Neurologic complications of systemic cancer

Neurologic complications occur frequently in patients with cancer. After routine chemotherapy, these complications are the most common reason for hospitalization of these patients. Brain metastases are the most prevalent complication, affecting 20 to 40 percent of cancer patients and typically presenting as headache, altered mental status or focal weakness. Other common metastatic complications are epidural spinal cord compression and leptomeningeal metastases. Cord compression can be a medical emergency, and the rapid institution of high-dose corticosteroid therapy, radiation therapy or surgical decompression is often necessary to preserve neurologic function. Leptomeningeal metastases should be suspected when a patient presents with neurologic dysfunction in more than one site. Metabolic encephalopathy is the common nonmetastatic cause of altered mental status in cancer patients. Cerebrovascular complications such as stroke or hemorrhage can occur in a variety of tumor-related conditions, including direct invasion, coagulation disorders, chemotherapy side effects and nonbacterial thrombotic endocarditis. Radiation therapy is the most commonly employed palliative measure for metastases. Chemotherapy or surgical removal of tumors is used in selected patients.     

Fostering a New Era of Vascular Access Device Selection in Neonates

Admission into the neonatal intensive care unit entails placement of multiple monitoring systems and lifelines for therapy. A vascular access device is essential to survival for most patients in the neonatal intensive care unit. Identifying the most appropriate device to meet an infant's current and anticipated infusion needs has historically focused on length of need rather than on other equally important indicators. Using this aged criterion has contributed to the exhaustion of the peripheral veins. Using a timely approach to vascular access device needs ensures early and timely placement. Providing education and ensuring the competence of staff who make decisions regarding device placement and care are warranted and lead to the prevention of complication-induced costly litigation. The goal of infusion therapy is to complete the delivery of required solutions and medications by avoiding device-related complications. Using the fewest number of devices and targeting placement of the best device to meet a patient's needs early in the course of therapy are paramount.     

Continuous rt-PA infusion as a salvage strategy to maintain patency of the infarct artery; safety of high cumulative dose and subsequent emergency coronary artery angioplasty and bypass surgery

Acute re-occlusion of an infarct artery reperfusion attained by thrombolytic therapy may be treated by emergency coronary angioplasty or bypass surgery. Repeated infusion of a thrombolytic agent is an additional treatment strategy. Three patients with reinfarctions that occurred very early after successful reperfusion were treated with continuous infusion of recombinant tissue-type plasminogen activator (rt-PA). These patients received a rt-PA dose of 300-360 mg while they awaited emergency mechanical revascularization procedures. Two patients had coronary angioplasty immediately after receiving repeated infusions of rt-PA and one underwent coronary bypass surgery while receiving a third rt-PA infusion. There were no bleeding complications in the 2 patients who underwent coronary angioplasty, and no excessive bleeding in the patient who received coronary bypass surgery. Thus, repeated continuous rt-PA infusions can be used to maintain the patency of recurrently occluding infarct arteries until definitive mechanical revascularization can be performed.     

Insulin infusion therapy. Potential benefits and risks

A mass of evidence favors the concept of euglycemic management of insulin-dependent diabetes, despite significant potential complications. Patients with advanced nephropathy and/or autonomic neuropathy are very poor risks, and infusion therapy does not reverse well-established complications. To well-motivated, educated patients, infusion therapy offers the conveniences of more flexible timing of meals and of having a premeal bolus infusion rather than a premeal injection. With improvement in the technology of continuous glucose monitoring and closed-loop systems, as well as basic improvements in immunologic techniques for islet transplantation, the future may offer a choice of excellent euglycemic therapies for insulin-dependent diabetes. Meanwhile, infusion therapy, which was once only a research tool, is now widely available and is appropriate for near-euglycemic management of diabetes in selected patients.     

