Acute Oncology Handbook R8 PDF

ACUTE ONCOLOGY HANDBOOK
Procedure
Reference:
CP48
Version:
V8
Document Owner:
Dr P Haji-Michael
Accountable
Committee:
Acute Oncology Group
Date Approved:
4th Nov 2013
Review date:
February 2016
Target audience:
All Clinicians
Key points
Suspected Sepsis
Nausea and Vomiting post chemotherapy
Central Venous Catheters
Acute Radiotherapy Complications
Management of Head and Neck Patients
Metastatic Spinal Cord Compression
Deteriorating Renal Function
Hypercalcaemia, Hypomagnesaemia
SVC Obstruction
Pain and Symptom Management
Pericardial effusion, Tamponade
CONTENTS
Introduction
Admission Criteria
Management of Suspected Sepsis
Nausea and vomiting post chemotherapy
Management of problems related to central venous catheters
10
Acute radiotherapy complications
11
Dose conversion chart for strong opioids
17
Management of head and next cancer patients on the MAU
19
Metastatic Spinal cord compression
20
Deteriorating renal function / acute renal failure
23
Management of hyperkalaemia
25
Suspected or diagnosed renal / biliary obstruction
28
Hypercalcaemia
29
Hypomagnesaemia
32
SVC obstruction
34
Management of alcohol withdrawal
36
Pain and symptom management
39
Management of raised intracranial pressure
40
Guidelines for the management of epilepsy in neuro-oncology patients
42
Management of pericardial effusions and cardiac tamponade
44
Consultation, approval and ratification process
46
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V.8 Doc Ref: CP48 Acute Oncology Handbook
ASSOCIATED DOCUMENTS
Guidelines for Hand Hygiene
Standard Precautions policy
Patient Isolation policy
Guidelines for Aseptic Technique
Sepsis Resuscitation Bundle
Guidelines for Management of Severe Sepsis and Septic Shock
NCP 29.0 - Care plan for the patient with neutropenia / neutropenic sepsis
550 Sepsis CCU
INTRODUCTION
From 2012 onwards, Acute Oncology teams at all acute Trusts and The Christie will support the care
of cancer patients who present as an emergency, especially those on current or recent treatment. For
patients undergoing treatment for cancer, all infective episodes need to be rapidly assessed and
treated urgently with antibiotics.
Purpose
Outlines immediate management of commonly-occurring oncological problems.
Provides structure to triage referrals for admission, including when seen on MAU, and for
admission to MAU if appropriate.
To prevent admissions that should not be accepted at The Christie and to direct transfers to
other hospitals, when appropriate.
To highlight where specific action is required, including consultant review if not already taken
place.
Support to education and training of junior medical and nursing staff and to direct staff to
existing sources of advice and guidelines available elsewhere.
Scope
This document applies to all clinical staff.
ADMISSION CRITERIA
The MAU was established to improve and co-ordinate the care of patients who may require admission
to The Christie, including those who are found to be unwell on-site while attending clinics or for
treatment as outpatients.
The Christie is a stand-alone tertiary cancer centre and not part of a general hospital. This means that
great care has to be taken to ensure that patients are not admitted whose primary need is for acute
medical or surgical services. The patients who are admitted to The Christie should be those who will
benefit most from specialist management of problems directly related to their cancer or its treatment,
especially if within a research trial. Other primary and secondary care services support patients with
cancer and other hospitals are often able to provide good care for patients admitted locally. The
important principles are that The Christie should strive to accept patients who are high priority for care
here (see below), while providing specialist oncological support and advice to those who are admitted
elsewhere.
See the MAU operational policy for full details of admission criteria.
Priorities for admission include
Patients currently on radiotherapy and chemotherapy treatment who have complications of
this, especially neutropenic sepsis
Patients in clinical trials, especially phase I trials
Patients who should not be admitted through MAU:
Patients with acute medical emergencies including chest pain
Page 3 of 46
Patients with acute surgical emergencies including undiagnosed acute abdominal pain,
haemorrhage, possible perforation
Patients with airway obstruction
Patients with acute mental health problems who need urgent psychiatric management
Patients already at another hospital who are in an unstable/deteriorating clinical condition
Patients with spinal cord compression due to metastatic disease in whom a single palliative
radiotherapy treatment would be the most that could be offered
Responsibilities for continuity of care

A number of patients are admitted via the MAU from outpatient clinics or outpatient treatment
departments (radiotherapy and chemotherapy) via the responsible oncology team with a management
plan in place.
All patients must be medically assessed as soon as possible, and have a documented management
plan, within 4 hours of arrival. There must also be discussions with the relevant consultant oncologist
within 24 hours. The patients care is required to be formally handed over and fully documented to the
usual oncology team at the earliest opportunity. It is important that until this has taken place, the
clinical responsibility lies with the on-call medical or clinical oncology teams. This includes patients
transferred out of the MAU on a Friday who require review over the week-end.
Many patients have common oncology-related problems, management of which is described in this
handbook. Discussion with, and direct review by consultant staff is particularly important for those
patients not admitted via clinics, whose presentation is outside the usual picture, or who are
deteriorating.
Advice and support
Acute oncology outreach support is triggered by the MEWS monitoring. Consultant to consultant
discussion is required when transfer for CCU/ITU support may be needed.
Surgical team support: while every effort should be made to avoid admission of patients who require
acute surgical assessment to the MAU, inevitably some problems arise in other patients on the MAU
or other wards. Assessment by the consultant oncologist and consultant to consultant referral is
required in these situations.
Other sources of help:
The Pain Team: especially when acute severe pain is the immediate problem such as with
pathological fractures. Available during working hours. Bleep the pain nurse specialist or page Dr
Arun Bhaskar, Consultant in Pain Management via switchboard.
The Specialist Palliative Care Team: help with specialist pain and symptom management especially in
the context of advancing disease.
During office hours, x 3072 or bleep 12634,-Saturday, Sunday 0900-2100 through switchboard.
A palliative care telephone advice service is available out of hours at weekends and Bank Holidays, at
St Anns Hospice. This service can be accessed via The Christie switchboard. Advice can also be
sought from the on-call palliative medicine SpR and Consultant.
The pharmacy and on-call pharmacists are another source of advice.
Emergency documents and guidelines
The Emergency documents icon is on the desktop of all trust computers and links to key clinical
guidelines and management protocols. The documents can also be found by following the link:
http://discover/documents/emergency.aspx
The following policies and guidelines are included:
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General
The Acute Oncology Handbook
Metastatic Spinal Cord Compression Guidelines
Clinical Guidelines for the insertion of chest drains
Extravasation policy
Guidelines on use of High dose IL2
Catheter management protocol after prostate brachytherapy
Policy for the Care of Central Venous Catheters
Infection
Guidelines for the Management of Sepsis
Antimicrobial guidelines of common infections
Blood
Management of patients on Warfarin and Heparin
Management of transfusion reactions
Assessment criteria for receiving/preparing to administer blood products
Transfusion Policy
Emergency medicine
Adult tachycardia algorithm
Adult bradycardia algorithm
Anaphylaxis algorithm
Adult Advanced Life Support Algorithm
Guidelines for the management of epilepsy in neuro-oncology patients
Patent upper airway algorithm
Emergency Laryngectomy Algorithm
TRACHEOSTOMY - bedhead signage
Clinical guidance - For acute atrial fibrillation
Symptom control
Pocket pain guide
Management of bowel obstruction in ovarian cancer
Guidelines for managing Nausea and Vomiting
Dont forget to also use the Trust intranet which has a wide variety of useful documents including the:
Ascitic paracentesis protocol http://discover/documents/default.aspx?Details=Y&Doc_ID=4152
The following is a summary of protocols for management of problems frequently seen on MAU.
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MANAGEMENT OF SUSPECTED SEPSIS

