Top Tips for Paediatric Oncology Lines

Cite this article as:
Ana Waddington. Top Tips for Paediatric Oncology Lines, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25732

Are you involved in the care of paediatric hickmans, port or picc lines  in paediatric patients? Lines, particularly those for oncology patients can sometimes leave nursing and medical staff all tangled up. Thanks to the Royal London Hospital Paediatric Oncology team, Ana Waddington and Amanda Ullman we are happy to share some handy top tips to improve line care:

    1. Use aseptic non touch technique (ANTT) when accessing Oncology patients Central venous lines 
    2. Clamping sequence is important, to prevent back-flow of blood up the device. But, the sequence (including positive vs neutral pressure) depends on the needleless connector that you use. Always check the manufacturer’s recommendations.
    3. Securing your line:  Always have at least one securement device (e.g., sutures, clasp, reinforced dressing) to keep the central line in the correct place – and two is even better
    4. Flushing: Flushing the central line with 0.9% sodium chloride after administration of viscous fluids is vital to prevent occlusion. 
    5. When accessing a totally implanted device (e.g., port-a-cathTM):
      • Consider local anaesthetic prior to insertion (e.g., LMX, Ametop, Emla)
      • Pinch the edges of the port- a cath to secure the location to insert your needle
      • Insert at 90 angle until you feel the needle hit the back
      • Don’t force it- you may cause some injury to the port chamber
      • Try repositioning yourself and the patient to an angle that feels more comfortable
      • If under the armpit, try lifting the patient’s arm to stretch the skin
      • Try not to go where there is bruising, adjust the skin
    6. There are 2 types of occlusion – Withdrawal Occlusion and Total Occlusion
        • Withdrawal Occlusion – flush gently with 0.9% Sodium chloride, get patient to look up and away from their line as they maybe causing an internal kink, change their position, if unsuccessful then can use Urokinase/Alteplase
        • Total Occlusion – Change bionector, take dressing down to check for external kinks, get patient to look up and away from their line as they maybe causing an internal kink, change their position, if unsuccessful then can use Urokinase/Alteplase
    7. No matter what the presentation (e.g., injection vs aspirate occlusion) always think through the possible causes, while problem-solving:
      • Consider mechanical occlusion: e.g., do you have malfunctioning needleless connectors? Are there external kinks? Plus [really importantly] is the tip position central? 
      • Consider infusate occlusion: i.e. have you just administered medications that may have precipitated? If so, talk to your pharmacist about how to dissolve.
      • Then think about thrombotic occlusion, and consider administering thrombolytic agents, like urokinase. If this doesn’t work, consider imaging e.g., lineogram
    8. Do not use prefilled syringes to flush off a PICC, as these are luer lock not luer slip syringes and they cause the PICCs to block
    9. Do not put heparin into a PICC line, they are to be flushed with 0.9% Sodium Chloride
    10.  If you run into trouble and are not sure what to do- make sure that you seek help with senior staff of your team, check your hospital policy/guidelines and the manufacturer instructions to solve the problem together.

For your convenience, the top tips are summarised in an A4 poster format (infographic by Grace Leo):

HeadSmart: Shaarna Shangamudavadivel at DFTB19

Cite this article as:
Team DFTB. HeadSmart: Shaarna Shangamudavadivel at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22597

Shaarna Shangamudavadivel is the HeadSmart fellow and currently doing her Ph.D. in how we can reduce diagnostic delays in the field of paediatric oncology. Paediatric cancers are rare but we’ll never pick them up if we are not aware of our unconscious biases, if we do not actively look for the zebras.

 

 

Doodle Medicine sketch by @char_durand

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. .

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Beads of Courage

Cite this article as:
Thom O'Neill. Beads of Courage, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14526

You know that feeling when something is completely and utterly good? Where there are no catches, no downsides; just pure unfiltered goodness. When you discover something that you believe couldn’t possibly get any better? Beads Of Courage – a simple yet beautiful programme to mark a child’s journey through illness – rouses that exact feeling.