Medical Adhesives in the NICU

Skin injury from medical adhesives is a known problem for neonatal intensive care unit (NICU) patients. Medical adhesive-related skin injury (MARSI) for all patient populations includes mechanical problems such as skin stripping, skin tears, and tension blisters; dermatitis reactions such as irritant contact dermatitis and allergic dermatitis; and other complications such as skin maceration and folliculitis. The most common seen in neonatal patients is epidermal or skin stripping; chronically hospitalized infants may also experience irritant contact dermatitis to a variety of adhesive products. Preventing MARSI is the goal, using the fewest and least irritating adhesive products; yet, secure fixation of medical life support equipment is imperative. This article will explore differences in neonatal skin that place NICU patients at risk for MARSI and selecting products that are most appropriate for the desired result. Barrier films and adhesive removers are also discussed in detail to determine which may be potentially beneficial to the NICU population.     

What's old is new again: patients receiving hepatic arterial infusion chemotherapy

Hepatocellular carcinoma (HCC) ranks as the eighth most common cancer in the world. Although uncommon in North America, the incidence of HCC in the United States has increased by 70% since the 1980s (Yu, Yuan, Govindarajan, & Ross, 2000). The most frequent causes of malignant hepatic disease in the United States are metastases from melanoma and primary tumors of the gastrointestinal tract, breast, and lung. Surgical resection and systemic chemotherapy are the standard treatments for this disease. However, surgery is not an option for patients with advanced disease, and the response rate from systemic chemotherapy remains low. An alternative therapy for patients with HCC or cancers with liver metastases is hepatic arterial infusion of chemotherapy directly into the liver. This method allows a high total body clearance and hepatic extraction to generate high hepatic and low systemic exposures. Nursing care of patients receiving hepatic arterial infusion of chemotherapy includes patient education and monitoring for complications.     

Home-based infusion therapy for patients with Fabry disease

Fabry disease is an inherited, progressive, life-threatening disease; therefore, lifelong therapy is needed. By replacing the deficient enzyme, disease progression may be delayed or halted, thereby avoiding serious complications. Hospital-based agalsidase therapy is generally perceived as inconvenient and home-based infusion therapy is greatly appreciated by patients, their families and healthcare professionals. Patients can get familiar with infusion therapy in a hospital setting and, if specific requirements are fulfilled, routine nurse-assisted infusion, or self-care, at the patient's home can be organized. A stable patient who tolerates the infusion and a suitable home environment are prerequisites for home therapy. The authors' clinical experiences underscore the safety and practicality of home therapy. In addition to a major positive impact on the patient's quality of life, home infusion therapy may reduce the constraints of hospital resources. This article reviews the collective experiences with agalsidase beta home infusion therapy and outlines how safe, patient-centred homecare can be organized. Home infusion therapy with Fabrazyme should not be withheld from patients considered eligible according to the proposed criteria. Similar approaches to other enzyme therapies are also possible.     

Fluid and electrolyte disturbances associated with cancer and its treatment

Individuals with cancer are subject to fluid and electrolyte imbalances because of the original disease process, therapy, and complications resulting from both the disease process and from therapy. These imbalances are life threatening either when they become extreme or when they occur very rapidly. Although almost any fluid and electrolyte disorder or combination of disorders can occur in people with cancer, this article will focus on the following more common, potentially critical imbalances: water excess, decreased vascular volume, hypercalcemia, hypokalemia, and tumor lysis syndrome, which includes hypocalcemia, hyperphosphatemia, hyperuricemia, and hyperkalemia. These imbalances will each be reviewed with a focus on their causes, signs and symptoms, and treatment. Additional readings on fluid and electrolyte imbalances in patients with cancer can be found in several recent articles.     

Pulmonary disease in the immunocompromised host. 1

With few exceptions, pulmonary complications in the immunocompromised host will proceed to death unless the clinician intercedes. The differential diagnosis of diffuse pulmonary disease in this setting includes (1) infection, most commonly from opportunistic organisms; (2) recurrence or extension of the basic underlying disease process to involve the lungs; (3) adverse pulmonary reaction to drugs; (4) a new, unrelated disease process such as cardiac pulmonary edema or pulmonary emboli; and (5) any combination of these categories. Up to a third of these patients have two or more complications, such as pneumonitis from two different opportunistic organisms or an opportunistic infection and a drug-induced pulmonary complication. An understanding of the host defense that is compromised enables the clinician to narrow the differential diagnosis. The most common types of impairment of defense mechanisms are reductions in the number of granulocytes, B-lymphocytes, or T-lymphocytes, and not uncommonly, two or all three of these types of cells are involved. Impairment of each of these cell types is associated with an increased frequency of infection by a particular group of organisms. Consequently, the clinician can be somewhat selective if empiric therapy is being considered. In the immunocompromised patient, most pulmonary complications, including drug-induced pulmonary disease and pulmonary emboli, are associated with fever that mimics an infection. Up to 25% of the pulmonary complications in these patients are noninfectious.     

