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These guidelines relate to the initial assessment and immediate management of Acute Oncology patients, i.e. patients presenting with an acute problem, demonstrating symptoms deemed as having been caused by:
It is emphasised that these guidelines focus on initial assessment at presentation and management for the first 24 hours. Patients should be referred to, or discussed with the Acute Oncology Team as soon as possible following presentation. The Acute Oncology team will provide further advice and on-going management guidance.
To aid in this urgent initial assessment, each protocol follows a RAG (Red, Amber, Green) format and quick reference assessment, which is in line with the UKONS Oncology/Haematology 24-Hour Triage Tool (V2, 2016):
https://www.ukons.org/site/assets/files/1134/triage_tool_poster.pdf
The Common Terminology Criteria for Adverse Events (CTCAE Version 4.3), an international standard set of criteria for defining adverse events (AE) and their grading within clinical trials and the routine management of Oncology/Haematology patients, has been applied to assist with the recognition and management of AE:
http://www.hrc.govt.nz/sites/default/files/CTCAE%20manual%20-%20DMCC.pdf
These guidelines are intended for use by all health care professionals who assess and/or manage acute oncology patients at presentation. The guidelines may also be useful as an adjunct to the UKONS Triage tool when providing care advice following telephone triage Appendix Page.
They are mostly single-page "see-and-treat" guides. Whilst drug names may be referenced within each protocol, this is offered as a guide only; it is acknowledged that local variation may apply.
Please be aware of NICE National Guidelines/ Pathways for the management of:
The development and consultation group worked to provide a set of generic guidelines based on national guidance and clinical expertise. They have now been reviewed and updated to ensure that they remain applicable and cover current best practice in the management of treatment induced toxicity and acute disease related complications.
The authors request that the original source is acknowledged in all copies or adaptations.
These Guidelines are for the use of medical professionals only. They are not intended for public use, including by oncology patients. UKONS does not permit the creation of derivative works, unless they are authorised.
The information contained in these guidelines is a consensus of the development and consultation groups' views on current treatment. They should be used in conjunction with any local policies/ procedures/ guidelines and should be approved for use according to the trust clinical governance process. Care has been taken in the preparation of the information contained in the guidelines. Nevertheless, any person seeking to consult the guideline, apply its recommendations or use its content is expected to use independent, personal medical and/or clinical judgment in the context of the individual clinical circumstances, or to seek out the supervision of a qualified clinician. The United Kingdom Oncology Nursing Society makes no representation or guarantee of any kind whatsoever regarding the guidelines content or its use or application and disclaim any responsibility for its use or application in any way.
The development of this App has been supported by grants from Bristol Myers Squibb (BMS) and Roche Products Limited. BMS and Roche Products Limited has had no control over the content of this App.
The following professional bodies have reviewed the guidelines and support use in practice:
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Patients with a suspected neutropenic sepsis will require IV antibiotics within 1 hour of presentation for assessment; this should be managed as per Guideline 12 - Neutropenic Sepsis
Requires IMMEDIATE medical assessment!
Hypersensitivity or an allergic reaction is an inappropriate and excessive reaction to an allergen; severity ranges from mild allergy to severe systemic reactions leading to anaphylactic shock if left untreated.
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life-threatening problems involving: the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes.
Treat as an emergency according to Resuscitation Council Anaphylaxis Guidelines:
https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/
Signs and symptoms:
Assessment: ABCDE approach
Observations: Calculate and monitor NEWS score. ECG cardiac monitoring.
Questions:
Differential diagnosis includes:
If this occurs during administration of treatment - STOP infusion/transfusion immediately.
Anaphylaxis - Airway, Breathing, Circulation problem - life threatening consequences; urgent intervention required.
Prolonged signs and symptoms not rapidly responsive to medication and/ or brief interruption of infusion or recurrence of symptoms following initial improvement.
Intervention or infusion interruption indicated; all symptoms respond promptly to treatment (e.g. antihistamines; NSAIDS, IV fluids).
Mild transient reaction: intervention or infusion interrupted not required.
Treat as an emergency according to the Resuscitation Council Anaphylaxis Guidelines - Page 7
Patients with a good response to initial treatment should be warned about recurrence of symptoms and in some circumstances be kept under observation for 24 hours.
This includes the following:
Normally a symmetrical widespread joint pain but can also be associated with muscle pain (myalgia).
Certain drugs can cause arthralgia, including: Taxanes, BRAF inhibitors, GCSF, immunotherapies.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant, they may be myelosuppressed/ neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es and Ca2+.
For patients receiving or received immunotherapy consider:
Questions:
Bedridden or disabling.
Severe pain - and/or loss of ability to perform some activities.
Moderate pain - interfering with some normal activities.
Mild pain - not interfering with daily activities.
Requires IMMEDIATE medical assessment!
Bleeding can occur secondary to injury, disease, or as a side effect of treatment. It can be a life-threatening event if massive blood loss or spontaneous bleeding occurs.
Thrombocytopenia is a reduction in the number of platelets in the blood. If platelet count is < 50 bleeding and or bruising may occur with minor trauma.
Intracranial haemorrhage is more likely if there is sepsis and a platelet count of < 20.
In a non-septic patient a platelet count of 10 or above may be adequate in the absence of additional risk factors for bleeding.
Coagulation abnormalities - due to disease e.g. liver metastases or disseminated intravascular coagulation (DIC) or treatment e.g. anti-coagulation therapy.
Identify: patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant, they may be myelosuppressed / neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis immediate antibiotics if sepsis suspected.
Many haematological disorders (malignant and non-malignant) can cause thrombocytopenia. Some patients, e.g. those with chronic lymphocytic leukaemia (CLL) or lymphoma may develop idiopathic thrombocytopenic purpura (ITP).
Consider viral infection e.g. parvovirus B19 as a cause of thrombocytopenia.
Patients who are receiving certain systemic anti-cancer treatment are at risk of thrombocytopaenia
If present, these conditions should be managed according to approved guidelines.
Observations: Calculate and monitor NEWS score.
Investigations: Urgent FBC, U&Es, LFT. Consider group and cross match, coagulation screen, INR (if on Warfarin), APTT ratio (if on IV Heparin). Anti-Xa level if on low molecular weight (LMW) heparin, as it can accumulate in the presence of renal failure. Fibrinogen if considering DIC.
Examination: Associated symptoms: Light headed, pallor, clammy, thirst, rash (petechial/purpura/punctate)
Questions:
Massive bleeding blood loss of > 4 units.
Life-threatening haemorrhage.
Bleeding - blood loss of 3 - 4 units.
Bruising - generalised petechiae, purpura and or bruising. New bruises, without significant trauma.
Bleeding - blood loss of 1-2 units.
Bruising - moderate petechiae, purpura and/or generalised bruising, with or without trauma.
Bleeding - mild self limiting, controlled by conservative measures, ecchymosis, occult blood in secretions
Bruising - petechiae or bruising in a localised or dependant area, with or without trauma.
Requires IMMEDIATE medical assessment
Pain may result from a wide range of causes, there is an urgent need to diagnose the cause of any patient presenting with chest pain to ensure that serious and life-threatening conditions are not missed.
Identify: Patients within 6/52 of chemotherapy specifically patients currently receiving 5 fluorouracil (5FU) or capecitabine, which can cause coronary artery spasm. Patients may be taking these drugs orally at home or via continuous infusion. Other chemotherapy drugs/monoclonal antibodies can cause reduction in heart function, but this is not usually an acute presentation.
All cancer patients have an increased risk of pulmonary embolism.
Observations: Calculate and monitor NEWS score.
Investigations: Urgent FBC, U&Es, Cardiac markers/Troponin. Urgent ECG. Consider ABGs, CTPA.
Questions:
Action: treat chest pain as 'Red' until proven to be non-cardiac/life-threatening.
The aim is to exclude a life-threatening cause, which needs immediate treatment, from other causes of chest pain.
If PE strongly suspected and same day CTPA not possible, consider commencing treatment with LMWH pending definitive investigation/diagnosis.
! Is the patient connected to an ambulatory intravenous infusion pump of 5 fluorouracil (SACT)? - If so arrange urgent disconnection.
! Is the patient taking oral SACT such as capecitabine? - If so ensure patient does not continue with this medication.
! These patients may also be myelosuppressed/neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Admit for monitoring and on-going assessment and management in accordance with local trust guidelines.
Initial triage assessment within 15 minutes.
Irregular and infrequent or difficult evacuation of the bowels; can be a symptom of intestinal obstruction or diverticulitis.
Identify: Patients who have received/receiving SACT or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed / neutropenic and at risk of sepsis. Immediate antibiotics if sepsis suspected. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis
Observations: Calculate NEWS score. Presence of bowel sounds.
Investigations: Urgent FBC, U&E, CRP, Ca2+, and LFTs. Consider abdominal X-ray.
Questions:
Examination: PR Examination (with caution in haematology patients). Presence and nature of bowel sounds. Rule out signs and symptoms of bowel obstruction.
N.B. constipation may be a presenting symptom of MSCC or hypercalcaemia. Ascites can often aggravate constipation - if present consider drainage.
Differential diagnosis includes:
No bowel movement for > 96 hours - consider paralytic ileus or bowel obstruction.
Severe - no bowel movement for 72 hours over pre-treatment normal.
Moderate - no bowel movement for 48 hours over pre-treatment normal.
Mild - no bowel movement for 24 hours over pre-treatment normal.
Patients may also have:
Admit for:
Initial triage assessment within 15 minutes.