This section briefly summarises the process for responding to calls from patients on chemotherapy
who are unwell and may be neutropenic. It is derived from the Guidelines for Management of
Neutropenic Sepsis, which are endorsed as a Trust and Cancer Network policy.
Note clinical teams and MAU staff should be familiar with the above guidelines, and refer to the detail
within e.g. choosing antibiotics. They are available on the Trust intranet and a copy is kept in the MAU
policy file. It is expected that all patients with suspected neutropenic sepsis will receive protocol
antibiotics WITHIN ONE HOUR of attendance on the MAU and a specific One hour to antibiotic
SOP outlines this process. Additional nursing policies, training and documentation have been
developed to allow the first dose of antibiotics to be administered by a nurse within 1 hour of a patient
attending the MAU.
Contents
Hotline assessment
First contact assessment
Review
Discharge
Hotline Assessment
The commonest method of presentation of patients with potential neutropenic sepsis will be via the
Acute Oncology Management Service (incorporating the Hotline). Calls will be taken predominately
by an acute oncology nurse advisor (AONA) or a Registrar / ward doctor for an initial telephone
assessment of any unwell patient.
Alarm indicators
The following features in the history should alert the clinician:
Cytotoxic chemotherapy within the previous 6 weeks and particularly within the last 21 days
Recorded oral or tympanic temperature of 37.5 C x 2 within 1 hour/380 C x 1
Rigors
Low temperature- <36 C
Features of hypotension: fainting, light-headedness, prostration (remaining in bed)
Grade 3 4 mucositis (difficulty tolerating oral fluids)
Grade 3 4 diarrhoea
Cough with green sputum and dyspnoea on minimal exertion
Spontaneous haemorrhage or purpuric rash
Management options
The Hotline assessment should reach a decision:
No indication for immediate assessment
Advise attend Christie MAU for assessment
Advise attend local DGH A&E for assessment
No indication for immediate assessment
If there is no concern regarding febrile neutropenia or other emergency requiring immediate
assessment, the patient should be reassured but must be advised to call again if symptoms worsen.
If the patient has problems requiring non-emergency attention then the patient may be advised to
attend their GP or the AONS will co ordinate an early OP appointment at the Christie or peripheral
hospital if appropriate. Medway proforma and annotation should be completed.
Choice of place of care for patients requiring assessment: Christie MAU or A&E department at
the nearest local hospital?
Once it has been decided the patient needs assessment, the following should help the clinician taking
the call where to direct the patient and family for that assessment
Page 6 of 46
Christie Hospital
Patient is within 45 minutes travelling time to the Christie and
Clinician making assessment is not concerned that the patient may be going into shock and
Bed available on MAU
A&E at the local hospital
Patient is greater than 45 minutes travelling time from the Christie or
The clinician is concerned that the patient may be in or close to shock (may need paramedic
ambulance to take to nearest A&E) or
No bed available on MAU
If patient is advised to attend local A&E then there should be liaison between Christie team and local
A&E team to advise on previous treatment, ensure compliance with protocol for management of
febrile neutropenia, and to establish on-going updates of condition. If the hotline call is taken out of
hours, the responsible oncology team should be informed at earliest opportunity.
First Contact Assessment
Patients advised to attend The Christie for assessment will be reviewed initially on the MAU.
Assessment
A nurse should assess all patients within 15 minutes of their arrival on the MAU. Any patient with
suspected neutropenic sepsis should receive antibiotics within one hour of arrival on the MAU. This
will occur prior to blood results becoming available or medical assessment. The door to needle
proforma should be completed and neutropenic policy antibiotics will be administered based on
Patient Group Direction (PGD) documents. For any unwell patient on chemotherapy the nursing and
medical assessment should be completed within an hour of arrival. The doctor should attend urgently
if the MEWS/other observations indicate developing shock (see below).
Nursing assessment
Temperature, blood pressure, pulse and respiratory rate, oxygen sats, weight.
Calculate MEWS score.
Blood draw for: full blood count, clotting, group and save, C reactive protein (CRP),
biochemical profile, blood cultures (from each lumen of line if in place, and also peripheral).
Request FBC and urea and electrolytes urgently.
Swabs: mouth, line site (if has indwelling cannula).
MSU, sputum culture (if producing sputum), stool culture (if c/o diarrhoea).
Start 4 hourly observations chart, fluid balance chart.
Medical assessment
Ward doctor should review case notes (on Medway if file not available), take a history and perform
directed physical examination as appropriate. Other investigations: CXR (for most patients), ECG (if
indicated), arterial blood gases (if indicated).
Who to Treat
Any patient with suspected neutropenic sepsis will be treated empirically. Subsequently
patients in the following groups will continue on neutropenic policy antibiotics:
All febrile patients with neutrophil counts <0.5 x10*/l and those whose counts are < 1.0
x10*/l and falling rapidly
Afebrile patients with neutrophil counts <0.5 x 10*/l should also be treated if they have
symptoms compatible with infection.
Management
Initiate antibiotic therapy without delay.
Do not wait for results of the full blood count.
Do not wait for results of microbiological tests.
Follow hospital guideline for choice of antibiotic.
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Risk groups
Document risk group and follow appropriate pathway: essentially three groups:
Febrile neutropenia (low risk): selected patients who can be managed on an early discharge
pathway.
Febrile neutropenia (high risk) but no organ failure: most patients. Typically respond well to
immediate broad spectrum IV antibiotics and will require an average inpatient stay of 5 days.
Complicated neutropenic sepsis with organ failure: requires aggressive and intensive
management and support and there is a substantial risk of fatal outcome.
Senior support
During usual working day, the responsible oncology consultant and registrar should be made aware
of the patients admission to MAU. If unable to attend promptly, and if the patients condition causes
concern, the on-call specialist registrar will attend with documented handover accepted by the
responsible team at the first opportunity. Out of hours the on-call registrar will support the ward team
and nurse practitioners in ensuring an appropriate plan is in place.
The responsible oncology consultant or on-call consultant should be phoned about any patient who is
not responding to immediate management and is deteriorating. The MEWS score will also trigger
critical care outreach.
Review
Nursing observations to include 4 hourly vital signs (temperature/pulse/BP/O2sats, respiratory
rate) and fluid balance.
Medical review at least twice a day
Daily bloods for FBC, U/E
Other tests as clinically indicated
Progress
4 possible outcomes from initial therapy:
Responding rapidly, no positive microbiological isolate:
Temperature remitting over 24 72 hours, tachycardia resolving, good organ function,
symptomatic improvement.
Consider transfer to low risk category for transfer to oral antibiotics and early discharge.
Satisfactory response but positive isolate identified.
Consider rationalising anti-biotic regimen, follow hospital guideline for duration of therapy
Delayed response but remains well, no organ compromise:
Resist the temptation to change the anti-biotic regimen unless microbiologic isolate positive.
If patient stable continue therapy for 72 hours before changing.
Patient unwell and not responding or deteriorating:
Escalate without delay (get consultant input dont wait for ward round),
Patient may require more detailed investigation and change in therapy.
See hospital guidelines.
Duration of Therapy
In the absence of a positive microbiological isolate, antibiotic therapy should be continued for
at least 24 hours after achieving a normal temperature and vital signs and for a minimum of 5
days.
Where a positive isolate has been obtained follow the hospital guidelines.
Discharge and Ongoing Care
Patients should generally remain in hospital until they have responded to therapy and counts have
recovered to a safe level. WBC > 1.0 x 109/L and or neutrophils > 0.5 x 109/L, afebrile for 24 hours,
normal vital signs for 24 hours
Early discharge may be appropriate for selected patient.
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NAUSEA AND VOMITING POST CHEMOTHERAPY

Timing
Acute emesis: within 24 hours of chemotherapy.
Delayed emesis if more than 24 hours post chemotherapy and may be prolonged for several
days.
Vomiting is LESS LIKELY to be associated with chemotherapy if onset 72 hours or more after
last treatment or duration longer than 7 days from last treatment.
Refer to
Guidelines for managing emesis associated with chemotherapy.
PCST guidelines for managing nausea and vomiting due to other causes.
Both are available on the Christie Intranet and in the MAU resource file.
See also ASCO Guidelines Journal Clinical Oncology, 24 2006, 2932 Kris et al.
Note
1. Patients with chemotherapy nausea and vomiting would not typically present with associated
abdominal pain. If this is present a surgical cause must be considered (see 3).
2. Patients with haematemesis should not be brought to the MAU (see 3).
3. Patients who may require acute surgical assessment and intervention should NOT be brought
to the MAU but directed to their local hospital. If there are other considerations (may be
neutropenic, in phase 1 trial) the situation should be discussed first with the team SpR or on
call SpR prior to giving patient directions.
4. Could this be infective e.g. norovirus? If hospital admission essential, manage patient in sideroom with precautionary measures.
Assessment
(i) History
Review medical records.
Establish type and date of most recent chemotherapy treatment
Frequency and duration of symptoms
Severity and establish recent oral intake
(ii) Any other symptoms:
Headache
Abdominal pain, constipation/diarrhoea
Medication
Thirst, confusion (metabolic e.g. hypercalcaemia)
Relevant co-morbidities e.g. diabetes mellitus
(iii) Examination
Hydration
Abdominal examination: signs of bowel obstruction, abdominal masses, hernia orifices,
ascites
(iv) Investigations
FBC/Profile, glucose (especially if on steroids)
Erect chest/abdominal film to exclude obstruction if indicated
Management
1. IV fluids if inadequate oral intake or evidence dehydration, or co morbidities that increase risk
of dehydration (diabetes, hypercalcaemia, frail)
2. Anti-emetics:
For patients admitted within 48 hours of any previous chemotherapy, continue 5HT3
antagonists and dexamethasone. Consider use of haloperidol 2.5-5mg/24 hours or
levomepromazine 6.25-12.5mg if prolonged drug induced emesis remains likely cause.
Consider other possible causes and choose anti-emetic(s) accordingly: prescribe
regular administration by parenteral route: probably via subcutaneous infusion
3. Treat underlying cause and handover to responsible oncology team at earliest opportunity.
Note: if subsequent clinical diagnosis appears to be obstruction, especially when this is an unlikely
scenario in the context of the patients underlying illness, the specialist registrar should escalate to the
consultant for prompt review by consultant on MAU, and to arrange for surgical assessment via
consultant-consultant referral to Christie surgical team. There may be subsequent transfer to another
hospital unless appropriate to be taken over by surgical team here.
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MANAGEMENT OF PROBLEMS RELATED TO CENTRAL VENOUS CATHETERS

Unable to aspirate blood?
Remove dressing and loop in line
Open clamp and move its position
Roll line between fingers where clamp has been moved
Gently stretch line ensuring secure at exit site
Ask patient to take a deep breathe/cough and move arms up and down
Is there pain swelling in neck/arm?
If yes this is due to thrombus: needs urgent Doppler ultrasound of the vein
If no swelling present, but unable to aspirate try flushing with 5ml saline and aspirating
immediately.
If no success, line is blocked: refer to procedure team x 3916 in working hours (see form on
intranet).
If able to flush but not aspirate, do not use line for chemotherapy or infusions. Make sure
patients medical team are made aware.
Damage to the line?
Clamp above damage and contact procedure team
Soreness at exit site or tunnel?
Look for signs of inflammation/discharge
Swab exit site for C&S
Start oral antibiotics
Fever/shivering/rigors, particularly after line has recently been accessed?
Line infection = systemic infection: needs urgent medical management
FBC and biochemistry
Blood cultures from both peripheral vein
CXR and infection screen
All intravenous antibiotics should be administered through the central venous catheter and not
through a peripheral cannula
Piperacillin/ Tazobactam or meropenem and vancomycin or teicoplanin are the recommended
antibiotics to use until results of blood cultures become available.
Note: Where the source of infection is likely to be in an indwelling catheter, consideration should be
given to removal of the line. This decision needs to be made immediately (within an hour) in patients
with signs of shock. The decision to remove a line should always be discussed with the patients
consultant if possible if he or she cannot be contacted, or at week-ends/out of hours then speak to
the on-call consultant.
Medical staff should ensure they are confident in removal of a central line out of hours: contact the
procedure team who would be very willing to arrange training in both line insertion and removal.
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ACUTE RADIOTHERAPY COMPLICATIONS

