cancer and blood disorders - care of paediatric patients...

CHHS17/160

Canberra Hospital and Health ServicesClinical Guideline Cancer and Blood Disorders - care of paediatric patients (infants, children and adolescents)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 3

Section 1 – Possible clinical presentations................................................................................3

Section 2 – On Admission/presentation....................................................................................3

Section 3 – Infection Control.....................................................................................................5

Section 4 – Nursing Care...........................................................................................................5

Section 6 – Fever Management................................................................................................6

Section 7 – Pain Management in Children with Cancer or a Blood Disorder............................7

Section 8 – Blood Products.......................................................................................................7

Section 9 – Involvement of the Primary Care Team and Multidisciplinary Team......................8

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Search Terms............................................................................................................................ 9

Doc Number Version Issued Review Date Area Responsible PageCHHS17/160 1 20/07/2017 01/05/2020 WY&C - Paeds 1 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Guideline Statement

Key ObjectiveThis guideline outlines the clinical management of infants, children and adolescents: receiving treatment for cancer who have ceased treatment for cancer or leukaemia within the last 3 months who have received a Stem Cell Transplantation (SCT) within the last 12 months or on immunosuppressive therapy who are existing Oncology or SCT patients with a Central Venous Access Device (CVAD) in

situ

BackgroundThe Canberra Hospital provides care for children and adolescents with cancer and blood disorders. Care is primarily managed by Oncologists and Haematologists at the Sydney Children’s Hospital or Children’s Hospital Westmead (the Primary Care Team). Paediatric patients will be admitted to the Canberra Hospital under the care of a paediatrician for ongoing management treatment and supportive care in collaboration with the Primary Care Team including Infectious Disease consultation.

The role of The Canberra Hospital as the secondary treatment centre is to:1. Deliver care according to prescribed treatment protocols as provided by the Primary

Care Team for the treatment of cancer or a blood disorder and;2. Provide supportive therapies as required for paediatric patients with cancer or a blood disorder.

The Paediatric Day Stay Unit (PDSU) provides routine care to this patient group including administration of chemotherapy and supportive treatments. The nursing staff liaise with the primary care team and Outreach Nurses to ensure there is a current up-to-date) treatment protocol and progress letters for each child and adolescent undergoing treatment.

Alerts Children and adolescents who are currently receiving treatment are able to bypass the

emergency department for direct admission to the Paediatric High Care Ward. During business hours Monday to Friday 0700 – 1630 patients are to phone PDSU. An

assessment of patient acuity will be made over the phone by PDSU staff, and in the case of an emergency the family may be advised to call an ambulance or be advised to present to the Emergency Department. If asked to present to the Day Stay Unit, the patient will be assessed by PDSU medical staff.

After hours families are advised to phone CHHS Switchboard and request that the Paediatric Registrar on Duty is paged to arrange for review on the Paediatric Ward. If the registrar is not contactable, the alternative is to contact the Nursing Team Leader.

All communication/correspondence from the Primary Care Team and the Oncology Outreach nurse regarding patients known to our service will be on CRIS. The most recent correspondence is also filed in hard copy in the Oncology/Haematology folders in the PDSU workroom.



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Back to Table of Contents

Scope

This guideline pertains to all Canberra Hospital and Health Services (CHHS) staff caring for a paediatric patient with cancer or a blood disorder admitted to CHHS.

This document applies to the following CHHS staff working within their scope of practice: Medical staff Registered and Enrolled Nurses Student nurses working under direct supervision Allied Health staff


Section 1 – Possible clinical presentations

A paediatric patient with cancer or a blood disorder may present for treatment for any (but not limited to) the following reasons: Febrile (a single temperature >38C by any route) and not neutropaenic Febrile and neutropaenic (a neutrophil count <1.0 x 109/L) (this requires urgent

management, and commencement of antibiotics within 60 minutes of presentation) Uncontrolled nausea and vomiting post chemotherapy Anaemia, thrombocytopaenia or bleeding – requiring transfusion of platelets and/or

packed red cells Complications associated with a CVAD (i.e. thrombus, occlusion, infection) Pain management Palliative Care Constipation Presenting for routine treatment as per treating protocol For ongoing management of chronic treatment side effects


Section 2 – On Admission/presentation

ALERT – do not flush CVAD prior to taking blood cultures. Withdraw a sample for blood culture specimen or discard amount first to minimise risk of a septic shower. (The ‘discard’ amount should also be sent for culture.)

The paediatric registrar should review any paediatric patient with cancer or a blood disorder within 30 minutes of arrival (except those presenting for routine care). If the registrar is unable to review the patient, contact the on-call paediatrician via the hospital switchboard.



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As patients with cancer or a blood disorder may not appear unwell, but are at risk of significant illness, the following should be performed upon admission/presentation: Full set of vital signs and early warning score, including blood pressure. Weight and height Access previous clinical record on CRIS, and ensure that the facsimile from the Oncology

Outreach Team regarding most recent treatment has been obtained from Oncology Folder at PDSU Workstation.