A disorder characterised by frequent and watery bowel movements. Grading is relative to normal baseline function.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed / neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis immediate antibiotics if sepsis suspected.
Observations: Calculate and monitor NEWS score.
Investigations: Urgent FBC, U&Es, Mg2+, LFT, CRP, phosphate. CDT screen. Consider checking total CO2 in serum or blood gases (arterial or venous) for pH/ bicarbonate with severe diarrhoea and potential bicarbonate loss. Stool sample for C&S/ova/cysts/parasites to rule out infective causes of diarrhoea-e.g. Campylobacter/salmonella, and CDT screen. Abdominal X-ray.
Questions:
Differential diagnosis includes:
Follow hospital infection control/prevention guidelines but -
Do NOT assume this is infective it is most likely to be drug induced in
this group of patients.
Increase > 10 episodes a day or grossly bloody diarrhoea.
Increase up to 7-9 episodes a day or severe increase in ostomy output and/or any of the following:
Increase up to 4-6 episodes a day over baseline or moderate increase in ostomy output or nocturnal movement or moderate cramping.
Increase up to 3 bowel movements a day over pre-treatment baseline or mild increase in ostomy output.
Patients with grade 3 or 4 diarrhoea require specialist secondary care to manage symptoms - IV resuscitation may be required. They should be admitted for further assessment and active management.
WITHHOLD SACT until Acute Oncology Team review and review all other medication as they may be contributing - if receiving Capecitabine or 5FU consider DPD deficiency.
If receiving or received immunotherapy treatment in the last 12 months - follow Guideline 21 - Gastro Intestinal Immune-Related Adverse Event (irAE).
Haematology patients - discuss with haematology team, urgently.
Further management detail below.
Review medication WITHHOLD DRUGS including any SACT that may be contributing until Acute Oncology or Site Specific team review.
ESCALATE TO RED for any of the following:
Initial Management
Requires IMMEDIATE medical assessment!
Difficulty breathing may include symptoms such as wheezing, choking, and a feeling of not getting enough air into lungs. Dyspnoea indicates a conscious appreciation of increased work done during breathing; principal factors in SOB are an increased work of breathing, increased ventilatory drive, impaired muscle function.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed/neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, Sputum and viral throat swab for C&S, blood cultures and CRP if pyrexial. ECG and CXR. Risk assess for VTE. Consider ABGs and troponin. Consider CTPA/VQ investigations to rule out pulmonary embolism, pneumonitis. Consider D-dimer. Serum β-D-glucan/galactomannan for fungal/Pneumocystis investigation in neutropenic/lymphopenic patients. If TB possible then test respiratory specimens for Mycobacterium tuberculosis. Consider GeneXpert PCR for TB in selected patients.
Questions:
Differential diagnosis includes:
Life threatening symptoms requiring ventilatory support.
New onset dyspnoea at rest.
New onset dyspnoea with minimal exertion.
New onset dyspnoea with moderate exertion.
Admit if evidence of:
For management of:
Initial triage assessment within 15 minutes.
Fatigue is a subjective unpleasant symptom, which incorporates total body feelings ranging from tiredness not relieved by rest or sleep to total exhaustion creating an unrelenting overall condition that interferes with the individual ability to function to their normal capacity.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed / neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, group and save, Ca2+, CRP, blood glucose, consider blood cultures. If the patient is receiving or has received immunotherapy in the past 12 months, check random cortisol, TSH and free T4.
Questions:
Differential diagnosis includes:
Bedridden or disabling.
Severe or loss of ability to perform some activities.
Moderate or interfering with some normal activities.
Increased fatigue but not affecting normal level of activity.
Requires IMMEDIATE medical assessment!
MSCC is due to a pathological vertebral body collapse or direct tumour growth causing compression of the spinal cord. Irreversible neurological damage ensues with resulting paraplegia. Early diagnosis and treatment is essential.
Identify:
Patients who have received/receiving systemic anti-cancer treatment or have a history of stem cell transplant are at risk of disease related immunosuppression. These patients may be myelosuppressed / neutropenic and are at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Key signs/symptoms:
If you have suspicion of MSCC then contact the Acute Oncology team and/or MSCC coordinator for advice regarding management.
Paralysis.
Severe sensory loss, paraesthesia or weakness that interferes with function.
Mild or moderate sensory loss, moderate paraesthesia, mild weakness with no loss of function.
Mild paraesthesia, subjective weakness; no objective findings.
N.B. Note: need for caution in patients with no previous known malignancy and lymphoma suspected as steroids might cause rapid resolution of the tumour, which may make histological diagnosis very difficult. If possible, steroids should be avoided before biopsy if lymphoma suspected.
For further information see NICE Metastatic Spinal Cord Compression guidelines at http://pathways.nice.org.uk/pathways/metastatic-spinal-cord-compression#
Initial triage assessment within 15 minutes.
An inflammatory reaction of the mucous lining of, the upper gastrointestinal tract from mouth to stomach (mouth, lips, throat), and surrounding soft tissues.
Identify: Patients who have received/receiving SACT or are at risk of disease related immunosuppression or a history of stem cell transplant (PBSCT). These patients may be myelosuppressed /neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, LFTs, CRP, Lactate and Blood Cultures (Oncology patients - consider the need for pathology investigations in grade 1 and 2 presentations on an individual basis and in light of any other presenting symptoms or risk factors)
Examinations and questions:Differential diagnosis includes:
Significant pain, minimal intake and /or reduced urinary output.
Painful erythema, and difficulty with eating and drinking.
Painful ulcers and /or erythema, mild soreness but able to eat and drink normally.
Painless ulcers, erythema or mild soreness, able to eat and drink normally.
Check all blood results and act on abnormalities e.g. Neutropenia or pancytopenia.
Assess for evidence of:
If receiving Capecitabine or 5FU consider DPD deficiency.
Admit for monitoring and management.
Consider parenteral hydration.
Analgesia, consider:
Assess for thrush/ candidiasis and arrange for an antifungal agent to be prescribed if required.
Consider referral to the SALT team and dietician for management support.
Consider the following mouth care advice:
Consider the following mouth care advice:
Initial triage assessment within 15 minutes.
Nausea is the sensation of being about to vomit. Acute chemotherapy induced nausea usually presents within the first 24 hours of receiving treatment. Delayed nausea may present any time after the first 24 hours and continues for up to 6 or 7 days after treatment.
Identify: Patients who have received/receiving SACT or are at risk of disease related immunosuppression or a history of stem cell transplant (PBSCT). These patients may be myelosuppressed /neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, LFTs, Ca2+, blood cultures and CRP. N.B. consider the need for pathology investigations in grade 1 and 2 presentations on an individual basis and in light of any other presenting symptoms or risk factors.
Questions:
Differential diagnosis includes:
Inadequate or no oral caloric and/or fluid intake.
Able to eat and drink but intake is significantly reduced.
Able to eat and drink with a reasonable intake.
IMMEDIATE assessment
Clinical suspicion of infection and potential for neutrophils < 0.5 x 109L (NICE)
Patients who have received or receiving SACT or have a history of myelosuppression or known bone marrow failure have the potential for neutropenia.
START TREATMENT AT POINT OF SUSPICION!
Initial assessment:
START TREATMENT AT POINT OF SUSPICION
Immediately:Take bloods and administer 1st IV antibiotics (DON'T wait for FBC result)
Door to needle time for first antibiotics should be less than one hour.
Clinical assessment:
Helpful link ED/AMU Sepsis Screening & Action Tool;
Sepsis
Trust - ED/ AMU Sepsis Screening & Action Tool
Signs of SEVERE sepsis - YES
Early signs of SIGNIFICANT sepsis - YES
Resuscitation Management:
Commence Neutropenic sepsis management:
Identify: Potential sources of infection
Rx: Presenting complaint/co-morbidity
Tx: ECG, ABGs, Urinalysis, and Swabs
Do not perform a CXR unless clinically indicated
1st line IV antibiotics in neutropenic sepsis as per NICE guideline:
NICE - Managing Suspected Neutropenic Sepsis in Secondary and Tertiary Care
Day One - Day of Admission | Day Two |
Monitoring | |
National Early Warning Score Chart (NEWS)
Every 15 minutes initially then regular monitoring according to patient's condition. |
NEWS Chart x 6 daily (every 4 hours)
Daily FBC and U&E blood tests. |
Chemotherapy Drugs | |
Discontinue on admission; ensure safe disposal of unused chemotherapy. | Do not recommence - requires oncology review. |
Antimicrobials | |
1st line antibiotics in neutropenic sepsis as per NICE guideline: Offer beta lactam monotherapy with piperacillin with tazobactam as initial empiric antibiotic therapy to patients with suspected neutropenic sepsis who need intravenous treatment unless there are patient-specific or local microbiological contraindications. Review previous microbiology results for multi-drug resistance (MDR) carrier status, e.g. MRSA, and consider adding appropriate treatment if MDR present. |
Improving?
Assess if all antibiotics still required and route of administration. Discontinue empiric antibiotic therapy in patients whose neutropenic sepsis has responded to treatment, irrespective of neutrophil count. Unresponsive fever 48 hours? Do not switch initial empiric antibiotics in patients with unresponsive fever unless there is clinical deterioration or a microbiological indication. Continue inpatient therapy in all patients who have unresponsive fever unless an alternative cause of fever is likely. |
Additional antimicrobials: Therapeutic monitoring/dose adjustment - Liaise with pharmacy and microbiology. | |
Do not offer an aminoglycoside, either as monotherapy or in dual therapy, for the initial empiric treatment of suspected neutropenic sepsis unless there are patient-specific or local microbiological indications. | Consider viral and fungal infections, liaise with microbiology. |
Cultures | |
Blood culture from central lines and peripherally, sputum, urine,
swabs-throat & skin lesions.
