapy

Team approach using nutritionist, nursing,

dentist, pain management team

Oral hygiene important-soft tooth brushes,floss

Source of bacteremia


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loss of taste

Affects appetite, nutrition

Which in turn affects healing

In this situation, we advisepatients to think of eating as a job

Sometimes, oral complicationsrequire nutrition supplements oralternatives


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MUCOSITIS

Chemotherapy is intended to injure rapidlydividing cells such as the MUCOSA

Presents with mouth sores, inflammation,sometimes sloughing of mucosa anywherein the GASTROINTESTINAL TRACT, RESPTRACT

Usually occurs in the mouth


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SIMPLE ORAL MUCOSITISTREATED WITH MOUTH RINSE

MAGIC MOUTHWASH

SALT WATER GARGLES

TOPICAL ANALGESIA i/e Xylocaineviscous, tantum

Systemic analgesia

NYSTATIN


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Upper GI tract

Heartburn

Very common

Antacid, Ranitidine, Pantoloc


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MANAGEMENT

Hydrationpo, IV if more SERIOUS

Dietfluids, BRAT (Bananas, Rice, Apples,

Toast)

Loperamide (immediately if on Irinotecan)

4mg followed by 2mg Q4H or until formed stool.Up to 16 mg per day

Usually rule out CDIFF first


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If severe, Ocreotide (Sandostatin)

Decreases fluid output from bowel

100mcg sc TIDGrowth hormone analogue-decreases

all salivary gland secretions

And Antibiotics may be consideredespec. if CDIFF positive

oral metronidazole or oralvancomycin

oral CIPRO


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ANEMIA

Bone marrow suppression fromchemotherapeutic agents

Secondary to malignancy

Anemia work-up

Chemotherapy induced anemia


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Erythropoietin, Aranesp

Stimulate marrow to produce

RBCsUsed while on chemotherapy only

Additional iron: po vs. iv

Sc injection


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Adverse effects ofErythropoietin

Flu-like illnessRashes

Diarrhea

HeadacheBone pain

Liver, kidney

Dosage: Eprex 40,000 units scqweekly Aranesp: 150mcg scqweeklyto 7 days)


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NEUROPATHY

Very common with vincristine, vinblastine,cisplatin

Usually temporary.

Sometimes leads to dose alterations orstopping of some drugs

Most commonly, we see numbness andtingling in fingers and toes


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MANAGEMENT:

May need to alter chemotherapeuticagents or doses thereof


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LONG TERM


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Cardiac Complications

Adriamycin or other anthracyclines

450mg per m2 dose lifetime

Strong treatment for breast cancerand hematologic malignancies

Affects myocardium longterm above

maximum dose


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Secondary Malignancies

Skin cancers

Breast cancers

Hematologic Malignancies


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Fatigue

Thorough history, physical exam

and ancillary tests

Fatigue workshop


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Arthropathy

Treated in usual fashion withNSAIDs, prednisone

Complications of Chemotherapeutic Drugs

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