Cetuximab: adverse event profile and recommendations for toxicity management

Cetuximab (Erbitux, IMC-C225, ImClone Systems Incorporated, New York, NY) is a monoclonal antibody targeted to the epidermal growth factor receptor. Expression of the epidermal growth factor receptor is associated with disease progression, poor survival, poor response to therapy, and the development of resistance to therapy in many solid tumors. Cetuximab blocks the binding of natural ligands to the epidermal growth factor receptor, thus inhibiting oncogenic processes associated with its activation. Infusion reactions, acneform skin rash, and nail disorder are the most clinically relevant adverse events observed. Because infusion reactions can be life threatening when severe, nurses must administer prophylactic treatment with an H1 antagonist prior to infusion and actively manage cetuximab-related infusion reactions when they occur. Management of infusion reactions typically includes vigilant patient monitoring, appropriate medical supervision, readily available resources for the treatment of infusion reactions, and initiation of institution- or practice-specific protocols when necessary. Acneform skin rash is the most common adverse event, but severe (grade 3 or 4) rash requiring interruption of treatment is not common. Topical and systemic antibiotic therapies may be administered to reduce symptoms. Nail disorder typically is mild to moderate and is observed infrequently; this also may be treated with systemic and topical antibiotics. Overall, the safety profile of cetuximab is favorable compared to that typically seen with chemotherapeutic agents. The acneform skin rash and nail disorder, which may affect quality of life, rarely threaten the general well-being of patients and typically are manageable.     

Choosing the right intravenous catheter

Infusion therapy in the home has been common for many years. The therapies appropriate for home infusion are numerous. The type of access device provided for the infusion is an important consideration for safe and effective care. That choice will take into consideration physician and patient preference and length of therapy. However, paramount to this decision are the characteristics of the infusate. It is essential to know the pH and osmolality of the drug as well as its potential vesicant properties. The nurse needs to act as the patient advocate to ensure that proper catheter selection is made. Patient teaching should be aimed at recognition of complications and immediate interventions to avoid problems.     

Home infusion therapy. First things first: the patient and the prevention of central catheter infections

During the past seventeen years, I've had the privilege of working as a home healthcare nurse in two rural counties in the Upper Peninsula of Michigan. In the early 1990s, it was rare that our agency received referrals for IV antibiotics, opiate infusions for pain management or for total parenteral infusion (TPN) to be administered at home. Most patients stayed in the hospital for infusion therapy. Today, as more healthcare treatments are being shifted from hospital to outpatient or home care settings, referrals for home infusion have become more common in our area as well as across the nation (Jarvis, 2001). I'll never forget my first patient whom I cared for with home infusion therapy for pain management. I learned a great deal from Sally, and to this day I always remember that I can make a real difference in patient outcomes when I keep--"First Things First": the patient and infection prevention--when caring for any of my patients.     

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.     

Intravenous infusion by superficial vein in the neonate

State-of-the-art equipment, such as extremly-low-volume controlled infusion pumps and Teflon catheters, has simplified the management of intravenous therapy in the newborn. This article details the proper I.V. insertion procedure for neonates. It also reviews indications for neonatal infusion, preferred insertion sites, types of catheters currently in use, and potential complications relevant to neonatal intravenous care.     

Carotid Doppler ultrasound findings in patients with left ventricular assist devices

Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory to medical management, as bridge therapy to myocardial recovery, as bridge therapy to cardiac transplantation, or as destination therapy for patients with unfavorable transplant candidacy. Neurologic complications are some of the most common and devastating complications in these patients. Preoperative carotid ultrasound is, therefore, a standard evaluation in patients at risk for cerebrovascular disease. Postoperative carotid artery Doppler sonography is performed in those patients with neurologic symptoms. It is likely, therefore, that sonographers, radiologists, and other physicians working in a center where LVADs are implanted will likely encounter a carotid artery Doppler study in this patient group. To our knowledge, the carotid Doppler findings in these patients have never been published. We review the Doppler ultrasound findings in 6 patients after LVAD insertion.     