Liaise with microbiology prior to altering regimen. Do not remove central lines as part of initial management of suspected neutropenic sepsis. NB. Central lines may need to be removed in cases of severe sepsis, if unsure seek senior clinical support |
Liaise with microbiology reinterim results.
Re-culture patient before changing antimicrobials. |
Fluid and Electrolyte Balance | |
Aggressive fluid replacement in dehydration.
Hourly urine output measurement. Replace Na+ and K+ judiciously. Early critical care management if deterioration, severe sepsis (any evidence of organ failure) or suspected invasive fungal infection. |
Monitor fluid intake and output
Maintenance fluids as required. |
Assess the patient's risk of septic complications according to NICE
guidelines and MASCC score
Discharge only if:
|
Initial triage assessment within 15 minutes.
Skin rash can be a side effect of:
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of allogeneic stem cell transplant. These patients may be myelosuppressed / neutropenic and are at risk of neutropenic sepsis and/or thrombocytopenia due to reduced marrow production or marrow infiltration and/or graft versus host disease: If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, LFTs, CRP, blood cultures if signs of systemic sepsis.
Questions:
Differential diagnosis includes:
If any of the following are present:
If any of the following are present:
Rash covering < 10% BSA, Macular/Papular eruption. Asymptomatic
Consider the following mouth care advice:
Initial management:
On-going management:
Ensure general care measures:
Newer targeted anticancer therapies, particularly EGFR antagonists, BRAF, MEK and MTOR inhibitors, are frequently associated with skin toxicities, which are often seen in particular patterns and at different stages of treatment.
Initial Assessment
Observations: Calculate NEWS score.
Investigations: FBC, U&Es.
NB: Isotretinoin is not indicated for the treatment of papulopustular rash
Papules and/or pustules covering < 10% BSA ± pruritus or tenderness
General management and advice (and management of other skin toxicity patterns)
Xerosis
Nail changes
NB. If the patient is receiving or has recently received SACT treatment please see Guideline 13 - Skin Rash
Confluent moist desquamation. (RTOG 3)
Patchy moist desquamation, moist oedema (RTOG 2b)
Tender or bright erythema without moist desquamation (RTOG 2a)
Faint or dull erythema (RTOG1)
Head and Neck - Mepilex Lite/Border (No Nu-Gel)
Skin - Mepilex Lite/Border, Allevyn Gentle, Atrauman.
Pelvis - Nu-Gel, Sitz Bath, Fan Therapy and Instllagel (around urethra).
Breast - Aquacel, Mepilex Lite / Border
Other - Mepilex Lite / Border
Head and Neck - Mepilex Lite/Border (No Nu-Gel)
Skin - Mepilex Lite/Border
Pelvis - Nu-Gel, Sitz Bath and Fan Therapy
Breast - Mepilex Lite
Other - Mepilex Lite
Analgesia may be required.
Head and Neck - E45
Skin - E45
Pelvis - E45
Breast - E45
Other - E45
Ask patient to contact the 24-hour advice line if symptoms worsen.
The advice above is for a guide only and each patient should be assessed individually. If unsure about products to use please seek further advice.
For further information please see - https://www.sor.org/learning/document-library/skin-care-advice-patients-undergoing-radical-external-beam-megavoltage-radiotherapy-0
A distinctive localised cutaneous reaction to certain antineoplastic agents. Symptoms include: Tingling or burning, redness, flaking/dryness, swelling, small blisters, sores on palms and/or sole.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed/neutropenic and at risk of sepsis. If present, this should be managed according to Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis.
Observations: Calculate NEWS score.
Investigations: FBC, U&Es.
Questions:
Moist desquamation, ulceration and severe pain in hands and or feet
Painful redness and or swelling of hands and / or feet
Mild numbness, tingling, swelling of hands and/or feet, with or without pain or redness
Consider admission for further management if any signs of infection or other treatment related toxicities
Initial triage assessment within 15 minutes
The forceful expulsion of the contents of the stomach through the mouth, and sometimes the nose.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed/neutropenic and at risk of sepsis. If present, this should be managed according to Guideline 12 - Neutropenic Sepsis. - immediate antibiotics if sepsis suspected
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, CRP, LFT, Mg2+, Ca2+, Glucose, Blood cultures and CRP, Cortisol, consider check CO2 in serum, or blood gases (arterial or venous) for pH/bicarbonate due to H+ potentially causing metabolic alkalosis.
N.B. consider the need for pathology investigations in grade 1 presentations on an individual basis and in light of other presenting symptoms or risk factors.
Questions:
Differential diagnosis includes:
MASSC guidelines here (User Details Required) - http://www.mascc.org/antiemetic-guidelines
> 10 episodes in 24 hours
6 - 10 episodes in 24 hours
3 - 5 episodes in 24 hours
1-2 episodes in 24 hours
Immune checkpoint inhibitors (ICPi) have been causatively associated with a number of endocrinopathies, including hypophysitis, hypopituitarism and adrenal insufficiency. Patients may present with nonspecific symptoms, which may resemble other causes such as brain metastasis or underlying disease.
Endocrine function panel:
TSH, Free T4, ACTH, cortisol prolactin, blood glucose, LH, FSH +/- testosterone/oestrogen
(9am cortisol is preferable but random cortisol measurement should be performed if the patient is unwell)
NB Values will be lab assay specific.
Severe or Life-threatening (Grade 3 + 4)
Suspect adrenal crisis:
Hypovolemic shock
Hypotension - SBP < 90mm Hg
Postural hypotension - > 20mm Hg drop
Dizziness/ Collapse
Nausea/ Vomiting
Abdominal pain/ tenderness/ guarding
Fever
Confusion/ delirium/ coma
Hyponatraemia/hyperkalaemia
Hypoglycaemia
Pre-renal failure
Severely unwell patient: severe dehydration, abdominal pain, or shock.
Investigations:
Moderate - Symptomatic (Grade 2)
Suspect endocrinopathy based on symptoms: Tiredness/fatigue, headache, weight loss, susceptibility to infection.
Investigations:
Cortisol (9am) > 450 mmol/L
Action:
Cortisol (9am) 100 - 450 mmol/L
Actions:
Cortisol (9am) < 100nmol/L
Treatment:
Actions:
CAUTION
Mild - Asymptomatic (Grade 1)
Identified on routine blood test.
Biochemical alteration in cortisol with serum level < 450 mmol/L
Hypoadrenalism is likely if cortisol is < 100mmol/L
Cortisol 100 - 450nmol/L
Investigations:
Actions:
Cortisol < 100nmol/L
Investigations
Treatment
Actions
Society for Endocrinology [SfE] guidelines for adrenal crisis:
www.endocrineconnections.com/content/5/5/G1
ESMO Guidelines - http://www.esmo.org/Guidelines/Supportive-and-Palliative-Care/Management-of-Toxicities-from-Immunotherapy
Clinical presentation
Typically, hypophysitis presents with headache, fatigue and visual loss. There are a range of non-specific symptoms including nausea, diarrhoea, malaise and anorexia, which may represent pituitary dysfunction and a low threshold for clinical suspicion is required. However, these typical symptoms are common in patients with complications of cancer undergoing SACT and other differentials, such as CNS metastases need to be considered.
Endocrine function panel:
TSH, Free T4, free T3, ACTH, LH, FSH & cortisol prolactin, blood glucose +/- testosterone/ oestrogen.
(9am cortisol is preferable but random cortisol measurement should be performed if the patient is unwell)
NB Values will be lab assay specific.
Severe mass effect symptoms such as:
or
Severe hypoadrenalism i.e.
PERSIST > 48 hours WORSEN or RELAPSE
Investigations:
Treatment:
1 mg/kg /day to reduce pituitary oedema, if headaches or neurological problems are present.
Actions:
Moderate symptoms:
or
Symptoms: Resolve or Improve to Mild. See Guideline 27 - Steroid Tapering
Investigations:
Treatment:
0.5-1 mg/kg /day to reduce pituitary oedema, if headaches or neurological problems are present.
Actions:
Vague symptoms:
No headache
or
Asymptomatic
Investigations
Actions
CAUTION: If thyroid function is also compromised within a hypopituitary picture ensure cortisol is replaced for 24 - 48 hours prior to commencing thyroid replacement (for which hypothyroidism guidelines should be instituted - Guideline 20 - Endocrinopathies - Thyroid Dysfunction)
www.endocrineconnections.com/content/5/5/G1
ESMO Guidelines - http://www.esmo.org/Guidelines/Supportive-and-Palliative-Care/Management-of-Toxicities-from-Immunotherapy
Immune checkpoint inhibitors (ICPi) have been causatively associated with a number of endocrinopathies, including hypo/hyperthyroidism. Observational studies have shown that there is a typical pattern of thyroid specific biochemical disturbance presenting with asymptomatic hyperthyroidism, before return to normal levels for a brief period. This is nearly always followed by the development of, in some cases profound, hypothyroidism that is frequently persistent and requires long-term thyroid replacement. Smaller subsets of patients develop isolated hypothyroidism over a period of weeks. Both groups appear to require long-term replacement in a majority of cases. Thyroiditis and autoimmune Grave’s disease hyperthyroidism can occur as well as primary hypothyroidism.