Acute skin reactions following radiotherapy
Occurrence
Caused by inflammation of the skin, leading to desquamation of the skin. With pelvic radiotherapy is
most pronounced in the groins, perineum and anal area. Usually presents from the second week
onwards of radiotherapy and persist for weeks following completion of treatment.
More common with concurrent chemotherapy.
Clinical Features
Symptoms: Pain: may affect toileting, mobility and patient may be unable to tolerate wearing clothes
over the affected area.
Signs: In pain. Affected skin erythematous, sore, epithelium may be broken or denuded
(desquamation) leaving a raw weeping area. Secondary infection may occur.
Investigations: FBC (neutropenia possible if having chemotherapy), U&E.
Management
Problem should have been anticipated and treated early.
Admission may be needed for those still on treatment or severe reactions requiring analgesia and
help with personal care.
Supportive care: area should be kept clean and friction avoided.
Analgesia if necessary. Loose fitting covering clothing, or preferably none, over affected area.
If epithelium intact: registrar review, aqueous or 1% hydrocortisone cream.
If epithelium denuded: consultant reviews to consider continuation of radiotherapy or chemotherapy,
analgesia, avoid cream and dressings if possible. Antibiotics if any sign of infection.
CNS radiotherapy
Occurrence
Caused by cerebral inflammation and oedema. Can occur at any time following the start of cranial
radiotherapy.
Clinical Features
Symptoms: headache, neurological symptoms especially a recurrence or exacerbation of pre surgical
symptoms. Visual disturbance. Decreased level of consciousness.
Signs: neurological signs. General decrease in GCS, papilloedema.
Investigations: FBC, U&E, glucose.
Management
Admit if on treatment.
Mild neurological symptoms: no decrease in level of consciousness.
Registrar review, increase or start steroids with gastric cover, analgesia as necessary.
If condition deteriorates despite increased steroids or if level of consciousness impaired, review of
patient by consultant oncologist.
Abdominal and pelvic radiotherapy: acute bowel reaction
Caused by irritation of the bowel by radiotherapy for rectal or gynaecological tumours but may occur
with any pelvic or abdominal radiotherapy.
Usually presents from the second week onwards of radiotherapy and symptoms may persist for 4-6
weeks following treatment.
Problems more likely if:
Concurrent chemotherapy
Page 11 of 46
Postoperative radiotherapy
NB Unlikely to be XRT bowel reaction if onset of symptoms after treatment completed, or worsening
symptoms 4 weeks or more after completion.
Referrals to the hospital of patients who may have an acute abdominal problem likely to need
immediate surgical assessment and intervention should not be directed to attend MAU unless there
has been prior consultant to consultant agreement. These patients should be directed to their local
A&E department.
Clinical features
Frequent, often watery, diarrhoea in association with
Lower abdominal/ pelvic pain: may be colicky and associated with bowel opening or constant.
Vomiting and anorexia.
Dysuria and urinary frequency.
Signs: May be dehydrated; abdominal tenderness may be present.
Differential diagnosis: Any acute bowel pathology, possible clostridium difficile infection
Investigations
FBC (neutropenia possible if having chemotherapy),
U&E (may have deranged electrolytes especially hypocalcaemia.
Does NOT require stool culture unless offensive watery diarrhoea.
Management
Mild symptoms: (no pain or mild colicky pain, no vomiting, mild or no abdominal tenderness, no
electrolyte imbalance)
Registrar review, oral fluids, low fibre diet, fybogel, loperamide regularly.
Does patient need admission?
Patient must be discussed with consultant oncologist after admission and before further radiotherapy
given.
Moderate or severe symptoms: (significant pain, especially if constant, vomiting, abdominal guarding
or rebound).
All patients need to be seen by consultant oncologist on the MAU. Should not be referred to the
surgeons until reviewed by oncology consultant and then by consultant to consultant referral.
No further radiotherapy unless agreed by consultant oncologist.
Pelvic radiotherapy: rectal pain and bleeding
Occurrence
Uncommon. Caused by irritation of the rectum by radiotherapy, usually to the prostate. Usually
presents from the second week of treatment but can occur following completion.
Clinical features
Symptoms: Severe tenesmus with frequent loose stools. Severe pain on bowel opening. Rectal
bleeding- usually fresh red blood on bowel opening or continually.
Signs: anaemia, pain. Abdominal signs unlikely. DO NOT ATTEMPT RECTAL
EXAMINATION
Investigations: FBC and group and save/ cross match as necessary, U&E. Does not require stool
culture unless offensive watery diarrhoea.
Patient requires admission if uncontrolled distressing symptoms such as tenesmoid pain and
diarrhoea, especially if treatment not yet concluded. Rectal bleeding in isolation would not be a
reason to admit and such patients post treatments require outpatient assessment.
Page 12 of 46
If patient at home and has significant bleeding should be admitted locally for resuscitation:
DO NOT BRING TO MAU but oncology registrar/ consultant should discuss with admitting team
before any investigations carried out. Sigmoidoscopy, rectal biopsy etc should all be avoided if at all
possible.
If bleeding mild (in association with other symptoms), admit to the Christie.
All patients need to be seen by consultant oncologist.
Treatment is supportive with analgesia and transfusion if necessary.
Stop any anticoagulants if clinically reasonable to do so.
Consider tranexamic acid 1g tds by mouth.
Rectal steroids probably not helpful and should be avoided. Try to avoid either constipation or
diarrhoea. No further radiotherapy unless authorised by consultant oncologist.
Surgical advice on management should be by consultant to consultant and after assessment by the
oncologist.
Differential diagnosis: Inflammatory bowel disease, diverticulitis.
Thoracic radiotherapy: pneumonitis
Occurrence
Caused by acute inflammation of the lung. Usually presents from the second week onwards of
radiotherapy in patients with a lung or oesophageal malignancy. Can occur in the first few weeks
following completion of treatment.
More common with concurrent chemotherapy.
Clinical Features
Symptoms: Increasing shortness of breath, cough, dysphagia (if associated oesophagitis).
Signs: may be dehydrated. Tachypnoea. Localised or generalised crepitations.
Investigations: FBC (neutropenia possible if having chemotherapy), U&E, CXR. Consider CT scan,
Sputum culture (if productive cough), CTPA if PE suspected.
Differential Diagnoses:
Pneumonia, cardiac failure, PE, pleural effusion, tumour progression. Lymphangitis.
Management:
Exclude other causes as far as possible. Oxygen, oral or IV steroids (with gastric cover):
dexamethasone 16mg daily.
If indicated antibiotics, anticoagulation, diuretics.
Thoracic radiotherapy: oesophagitis
Occurrence
Caused by inflammation of the oesophagus. Usually presents from the second week onwards of
radiotherapy in patients with a lung or oesophageal malignancy. Can occur in the first few weeks
following completion of treatment. More common with concurrent chemotherapy.
Patients may be malnourished pre treatment and the main aims of management are to treat
symptoms and maintain nutrition.
Admission required if
Patient not coping with pain
Unable to take adequate nutrition/hydration
Needs to complete course of radiotherapy
Clinical Features
Symptoms: dysphagia leading to decreased intake and dehydration. Vomiting, especially if
radiotherapy field in the lower thorax/ upper abdomen.
Signs: May be dehydrated. In pain
Investigations: FBC (neutropenia possible if having chemotherapy), U&E
Nutritional assessment and referral to dietetics team if indicated.
Page 13 of 46
Management:
Problem should have been anticipated and treated early. See also detailed guidelines for radiationinduced oesophagitis in section below.
1. Even if severe dysphagia, endoscopy and biopsy should not be undertaken
2. If radiotherapy not completed, further treatments to be authorised by consultant oncologist
after review of the patient.
Guidelines for Management of Acute Radiation Oesophagitis - Produced by the Lung Disease
Group November 2008
Radiation oesophagitis is the most important dose-limiting acute toxicity during thoracic irradiation for
lung malignancies. Concurrent chemotherapy and radiotherapy can result in an earlier onset and
increased severity of radiation oesophagitis due to a radiosensitisation effect of normal mucosa by
chemotherapeutic drugs.
Clinical Features
Symptoms
The symptoms of oesophagitis are dysphagia and pain. Patients may experience pain in the
retrosternal area, back or epigastrium. Moderate dysphagia may necessitate a change to a soft diet
and in severe cases patients may only be able to swallow liquids for a period of time.
Time course
Symptoms of oesophagitis may begin in the second or third week of a course of radiotherapy, and
can increase progressively thereafter. The symptoms may continue to worsen for one or two weeks
after the course of radiation is completed, and then gradually settle over a period of six to eight
weeks.
Anticipation
Radiation oesophagitis will occur if part of the oesophagus is within the Planning Target Volume
(PTV). The degree of oesophagitis and severity of symptoms is likely to increase with the length of
oesophagus included in the PTV. At this time, there is no role for radio-protectors (e.g. - amifostine)
outside of clinical trials.
Patient Preparation
Patients should be warned of the possibility of oesophagitis, with particular reference to the clinical
features and management options, before starting treatment. Early assessment by a dietician can be
helpful, particularly if the patient has already lost weight as an effect of their lung cancer.
NCI CTCAE version 3.0 grading
Grade 1
Grade 2
Asymptomatic
Symptomatic;
clinical
or altered
eating/
diagnostic
swallowing (e.g.observations
altered
dietary
only: intervention habits);
oral
not indicated
supplements
indicated
Note
Grade 3
Severely altered
eating/
swallowing
(e.g.inadequate oral
caloric or fluid
intake);
tube
feeding, TPN or
hospitalization
indicated
Grade 4
Grade 5
Life-threatening
Death
consequences;
urgent operative
intervention
indicated
Grade 3 oesophagitis is indicative of hospitalisation, but naso-gastric tube feeding is not

recommended for these patients due to risk of trauma from insertion and short time span of
symptoms
Grade 4 oesophagitis will include severe oesophageal ulceration or perforation.
Management
Page 14 of 46
Particular care is required to ensure that the patient maintains an adequate fluid intake
throughout treatment and afterwards.
Regular review and advice from a dietician can help to ensure that nutritional intake is
appropriate and that dietary supplements are introduced at the appropriate time. Patients
should be weighed weekly and seen at least once a week by the clinical team during
treatment.
Opioids should be initiated early if the radiation-induced pain is not controlled by paracetamol
and other supportive medications added accordingly (see below)
Generally radiotherapy should not be interrupted because of oesophagitis. Radiation
oesophagitis is eventually self-limiting, but early treatment of symptoms can help patients to
maintain their fluid and nutritional intake.
1. Analgesics
1.1
Soluble paracetamol or paracetamol liquid preparations
1 gram every 4-6 hours (maximum 4 grams in 24 hours).
1.2
Opioid analgesics - initiation
1.2.1
1.3
1.4
Oral morphine solution 10mg/5ml (oramorph )