Acute lymphoblastic leukaemia – presentation

Cite this article as:
Henry Goldstein. Acute lymphoblastic leukaemia – presentation, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.1248

Hamish, 5, has been tired and miserable for the last week of the school holidays. On the second day back at school, his Mum is asked to collect him after a bleeding nose that lasts about fifteen minutes. The teacher comments to Mum that Hamish is looking a bit “thin & pale”, and they’ve noticed a lot of bruising on his shins.

The GP agrees and orders a full blood count, which shows: Hb 50 g/L (100 – 150); Plt 2 x109/L (150 – 450); WCC 45.8 x109/L (80% lymphocytes, 30% blasts); “Blasts seen on film”.

View all our Acute Lymphoblastic Leukaemia Week posts

Bottom Line

ALL is the most common childhood haematological malignancy

Paediatric oncology is strongly consultant-driven

First presentation to the tertiary oncology centre is extremely stressful and a medically intense time

Aim is to achieve remission in induction

ALL may present in a broad variety of signs & symptoms<

The GP phones you, the Paeds Oncology registrar, with these results, and Hamish soon arrives into Emergency. You phone the consultant, who attends to meet family, take the history and examine Hamish.

Hamish looks pale but bright eyed. Vitals are 36.9oC, HR 130, RR 25, SaO2 97%, BP is normotensive with brisk capillary refill.

Further History

Has been grizzly and “not himself” for the last ten days: picking at food; complaining of sore legs for 2/7.  Not recently unwell/coryzal symptoms/diarrhoea. No wheeze. No steroid exposure. No blurry vision. Developmentally meeting milestones. No FHx of childhood malignancy.

(When taking the history, specifically ask about B symptoms: fever, night sweats, and weight loss).

Further examination

Pale boy with signs of weight loss. Bruising of the elbows, knees and legs. HS 2+ flow murmur. Lungs – no wheeze, good equal air entry. Abdomen soft, bowel sounds, liver 5cm below the costal margin, spleen 8cm below costal margin, not tender. Enlarged inguinal nodes bilaterally. Testicular examination – normal size for age. Aside from the bruising, you identify no areas of broken skin, boils, erythema or rashes. ENT examination is unremarkable. Fundoscopy unremarkable.

(Also, note any dysmorphism, Tanner stage, Lansky performance score).

What is ALL?

Acute lymphoblastic leukaemia is the most common childhood cancer. It is bimodal in incidence in childhood with peaks at around 2 years, and then at around 16 years of age.

ALL accounts for around 80% of childhood leukaemias, the remainder being acute myeloid leukaemia and rarer types. Approximately 85% of children with acute lymphoblastic leukaemia have B-cell ALL, with ~15% having T-Cell ALL. 2-3% will have Burkitt lymphoma, a mature B-cell leukaemia, treated differently from most leukaemias.

How does ALL usually present?

The most common presentations are with bone pain. Many children experience bone aches due to ‘growing pains’, so it’s important to know how to differentiate bone pain related to oncology issues, and growing pains.

  • bone pain tends to wake you up in the middle of the night, whereas growing pains are usually felt more when the child is falling asleep
  • children with growing pains should not have difficulty walking
  • growing pains tends to present as a pattern i.e. same type of pain at the same of day
  • children with growing pains will have completely normal blood counts
  • there should be no fever or weight loss associated with growing pains

As with this case, ALL can also present with bleeding. Other presentations include splenomegaly (10-20%), mediastinal mass, renal failure (due to hyperuricaemia), or leukostatic symptoms (respiratory distress, altered mental status) in patients with a high WCC .

Rarely patients who initially are thought to have ITP actually turn out to have ALL.

ALL can also include extramedullary sites e.g. CNS, testes, liver/spleen, kidneys, skin (rare). With this in mind, the list of presenting features include…

  • Typically weight loss (or failure to thrive), anaemia, fatigue will be present
  • Bone or joint pain
  • Bruising
  • Epistaxis or bleeding gums
  • Recurrent fever (low grade)
  • Persistent cough
  • Dizziness
  • Lymphadenopathy (including tonsillar hypertrophy)
  • Priapism
  • Wheeze (from a mediastinal mass) or
  • Blurry vision/diplopia
  • Testicular enlargement
  • Headaches (with papilloedema & retinal haemorrhages)
  • Respiratory distress (hyperviscosity)
  • Cranial nerve palsies

Practical points at diagnosis

For some paeds oncology departments, there is a policy that the most senior ED doctor should place the cannula for a patient’s first presentation. In a stressful time for the child and family, this is a drip that needs to go in first time with as little fuss as possible. It is important for the medical staff to build trust with child and family early.

