Role of the oncology nurse

in regional infusion

chemotherapy

Jan Carter, RN

Jan Carter, RN, is a n operating room nurse at King Edward VII Memorial Hospital, Paget, Bermuda. Formerly a n oncology nurse at Lahey Clinic, Bos- ton, she has a n associate degree f rom Northeastern University, Boston.

At the Lahey Clinic, carcinoma of the liver is treated with various chemo- therapeutic agents and methods. One of the more recent modes of treatment is regional hepatic arterial infusion. The oncology nurse, an important member of the treatment team, is trained in the operation of various in- fusion pumps and is responsible for setting up the equipment and for re- lated complications. She must also have adequate knowledge of the vari- ous chemotherapeutic drugs and their toxic manifestations.

Many patients with primary cancer and metastatic cancer of the colon to the liver are treated at the Lahey Clinic with regional arterial infusion. This treatment is based on the concept that continuous exposure of tumor cells to an antimetabolite is required for effective antimetabolite activity to develop in the tumor cell population. Cancer cells are vulnerable to an an- timetabolite during deoxyribonucleic acid (DNA) synthesis. Therefore, the continuous exposure of the tumor to this type of drug should affect most of the cells as they enter the DNA phase. Systemic intravenous injections of an antimetabolite would only be able to break up the tumor cells entering the DNA synthesis phase for approxi- mately two hours after the injection before it is excreted.

For arterial infusions of the liver, the Lahey Clinic primarily uses floxuridine (FUDR). Approximately 5.0 ml FUDR are infused per day. There is no set number of days a pa- tient is treated with this drug. The patient is infused until toxicity be- comes evident. Stomatitis, pharyn- gitis, anorexia, nausea, and vomiting are subjective symptoms of toxicity. Weekly blood studies detect leukope- nia, thrombocytopenia, and anemia. When toxicity is evident, the patient is

662 AORN Journal, March 1977, Vol25, No 4

Medicine Bag - (101)

Needle-, ( 1 10)

Bag Fitting--- (1021

Position Studs(2 (103)

Pump Tubing”

Nylon Roll&

(104) , /’

Segment Screw-- (105) Cover

I

Tube Grommb (107)

Track Segment (106)

Monoflow Valve (109)

The chronometric infusion pump is used in direct catheterization.

instructed to insert a sterile water bag into his pump until the symptoms dis- appear. Then a second course is begun.

It has been shown that a treated group with hepatic metastasis at the Lahey Clinic had a survival rate of 65.9% at six months and 36.6% at one year compared to a 17.9% survival of an untreated group at six months and 10.4% survival at one year, a threefold improvement that is significant.

The oncology nurse’s specific duties include (1) preparing and administer- ing drugs ordered for patients receiv- ing chemotherapeutic infusion in the hospital, (2) furnishing outpatients with adequate supplies of medication, (3) giving detailed instructions to pa- tients and their families regarding

management of therapy a t home, (4) maintaining ongoing records of pa- tients who are hospitalized, and ( 5 ) maintaining accurate inventory of in- fusion equipment and drug supplies and reordering them when necessary.

In addition, the oncology nurse must emotionally support the patient and his or her family through telephone calls and instruction sessions, en- couraging them to verbalize their anx- ieties and fears.

Preoperative nursing care. The pa- tient is evaluated by preestablished criteria before being selected a candi- date for regional infusion chemothera- py. The criteria depends basically on the debility of the patient as well as the distortion of vessel anatomy by

AORN Journal, March 1977, Vol25, No 4 6 63

previous x-ray therapy and operation. If the patient has disease too advanced to permit direct hepatic arterial inser- tion, he will be treated with per- cutaneous placement of the catheter. The patient is hospitalized as soon as possible, and the procedure takes place within three days after admission.

Rapport between the oncology nurse and the patient should be initiated when the patient is admitted to the hospital or a t least before the patient goes to surgery. If the patient has been

treated as an outpatient, the nurse and patient have already met. During this early contact, the nurse discusses with the patient, in basic terms, the pump that will be used. A Watkins chronometric infusion pump is used in the direct catheterization of the hepat- ic artery, and a Bowman high-volume arterial infusion pump is used ini-

tially in the percutaneous placement of the hepatic artery catheter.