Starting dose 5mg (2.5ml) every 4-6 hours AND as required (prn) up to 1 hourly
1.2.2 Alternatively oxycodone liquid 5mg/ 5ml (oxynorm )
Starting dose 2.5mg (2.5ml) every 4-6 hours AND as required (prn)
(Note 1mg oxycodone is equivalent to 2mg of oral morphine)
Opioid analgesics maintenance (stable pain- only in patients able to manage tablets)
1.3.1 Morphine sulphate tablets (modified release) MST continuus
Starting dose estimated by total daily oral morphine requirements in 24 hours and
given in divided doses 2 x daily 12 hours apart. Oral morphine solution (dose = 1/6
total daily morphine) as required (prn)
1.3.2 Alternatively, oxycodone tablets (modified release) oxycontin
Starting dose estimated by converting relevant total daily oral morphine or oxynorm
liquid requirements in 24 hours and given in divided doses 2 x daily 12 hours apart.
This is preferred option if mild renal impairment. Oxycodone liquid (dose = 1/6 total
daily oxycodone) as required (prn)
1.3.3 If concern about significant renal impairment, alternatives include oral hydromorphone,
fentanyl or alfentanil infusion under guidance from a pain specialist.
Opioid analgesics parenteral route
1.4.1 If stable pain but oral medication difficult due to odynophagia and nausea, consider
fentanyl patches (durogesic ) 12mcg, 25mcg, 50mcg, 75mcg or 100mcg to substitute
for equivalent total daily morphine requirement (see conversion chart). Patches need
replacement every 72 hours and can be self-managed in the out-patient setting.
Breakthrough (prn) top-up should be by oral liquid opioids.
1.4.2
If unstable pain commence continuous subcutaneous driver infusion of morphine or

diamorphine or oxycodone (see conversion chart). Ideally managed on a ward with
staff trained in controlled drug administration. Breakthrough (prn) top-up can be via
subcutaneous injection or by oral liquid opioids. Once pain stabilised consider
substituting in dose-equivalent fentanyl patch.
1.4.3
Alternatively, if patient is hospitalised, intravenous morphine 1mg/1ml administered by

PCA (patient-controlled analgesia) can be commenced with advice from the specialist
pain team, using boluses of 0.5mg-2mg per 5 minute lockout. Background intravenous
infusion of morphine up to 5mg/ hour can be added to titrate to effect. Intravenous
oxycodone 1mg/1ml can be used instead by the same method.
Caution is required as all opiate drugs can cause constipation.
2. Mucosal coating agents

Sucralfate suspension, 1gram in 5mls taken 4-6 hourly, 1 hour before meals
Page 15 of 46
3. Proton pump inhibitors (PPI)

3.1
If acid reflux is contributing to symptoms, a PPI should be prescribed at full
dose.
Lansoprazole 30 mgs daily.
Orodispersible preparation (FasTab ) is recommended if swallowing is difficult
Omeprazole 40mg daily.
Dispersible tablet preparation (Multiple-unit pellet system- MUPS ) is a useful alternative
if swallowing is difficult
3.2
All patients with grade 3 oesophagitis should receive a PPI.
3.3
All patients with grade 4 oesophagitis should receive intravenous PPI.
4. Oesophageal candidiasis
4.1
Inflamed oesophageal mucosa is commonly secondarily infected with candida, especially if
the patient is on steroids or is diabetic. Fluconazole suspension, 100mgs daily for 7 days.
Liver function tests should be monitored.
4.2
All patients with grade 3 or above oesophagitis should be treated for oesophageal candidiasis.
5. Hydration and Nutrition
5.1
Adequate oral intake of fluid should continue during radiotherapy. Switch to a soft, pureed or
liquid diet is recommended. Early dietician input is recommended.
5.2
Dietary supplementation by milk-based or juice-based high-calorie drinks can supplement
meals (3/ day increased to 6/ day if no solid meals tolerated).
5.3
Hospitalisation for grade 3 oesophagitis will necessitate intravenous fluid rehydration with
electrolyte replacement, especially where platinum chemotherapy has been used.
5.4
If grade 4 oesophagitis is suspected, patient should be nil by mouth (NBM) and a prompt
surgical review sought. Intravenous broad spectrum antibiotics should by give for bacterial
super infection with antifungal cover and microbiologist advice sought. Consideration should
be given to TPN (total parenteral nutrition).
6. Indications for hospitalisation
6.1
Uncontrolled unstable pain and odynophagia. Specialist input from the local pain team or
palliative care team for symptom management should be sought.
6.2
Unable to tolerate oral fluids, biochemical dehydration or electrolyte imbalance.
6.3
Uncontrolled nausea.
7. Follow-up after radiotherapy
7.1
Patients with radiation oesophagitis should be reviewed weekly until the symptoms of
oesophagitis start to resolve. Usually, the symptoms will be significantly improved by around
four weeks after completion of radiotherapy and should be much better by eight weeks after
completion of treatment.
7.2
Where rapid escalation of opioid drugs has previously occurred, weekly reviews of pain
requirements with down-titration of drugs should occur to avoid unnecessary opioid toxicity.
7.3
If patients are still having difficulty swallowing solids eight weeks after treatment is finished,
referral
for
endoscopy
and
possible
gentle
bouginage
is
indicated.
Page 16 of 46
DOSE CONVERSION CHART FOR STRONG OPIOIDS NB prn dose = 1/6 24 hour total dose
Morphine
Morphine
Diamorphine
Diamorphine
Fentanyl
Oxycodone
Oxycodone
4hrly
M/R
s/c
s/c
patch
4hrly
M/R (bd)
Bd
4hrly
over 24hrs
(mcg/hr)
(OxyNorm )
(OxyContin)
Hydromorphone
Instant Release
4hrly
Hydromorphone
M/R
bd
10mg
20mg
30mg
40mg
50mg
60mg
70mg
80mg
90mg
100mg
110mg
120mg
140mg
160mg
180mg
1.3mg
2.6mg
3.9mg
5.2mg
6.5mg
7.8mg
9.1mg
10.4mg
11.7mg
13mg
14.3mg
15.6mg
18.2mg
20.8mg
23.4mg
4mg
8mg
12mg
16mg
20mg
24mg
28mg
32mg
36mg
40mg
44mg
48mg
56mg
64mg
72mg
30mg
60mg
90mg
120mg
150mg
180mg
200mg
240mg
260mg
300mg
330mg
360mg
420mg
480mg
540mg
5mg
7.5mg
10mg
15mg
15mg
20mg
25mg
30mg
30mg
35mg
40mg
40mg
50mg
55mg
60mg
20mg
45mg
60mg
90mg
100mg
120mg
150mg
160mg
180mg
210mg
240mg
240mg
300mg
330mg
360mg
25
25-50
50
75
75
100
125
125-150
150
150-175
175
200
225
275
300
5mg
10mg
15mg
20mg
25mg
30mg
35mg
40mg
45mg
50mg
55mg
60mg
70mg
80mg
90mg
10mg
30mg
40mg
60mg
70mg
90mg
100mg
120mg
130mg
150mg
160mg
180mg
200mg
240mg
270mg
Page 17 of 46
MANAGEMENT OF HEAD AND NECK CANCER PATIENTS ON THE MEDICAL ADMISSIONS

UNIT
Complications of radiotherapy, chemotherapy and chemo-radiotherapy
Head and Neck Team contacts
Dr Slevin 12828
Dr Sykes 12545
Dr Yap 12715
Dr Lee 12531
Nurse clinician, Kathleen Mais x 3428 / 12589 / 075944 38631
Clinical nurse specialist Debbie Elliott x8041/12610
The above are available to provide advice within working hours.
Please ensure that any patient with an altered airway (i.e. tracheostomy or laryngectomy) is referred
for review by Kathleen Mais or Debbie Elliott within 24 hours of admission (or first thing Monday
morning).
Common reasons for admission to MAU for head and neck patients
1. Neutropenic sepsis
2. Patients on radiotherapy who require nutritional support
3. Nausea and vomiting
Note: Patients with airway obstruction should NOT attend MAU but be referred to the local ENT
service via A&E
Do not stop scheduled radiotherapy! Discuss with head and neck team who will review patient
1. Patients with neutropenia / neutropenic sepsis
Please inform the nurse clinician of the admission (email or x 3428)
See section on neutropenic sepsis and full guidelines on management
Avoid gentamycin in patients receiving cisplatin as part of their chemotherapy.
These patients will need IV fluids and strict mouthcare:
Saline mouthwash 2 hourly
Sodium bicarbonate mouthwash 2 hourly
Difflam a mouthwash for pain relief
Use Corsodyl / chlorhexidine mouthwash only in patients on chemotherapy, not radiotherapy
2. Patients on radiotherapy who require nutritional support
(Usually in association with severe mucositis)
Ensure adequate fluid intake aim for 3 litres/day: via IV or NG tube if insufficient orally (loss
increased by copious phlegm production).
Early insertion of NG tube and feeding plus fluids.
Reduce risk of re-feeding syndrome: thiamine supplements, check magnesium.
Review drug chart and ensure medications are soluble/liquid (ask pharmacy advice).
If patient coughs on taking food/fluids, keep nil by mouth, insert NG tube and request speech
and language therapy assessment.
Prescribe
Mouth wash regimen as above
Treat respiratory infection/discoloured phlegm:
Antibiotic e.g. amoxicillin
Antifungal e.g. fluconazole
Treat skin infection
E.g. flucloxacillin
Ask advice on dressings
Page 18 of 46
Analgesia:
Paracetamol suspension
Oral morphine e.g. Oramorph prn
Fentanyl patches once regular morphine tolerated (start 25mcg/24 hours; 12 mcg/24hours if
elderly)
Avoid reliance on injections- oral route better
Avoid NSAIDs if on cisplatin; always combine with PPI
3. Patients admitted with nausea and vomiting