Endocrine function panel:
TSH, Free T4, ACTH, cortisol prolactin, blood glucose, LH, FSH +/- testosterone/oestrogen.
(9am cortisol is preferable but random cortisol measurement should be performed if the patient is unwell)
NB Values will be lab assay specific.
Hypothyroidism
TSH of > 10 mULN and Free T4 < lower limit of normal (LLN)
NB Values will be lab assay specific.
Symptoms:
Investigations:
Hyperthyroidism
TSH < 0.40 mULN and Free T4> upper limit of normal (ULN)
NB Values will be lab assay specific.
If TSH low and T4 normal or low need to exclude pituitary dysfunction.
Check TSH receptor antibodies.
Symptoms:
Investigations:
Treatment:
Actions:
1. Asymptomatic
The majority of cases become hypothyroid within a matter of weeks.
Actions:
2. Symptomatic
The majority of cases become hypothyroid within a matter of weeks. If persistent manage in collaboration with an endocrinologist.
Added Investigations:
CAUTION: If thyroid function is also compromised within a hypopituitary picture ensure cortisol is replaced for 24 - 48 hours prior to commencing thyroid replacement (for which hypothyroidism guidelines should be instituted)
Society for Endocrinology [SfE]:
www.endocrineconnections.com/content/5/5/G1
ESMO Guidelines:
Gastrointestinal (GI) irAEs are among the most common, if they are left unrecognised or untreated, they can become life threatening. These toxicities can be managed effectively in almost all patients by using established guidelines that stress vigilance and the use of corticosteroids and other immunosuppressive agents when necessary.
As with all irAEs this can be a delayed effect of treatment and can occur up to 12 months after completion of treatment.
If any of the following symptoms are present:
If any of the following symptoms are present:
< 4 stools / day over baseline or mild increase in ostomy output.
NO history of abdominal pain, mucous / blood in stools.
Investigations:
Refer and review by gastroenterologist
Treatment:
Use analgesia with CAUTION.
Actions:
PERSIST ≥ 3 days IV corticosteroids
Review patient daily. If no improvement within 72 hours, seek further urgent gastroenterology advice/opinion for management with infliximab.
Investigations:
Treatment:
Actions:
Assess response to treatment within 72 hours.
Investigations:
Treatment:
Actions:
Symptoms: PERSIST (≥5 days) or WORSEN or are associated with deranged U&Es
PERSIST WORSEN RELAPSE
Symptoms: Resolve or Improve to Mild. See Guideline 27 - Steroid Tapering
CAUTION - Discontinue loperamide and/or codeine in patients with moderate to severe symptoms as these drugs increase the risk of colonic dilatation and perforation.
Hepatic transaminases (ALT / AST) and bilirubin must be evaluated before each dose of immunotherapy, as early laboratory changes may indicate emerging immune-related hepatitis. Elevations in LFT may develop in the absence of clinical symptoms. This guidance should be used in context of baseline LFT and presence of known liver metastases.
Mandatory investigations and actions at initial assessment:
Ultra Sound Scan in the first 12- 24 hours to assess spleen size and include doppler to assess flow in hepatic veins and arteries
Observations: Monitor and document Glasgow Coma Scale and NEWS
Early/Urgent referral to hepatologist required
Investigations:
Treatment:
Grade 3 -
Grade 4 - IV methylprednisolone 2mg/kg/day
Actions:
Treatment:
Actions:
Review patient daily, if no improvement within 72 hours, seek urgent hepatologist advice /review regarding on-going management -patients may require further treatment with immunosuppressive drugs, such as MMF or Tacrolimus.
Symptoms: Resolve or Improve to Mild See Guideline 27 - Steroid Tapering
Biochemical Abnormality PERSISTS (≥3 days), WORSEN or RELAPSE
Symptoms: Resolve or Improve to Mild See Guideline 27 - Steroid Tapering
Neurologic irAEs can manifest as central abnormalities (e.g. aseptic meningitis, encephalitis) or peripheral sensory/ motor neuropathies (e.g. Guillain-Barre Syndrome). Early recognition and treatment of neurologic irAEs is critical to its management. As neurologic symptoms can be common in subjects with cancer, it is important that an evaluation/ work-up can distinguish between non-drug-related causes (e.g. progression of disease, concomitant medications, infection) and a possible drug-related AE as the management can be quite different.
Investigations:
Management
Investigations:
Management:
Cranial nerve involvement?
◀ Yes - Grade
2
▼ No - Grade 1
Investigations:
Management:
Worsen
Resolved or Improved (Grade 1) Continue with iCPi.
PERSIST > 5 days WORSEN or RELAPSE
PERSIST > 5 days WORSEN or RELAPSE
Manage under guidance of neurology team Management escalation:
Resolved or
Always make sure that the Acute Oncology Team are informed of the patient's assessment and/or admission as soon as possible.
Immediate advice is available from the Acute Oncology Service or the 24 Hour Oncology on call rota.
WITHHOLD! SACT, including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.
Pulmonary irAEs have been observed following treatment, they have occurred both after a single dose and after as many as 48 treatments. The frequency of pulmonary AEs may be greater with immunotherapy combination therapies than with monotherapy and more common in lung cancer than in melanoma. The majority of cases reported were Grade 1 or Grade 2 and presented with either asymptomatic radiographic changes (e.g. focal ground glass opacities, patchy infiltrates) or with symptoms of dyspnoea, cough, or fever. Subjects with reported Grade 3 or Grade 4 pulmonary AEs were noted to have more severe symptoms, more extensive radiographic findings, and hypoxia.
Severe new onset of symptoms limiting self-care ADL; or Hypoxia (new or worsening); or Acute Respiratory Distress Syndrome (ARDS).
Mild to moderate new onset of symptoms limiting instrumental ADL (e.g. dyspnoea, cough, fever, chest pain)
Clinically asymptomatic with radiographic changes only (e.g. focal ground glass opacities, patchy infiltrates).
Clinical Assessment & O2 SATS
Investigations:
To exclude atypical infections:
Treatment:
Actions:
Investigations:
Treatment:
Actions:
Investigations:
Actions:
WORSEN
PERSIST WORSEN or RELAPSE
Symptoms: Resolve or Improve to Mild. See Guideline 27 - Steroid Tapering
Continue with daily review, if no improvement within 72 hours; seek chest physician advice / review for further management
Please see Guideline 27 - Steroid Tapering for advice regarding management of patients receiving high dose or long-term steroids.
Elevated creatinine and biopsy confirmed tubulointerstitial nephritis and allergic nephritis have been infrequently observed following treatment with immunotherapy agents. The frequency of renal AEs may be greater with combination therapies than with monotherapy. Most cases were Grade 2 or Grade 3 and based on creatinine elevation. Patients with a history of RCC or prior nephrectomy do not appear to be at higher risk. Events were managed with corticosteroids and in all cases renal function partially or fully improved.
Creatinine > 3 x ULN = Stage 3 AKI
Creatinine > 1.5 - ≤ 3 x increase from baseline = Stage 2 AKI
Creatinine < 1 - 1.5 x increase from baseline=Stage 1 AKI
Urgent referral to renal team for renal biopsy/USS and urgent advice
Investigations:
Treatment:
Actions:
Investigations:
Treatment:
Actions:
Investigations:
Actions:
WORSEN
Symptoms: PERSIST (≥ 5 days) or WORSEN or RELAPSE
Symptoms: Resolve or Improve to Mild. See Guideline 27 - Steroid Tapering
Review patient daily, if no improvement within 72 hours, seek nephrologist advice for further management.
Symptoms: Resolve or Improve to Mild
See Guideline 27 - Steroid Tapering
Detect AKI by using one of the following criteria:
A 25% or greater fall in eGFR in young people in the last 7 days.
https://pathways.nice.org.uk/pathways/acute-kidney-injury
http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdf
Dermatological irAEs common and although they are typically mild to moderate in severity, if left unrecognised or untreated, they can become life-threatening. These toxicities can be managed effectively in almost all patients by using established guidelines that stress vigilance and the use of corticosteroids and other immunosuppressive agents when necessary.
Skin sloughing > 30% BSA with associated symptoms:
Skin rash affecting > 30% of BSA or grade 2 with substantial symptoms
Skin rash affecting 10% - 30% of BSA with or without symptoms
Skin rash, affecting < 10% Body Surface Area (BSA) with or without symptoms
Clinical Assessment:
Investigations:
Treatment:
Actions:
Clinical Assessment:
Investigations:
Treatment:
Actions:
Clinical Assessment:
Investigations:
Treatment:
Actions:
Symptoms: Resolve or Improve to grade 1 - 2. See Guideline 27 - Steroid Tapering
Symptoms: PERSIST (≥ 5 days) or WORSEN or RELAPSE
Symptoms: Resolve or Improve to grade 1 - 2. See Guideline 27 - Steroid Tapering
WORSEN
Many patients will receive moderate- to high-dose steroid therapy for their immune-related toxicity for several weeks. Length of tapering is usually dictated by the severity of the irAE. Regular monitoring during tapering is strongly advised, as there is an increased risk of irAE recurrence. PPI cover should be maintained during tapering process.
Steroid tapering should only be considered when symptoms are improving.
Upon discharge:
CAUTION - during and after the tapering process as the adrenal axis may be suppressed and there is a risk of iatrogenic hypoadrenalism - if symptoms occur follow Guideline 18 - Endocrinopathies - Adrenal Crisis
This is the most common steroid-related side effect. Sleep hygiene counseling is important. Patients may require short-term use of 1st line treatment for insomnia e.g. zopiclone.