An illustration of the pump is shown to the patient. However, we do not go into detailed explanations. The success of the treatment depends on the pa- tient’s involvement in the postop- erative care. We believe that this preoperative teaching helps alleviate his anxiety and encourages his postop- erative participation.

Direct placement of catheter. If direct catheterization of the hepatic artery is

The Bowman pump is used initially in the percutaneous placement of the hepatic artery catheter.

undertaken, the patient arrives in the recovery room with the catheter sewn in. situ and protruding through the ab- domen. This outer catheter is attached to a monoflow valve (allo*ing no blood backflow), which is wrapped in a sterile gauze dressing and covered with an abdominal pad. The oncology nurse attaches the chronometric infu-

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sion pump, a type of clock-driven mechanism designed for continuous prolonged ambulatory infusion, to the monoflow valve that is connected to the surgically placed indwelling cathe- ter.

The chronometric infusion is a com- pact, self-contained portable infusion apparatus weighing 15 ounces and de- veloped by Elton Watkins, Jr , MD. The apparatus injects small volumes of parenteral drug solution at a fixed ac- curate rate through a fine Teflon catheter passing to a blood vessel. The pump can be used for long-term con- tinuous therapy in ambulatory pa- tients.

Avoiding any unnecessary manipu- lation of the equipment, the nurse con- tinues to reassure the patient as she straps an adjustable harness to the patient’s chest to hold the ambulatory pump.

Other methods of holding the pump are a sling, a vest, or attached t o a brassiere.

The oncology nurse instructs the re- covery room staff to wind the pump every eight hours, to check the inci- sion for bleeding, and to check the catheter for kinks and backflow. She notes in the progress section of the patient’s chart whether a chemothera- py agent or sterile water is being in- fused and pertinent information the physician should be aware of regard- ing the patient or pump.

Postoperative patient instruction. On the first postoperative day, the patient receives a pamphlet with general in- structions on the care of the pump, the catheter, and the site of catheter exit and instructions on the pump and changing the medicine bag. At this time the harness, which supports the pump, can be adjusted for more com- fort. The patient may want to discuss the social implications of wearing the pump, which constantly emits a tick-

ing sound. He also should be en- couraged to state any problems or uncertainties, for the oncology nurse may be able to devise solutions based on previous experiences.

Instructions on the infusion pump are begun the second postoperative day. By then, the patient is usually less distressed about his new addition and eager to learn its mechanisms. During the first few days of instruc- tion, the patient uses a demonstration model for practice.

A member of the patient’s family or close friend should also be familiar with the pump. Instruction takes about seven hours (one hour a day for one week). Over this span of time, questions can be answered regarding activity, diet, or disease while receiv- ing this treatment.

It is essential to maintain sterility while replacing medication bags. Em- phasis on asepsis should be done in a flexible manner, however, so the pa- tient does not become fearful of the pump. The patient and family member practice inserting bags into the model pump until they comprehend sterility, how to avoid complications, and methods of checking the pump for leakage and operation.

Problems of the pump. Some com- mon problems that may occur with the pump are (1) splitting of the tract tub- ing, which is usually the result of ex- cessive tugging while replacing the medication bag; (2) failure of the medication to infuse, which could be caused by incorrect insertion of the infusion bag, turning the segment screw that regulates the flow too far counterclockwise, kinking in the ex- ternal catheter, or a clot in the in- dwelling catheter; and (3) overwinding the pump, as in a clock, which will snap the spring mechanism and cause it to fail to operate. Patients are in- structed to wind the key only eight full

AORN Journal, March 1977, Vol25, No 4 665

turns every eight hours to prevent this problem.

If the patient lives a distance from the Lahey Clinic, he is instructed how to replace the tract segment if the tract tubing splits and how to attach a new pump should it break from trauma or from being overwound.

Discharge instructions. When the patient has recovered from the opera- tion and lessons relating to the mechanics of the chronometric infu- sion pump have been completed, he is discharged from the hospital with the following supplies and information:

1. Medication forms on which the patient logs the date the infusion bag is changed and whether chemotherapy or sterile water is being infused. At each clinic visit, these forms are given to the oncology nurse to update the patient’s course of treatment record.