See section on post-chemotherapy nausea and vomiting and relevant guidelines in MAU resource file
Think list
Chemotherapy related: continue 5HT3 antagonist or haloperidol/ levomepromazine.
Hypercalcaemia: treat cause and prescribe haloperidol.
Pharyngeal irritation (secretions), gastritis, constipation cyclizine.
Cerebral oedema (acute XRT reaction; note brain metastases rare in head and neck cancers):
dexamethasone plus PPI, plus cyclizine.
Vestibular irritation from XRT prochloperazine, hyoscine.
Fullness/ intolerance NG feeding-try metoclopramide.
Opioids (introduction) metoclopramide or haloperidol.
Page 19 of 46
METASTATIC SPINAL CORD COMPRESSION (MSCC) ASSOCIATED WITH MALIGNANT

DISEASE
MSCC is defined as spinal cord compression by direct pressure and/or the induction of vertebral
collapse or instability. This may be due to metastatic spread or direct extension of malignancy that
threatens or causes neurological disability. MSCC is an oncological emergency which if left untreated
can result in varying degrees of paralysis, loss of bladder and bowel sphincter control due to
compression of the spinal cord at a single or multiple levels.
People with breast, lung or prostate cancer account for more than 50% of MSCC diagnoses, but it
can also be caused by any cancer that metastasise to bone or haematological cancers. Research
has shown that 77% of people diagnosed with MSCC had an established diagnosis of cancer,
whereas 23% presented with MSCC as the first presentation of malignancy (National Spinal Task
Force 2013)
Presentation
Early presentation, diagnosis and treatment before neurological symptoms develop is vital as the
patients ability to walk at diagnosis directly relates to their ability to walk post treatment.
Signs and symptoms will depend upon the level of the spinal cord that is damaged. Over 90% of
patients present with back pain as the first sign of MSCC. This can be local or radicular, often
described as a new pain or change in character of previous pain. Patients may describe this pain as
a band-like pain around the chest or abdomen. The motor, sensory and autonomic signs occur late
in the evolution of MSCC and will be distributed below the level of the cord compression. In adults the
spinal cord ends at the L1-L2 junction (L2-L3 for children).
Note: If cord compression is the initial presentation in a patient not known to have a cancer, then it is
important to establish the diagnosis of cancer and also identify the primary site. Please discuss with
your senior colleague without delay.
Clinical Pathway
Please refer to the Christie and Network guidelines and the MSCC Pathway and accompanying
notes: (http://www.christie.nhs.uk/the-foundation-trust/treatments-and-clinical-services/clinicalservices/acute-oncology.aspx)
This information will give a detailed description of MSCC from suspected diagnosis through to
rehabilitation.
The MSCC Co-ordinator service, during working hours (9 am to 5 pm), is available to take calls from
the referrer to triage all patients with suspected or confirmed MSCC. The Co-ordinator will liaise with
the on-call clinical oncology SpR and agree a management plan within 4 working hours (between 9
am and 6pm. After 6 pm the management plan may be finalised the following working day).
Out of hours, calls will be taken by Acute Oncology Outreach Nurse Specialists (AOONS).
It is expected that the patient would be admitted to, and investigated at their local hospital. If the
patient is transferred to The Christie for treatment, the local hospital will accept the patient back once
treatment has been completed.
Investigation
The aim is to establish the diagnosis. Urgent MRI scan of the WHOLE SPINE must be done within 24
hours of clinical suspicion of cord compression at the patients local hospital. This confirms the
diagnosis and also gives information on the anatomical details needed for the treatment.
In cord compression associated with metastatic cancer, MRI scans show more than one level of
disease in 50% of patients.
Immediate management
All patients with suspected MSCC should be admitted to their local hospital, put on flat bed rest, log
Page 20 of 46
rolled, started on 16 mg/day of Dexamethasone with PPI cover. Once MSCC is diagnosed on MRI
scan spinal stability should be assessed and documented. Input from the radiologist and AHP teams
is vital in assessing stability.
Definitive Management
This depends on the triage outcome. The triage process will take the patients current status and
prognosis into account. Please refer to the Christie protocols and MSCC information for further
details.
Treatment options:
1. Surgery
2. Radiotherapy
3. Best Supportive Care
Definitive treatment plan - either radiotherapy or surgery - should be established as soon as
possible, ideally within 24 hours of the diagnosis
Patients with mechanical back or neck pain, early neurological symptoms indicating the possibility of
spinal instability, single or limited levels of disease and a good performance status should be
considered for surgical decompression. Surgery followed by post-operative radiotherapy for selected
patients is associated with the best neurological outcome.
If patient is not suitable for surgery, fractionated radiotherapy within 24 hours should be considered.
These patients should preferably be admitted to the Christie with agreement to transfer back for
continuing rehabilitation once treatment has been completed. If a bed is not available then
arrangements should be made for daily transfer from the local hospital with patient being
accompanied by a healthcare escort.
For patients unable to tolerate treatment, or who have established paralysis in the absence of pain,
should be referred to the local Specialist Palliative Care team for Best Supportive Care in the
community.
For full details on treatment options please access the Christie protocols and MSCC information
website
For patients at The Christie
On clinical suspicion of MSCC, please follow immediate management guidance and arrange an
urgent inpatient MR scan of the spine. On confirmation of MSCC contact the MSCC co-ordination
service via Lena Richards on bleep 12616.
Consider the possibility of cord compression especially if the patient complains of
- Recent escalation of severe spinal pain, worse on movement and poorly responsive to
analgesia
- Pain and/or electric shocks/tingling in the spine, aggravated by coughing, sneezing, straining
and usually lying down
- Tight band around the chest or abdomen
- Legs feel stiff and heavy, unsteady gait
- Urinary hesitancy - or retention
Actions
1. On suspicion of cord compression urgent management is required. Take the appropriate history
(duration, onset, primary cancer, spinal and visceral metastases, patient whether on steroids,
neurological and functional assessment, performance status and PMH). Contact the team
registrar and discuss immediate management. If the team registrar is not contactable please
discuss with the on call clinical oncology registrar or the MSCC co-ordination service.
2. Commence dexamethasone 8 mg b.d. (under PPI cover) after discussion with the registrar.
Page 21 of 46
3. Request urgent MRI scan and discuss with the radiologist directly without delay. If out of hours
during weekdays consider doing this on the next working after discussion with the team registrar.
If this situation occurs during the weekend, urgent scanning on the same day may be appropriate
but always discuss this first with the on call clinical oncology registrar.
4. If MSCC is confirmed, the treating team must inform the MSCC co-ordination service, a triage
form must be completed and the pathway must be followed as described above.
DONT FORGET!
- All patients with suspected cord compression must be assumed to have an unstable spine
until proved otherwise. They should be nursed flat and kept strictly on bed rest and log rolled.
Fit a collar if cervical lesion suspected
- Consider thromboprophylaxis if no contraindication
- Pain management - but steroids and immobilisation will help considerably in most
- Urgent referral to physiotherapy within 24 hours
- Take time to explain to the patient and family: information leaflets are available for patients at
risk of, and with established, spinal cord compression
- Refer to the Christie protocols and information available on the The Christie website
- Referral to occupational therapy within 48 hours to ensure early and timely discharge planning
- MSCC Co-ordination service
Telephone 0161 446 3658 (external to The Christie)
Contact Lena Richards via bleep 12616 (internal to The
Christie)
For the full NICE recommendations follow the link CG75 Metastatic spinal cord compression:
quick reference guide
For the full Christie guidelines, Pathway and MSCC information follow the links:
The Christie website:
http://www.christie.nhs.uk/the-foundation-trust/treatments-and-clinical-services/clinicalservices/acute-oncology.aspx
The Christie intranet:
(http://discover/departments/clinical_oncology/protocols.aspx#scc)
Page 22 of 46
DETERIORATING RENAL FUNCTION / ACUTE RENAL FAILURE

Always be alert to sudden increases in serum creatinine. If a patients serum creatinine does suddenly
rise, think about possible causes immediately and alert the team SpR/consultant.
Do not wait until the consultant ward round. Be mindful of patients who might deteriorate over the
weekend. Cancer patients can rapidly develop acute renal failure.
Common signs include:
1)
2)
3)
4)
5)
6)
oliguria
confusion
nausea, vomiting, anorexia
haematuria
back pain/pelvic pain
unexpected signs of opioid toxicity (drowsiness, myoclonic jerks) in patients on stable doses
Common causes of new renal impairment/failure in cancer patients:

1)
Pre-renal failure dehydration due to vomiting, diarrhoea, anorexia (can be due to disease
or side effects from treatment).
2)
Nephrotoxic drugs platinum chemotherapies, NSAIDS, antibiotics, contrast.
3)
Obstruction consider in any patients with retroperitoneal and/or pelvic malignancy
(particularly gynaecological or urinary tract disease). Also consider in patients who have
received previous retroperitoneal or pelvic radiotherapy.
4)
Sepsis be aware of risk of neutropenic sepsis if patient on chemotherapy
5)
Tumour
lysis
syndrome
signs
include
hyperkalaemia,
hyperuricaemia,
hyperphophataemia, secondary hypocalcaemia. Suspect in patients who have received
chemotherapy for a bulky chemosensitive tumour (e.g. high-grade lymphoma, leukaemia,
germ cell, small cell lung cancers). Increased risk if pre-treatment urate high and/or renal
impairment.
Investigations
Full history and examination (including MEWS score to trigger critical care input if
required).
Full biochemical profile, FBC, clotting (f nephrostomy likely to be considered), urate (if
tumour lysis syndrome suspected).
Blood cultures, urine culture, central line culture (if line in-situ) if patient pyrexial or sepsis
suspected.
Renal ultrasound to exclude obstruction.
CXR to exclude respiratory cause for sepsis; to assess pulmonary oedema if obstructive.
ECG if hyperkalaemic.
Management
Always inform team SpR (on-call SpR if out-of hours or team SpR not available). Will often require
critical care input.
1)
Hyperkalaemia (>6.5mmol/l)
a. Urgent ECG.
b. 10ml 10% Calcium Gluconate IV if any ECG changes (repeat every 10 minutes until
ECG changes normalise).
c. 250ml 10% Dextrose with 10U Actrapid insulin (over 30 minutes).
d. 5-10mg nebulised salbutamol.
2)
Optimize Fluid Balance

a. Assess hydration clinically (skin turgor, mucous membranes).
b. Urinary catheter (input/output measurements).
c. IV colloid and/or crystalloid if clinically volume depleted.
d. Critical care input if CVP monitoring required.
Page 23 of 46
3)
4)
5)
Obstructive renal failure can be rapidly resolved by nephrostomy insertion. Team must
discuss this with consultant radiologist.
Tumour lysis syndrome (if suspected, call team SpR immediately). Consider fluid
rehydration, urine alkalization, rasburicase. Patients at risk of tumour lysis syndrome should
have started prophylactic allopurinol before chemotherapy.
Caution with opioid analgesics:
- If patient is showing signs of mild toxicity, reduces doses by 30-50%.
- If rapid deterioration in renal function, stop all long acting opioids and use instant
release preparations, again with 50% dose reduction and at longer intervals i.e. 4-6
hourly.
- Note removal of fentanyl patches takes 17.5 hours for levels to drop by 50%:
patient needs close monitoring.
- Where pain management is a problem, contact palliative care or pain team for
advice.
Page 24 of 46
GUIDELINES FOR THE MANAGEMENT OF HYPERKALAEMIA IN ADULT PATIENTS
CAUSES OF HYPERKALAEMIA
Rhabdomyolysis/Tumour lysis syndrome
Renal failure
Drugs (e.g. ACE inhibitors,
angiotensin II receptor blockers,
spironolactone, potassium sparing
Diuretics).
Massive Transfusion
Addisons disease
Metabolic acidosis (especially DKA so
liaise with Diabetologists).
High platelet count and high WBC
artificially raise the potassium level.
(Repeat sample in Lithium heparin & inform lab)
NB Spurious elevation of potassium may be seen
with extremely high white cell or platelet counts
SIGNS & SYMPTOMS

May be asymptomatic but can cause:
ECG changes (Tall and peaked T
waves, small or absent P waves,
prolonged P-R interval, depressed ST
segment & risk of ventricular
tachycardia).
Muscle weakness
Hypotension
Bradycardia
Normal range for potassium
3.5-5.5mmol/L
Hyperkalaemia is classified as:
mild (K+ 5.5 - 6.0)
moderate (K+ 6.1 - 6.4) or
severe (K+ 6.5) or if ECG changes
present
Managing mild and moderate hyperkalaemia

1. Stop further accumulation of potassium
e.g. stop any potassium containing infusions, medications (sando K)
Stop any potassium sparing medications ACEi, ARBs, spironolactone, amiloride etc.
2. Do an ECG except in cases of mild hyperkalaemia (potassium less than 6.0) or in the
absence of symptoms
If ECG changes present move to treatment of severe hyperkalaemia protocol
3. Maintain bicarbonate level with oral replacement (venous bicarbonate levels can be checked
in the laboratory)
Ongoing Management
4. Start a low potassium diet
5. Consider the use of Calcium Resonium
Contraindications to calcium resonium include conditions associated with hypercalcemia (e.g.
hyperparathyroidism, multiple myeloma, sarcoidosis or metastic carcinoma), or obstructive bowel
disease
NB attempts to lower potassium levels may not be appropriate in the last days of life. If in
doubt discuss with the appropriate parent team
Page 25 of 46
FIVE STEP APPROACH TO TREATING SEVERE HYPERKALAEMIA

1. Stop further accumulation of potassium
- e.g. stop any potassium containing infusions, medications (sando K)
2. Monitor the ECG
- An ECG is mandatory in moderate/severe hyperkalaemia. Look for tall and tented T waves,
flattened P waves, prolonged PR interval, QRS widening, Sine wave or bradycardia.
- A normal ECG can be present in severe hyperkalaemia and does not stop the need for
treatment. ECG changes require urgent treatment (see step 3)
3. Protect the myocardium (stabilise cardiac membrane)
- In the presence of ECG changes give 10ml of 10% Calcium Gluconate over 3-5 minutes and
ideally though a large bore cannula. (if the patient is on digoxin then slow the rate of infusion
i.e. infuse 10ml of 10% calcium gluconate in 100ml of normal saline over 20-30 minutes)
- The effect of calcium gluconate occurs after 1-3 minutes and can last up to 1 hour. A repeat
ECG must be checked after 10 minutes and further infusions should be given (up to 5 cycles)
if the ECG does not normalise.
- An ECG that does not normalise is an indication for urgent dialysis.
4. Shift the potassium into cells
(a) Insulin:Dextrose infusion should be given into a large bore cannula to drive potassium into
cells. Prescribe as 250ml of 10% Dextrose with 10 units of actrapid insulin over 30 minutes.
(NB monitor the blood sugar levels before infusion and at 10 minutes, 30 minutes and 60
minutes)
- *Higher strengths of dextrose (20%/50%) can only be given via a central line and must never
be administered peripherally
(b) Give salbutamol nebulisers 10mg nebulised lowers the serum potassium level by
0.5mmol/l 1mmol/l
- Stop in presence of tremor, tachycardia or arrhythmias
- Never give salbutamol as a single agent treatment, only use in combination with
insulin:dextrose infusion.
- 20mg of nebulised salbutamol may be considered at 2hours although this should not be given
in the presence of ischaemic heart disease.
-
NB The use of insulin:dextrose infusion and salbutamol nebulisers is seen to have an additive
effect when used in combination.
Salbutamol Nebuliser effect lasts up to 2 hours
Insulin:Dextrose infusion effect lasts up to 4-6 hours
A repeat U+E should be taken 4-6 hours after treatment is started
5. Further treatment
- In refractory hyperkalaemia Sodium Bicarbonate may be considered (should be discussed
with renal physician or critical care)
- Furosemide given IV to produce a potassium losing diuresis may be considered if the patient
is not dehydrated
- Intravenous hydration in presence of dehydration
- Definitive treatment with haemofiltration/haemodialysis should be considered early in patients
with refractory hyperkalaemia, especially in the presence of ECG changes
Page 26 of 46
Hyperkalaemia Flow Chart
Mild Hyperkalaemia
(5.5-6.0mmol/l)
Moderate Hyperkalaemia
(6.1-6.4mmol/l)
Severe Hyperkalaemia
(over 6.5mmol/l)
ECG Required in
presence of symptoms
ECG always
required
Urgent Repeat ECG
Consider repeating
No ECG
changes
ECG changes present
ECG
changes
Stop further
accumulation
Urgent calcium
Gluconate 10ml 10%
over 10 minutes
Maintain bicarbonate
Levels with oral
replacement
Repeat ECG and repeat

Calcium Gluconate if
Changes still present
(up to 5 times)
Consider calcium
resonium
Insulin:Dextrose infusion
250ml of 10% dextrose with
10 units actrapid insulin.
Give over 30 minutes
Salbutamol Nebulisers
Up to 10mg
*see guideline notes.
Repeat bloods in 4-6

Hours and repeat the
Above as needed.
In refractory
hyperkalaemia seek
senior help
MASTER: http://cht-sharepoint2/hotline/ALGORITHMS/Hyperkalaemia%20Algorithm.ppt
Page 27 of 46
SUSPECTED OR DIAGNOSED RENAL / BILIARY OBSTRUCTION

Consider possibility of renal or biliary obstruction in the unwell patient with no obvious source of
sepsis . Biliary obstruction may be present despite normal bilirubin levels (suspect if alkaline
phosphatise approaching 1000U/l). These patients are at risk of associated sepsis as well as acute
renal failure and in some, drainage may be life-saving.
Contact the interventional radiology team URGENTLY if either there is suspicion or on diagnosis of
obstruction, to discuss arrangements and work up for urgent drainage. The Christie has a 24/7
service for drainage of hydronephrosis but this should rarely be required out of hours.
1. Check / recheck FBC/biochemistry and clotting
2
3
Contact interventional radiology team ASAP to discuss:

- working hours extension 3322 to speak directly to interventional radiologist
- out of hours via switchboard to speak to the on-call radiology registrar
If procedure envisaged, immediately discontinue warfarin and any antiplatelet drugs; stop
heparin on the day of a planned procedure. Recheck clotting if necessary.
The INR should be 1.4 or less pre-procedure - give vitamin K 5-10mg i.v. if associated with
biliary
obstruction,
fresh
frozen
plasma
if
other
causes
Patients who already have a biliary or ureteric stent in situ, which may have occluded, must be
assumed
to
be
septic.
Start
broadspectrum
antibiotics.
Blocked external drains. A nephrostomy or a biliary drain is there for a reason and must drain
urine or bile continuously. If this tails off, try flushing in the first instance:
Clean the luer connector thoroughly with two alcohol wipes. Using aseptic, no-touch technique
inject 5ml of sterile saline rapidly. If drainage does not resume, attempt aspiration. If drain
confirmed blocked, this may need changing urgently, depending on the patients condition and
biochemistry.
Note: do not repeat ad lib increasing the pressure in a septic system may cause bacteraemia.
See also guidelines for management of sepsis
Page 28 of 46
HYPERCALCAEMIA
The most common causes of hypercalcaemia in cancer patients are;
1)
Bone metastases especially breast, prostate cancers and myeloma
2)
Paraneoplastic syndrome (may be associated with tumour-induced parathyroid hormone in
absence of bone metastases), seen especially squamous carcinomas e.g. lung, head and
neck, cervix
Calcium level and symptoms
Remember to use calcium level adjusted for any fall in albumin:
Corrected calcium = serum ca + ( (40-albumin) x 0.02): normal < 2.8mmol/l
Note in conditions such as primary hyperparathyroidism, the patient may tolerate chronically elevated
levels above 3 mmol, hence time for renal calculi to develop.
In cancer patients, rapid rise in serum calcium is associated with symptoms, even at lower levels.
Levels of > 3.5 mmol/l will lead to increasing psychosis and coma with fatal arrhythmias.
Typical acute presentations of symptomatic hypercalcaemia in usually include
nausea and vomiting
thirst and polydipsia
polyuria
clinical dehydration
agitation and confusion
palpitations (atrial and ventricular arrhythmias, bradycardia)
Note
- a patient with acute hypercalcaemia can appear to be imminently dying and can improve
dramatically with treatment over a few days
However patients recognize more subtle symptoms. Those with recurrent episodes can often identify
a rising calcium level associated with onset of anorexia, lethargy and muscle weakness.
Decision to treat
Need to base the decision on assessment of each situation and consider
- the patient: severity of symptoms, evidence of dehydration
- biochemistry: corrected calcium level and renal function
- context: in very advanced disease if patient is asymptomatic or has other significant conditions, it is
not always appropriate to treat the hypercalcaemia. Obtain a picture of the general condition a week
or so prior to the onset of hypercalcaemic symptoms
Mild hyercalcaemia: corrected calcium < 3 and asymptomatic. May be managed as an outpatient,
with emphasis on encouraging good oral fluid intake. Patient and calcium should be monitored unless
there is an end of life care plan agreed and documented.
Moderate to severe hypercalcaemia: corrected calcium 3 mmol/l and above and/OR have significant
symptoms. dehydration
Where should symptomatic patients be treated?
If patients are currently undergoing treatment for their disease admit via MAU to the Christie.
Otherwise, hypercalcaemia can be managed at local hospitals*. Do not transfer a patient for
treatment for correction of hypercalcaemia alone if already an in-patient at another hospital. This
would only be necessary in exceptional circumstances and should therefore always be discussed with
the team SpR/consultant.
*Some hospices are prepared to manage hypercalcaemia in patients known to them but not all are
able to do so: if considered as an option it is important to contact the hospice team to discuss.
Page 29 of 46
Check if there has been previously documented episodes of hypercalcaemia and if so, the interval
since last treatment. Frequent recurrences of hypercalcaemia are associated with a poor prognosis
(in terms of a few weeks) especially if no further systemic anti cancer treatment can be offered. In this
situation discuss with oncology team and consider input from palliative care team, but always treat
symptoms (vomiting, agitation) and give iv fluids while this decision is being made.
Immediate management
1)
Full biochemical profile
2)
ECG if level >3 mmol/l and cardiac symptoms
3)
IV fluids: N saline 2-3 litres prior to bisphosphonate treatment in symptomatic patients, K+
supplements as indicated. Do not use furosemide unless there is fluid overload.
This may be adequate for asymptomatic patients with a serum adjusted calcium <3.0mmol/l. Review
patient with oncology team.
4) If symptomatic and/or serum adjusted calcium 3.0mmol/l, then give a bisphosphonate to
reverse the tumour induced release of calcium from bone. This should be administered post
rehydration within 48 hours of admission if appropriate to treat.
Treatment of choice at the Christie is IV zolendronic acid. This is given in 100mls normal saline (iv
over at least 15 mins). Note not ward stock, contact pharmacy to supply.
Dose depends upon renal function:
Creatinine clearance ml/min
>60
50-60
40-49
30-39
Zoledronic acid dose

4 mg
3.5 mg
3.3 mg
3 mg
For patients with a creatinine clearance < 30 ml/min use iv ibandronic acid 2mg in 500 mls of
normal saline over 1 hour.
Side effects of zoledronic acid include
Pyrexia, arthralgia (flu-like symptoms) up to 3 days post infusion
Hypersensitivity and anaphylaxis rare but can occur
Impaired renal function (hence caution with dose)
Lowered serum magnesium and potassium
Nausea, vomiting, dyspnoea and wheeze
Conjunctivitis and uveitis
Pancytopenia, anaemia
*(Note other hospitals/hospices may use pamidronate 30-90mg over 2 hours depending on
calcium level and renal function).
5) Important - do not omit to treat hypercalcaemic symptoms: sub cut haloperidol 1.5-3mg
/24hours is effective for the chemically-mediated nausea induced by hypercalcaemia. If
there could be other factors causing nausea and vomiting combine with cyclizine 150g/24
hours in a subcutaneous infusion. Higher doses of haloperidol e.g. 5-10mg/24hours may be
needed if the patient is agitated and distressed (see also guidelines for managing
agitation and confusion)
6) Review medication: stop furosemide and especially thiazide diuretics;
calcium/Vitamin D supplements.
discontinue any
Subsequent management
Daily monitoring of biochemistry while inpatient at the Christie: this is primarily to assess urea and
electrolyte balance rather than the calcium level. Hydration will lead to clinical improvement
Page 30 of 46
although the serum calcium usually takes 3-5 days to fall and maximal effect by 7-10 days.
Continue IV fluids until calcium normalised and symptoms improved, or if patient remains unwell.
The dose of zoledronic acid may be repeated at 7 days if the calcium level remains elevated.
Occasionally calcitonin may be used: discuss with oncology team. Corticosteroids do not play a
part in management of hypercalcaemia except as part of chemotherapy treatment regimens used
for patients with lymphoma and myeloma.
If the patient is clinically deteriorating with ongoing hypercalcaemia despite treatment the
prognosis is likely to be short and with discussion with patient and family, plan for urgent
discharge home or possibly hospice.
For most patients who have responded well, explain to the patient that there could be recurrence
of the hypercalcaemia and to report further symptoms early. Regular outpatient administration of
bisphosphonates may be indicated especially if no other anti-tumor treatment is planned.
Zoledronic acid is convenient as given over a 15 minute OP treatment every 3 weeks.
Denosumab may be considered in out patients unable to tolerate bisphosphonate maintenance
treatment-usually breast cancer. This has a risk of causing severe symptomatic hypocalcaemia
and is given every 4 weeks. It should not be given unless corrected Ca is > 2.0mmol. The
manufacturers recommend concurrent treatment with calcium and vitamin D supplements.
Currently it is not approved for use in management of acute hypercalcalemia.
If the first presentation of hypercalcaemia
Consider possible causes of hypercalcaemia in this patient and investigate appropriately following
discussion with team SpR/consultant (e.g. bone scan, serum PTH); review ongoing medication.
Always consider other non-cancer associated causes of hypercalcaemia such as primary
hyperparathyroidism, especially if there has been chronic elevation and seek advice from the
endocrinology team if appropriate.
Page 31 of 46
HYPOMAGNESAEMIA
The normal range for serum magnesium at the Christie Hospital is 0.60 to 1.0 mmol/L. This is a
problem which can be managed at local hospitals or hospices and would not require admission of the
patient to the Christie.
Risk factors for hypomagnesaemia
The commonest risk factors for hypomagnesaemia in patients treated at the Christie are drugs or GI
disturbance. Other causes are less common.
Drugs
Systemic Anticancer Treatment e.g. Platinum chemotherapy, Cetuximab, high-dose interleukin-2
therapy, pegylated liposomal Doxorubicin
Others e.g. Foscarnet therapy for cytomegalovirus infection, Cyclosporin therapy - post-transplant
patients, Amphotericin B therapy for fungal infection, Diuretic therapy - loop and thiazide, Gentamicin,
Patients receiving TPN.
Gastrointestinal
Include - diarrhoea and vomiting, poor nutrition, gastrointestinal fistula, surgical resection,
malabsorption
Renal
Include - uncontrolled diabetes mellitus/ ketoacidosis, chronic alcoholism, hyperthyroidism,
hyperparathyroidism, hyperaldosteronism, hypercalcaemia/ hypophosphataemia, renal tubular
reabsorption defects
Fluid shifts extracellular to intracellular
Include - acute pancreatitis, re-feeding syndrome, massive blood transfusion, acidosis
Signs and symptoms of hypomagnesaemia
Hypomagnesaemia may be asymptomatic. If symptoms are present they are often non-specific and
include:
Other metabolic abnormalities
Hypokalaemia and hypocalcaemia are commonly seen. Hypomagnesaemia should be
considered in any patient with persistent/ recurrently low potassium or calcium.
Muscle weakness and neuromuscular excitability
Ataxia, tremor, seizures, carpo-pedal spasm
Cardiac arrhythmias (widening of QRS complex and peaking of T waves on ECG)
Altered mental state: Depression, psychosis, delirium and coma
Initial management Investigations
Serum Magnesium and other electrolytes Potassium, Phosphate, Calcium
Note hypoalbuminemic states may result in spuriously low Mg values.
Clinical assessment of cause
Additional blood tests as necessary e.g. Amylase, Thyroid function
ECG
Treatment
Serum Magnesium
If < 0.4 - treatment should be instituted
If 0.4 0.6 - supplements should be considered based on a risk/ benefit assessment. If the patient
has symptoms or there are on-going risk factors then treatment is likely to be required.
Drugs - consider whether any contributing medications can be stopped e.g. replacing loop diuretic
with a potassium sparing diuretic.
Magnesium replacement Oral Mg is preferred to IV Mg
Oral Mg
Magnesium glycerophosphate can be used (magnesium sulphate is not absorbed enterally). Starting
Page 32 of 46
dose is two capsules bd (4 mmol/tablet).