Although most specialties would have the registrar or senior resident “do the admission”, oncologists will often meet the family as soon as they are referred. The family will be seeing a lot of their oncologist, and establishing trust and rapport very early in the piece is important.

In this kind of presentation – from the community in a stable child during daylight hours – the oncologist will often have spoken to the haematologist about the film prior to meeting the patient. This enables them to give the most likely diagnosis (based on the film and history/examination) & answer a few questions.

References

National Cancer Institute – Childhood Acute Lymphoblastic Leukaemia Treatment (PDQ) – Risk-based Treatment Assignment

Peppercorn J et al. Comparison of outcomes in cancer patients treated within and outside clinical trials: conceptual framework and structured review. Lancet 2004; 363: 263–70

QPHON Guide to the Care of Children with Cancer in Queensland Document No. 2.1 15062012 © 2012 State of Queensland Queensland Health. via Q-Health intranet.

Febrile neutropenia

Cite this article as:
Henry Goldstein. Febrile neutropenia, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2912

You’re working as the paeds reg overnight at a regional centre when ED phones you about an incoming patient – Josef, 8 – who’s in a delayed intensification cycle of his treatment for ALL and has a fever of 38.6oC. Josef’s last chemotherapy was last week, and an FBC done 2 days ago showed WCC 4.0×109/L with an absolute neutrophil count 0.9×109/L.

 

Bottom Line

  • Fever in the setting of neutropaenia may be the only herald of a severe, potentially life-threatening infection.
  • Febrile neutropenia is an oncologic emergency.
  • A thorough history and physical examination are essential in cases of febrile neutropaenia.
  • Find and follow your local protocol and discuss it with a senior early.
  • Isolate the child to reduce the chances of further infection.

 

Why is fever in an oncology patient dangerous?

Febrile neutropaenia may be the only feature of a life-threatening infection, a major cause of morbidity and mortality in paediatric oncology patients. A 2005 study of over 12000 children established a mortality rate as high as 3%. Around 1 in 5 children will have microbiologic evidence of infection during induction chemotherapy, and this number jumps to ~40% if the fever returns upon ceasing antibiotic therapy.

 

You move Josef to a resus bay with isolation (and cytotoxic) procedures in place. He is febrile to 38.6oC, mildly tachycardic but normotensive. You do not identify an immediate threat to life after considering shock, overwhelming sepsis, respiratory compromise.  You take a thorough history and examine Josef.

 

What is the criteria for febrile neutropenia?

Fever is any temperature >38.5°C, or >38.0°C for one hour.

Neutropenia is an absolute neutrophil count  <0.5×109/L, or <1×109/L with a predicted decline to less than 0.5×109/L within 48 hours.

What are the specific features of the history?

What is the child’s oncology diagnosis and where in the treatment course are they? Different chemotherapeutic agents have relatively stronger myeloablative effects, leading to more fulminant and predictable neutropenia. As chemo agents vary with diagnosis and cycle, it’s important to clarify which medications have been given and the number of many days since last chemotherapy.

Compliant with antifungal & pneumocystis prophylaxis? Think about PCP pneumonia in any oncology child presenting with work of breathing.

What kind of central venous access +/- last accessed? Central venous access is a double-edged sword – an essential access for chemo that allows a reduction in the number of peripheral venipuncture, but also the most common source of bacterial infection in chemo kids.

Sick contacts? Remember, just because your patient has an oncology diagnosis doesn’t mean they don’t catch other age-appropriate illnesses, like gastroenteritis, upper respiratory infections and the like. Of course, they’re often more severe, but it’s important to look!

 

Specific features on examination?

Examine for signs of dehydration, sepsis and anaemia.