2. A list of subjective toxic signs and symptoms t o be aware of with instruc- tions to notify the physician should they occur.

3. A medical release letter explain- ing the ticking sound so the patient is able to travel with minimal questions asked. 4. A prescription sheet stating blood

studies t o be carried out weekly (hemoglobin, white blood count, platelets, serum glutamic oxaloacetic transaminase, alkaline phosphatase, bromsulphalein, cholesterol, bilirubin, total protein, blood urea nitrogen, cal- cium) with results sent to the physi- cian’s office so he may determine when toxicity occurs. This method allows the patient to have his blood drawn at a local laboratory or hospital.

5. An ample amount of medication and water bags with a n equal number of alcohol wipes. When toxicity is evi- dent, the patient, under the physi- cian’s direction, inserts a water bag into the pump.

6 . Three machine washable har- nesses.

7. An extra winding key in case one is lost.

Each patient leaves the hospital with an awareness that someone will always be available should complica- tions or questions arise. A follow-up appointment is made prior to dis- charge.

Percutaneous placement of hepatic artery catheter. The hepatic artery catheter is placed percutaneously if the patient is considered a poor surgi- cal risk and unable to tolerate laparotomy for direct catheterization. The radiopaque catheter is inserted into the hepatic artery via the brachial artery. This procedure is done under fluoroscopy in the radiology depart- ment. The patient is returned to his room with a syringe containing hepa- rin and sterile water adapted to a three-way stopcock. This solution is periodically flushed through the tub- ing while the Bowman high-volume arterial infusion pump is being pre- pared.

The Bowman high-volume arterial infusion pump is initially used for ten days assuring the patient a t least one full course of chemotherapy before dis- charge. An aluminum cart with three shelves for various supplies supports this electric peristaltic device. Con- tainers of a t least four liters of infu- sion drug are hung in tandem to eliminate daily manipulation and the possibility of contamination or air em- bolism. Each bottle is carefully labeled by number, date, hour checked, and dose of medication by the oncology nurse. A six-foot plastic tube connects the patient’s stopcock to the infusion pump; this allows the patient free movement while in bed, and a 12-foot cord enables him to ambulate with assistance. An instruction sheet de- scribes all necessary supplies.

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Since the internal catheter is not sutured in place, precautions are necessary to prevent dislodgement. A piece of tape placed approximately one inch below the incision immobilizes the catheter. To prevent infection, a 4 x 4-inch sponge dabbed with an an- tibiotic ointment covers the incisional site. Several strips of tape wrapped around the patient’s arm aid in stabilizing the catheter. Finally, a three-inch roll of gauze wrapped around the upper aspect of the arm protects the dressing. The patient is instructed not to raise his arm above his head as this motion will pull at the catheter.

Daily checks are carried out by the oncology nurse. She replaces the empty bottles, regulates the infusion rate under the direction of the physi- cian, observes the patient for toxic symptoms, and redresses the bandage every few days. She also informs the staff nurse of possible complications such as discoloration, numbness or tingling sensation, or excessive bleed- ing from the operative arm. Axillary pulses should be recorded frequently since this is the site of the catheter insertion. If absent, a clotted catheter might be suspected. A rubber-tipped snap taped to the cart serves as an emergency clamp should any adapter become disconnected or blood backflow through the tubing is observed.

With completion of this ten-day course, the ambulatory Watkins chronometric infusion pump is at- tached to the patient’s stopcock. The patient is instructed on the use and care of the pump as previously dis- cussed with additions. It is necessary to redress the arm bandage every two weeks. The technique must be taught to a family member or arrangements can be made with a visiting nurse.

Since the internal catheter is not sewn in situ and because of the arte-

rial pressure, it is not uncommon for the tip of the catheter to become dis- lodged after the patient leaves the hospital. Many catheter displacements are caused by extensive pulling at the catheter site; therefore before dis- charge, the patient should be reap- prised of the need for limited arm activity. Approximately every six weeks, the patient returns to the radiology department where a radiopaque dye is injected into the catheter. Should the catheter be dis- lodged, the radiologist will manipulate it back into its proper position. How- ever, if a thrombosis of the artery is noted, the catheter will be withdrawn and other methods of chemotherapy will be utilized.