A baseline HbA1c should be requested at steroid initiation and random afternoon blood sugar monitoring (BM) should be undertaken whilst on treatment. If new hyperglycemia is detected, Endocrinology advice should be sought (many patients will require short term insulin in this setting). Pre-existing diabetes may require escalation in oral hypoglycaemic agents or insulin.
Vitamin D and calcium levels should be taken at baseline and if low, replaced as appropriate. In patients on steroids for >3 months, or with pre-existing osteoporosis, a bisphosphonate should be considered e.g. weekly alendronic acid.
In patients receiving the equivalent of prednisolone 25mg for > 6 weeks we suggest PJC prophylaxis with co-trimoxazole (80/400mg Mon/Wed/Fri).
Prophylactic antifungals i.e. Fluconazole and monitoring of patient's oropharynx.
If patients are on other immuno-modulatory agents e.g. Mycophenylate mofetil, consideration may be given to CMV prophylaxis with valgancyclovir, especially if CMV IgG negative and lymphopenic.
Ascites is the accumulation of protein rich fluid in the peritoneal cavity and can be classed as an exudate or transudate. Ascites typically develops in the setting of recurrent and/or advanced cancer, the commonest sites being ovarian, breast and colo-rectal.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of stem cell transplant. These patients may be myelosuppressed /neutropenic and at risk of sepsis. If present, this should be managed according to Guideline 12 - Neutropenic Sepsis.
Observations: Calculate NEWS score.
Investigations:
Signs and symptoms:
Life threatening consequences; urgent operative intervention indicated
Severe symptoms; invasive intervention indicated
Symptomatic; medical intervention indicated
Asymptomatic; clinical or diagnostic observations only; intervention not indicated.
Check all blood results and act on abnormalities e.g. neutropenia or pancytopenia.
Admit as an emergency and arrange for urgent drainage of ascites under USS control.
Plan further management in accordance with trust local guidelines depending upon differential diagnosis.
Discuss with the Acute Oncology team.
Check all blood results and act on abnormalities e.g. neutropenia or pancytopenia
Arrange for elective admission for insertion of ascitic drain under USS control in accordance with local guidelines/practice.
Discuss with Acute Oncology team.
Telephone/ review patient within 24 hours and ask patient to contact the 24-hour advice line if symptoms worsen.
Carcinomatous lymphangitis refers to a diffuse infiltration and obstruction of the pulmonary parenchymal lymphatic channels. It is associated with many malignancies but 80% are adenocarcinomas, predominantly breast, but also lung, colon and stomach.
Clinically patients present with:
Radiation pneumonitis/treatment related pulmonary fibrosis should be considered as can cause similar symptoms. Diagnosis is based on clinical suspicion in a patient with metastatic cancer and appropriate symptoms. Chest X-rays can appear normal in 30-50% of cases, but characteristic changes include:
Investigations: consider checking ABGs.
Other more general changes include:
High resolution CT Scanning is the investigation of choice if CXRs are equivocal or the clinical picture is not obvious.
Consider urgent referral to the palliative care team for symptom management and advice.
There are several risks and complications related to the insertion and maintenance of CVADs. These are briefly discussed below. If you have any concerns relating to any of the following problems please refer to your Local Management Guidelines or contact your Acute Oncology Team.
Removal of the line is not always necessary; please seek appropriate advice from your Acute Oncology Team or the 24-hour oncology on call rota before removing a line.
Localized infection: Tunnel infections can occur in skin tunnelled CVADs, around the insertion site of PICCs or in the port pocket. These areas should be examined prior to access and/or daily by HCP or self-monitoring for any signs of redness, swelling or discharge, pain or tenderness at the exit site. Absence of discharge does not rule out local infection because if a patient is neutropenic, pus may not be produced. If neutrophils are in normal range and the patient is well and apyrexial, localized infection can be treated with oral or intravenous antibiotics according to the clinical condition of the patient at that time. Lack of response to antibiotics should be acted upon quickly so that infection does not progress further.
Luminal infection: Often presents as pyrexia/shivers/rigor following catheter flushing. If untreated this can progress to septicaemia. If a CVAD infection is suspected the patient should be admitted to hospital for blood cultures and intravenous antibiotics. This is a serious complication of CVADs and can be life threatening if the patient has recently received chemotherapy and is neutropenic.
Any heath professional caring for a patient with a CVAD must be able to recognize the signs and symptoms of sepsis. First dose of antibiotics for patients with neutropenic sepsis should be delivered as per national directives within 1 hour of arrival to hospital to injection time. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Seek advice regarding line removal from the Acute Oncology Team or the 24-hour oncology on call rota..
Thrombosis is the formation of a clot within a blood vessel. Signs and symptoms of thrombosis secondary to CVAD insertion include; pain in the arm, shoulder or chest, swelling, auxiliary blood vessel formation. Thrombosis should be managed according to locally agreed guidelines.
This is the inflammation of the intima of the vein and it can be mechanical or infective in origin. Mechanical phlebitis is most common in PICCs and can occur within 72 hours to a week of CVAD insertion. Signs and symptoms include pain, erythema, warmth, and a venous cord may be palpable. Mechanical phlebitis can be treated effectively with application of heat pads every 4-6 hours for 20 minutes at a time. Patients should also be offered analgesia as required. CVADs should not be removed without seeking appropriate advice from the AOS Team.
This results from uncontrolled bleeding around the site of insertion. It is a hard and painful swelling with infiltrated blood. Hirudoid cream can be used to soothe and relieve bruising and haematoma: 5-15cm of cream applied over affected area up to 4 times daily and gently massaged into the skin. Firstly check if the patient is taking any anticoagulant therapy or aspirin. Also check platelet count and clotting.
Although secured in place, the catheter tip can migrate from its desired position just above the right atrium. This can be due to the patient being very active, or the catheter not being secured properly or in the case of skin tunnelled catheters poor granulation may result in the Dacron cuff slipping. The sign is that the length of the catheter outside the body gets longer. It is important to always check the length before any manipulation of the catheter. If the Dacron cuff is visible or the length of the PICC is greater outside the body, chest x-ray will be required to confirm the position of the catheter tip. Symptoms of catheter migration can include pain in the neck and a rushing sound in the ear during flushing. Management will depend on tip position but may require removal of device.
This is a very rare complication. Methods to reduce the risk of air embolus should be used when inserting, accessing or removing a CVAD. Only health professionals trained and competent to do so should be inserting, accessing or removing. Local policies should be adhered to. If a patient suddenly becomes acutely short of breathe and distressed, air embolism should be suspected. Check the CVAD for any obvious damage and clamp above if any are apparent. Lay the patient in left lateral Trendelenburg position and call for urgent medical assistance.
If it is an open-ended catheter that is split above the clamp, use an atraumatic clamp (or clamps covered in gauze) above the damaged area. Apply an occlusive dressing over the split area. Consider repairing the CVAD if appropriate or it may require removal.
Arrangements then need to be made for replacement of the CVAD. Inspect the catheter to ensure that it is intact if in doubt then X-ray confirmation is required.
Patency of CVADs should be established prior to administration of any drug or solution (RCN 2010). This is to ensure that any risk of extravasation is minimized. Occlusion can be termed complete, partial or withdrawal occlusion.
Complete occlusion can be due to a clot or drug precipitation within the line or a fibrin sheath completely enveloping the device. It results in an inability to either withdraw blood or infuse liquids.
Partial occlusion can be due to a small blood clot within the catheter or an external obstruction, for example a twist or a kink in the catheter. It results in difficulty withdrawing blood.
Withdrawal occlusion can result from a fibrin tail or malposition of the tip of the catheter and results with inability to withdraw blood but fluids can be administered with ease.
Fibrin sheaths can form as quickly as 24 hours following insertion, fluids can be administered but aspiration of blood is impossible as the fibrin acts as a valve (Amesur 2007).
Consider cathetergram when diagnosing the reason for catheter blockage.
Unblocking Central Venous Catheters
Thrombolytics such as urokinase are used to re-establish patency of CVADs obstructed with intraluminal or extra luminal thrombus or fibrin sheath. This agent breaks down fibrin. Thrombolytics should be prescribed by the medical staff and administered by staff that have been trained to do so, only after other reasons for catheter obstruction have been ruled out.
Cerebral space occupying lesion - may be primary disease site or metastatic deposits.
Acute cerebral /other CNS oedema - may be disease related e.g. developing around an intrinsic lesion within the brain tissue e g. a tumour or an abscess or treatment related in the patient who is receiving radiotherapy.
Identify: Patients who have received/receiving systemic anti-cancer treatment or are at risk of disease related immunosuppression or a history of bone marrow transplant. These patients may be myelosuppressed/ neutropenic and at risk of sepsis. If present, this should be managed as per Guideline 12 - Neutropenic Sepsis - immediate antibiotics if sepsis suspected.
Observations: Calculate NEWS score.
Investigations: Urgent FBC, U&Es, CT scan of head (If CT negative and strong suspicion of brain lesion, due to clinical presentation, consider MRI brain).
Full Clinical / neurological assessment: Signs and symptoms may include new onset of seizures, headache, visual disturbance, nausea and/or vomiting, cognitive dysfunction, confusion, disorientation and/or memory loss, motor dysfunction, symptoms of stroke.
Questions:
NOTE: If there is no history of previous malignancy please see Guideline 38 - Malignancy of Unknown Origin (MUO) Cancer of Unknown Primary (CUP)
Serious neurologic impairment which includes paralysis, coma or seizures > 3 per week despite medication management - hospitalisation required
Neurologic findings requiring hospitalisation for initial management
Neurologic findings present are sufficient to require home care, nursing assistance may be required. Medications including steroids/ anti-seizure agents may be required.