Examine the central line site. A good time to look is when the line is being accessed for cultures. Check the age of the dressing and note any erythema or cracks in the line.

Look at the skin all over.

Examine as for a fever without source.

Have a good look in the mouth – mucositis is common and a possible entry site.

Likewise, the perianal area is susceptible to skin breakdown, with or without perianal abscesses.

Take particular note of any areas of erythema.

 

Why is skin erythema of particular importance?

It’s worth considering the pathophysiology of erythema; local inflammatory mediators (IL-1, IL-6, TNFa) signal neutrophils to marginate, roll and undergo diapedesis to the area of action. But in the absence of a full neutrophil response, any localized erythema will likely be reduced, and pus not formed in the usual volume.

Thus, the smallest area of erythema should be considered as a possible source for infection, especially around central access sites or surgical wounds.

 

Which investigations are indicated?

FBC (are they actually neutropaenic?)

Blood culture (central lines/PICC)

Urea & electrolytes, consider calcium, magnesium, phosphate (dehydration, renal dysfunction, tumor lysis syndrome)

Liver function tests (liver dysfunction secondary to chemotherapy agents)

Urinalysis (clean catch)

CXR if increased work of breathing, poor SpO2

Nasopharyngeal aspirate if rhinorrhoea (make sure the PLT >50×109/L beforehand)

Consider coagulation profile

Focused investigations as per history and examination

Stool sample if diarrhoea, with C. difficile toxin if on recent antibiotics

 

IV access is gained, via Josef’s tunneled central line, by an experienced staff member. Bloods are sent for FBC, culture and UEG, LFT, Ca/Mg/PO4, coags.

 

What is the management?

Most hospitals have well-established protocols for the treatment of febrile neutropenia. Be aware of where to find yours and the choice of anti-infective agents.

Start antibiotic treatment promptly; it may be life-saving. This is not a time to faff about waiting for the results of investigations as antibiotics are the treatment irrespective of any preliminary results.

Some protocols advise anti-fungal treatment in addition to antibiotics. These protocols will vary between centres and over time with changing resistance patterns.

Remember to discuss your patient with the oncologist on call; these kids will usually need admission and, on occasion, transfer to the tertiary oncology centre.

Antibiotics are the mainstay of treatment in febrile neutropaenia. Miadema and her Dutch colleagues are presently undertaking a Cochrane Review of intravenous vs oral empiric treatment of febrile neutropaenia.

The Therapeutic Guidelines currently recommends:

Piperacillin+tazobactam 100+12.5mg/kg (Max 4+0.5g) IV q8h

or cefipime 50mg/kg (Max 2g) IV q8h

or ceftazidime 50mg/kg (Max 2g) IV q8h

If you have a suspicion of MRSA, central line infection or haemodynamically unstable, add vancomycin. Gentamicin or amikacin may be indicated.

Treat dehydration with the appropriate fluids and if the child is nauseated or vomiting, antiemetics.

 

References

Basu, K et al. Length of stay and mortality associated with febrile neutropenia among children with cancer. J Clin Oncol. 2005 Nov 1;23(31):7958-66.

RCH Melbourne CPG – Febrile Neutropenia 

Management of Fever in the Paediatric Oncology Patient v3.0 17102012 Febrile Neutropenia Protocol QPHON QCCC

Miadema et al. [Protocol] Empirical antibiotic therapy for febrile neutropenia in pediatric cancer patients. Cochrane Library.

Lehrnbecher, T. Guideline for the Management of Fever and Neutropenia in Children With Cancer and/or Undergoing Haematopoetic Stem-Cell Transplantation. JCO Dec 10, 2012, vol. 30, no 35 4427-4438

Afzal, S. et al. Risk Factors for Infection-Related Outcomes During Induction Therapy for Childhood Acute Lymphoblastic Leukemia, The Pediatric Infectious Disease Journal • Volume 28, Number 12, December 2009 pp 1064-68

Therapeutic Guidelines : Antibiotic. Severe Sepsis: empirical therapy (no obvious source of infection): febrile neutropenic patients. Therapeutic Guidelines Group. Revised June 2010. (etg40 July 2013)