Use CVAD where possible as per Central Venous Access Device (CVAD) Management - Children, Adolescents and Adults

If the child presents with fever or suspected febrile neutropenia (refer to Section 6 – Fever Management):o do not wait for anaesthetic cream to numb skino Obtain aerobic and anaerobic blood cultures from all lumens of the CVAD or a single

sample if the child has an implanted venous device (repeat every 48hrs until 3 consecutive negative culture results).

o Peripheral blood specimen must be taken and Intravenous Antibiotics (IVABs) commenced if a CVAD cannot be accessed within 30 minutes of the child’s presentation

Take blood for: o full blood count (FBC) and differentialo urea, electrolytes and creatinine (UEC)o glucoseo liver function test (LFT)o venous gaso lactateo group, screen & hold.

Blood sample for lactate measurement must be processed as soon as possible as lactate may appear falsely elevated in stored samples. Patients with high levels of lactate (> 2 mmol/L) are at high risk of mortality and hence must be managed as per severe sepsis/shock pathway irrespective of other features

Other tests to be performed:o Urinalysis +/- urine culture (clean catch or catheter specimen) if urinalysis results are

abnormal o Chest Xray if clinical symptoms suggest pulmonary diseaseo Nasopharyngeal Aspirate for patients with respiratory symptoms (nasal swab if

thrombocytopenic, due to risk of haemorrhage) o Swab of suspicious skin lesions for microscopy, culture anc sensitivity (MC&S) and

Herpes Simplex Virus (HSV) Polymerase Chain Reaction(PCR testingo Inform paediatric team and liaise with primary treating teamo Stool specimen for MC&S, viral antigens and C. difficile if symptomatic




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Section 3 – Infection Control

Standard PrecautionsAll paediatric patients require standard precautions at all times as per the CHHS Clinical Procedure Healthcare Associated Infections (HAI) (which can be found on the policy register http://inhealth/PPR/default.aspx), standard precautions must be used for the treatment and care of all patients, regardless of their known or perceived infectious status.

Isolation requirements Children who are neutropaenic should be placed in protective isolation using a single

room with positive pressure air conditioning and an ensuite bathroom. If a child with a haematological/oncological disorder is admitted to the ward and is not

neutropaenic the child will not require isolating however they should be accommodated in a room with other non infectious patients. A single room is always the first option.

Additional PrecautionsIf a child has a known infection, or is colonised with a multiresisant organism or is awaiting confirmation of test results for a respiratory or any other infectious illness or condition, precautions should be taken according to the HAI Procedure.

Transmission based precautions i.e. contact precautions, droplet precautions and airborne precautions, are used for patients who are known or suspected to be infected or colonised with important or highly transmissible pathogens. They must be used in conjunction with Standard Precautions and frequently with each other.

Management of paediatric patients with infectious issues requires liaison with the Infection Prevention and Control Unit (IPCU), who are responsible for all screening and clearance protocols applied to patients requiring isolation.

It should be assumed that all oncology/haematology children are immunocompromised and therefore at risk for all vaccine-preventable diseases.


Section 4 – Nursing Care

Allocation of careNursing staff allocated the care of a paediatric oncology patient will ideally have prerequisite level of skill and knowledge: Care of CVAD according to relevant hospital guideline Completion of CVAD Care and Maintenance (eLearning) (available on Capabiliti) and

attainment of relevant CVAD Competency Completion of Cytotoxic Safe Handling course (book via Capabiliti) to ensure safe

handling of cytotoxic waste



https://training.health.act.gov.au/

https://training.health.act.gov.au/

http://inhealth/PPR/default.aspx

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Consideration should be given when allocating nursing care to patients with cancer or a blood disorder to ensure that the nurse caring for these children should not be caring for another patient known to have a respiratory illness or diarrhoea/vomiting illness.

Monitoring of Patients Vital signs monitored 4 hourly, unless otherwise indicated by clinical condition (1 hourly

for children admitted with fever and neutropenia) Daily BP unless otherwise indicated by clinical condition (BP hourly for 4 hours in children

admitted with fever and neutropenia) Regular skin integrity assessment (particularly when thromocytopenic or neutropenic)

including the perianal area at least once/day Regular Mouth check for thrush or ulceration (mucocitis can be a side effect of

chemotherapy) at least once/day Strict fluid balance assessment (this may include daily weight) Urinalysis as indicated


Section 6 – Fever Management

In children with a blood disorder/cancer a fever may be the only presenting factor suggesting an infection

Neutropaenic hosts have a decreased ability to manifest an inflammatory response, therefore signs and symptoms may be subtle

Families are advised to refrain from administering antipyretics until the fever is assessed on admission. The presence of a fever does not necessitate the use of antipyretics. In an oncology population it is preferable to monitor the fever to see how it progresses for at least two hours before administering paracetamol (15mg/kg)

Ibuprofen is not recommended for children with cancer or a blood disorder.