Fully functional status (i.e. able to work) with minor neurologic findings, no medication needed.
Dexamethasone 16mg oral OD (IV if required) with PPI cover
Anti-epileptic medication if having convulsions.
Admit for monitoring, on going assessment and management in accordance with local trust guidelines.
Early critical care management/advice if deterioration.
Note: need for caution in patients with no previous known malignancy if lymphoma suspected, steroids might cause rapid resolution of the tumour, which may make histological diagnosis very difficult. If possible, steroids should be avoided before biopsy if lymphoma suspected. This should also be considered in patients presenting with MSCC.
Commence dexamethasone
8-16mg oral OD (IV if required) with PPI cover
Anti-epileptic medication if having convulsions.
Admit for monitoring and care.
Patients should not be discharged until the Acute Oncology Team has reviewed them.
Telephone/review patient within 24 hours and ask patient to contact the 24-hour advice line if symptoms worsen or persist
Patients should be discussed with either the Acute Oncology Team or on call oncologist as they may require specialist review and management planning prior to discharge.
Advise to contact the 24 hour advice line if symptoms worsen or persist.
Referral to the Acute Oncology Team is recommended for all patients, immediate advice is available from the Acute Oncology on call rota.
Patients with no known malignancy will require neurosurgical referral
Patients with known primary disease presenting with metastatic disease require referral to the Brain and CNS MDT.
Patients on active anti - cancer treatment will require oncological review prior to further treatment.
Consider palliative care referral in patients with poor performance status, advanced disease, for symptom control advice.
This is the accidental administration of drugs into the extra vascular tissue instead of into the vein. If the drug extravasated is a vesicant, the damage to the surrounding tissue can be extensive and tissue necrosis can occur.
Extravasation may be linked to peripheral cannulation or a Central Venous Access Device (CVAD).
Action:
Act immediately - Extravasation of a vesicant drug should be treated as an emergency. If it is discovered the local Acute Oncology Team should be contacted, if out of hours use the Acute Oncology on call rota contact. The local extravasation policy should be followed, and recommended antidotes should be administered appropriately.
Although administration of drugs via CVADs carry less risk of extravasation than peripheral administration, if it does occur the damage is likely to be larger and more severe than with peripheral administration. This is because the event is not likely to be noticed immediately and delays to the treatment of extravasation result in damage limitation rather than cure.
Signs and symptoms include:
Extravasation of a vesicant drug should be treated as a medical emergency.
If it is discovered the local Acute Oncology Team should be contacted, if out of hours use the 24 hour telephone on call contact. The local extravasation policy should be followed, and recommended antidotes should be administered appropriately.
If the patient is receiving an active infusion STOP the infusion immediately
▼Leave the central venous catheter in place.
▼Attempt to aspirate as much drug as possible with a new syringe.
▼For ports, aspirate then remove needle
▼Inform a senior member of the Acute Oncology Team
▼Organise X-ray of line or cathetergram
For vesicant extravasations or large volumes of irritant drugs refer to plastic surgeon as soon as possible after detection.
Definition: A disorder characterized by laboratory test results that indicate an elevation in the concentration of calcium (corrected for albumin) in blood.
Corrected calcium > 3.4mmol/L requires URGENT treatment.
Corrected serum calcium
> 3.4 mmol/ l
Requires urgent correction due to the risk of dysrhythmia and coma.
Corrected serum calcium
> 3.0 - 3.4 mmol/ l
May be well tolerated if risen slowly, but may be symptomatic and prompt treatment is usually indicated.
Corrected serum calcium
> 2.9 - 3.0 mmol/ l
Often asymptomatic and does not usually require urgent correction
Corrected serum calcium of
> ULN -2.9 mmol/ l
(ULN = upper limit of normal)
Check FBC, ESR, U&E, LFT, TFT, PTH, cortisol, vitamin D & myeloma screen, start IVI & seek advice from endocrinologist - consider new cancer. Review need for any drugs, which may affect renal blood, flow e.g. NSAIDs, diuretics, ACEIs, ARBs
Patients with known active malignancy?
If 1st episode of hypercalcaemia, give 2-4 litres of 0.9% sodium chloride IV followed by zoledronic acid 4mg IV in 100ml 0.9% sodium chloride or pamidronate, dose according to corrected calcium.
Seek advice from endocrinologist. Review need for any drugs, which may affect renal blood, flow e.g. NSAIDs, diuretics, ACEIs, ARBs
If 2nd or subsequent episode of hypercalcaemia, give 2-4 litres of 0.9% sodium chloride IV, followed by zoledronic acid 4mg IV in 100ml 0.9% sodium chloride.
Review need for any drugs, which may affect renal blood, flow e.g. NSAIDs, diuretics, ACEIs, ARBs
If creatinine clearance is <30ml/min (GFR<10), do not give bisphosphonate. SEEK ADVICE.
Zoledronic acid dose needs to be reduced if renal impairment present.
DO NOT GIVE FURTHER BISPHOSPHONATE UNTIL AT LEAST 4 DAYS AFTER PREVIOUS DOSE
Maximum effect not seen yet - there is a risk of hypocalcaemia if further bisphosphonate given too soon.
If calcium remains elevated SEEK Endocrinology /oncology ADVICE regarding second line management.
Check calcium weekly, levels remain high and it is 3 weeks or more since last dose of bisphosphonate, give zoledronic acid 4mg IV; if less than 3 weeks since last dose of bisphosphonate, SEEK Endocrinology /oncology ADVICE especially if renal impairment present.
Inform the Acute Oncology Team of the patient's assessment and/ or admission as soon as possible.
Immediate advice is available from the Acute Oncology Service or the 24 Hour Oncology on call rota.
WITHHOLD! SACT, including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.
A disorder characterised by laboratory test results that indicate a low concentration of magnesium in the blood. Many cancer drugs can lead to hypomagnesaemia for example cisplatin, carboplatin, liposomal doxorubicin, cabozantanib, cetuximab, and panitumumab. Other drugs commonly used in cancer patients, e.g. diuretics, gentamicin and other aminoglycoside antibiotics, can cause or contribute to low magnesium. Patients with severe treatment related diarrhoea are also at risk. Normal magnesium range = 0.70 - 0.99 mmol/L (Values will be lab assay specific).
Hypomagnesaemia is often detected on blood tests when the patient is being assessed for other reasons therefore most patients are asymptomatic as the levels are only mildly depressed ( > 0.50mmol/L).
When serum magnesium levels drop more significantly ( < 0.50mmol/L) most patients have non-specific symptoms but they may then go on to develop:
Investigation: ECG and consider continuous cardiac monitoring. Check potassium levels and Ca2+.
Note: review antiemetics there may be contraindications in patients with low magnesium. Review PPIs and stop if possible as these are frequent causes of hypomagaesaemia.
Examination Findings
Neuromuscular Irritability: Hyperactive deep tendon reflexes, muscular fibrillation, +ve Trousseau (facial nerve hypersensitivity) & Chvostek (metacarpal hyper flexion) signs, dysarthria or dysphagia secondary to oesophageal dysmotility.
CNS Hyper sensitivity: Irritability and combativeness, disorientation, psychosis, ataxia, vertigo, nystagmus & seizures
Cardiac findings (ECG): Paroxysmal atrial and ventricular dysrhythmias, repolarisation alternans
< 0.3 mmol/L Life threatening consequences
< 0.3 - 0.4 mmol/L
< 0.4- 0.5 mmol/L
< LLN - 0.5 mmol/L
Admit for administration of Magnesium Sulfate by intravenous infusion.
In severe cases such as cardiac arrhythmias Magnesium Sulfate can be given as a bolus but under HDU / ITU supervision.
Consider continuous cardiac monitoring
Admit for administration of Magnesium Sulfate by intravenous infusion.
Correct any other electrolyte imbalance as necessary
Consider continuous cardiac monitoring
Consider oral Magnesium replacement to avoid a fall to critical levels: Magnaspartate, Mag Glycerophosphate (Discuss with pharmacy).
Check bloods in 24 - 48 hours.
Correct any other electrolyte imbalance as necessary.
Encourage Mg rich diet e.g. spinach, pumpkin seeds, avocado, almonds, figs, swiss chard.
These patients are typically asymptomatic.
Consider oral Magnesium replacement to avoid a fall to critical levels: Magnaspartate, Mag Glycerophosphate (discuss with pharmacy).
Encourage Mg rich diet e.g. spinach, pumpkin seeds, avocado, almonds, figs, swiss chard.
Hyponatraemia can be defined as serum sodium < 135 mmol/L. The clinical significance of hyponatraemia depends on its severity, its speed of onset and its underlying cause. Severe hyponatraemai can be life threatening.
Observations: Calculate NEWS score. Fluid balance.
Investigations: FBC, U&Es. Cortisol, Thyroid Function, LFT, Serum Osmality, to confirm true hypo-osmolar hypoNa, Plasma Glucose to exclude hyperglycaemia as a cause, Urine osmolality and Na+
Symptoms:
The clinical significance of hyponatraemia depends on its:
Management decisions should be based on presenting clinical symptoms rather than the degree of hyponatraemia.
N.B. Severe symptoms are unlikely with serum sodium >130 mmol/L and alternative causes of neurological dysfunction should be considered in this context.
The decision to treat with hypertonic fluid and supervision of treatment should be the responsibility of a senior clinician with appropriate training and skill.