Extracorporeal membrane oxygenation: current use and future directions

Extracorporeal membrane oxygenation (ECMO) is the process of using prolonged cardiopulmonary bypass to support patients with reversible respiratory and/or cardiac failure who are refractory to maximal conventional therapy. This process has been used extensively for critically ill neonates, with encouraging results. The use of ECMO in the pediatric population has been limited but is increasing. The history, mechanics, and current applications of ECMO are discussed in this article. Critical care nursing management of the pediatric or neonatal ECMO patient focuses on optimizing recovery of the pulmonary and/or cardiac system while preventing complications. A case study of a pediatric ECMO patient is presented which illustrates the complex nursing care issues related to use of this intervention. Future directions for ECMO are addressed.     

Head trauma

Head injury is a common occurrence in the multiply injured patient. Because it is so common, physicians in busy emergency rooms should be well versed in its evaluation and treatment. A guide to appropriate evaluation and treatment has been established by Becker et al. Patients can be divided into four categories, depending on degree of neurologic injury. Group I patients suffer transient loss of consciousness only and then return to normal; they require observation only. Group II patients suffer loss of consciousness and continue to have impaired cognitive functions; they require observation and a CT scan. Group III patients suffer loss of consciousness, continue to have disordered cognitive functions, and have significant motor deficits. This group can be subdivided into patients with and without focal neurologic deficits. Both of these will require aggressive therapy to control intracranial hypertension, CT scanning, and possibly surgery. The last category, group IV, includes patients who meet the requirements of brain death. No further work-up or therapy is needed for this group. Patients who suffer head injury are at risk for many complications, but two that are emphasized are postconcussion seizures and the postconcussion syndrome. Identifying factors that predispose the patient to these complications can help to minimize their occurrence.     

Fluid and electrolyte disorders associated with diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic coma

DKA and HHNK are emergency conditions requiring quick medical care and nursing intervention. DKA can develop at any age and is most likely to occur in the insulin-dependent patient. The hallmark signs of DKA are a relative or absolute lack of insulin along with acidosis, ketosis, and hyperglycemia. Insulin and fluid and electrolyte therapy are initiated to control the hyperglycemia and prevent shock and further complications. The patient in HHNK presents with a very high serum glucose level (higher than in DKA), a high serum osmolarity, and usually no ketosis or acidosis. The patient may also experience more severe and sudden neurologic changes than those in DKA. Most patients who experience HHNK are older and may also have some other underlying disease process present. The nursing process should be used to correct the fluid and electrolyte imbalances and to prevent further complications in both DKA and HHNK. The patient needs to understand the reasons for his or her hyperglycemic crisis and how to prevent it from occurring in the future. Assessment of the patient's knowledge about diabetes is essential so that proper education can be incorporated into his or her plan of care.     

Infusion therapy part one: minimising the risks

The role of the nurse in infusion therapy has evolved with advances i in vascular access technology and the variety of infusion devices available. With increasing numbers of patients requiring vascular access for a range of parenteral therapies, nursing staff need to demonstrate an understanding of the range and management of vascular access devices (VADs) and the clinical indications for individual devices. This article, the first of two, provides information on the type of VADs available and emphasises the importance o patient assessment to ensure safe, reliable and high-quality care for individual patients. The second part, to be published next week, examines some of the common complications associated with infusion therapy and identifies preventive measures.     

Neonatal necrotizing enterocolitis: diagnosis, management, and pathogenesis.

The diagnosis of neonatal necrotizing enterocolitis is one of great concern to pediatric and neonatal clinicians. Intravenous access remains an integral part of the medical and surgical management of infants with this diagnosis, and the infusion nurse is intimately involved in the care of these patients. This article discusses the definition of necrotizing enterocolitis, presents current knowledge regarding its basic pathophysiology, and identifies common and rare sequelae of this oftentimes devastating disease of premature infants. Medical and surgical management goals of therapy are described. This overview will aid the infusion nurse in caring for these patients.