Antibiotic Treatment:Refer to NSW Health Guideline: Paediatrics - Initial Management of Fever or Suspected Infection in Paediatric Oncology and Stem Cell Transplantation Patient for guidance on empiric antibiotics, specifically: Empiric antibiotic treatment – Page 7 & 8 of hyperlinked guideline Modifications to first dose empiric antibiotic regimen:

o Vancomycin Allergy – Page 12 of hyperlinked guidelineo History of Colonisation with Drug Resistant Organisms – Page 13 of hyperlinked

guidelineo Indications for vancomycin use – Page 13 of hyperlinked guidelineo Abdominal or Perineal Infection – Page 13 of hyperlinked guidelineo Antifungal Therapy – Page 13 of hyperlinked guideline


Section 7 – Pain Management in Children with Cancer or a Blood Disorder



http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_013.pdf


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Children may experience pain as a result of the side effects of treatment, disease process or procedural pain. The consulting paediatrician, Acute Pain Service, palliative care and/or primary care team should be consulted for long term pain management strategies.

Common pain experienced by children with oncology and haematology disorders include: Mouth pain including thush infection, HPV infection and ulceration resulting from

chemotherapy (known as mucositis) Bone pain from disease process or as a side effect of stem cell growth factor treatment

or chemotherapy Gastrointestinal pain as a result of ongoing vomiting, diahorrea or constipation or

infection Disease progression requiring palliation


Section 8 – Blood Products

Blood and blood product administration is guided by the CHHS Clinical Guideline Fresh Blood Products Administration

At CHHS, it is recommended that all blood products given to this patient population be: Cytomegalovirus (CMV) negative (unless the child has tested positive for CMV) and Irradiated

All blood products at CHHS are leukocyte depleted so a whilte cell filter is not required at the time of administration

Some children require antihistamine and/or steroid prophylaxis prior to platelet and blood transfusions. Commonly, these patients are those who have had a previous reaction or have received a stem cell transplant. Review of medical records will identify patients who normally receive antihistamine and steroid prophylaxis, or the parents may know this information.

Packed Red Blood Cells should be given if HB<70g/L or if symptomatic. To calculate the packed cells required use the formula below: Packed cells (mls) = wt (kg) x Hb rise required(g/L) x 0.4 eg. A 10kg child requiring Hb to rise from 60 to 110g/L 10 x 50 x 0.4=200ml

Note: The volume given should not exceed 15ml/kg – if the calculated volume exceeds 15ml/kg, please discuss with the Primary Care Team.

Some children require diuretics when receiving blood products. This is often indicated in children with renal conditions or when receiving more than one unit of blood products. The decision to use diuretics should be determined by the Primary Care Team.



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Section 9 – Involvement of the Primary Care Team and Multidisciplinary Team

It is an expectation that the admitting team ensure engagement of the Primary Care Team.

Sydney Children’s HospitalMonday to Friday – page treating team Fellow via switchboard (02) 9382 1111Weekends and Public Holidays – page Registrar on call via switchboard (02) 9382 1111

Children’s Hospital Westmead Monday to Friday – page treating team fellow via switchboard (02) 9845 0000Weekends and Public Holidays – page registrar on call via switchboard (02) 9845 000

Social Worker and PsychologyContact during first business hours of the admission unless urgent issues arise.TCH Social Workers and Psychologists can assist with many of the practical and emotional issues that may be experienced by families whose child has cancer or a blood disorder.

Outpatient Care Please advise Paediatric Day Stay CNC or nursing staff of any patients who have been admitted as inpatients.All children who have received inpatient treatment should have a discharge summary faxed to the Paediatric Outpatient Department. This discharge summary should include details of medical care given as well as date of: last CVAD dressing last CVAD maintenance flushes next blood tests required




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Implementation

The publication of this guideline will be communicated to all staff who may be involved in caring for paediatric patients with cancer or a blood disorder, and the content of the Guideline will be incorporated into the existing training program for paediatric nursing and medical staff.


Related Policies, Procedures, Guidelines and Legislation

Blood Culture Collection Clinical Procedure Fresh Blood Products Administration (Adults, Paediatrics and Neonates) Healthcare Associated Infections Children and Infants: Acute Management of Fever Clinical Practice Guideline Antimicrobial Stewardship Procedure Patient Identification – Pathology Specimen Labelling Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults

(not Neonates) NSW Department of Health, Sydney, Australia, Clinical Practice Guideline: Infants and

children: Initial Management of Fever or Suspected Infection in Oncology and Stem Cell Transplantation Patients, first edition, [Internet, last updated October 2015, date viewed 28th March, 2017], Available from: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_013.pdf


References

1. NSW Department of Health, Sydney, Australia, Clinical Practice Guideline: Infants and children: Initial Management of Fever or Suspected Infection in Oncology and Stem Cell Transplantation Patients, first edition, [Internet, last updated October 2015, date viewed 28th March, 2017], Available from: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_013.pdf


Search Terms

Paediatrics, child, infant, fever, neutropaenia, infection, cancer, leukaemia, immunosupressed, chemotherapy, blood

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.





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Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval21/07/2017 Complete Review Liz Chatham, ED WY&C CHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/493 Paediatrics – Care of Patients with Cancer and Blood Disorders