The aim is to achieve a 5mmol/l rise in serum Na+ within the first hour, reducing immediate danger from cerebral oedema while minimising the risk of over-rapid correction and osmotic demyelination.
< 125 mmol/ L
125 - 129 mmol/ L
130 - 135 mmol/ L
N.B. The severity of symptoms may not match the degree of hyponatraemia: profound hyponatraemia may be symptom free, while some patients with moderate biochemistry may have significant signs and symptoms.
STEP 1. Patients with severe symptoms require immediate management, irrespective of cause
Within 1st Hour
IV infusion 150 mls of 3% hypertonic saline or
equivalent
Over 20 mins in close monitoring environment
Check Na+
IV infusion 150 mls of 3% hypertonic saline or
equivalent
Over 20 mins whilst waiting result
Repeat twice or until 5mmol/l increase in Na+
Follow up management after 5mmol/l rise in Na+
Stop infusion hypertonic saline
Keep IV line open with minimal volume 0.9% saline
Start diagnosis –specific management
Limit increase in Na+ to 10mmol in first 24h
Limit increase Na+ to additional 8mmol/l every 24h thereafter until Na+ 130mmol/l
STEP 2 recommended approach if no improvement following 5mmol/l rise in Na+ in the first hour
IV infusion 150 mls of 3% hypertonic saline or equivalent
Over 20 mins in close monitoring environment
Aim additional 1mmol/l increase in Na+.
Indications for stopping infusion
Symptom improvement
Na+ increases >10mmol/l in total or 130mmol/l (whichever is first).
Explore other causes of symptoms and refer to endocrinology for further advice and guidance.
Differential diagnosis of hyponatraemia following emergency treatment
Urine osmolality = <100 mOsm/kg
Primary polydipsia, Inappropriate iv.fluid Low solute intake
Urine osmolality = >100 mOsm/kg
Urine Na+ <30 mmol/l
Urine Na+ > 30 mmol/l
Urine Na+ >30 mmol/l Taking diuretics or ACEI
Heart failure
Portal hypertension
Nephrotic syndrome
Hypoalbuminaemia
Third space loss
GI loss
Previous diuretic use
SIADH
AVP-like drugs
NSAID
Salt wasting
Vomiting
Hypoadrenalism
Cerebral salt wasting
Consider all other causes
Useful Links
https://cks.nice.org.uk/hyponatraemia - !scenario
https://eje.bioscientifica.com/view/journals/eje/170/3/G1.xml
http://www.endocrineconnections.com/content/5/5/G4/F3.expansion.html
An accumulation of fluid within the pericardial sac leading to an effusion can be a presenting symptom in acute oncology patients. Two thirds of cancer patients have subclinical pericardial effusions with no overt cardiovascular signs or symptoms. 50% of cases initially present with symptoms of cardiac tamponade. Symptoms are often attributed to underlying cancers and are often a pre-terminal event; however, prompt diagnosis and management can achieve significant palliation.
Causes
Most malignant pericardial effusions result from direct malignant involvement with the pericardium. Other, rarer causes of effusions in cancer patients include radiation-induced pericarditis or chemotherapy-induced pericarditis associated with agents such as doxorubicin or cyclophosphamide.
Clinical Findings
Other common symptoms include:
On examination, findings include:
Diagnosis:
Questions:
Differential diagnosis would include
Cardiac tamponade - life-threatening consequences; urgent intervention required
Effusion with haemodynamic consequence
Moderate effusion with no or minimal haemodynamic consequence and good left ventricular function
Small effusion with no haemodynamic consequence
Admit patient for on-going assessment, monitoring and symptom management.
Withhold anticoagulation.
Consider immediate therapeutic drainage if cardio-vascular compromise.
Treatment is best managed with urgent referral to cardiology or cardiothoracic surgical teams - contact SpR on call.
Inform Acute Oncology Team.
All treatment options should be balanced against the patient's symptoms, overall performance status, level of disease and predicted benefits.
Enquire regarding signs of sepsis/productive cough - escalate to Grade 3 Red as appropriate
Discuss with the Acute Oncology team prior to discharge for ambulatory management.
Early referral to cardiology for management advice
Telephone/ Review patient within 24 hours and ask patient to contact the 24-hour advice line if symptoms worsen
Proven malignant pleural effusion
Contact the respiratory team and inform the acute oncology team
Symptomatic?
No
▼
Observe unless drain advised for other reasons
Yes
▼
Long life expectancy and limited systemic disease?
Yes
▼
Consider referral to thoracic surgeons for thoracoscopic drainage / pleuradesis / PleurX or other indwelling catheter
No
▼
Systemic therapy likely to lead to rapid resolution?
Yes
▼
Urgent oncology referral for possible SACT
No
▼
Follow local pathway for insertion of Intercostal tube and drainage.
NOTE: there may be an ambulatory service available locally for the management of stable patients requiring drainage of pleural effusion - contact the respiratory or acute oncology team for advice.
The aim of this pathway is to enable early identification of patients that would benefit from anti-cancer treatment and to prevent unnecessary investigations in those patients who are unfit for treatment or do not wish to proceed with treatment.
Initial Assessment
Observations: Calculate NEWS score.
History: Full history including rate of change of symptoms. Assess and record current performance status and co-morbidities.
Assess/establish patients understanding and wishes with regards to investigation and treatment pathway.
Examination: Complete clinical examination (including a breast, PR, PV, testicular and skin examination)
Laboratory Investigations:
Note: other tumour markers are generally not useful in diagnosis
Imaging:
Other investigations:
Further management:
Patterns of disease requiring URGENT specific action:
Spinal cord compression - urgent admission and referral to acute oncology team and/or spinal cord co-ordinator.
Men with midline disease - urgent referral to oncology (? germ cell).
Superior Vena Cava Obstruction - urgent referral to lung MDT for consideration of stent.
Suspected lymphoma, myeloma, plasmacytoma - urgent referral to haematology.
Patterns of disease requiring specific action:
Men with bone metastasis and elevated PSA - referral to urology MDT.
Women with axillary nodes - referral to breast surgeons/ MDT.
Women with peritoneal disease - referral to gynaecology /MDT, unless histology suggests non-gynaecology origin.
Solitary liver lesion - requires referral to hepatobiliary MDT.
Neck nodes - requires referral to head and neck or neck nodes clinic as appropriate locally.
Isolated brain metastasis - requires referral to neurology MDT.
Always make sure that the Acute Oncology Team are informed of patient's assessment and/ or admission as soon as possible.
Immediate advice is available from the Acute Oncology on call rota.
Definition: A disorder characterized by inflammation focally or diffusely affecting the lung parenchyma.
Signs and symptoms of radiation or chemotherapy induced pneumonitis:
Clinical pneumonitis, or inflammation of the lung(s), can often display non-specific signs.
These can include:
Clinical radiation pneumonitis may develop in 20% of lung carcinoma patients:
Initial Assessment:
Dyspnoea / symptoms at rest or requiring ventilatory support
Dyspnoea / symptoms at normal levels of activity
Dyspnoea / symptoms on exertion
No new symptoms
Severe symptoms requiring hospitalisation
Review by chest physician
▼
Treat with high dose steroids:
▼
Monitor closely as Urgent intervention may be indicated
(e.g. tracheotomy or intubation)
Mild or moderate symptoms, manageable on an outpatient basis
▼
High dose steroids
e.g. prednisolone 50mg od. With PPI cover
Specialist advice needed for on-going steroid dosing
SVCO is an obstructive emergency that may occur as the result of progression of a malignancy or may be the diagnostic symptom.
SVCO is caused by external pressure, thrombus or direct tumour invasion causing obstruction of the superior vena cava and occurs in 3% - 8% of patients with cancer.
Questions:
Differential diagnosis would include:
Signs and symptoms:
Investigations: CTPA to define tumour extent, site of occlusion or stenosis and extent of any thrombus. SVCO can be an incidental finding on CT.
Significant cerebral oedema (confusion) or significant laryngeal oedema (stridor) or significant haemodynamic compromise
Mild or moderate cerebral oedema (headache, dizziness) or mild/moderate laryngeal oedema or diminished cardiac reserve (syncope after bending)
Oedema in head or neck with functional impairment (mild dysphagia, cough, visual disturbances)
Oedema in head or neck Vascular distension, cyanosis; plethora
Admit for further assessment and on-going management.
Monitor for evidence of:
Address life threatening symptoms e.g. stridor.
Treatment initially aimed at symptom management.
Commence high dose steroids + PPI - if not contraindicated.
Seek Urgent Advice from the Acute Oncology and/or the Respiratory team to guide investigations and management.
Enquire regarding signs of sepsis/productive cough - escalate to Grade 3 Red as appropriate.
Consider steroid therapy to manage symptoms of oedema and prevent deterioration.
Enquire if history of underlying chest complaints e.g. asthma, COPD - advise patients around usual management of exacerbations advise to discuss with GP or other associated health professional managing this condition.
Discuss with the Acute Oncology team - arrange urgent oncology and/or respiratory review.
Telephone/review patient within 24 hours and ask patient to contact the 24-hour advice line if symptoms worsen or persist.
Manage in accordance with trust local guidelines depending upon differential diagnosis and clinical status.