Discussion. Management on an out- patient basis is a crucial aspect of the treatment of patients using regional hepatic arterial infusion as a mode of therapy for carcinoma of the liver. Most patients are concerned about three points.

Actiuity. Although the patient is en- couraged to resume normal activities within reason, he will often need reas- surance as to what specific activities are permitted.

Diet. Patients with no other com- plicating diseases are not restricted in diet. Because anorexia is a common symptom of carcinoma of the liver, pa- tients are encouraged to eat foods they like that agree with them. Many pa- tients need assistance in maintaining an adequately nutritious diet.

Ambulatory pumps. The content of the medicine bags will last for at least four days. The bag collapses as it in- fuses, and therefore, it is difficult to estimate by sight the exact amount of fluid remaining. If a patient is ap- prehensive about waiting until the fourth day, we suggest that he change the bag a day earlier.

A candid relationship between the

AORN Journal, March 1977, Val 25, No 4 667

oncology team and the patient regard- ing diagnosis, the nature and approx- imate length of therapy, and progress o f the patient i s essential. Patients must play an active role in the man- agement of the i r infusion programs.

Emotionally, these patients vary be- tween hopefulness and discourage- ment. Unfortunately, many patients expect to become asymptomatic before their discharge f rom the hospital. They must be reminded continuously that alleviation of subjective symp-

Aggressive approach to hand injuries An aggressive approach to reoperation of severe hand injuries following initial healing is necessary for rehabilitation according to F Calvin Bigler, MD, Garden City, Kan. In an exhibit presented to the American College of Surgeons at its Clinical Congress in Chicago, Dr Bigler reported on three cases involving young men who injured their hands in serious accidents.

A 19-year-old man pushed up against the manifold of a car in an effort to free himself after being pinned underneath it. He received severe third-degree burns on both hands, especially in the palms. A 22-year-old man caught his left hand in a flaker, a machine that processes corn to make it more digestible as cattle feed. A 19-year-old man lost his entire right hand and all but the thumb of the left hand when they were caught in a metal-stamping machine.

In all hands, missing skin and soft tissue were replaced by attaching the remainder of the hand to the abdomen and transferring a pedicle graft. Abdominal pedicle grafts also were used to provide blood supply to two burned fingers with markedly impaired blood flow. Gangrene of the fingers was prevented.

A variety of plastic surgery techniques were used to obtain some function. Relative lengthening of two fingers was accomplished by using bones of the hand. -A lobster claw hand was created by using peg bone grafts set in the ends of the bones of the destroyed

toms f rom th is therapy w i l l not occur immediately, and that toxic symptoms wil l precede remission. At times, pa- tients mistake drug toxicity as pro- gression of disease.

With continued support and honesty f rom the oncology nurse, the patient feels free to discuss realistically h i s symptoms and progress wi thout fear of being rejected. H e i s also assured of h i s own importance as an integral member of- the therapeutic team car-

ing for him. 0

thumb and little finger. This right hand is used to work, write, and eat. It opens to 4.5 cm and closes tightly on a single sheet of paper.

Cancer cell growth in surgical wounds Certain factors in a healing wound may affect the growth of cancer cells in surgical scars, according to a presentation to the American College of Surgeons by W Jefferson Pendergrast, Jr, MD, department of surgery, Emory University School of Medicine, Atlanta, and J William Futrell, MD, department of plastic surgery, University of Virginia Hospital, Charlottesville.

Tumor cells found within scar tissue of an old wound may be protected from normal body defense mechanisms, the authors told the October Clinical Congress in Chicago. Such tumors were able to grow faster and appeared earlier in the controls.

hematoma or serum, they appear earlier and grow faster, possibly because blood and serum provide a rich culture medium. Conversely, when tumor cells are found in fresh wounds, they may not be protected from the body's natural defenses. The inflammatory response of the body to an acute wound coupled with increased lymphatic flow to the area is probably responsible for the lack of tumor growth.

When tumor cells are found in a

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