Further management may include:
Name | Role | Organisation |
---|---|---|
Dr.Ruth Board | Consultant Medical Oncologist and Lead Cancer Clinician | Royal Preston Hospital |
Philippa Jones | Macmillan Acute Oncology Nurse Advisor | Wolverhampton NHS Trust |
Joanne Upton | Chemotherapy Lead Nurse and Skin Cancer Advanced Nurse Practitioner | The Clatterbridge Cancer Centre |
Name | Role | Organisation |
---|---|---|
Nicky Adams | Macmillan Acute Oncology Nurse Consultant | Walsall Healthcare NHS Trust |
Dr. Clare Barlow | Consultant Medical Oncologist | Taunton and Somerset NHS Trust |
Lisa Barrott | Cancer Matron and Acute Oncology Nurse Lead | Royal Sussex County Hospital |
Dr. Tim Cooksley | Acute Physician | Christie Hospital NHS Foundation Trust |
Alison Hodge | Advanced Nurse Practitioner Acute Oncology & CAU | The Royal Marsden NHS Foundation Trust |
Dr. James Larkin | Consultant Oncologist | The Royal Marsden |
Dr. Anna Olsson-Brown | Medical Oncology Registrar | The Clatterbridge Cancer Centre NHS Foundation Trust |
Dr. Clare Philiskirk | SpR Acute Internal Medicine | Sandwell and West Birmingham NHS Hospital trust |
Dr. Lavinia Spain | Medical Oncology Fellow | The Royal Marsden NHS Foundation Trust |
Name | Role | Organisation |
---|---|---|
Dr. CG Antoniades | Reader & Honorary Consultant Hepatologist | Division of Digestive Diseases, Imperial College London & Liver Intensive Care, King's College London |
Dr. Craig Barrington | Clinical Oncology Registrar | South West Wales Cancer Centre |
Dr. Oliver Brain | Consultant Gastroenterologist | John Radcliffe Hospital, Oxford |
Dr. Juliet Brock | Clinical Oncology Consultant | Sussex Cancer Centre |
Dr. Sarb Clare | Consultant in Acute Medicine | Sandwell and West Birmingham NHS Hospital Trust |
Dr. Sinead Clarke | Macmillan GP and CCG Lead. | Cheshire CCG |
Dr. Peter Correa | Consultant Clinical Oncologist | University Hospitals Coventry & Warwickshire |
Dr. Pippa Corrie | Consultant and Associate Lecturer in Medical Oncology. | Cambridge University Hopsitals NHS Foundation Trust |
Dr.Antonia Creak | Consultant Clinical Oncologist. Clinical lead for CUP and Acute Oncology |
Sussex Cancer Centre |
Dr. D Durai | Consultant Gastroenterologist | University Hospital of Wales |
Dr. Jackie Dominey | GP Clinical Lead End of Life | Solihull CCG |
Dr. Ricky Frazer | Acute Oncology Fellow | South West Wales Cancer Centre |
Dr. Andreas Hiersche | Lead Palliative Medicine Consultant | BSUH |
Dr. Claire Higham | Consultant Endocrinologist | Christie Hospital NHS Foundation Trust |
Dr. Chris Jenkins | Consultant Haematologist | Aneurin Bevan University Health board |
Dr. Andrew Lansdown | Consultant Endocrinologist | Cardiff and Vale University Health Board |
Dr. Ashling Lillis | ||
Dr. Anna Lock | Palliative Care Consultant | SWBH |
Professor Paul Lorigan | Reader in Medical Oncology | Christie Hospital. |
Dr. Ciara Lyons | Locum Consultant Clinical Oncologist | Northern Ireland Cancer Centre |
Dr. Ernie Marshall | Consultant Oncologist Clinical Director of Chemotherapy |
Clatterbridge Cancer Centre |
Dr. Claire Mitchell | Medical Oncology Consultant | Christie NHS Trust |
Dr. Paul Nathan | Consultant Medical Oncologist | Mount Vernon Hospital |
Dr. Tom Newsom-Davis | Consultant Oncologist | Chelsea & Wesminster Hospital |
Dr. Jenny Pascoe | Medical Oncologist | University Hospitals Birmingham |
Dr. Mridula Rajwani | Chief Registrar in Ambulatory Medicine | Oxford |
Dr. Paula Scullin | Consultant Medical Oncologist | Northern Ireland Cancer Centre |
Dr. Raj Sinha | Speciality Doctor in Medical Oncology | Sussex Cancer Network |
Dr. Susannah Stanway | Consultant Oncologist | The Royal Marsden NHS Foundation Trust |
Dr. Andrew Stewart | Cons Haematologist | University Hospital of the North Midlands |
Dr. Joanna Stokoe | Consultant Clinical Oncologist | Sussex Cancer Centre |
Dr. Natalie Walker | Consultant Physician | Bolton NHS Foundation Trust |
Dr. Sarah Williams | Medical Oncologist | University Hospitals Birmingham |
Dr. Matthew Winter | Consultant Medical Oncologist | Sheffield |
Dr. Alison Young | Consultant Oncologist | Leeds Teaching Hospital |
Dr. Nadia Yousaf | Consultant Medical Oncologist (Lung/AOS) | Royal Marsden |
Caroline Adcock | Acute Oncology CNS | The Shrewsbury and Telford NHS Hospitals Trust |
Melanie Bowling | Advanced Nurse Practitioner Acute Oncology |
Burton Hospital Trust |
Sharon Budd | Trauma Nurse | Royal Derby Hospital |
Helene Buijs | Macmillan Senior Acute Oncology CNS | Northwick Park Hospital |
Amanda Callister | Senior Chemotherapy Nurse | St. James's Hospital, Leeds |
Leigh Collins | Advanced Nurse Practitioner Acute Oncology |
University Hospital Bristol |
Clare de Marco Masetti | Macmillan Acute Oncology/MUO Advanced Nurse Practitioner | Bolton Foundation Trust |
Liz Gifford | Clinical Nurse Specialist Skin Cancer | University Hospitals Southampton |
Val Harris | Melanoma CNS | Velindre Cancer Centre |
Caroline Harnett | Lead Acute Oncology and CUP Clinical Nurse Specialist | Torbay and South Devon NHS Foundation Trust |
Jackie Hodgetts | Nurse Clinician | The Christie Hospital |
Annie Law | Acute Oncology Advanced nurse Practitioner | University Hospitals of Leicester |
Ursula McMahon | Acute Oncology Nurse Specialist | Wrightington, Wigan and Leigh NHS Foundation Trust |
Stephanie O'Neill | Acute Oncology Clinical Nurse Specialist | University College London Hospital |
Rachel Powell | Oncology CNS | Heart of England NHS Foundation Trust |
Rosie Roberts | Chemotherapy Specialist Nurse Macmillan Acute Oncology Project Manager |
Velindre Cancer Centre / Wales Cancer Network |
Caroline Thomas | Acute Oncology Nurse Specialist | University Hospital Birmingham |
Jenni Thomas | Acute Oncology/Chemotherapy Sister | Sandwell and West Birmingham Hospitals. |
Joan Thomas | Nurse Unit manager Chemotherapy Day Units & Clinical Research |
Peninsula Health, Australia |
Sarah Tucker | Acute Oncology Clinical Nurse Specialist | University College Hospital |
Emily (Hui-Ying) Wang | Macmillan Acute Oncology and CUP Clinical Nurse Specialist Cancer and Palliative Care |
Homerton Hospital |
Tracy Wild | The Pennine Acute Hospitals NHS Trust | Macmillan Acute Oncology Nurse |
Sonja Watson | Acute Oncology Clinical Nurse Specialist | Royal Sussex County Hospital |
Anita Young | Macmillan AOS CNS | ULHT |
Dharmisha Chauhan | Sarcoma, Melanoma and Skin Specialist Pharmacist | The Royal Marsden NHS Foundation Trust |
Rhiannon Walters-Davies | Medicines at Home Manager | Velindre Cancer Centre |
Edna Young | Lay Representative | National Chemotherapy Board |
Conor Fitzpatrick | Therapy Radiographer | The Christie Hospital |
Raxa Ford | Senior Lead Review Radiographer | BSUH |
Alfred So | Medical Student | University of Manchester. |
Greater Manchester Cancer | GMCA Greater Manchester Combined Authority |
The UKONS Board and project leads wish to thank:
Condition | Response |
---|---|
All Green | Self care advice |
1 Amber | Review within 24 hours |
2 or more amber | Escalate to red |
Red | Attend for assessment as soon as possible |
Patients may present with problems other than those listed below, these would be captured as “other” on the log sheet checklist. Practitioners are advised to refer to the NCI-CTCAE common toxicity criteria V4.03 to assess the severity of the problem and/or seek further clinical advice regarding management.
CAUTION! Please note patients who are receiving or have received IMMUNOTHERAPY may present with treatment related problems at anytime during treatment or up to 12 months afterwards. If you are unsure about the patient's regimen, be cautious and follow triage symptom assessment.
The section below scolls horizontally
These Guidelines are for the use of medical professionals only. They are not intended for public use, including by oncology patients. UKONS does not permit the creation of derivative works, unless they are authorised.
The information contained in these guidelines is a consensus of the development and consultation groups' views on current treatment. They should be used in conjunction with any local policies/ procedures/ guidelines and should be approved for use according to the trust clinical governance process. Care has been taken in the preparation of the information contained in the guidelines. Nevertheless, any person seeking to consult the guideline, apply its recommendations or use its content is expected to use independent, personal medical and/or clinical judgment in the context of the individual clinical circumstances, or to seek out the supervision of a qualified clinician. The United Kingdom Oncology Nursing Society makes no representation or guarantee of any kind whatsoever regarding the guidelines content or its use or application and disclaim any responsibility for its use or application in any way.