Magnesium salts may result in diarrhoea and should be given with or after food to minimise the risk of
diarrhoea.
Intravenous Mg would be preferred in patients with symptoms or who have developed Mg <0.4
despite oral replacement.
The licensed dose of intravenous magnesium is 20 mmoles (5 grams) magnesium sulphate diluted in
1 litre of 0.9% sodium chloride or 5% dextrose and infused over 3 hours. A 12 hours infusion is
preferred as this will maximise replenishment of intracellular magnesium, and reduce the proportion of
administered magnesium lost through renal excretion.
The infusion can be given in 500ml of sodium chloride or 5% dextrose if there are concerns that the
patient is at risk of fluid overload.
Magnesium Sulphate should be used if available. Magnesium Chloride could also be used as an
alternative if Magesium Sulphate is not available.
Subsequent oral Magnesium supplements should be considered in all cases.
If cardiac arrhythmias/ ECG changes present:
Seek senior and Critical Care advice.
Subsequent monitoring
Check serum magnesium daily after commencement of magnesium replacement therapy as an
inpatient.
If oral replacement is prescribed on an outpatient basis, arrangements must be made to check serum
magnesium levels weekly (or more frequently if patients with renal impairment).
Cautions
The following groups of patients are at greater risk of hypermagnesaemia, or of severe compromise if
they were to become hypermagnesaemic. Consider slower rates and lower doses (25-50% of
planned dose) of magnesium supplementation, and closer monitoring of serum magnesium levels
Patients with renal impairment
Patients with myasthenia gravis
Patients with impaired respiratory function
Patients with heart block or other cause of bradycardia
Page 33 of 46
SVC OBSTRUCTION
Caused by extrinsic compression by right upper lobe bronchial cancers, nodal masses or rare
tumours arising within the anterior mediastinum.
May be associated with or caused by, thrombosis: check if central venous catheter is in place.
Clinical signs: swelling of face and upper limbs; distended collateral veins; breathlessness,
headache, cyanosis and stridor. Assess the degree of respiratory distress.
Investigations
FBC, profile, clotting screen
Chest x-ray
Ultrasound to check patency of central venous catheter if thrombosis suspected in brachial/central
veins
CT scan (after discussion with own oncology team)
If underlying pathology not already established, biopsy of superficial node or mediastinal disease
may be needed.
Management
Patients should be assessed by the registrar or on-call registrar.
Patients are more comfortable sitting up, with oxygen: consider Heliox (helium /oxygen mix) for
patients with marked stridor as this is easier to breathe. Contact physiotherapy
team/Rehabilitation unit.
The treatment of choice is insertion of a stent into the occluded section of vein, often with
immediate improvement in symptoms. Discuss with consultant radiologist. Radiotherapy may be
required following this.
If radiotherapy is considered e.g. lymphoma, commence dexamethasone 8mg bd with PPI cover
and contact the clinical oncology registrar on-call. Some patients will be given chemotherapy e.g.
lymphoma/small cell lung cancers.
NB Patients with airway obstruction should not be brought to the MAU but directed to their nearest
hospital with an on-call ENT team.
Head & Neck Disease Group Guidelines for Management of STRIDOR
Stridor is a harsh inspiratory or expiratory sound due to partial obstruction of the upper respiratory
tract
Stridor with a compromised airway is a medical/surgical emergency. Early recognitionand
treatment can help to prevent a potentially life-threatening situation, requiring an emergency
tracheostomy, to develop.
Causes
Internal e.g. Tumour, oedema*, foreign body, laryngospasm
*oedema may occur due to radiotherapy to the larynx area, or infection.
Extrinsic external compression e.g. from tumour, lymphadenopathy
Assessment of stridor
How noisy is the breathing?
Can the patient talk in complete sentences?
Is patient pale/cyanosed?
Check O2 saturation, respiratory rate andpulse rate. Get MEWS score
Is patient confused/disorientated /aggressive? Could be due to hypoxia (even in absence of
Page 34 of 46
severe stridor)
Management
Contact ENT & Critical Care as soon as stridor is identified. Notify treating team. In case of
severely compromised airway get urgent ENT opinion (Fast bleep ENT / Critical Care).
Instigate medical management as soon as possible (see box below).

Monitor O2 saturations, pulse, respiratory rate, BP. Obtain MEWS score
Sit patient upright
Do not allow radiotherapy treatment for that day until patient has been medically assessed
Medical management of stridor:
o Give 100% oxygen (humidified when possible); consider Heliox (from Surgical
Theatres)
o Cannulate and give dexamethasone 8mg IV.
o Give nebulised adrenaline 1:1000 2mls in 5mls saline, PRN up to 1 hourly
o Consider IV antibiotics, depending on severity of patients condition
o Keep nil by mouth
ENT personnel will need the following for direct visual assessment of airway:
Light source (available from Outpatients or Ward 10)
Flexible nasendoscope available in Outpatients Endoscopy Room (Door code C3679Z)
Have Minitrach set available (from Emergency Trolley)
Patient is likely to need transfer to A&E at Wythenshawe or MRI for ENT review.
Dial 999
Alert ENT SpR at receiving hospital
Patient should be accompanied during transfer by medical personnel competent to secure an
obstructed airway
Contact Numbers:
ENT Fellow
bleep 12702
Critical Care
Debbie Elliott
Kathleen Mais
H&N CNS Ext 8041, bleep 12610

H&N Nurse Clinician Ext 3428, bleep 12589
Page 35 of 46
MANAGEMENT OF ALCOHOL WITHDRAWAL

See also hospital guidelines for detection and management of alcohol related disorders
Alcohol withdrawal may be life-threatening and therefore it is important to recognise, and treat, clinical
features early.
Only 40% of heavy drinkers experience withdrawal signs which range in severity:
Uncomplicated withdrawal symptoms develop within 12 hours after last drink; tremor,
sweating, tachycardia, raised BP and pulse, pyrexia, nausea, anorexia, insomnia, anxiety and
mild confusion. Symptoms peak in 10-30 hours, subside by 40-50 hours
Hallucinosis onset within 24 hours of last drink, stop within another 24-48 hours. Both auditory
and visual hallucinations occur with otherwise clear sensorium (e.g. accusatory/derogatory
voices, bugs crawling on bed)
Alcohol-related seizures onset within 12-48 hours of last drink, more likely if history of
epilepsy, previous withdrawal seizures or multiple detoxifications. Fits tend to be generalised
(if focal suspect head injury) and may occur in bouts. In 30%, followed by delirium tremens
Delirium tremens while occurring in only 5%, is associated with highest morbidity and
mortality. Develops within 72 hours but up to several days after the last drink with marked
tremor, confusion, disorientation, agitation, restlessness, fearfulness, visual and auditory
hallucinations and paranoid ideation and delusions. Autonomic features include tachycardia,
seating and fever leading to dehydration.
Patients at risk of DTs if consumption more than 16 units (half to one bottle spirits/day) also if
older, poor nutrition, co-existing medical problems such as chest infection.
Alcohol intake should be assessed and if patients are identified as dependent, it is the responsibility
of the admitting doctor to prescribe an alcohol detoxification regimen together with Pabrinex for
prophylaxis against Wernickes encephalopathy.
Management of acute alcohol withdrawal
General care: patients need regular monitoring including vital signs and fluid balance; correct
dehydration and electrolytes where indicated. Keep patients orientated and reassured that any
distressing symptoms will settle.
Chlordiazepoxide: The oral treatment of choice, but follow guidance below carefully.
Dose should be titrated against severity; most require treatment for 24 hours followed by 2-3 hourly
assessments. This may need to continue for 48 hours if seizures or DTs develop. Give additional prn
doses (5-20 mg) if symptoms breakthrough.
Patients must be monitored for signs of benzodiazepine toxicity and medically reviewed at least once
/24 hours.
The following is a suggested prescribing regimen for an adult male: reduce if elderly, female or
evidence liver impairment.
Doses in excess of 30mg qds should only be prescribed if severe withdrawal is expected and the
patient must be carefully monitored: doses of 40mg qds should not be used in women, the elderly or if
evidence of liver impairment. The maximum dose of chlordiazepoxide is 200mg/24 hours unless on
specialist psychiatric advice.
Day
1
2
3
4
5
6
Morning
30mg
30mg
20mg
15mg
10mg
10mg
Midday
30mg
20mg
20mg
15mg
10mg
Afternoon
30mg
20mg
20mg
15mg
10mg
Night
30mg
30mg
20mg
15mg
10mg
10mg
10mg
Page 36 of 46
Total
120mg
100mg
80mg
60mg
40mg
20mg
10mg
Special situations
1. Patient vomiting or refuses oral medication: use lorazepam im/sc (1mg is equivalent to 15mg oral
chlordiazepoxide)
2. Liver impairment: Caution needed as metabolism of benzodiaezepines is impaired leading to
over-sedation. In patients with significantly impaired liver function, substitute oxazepam im (doses
as for chlordiazepoxide above). Oxazepam can be given IV as a 30 minute infusion see BNF.
Parenteral treatment should be followed by oral vitamin supplements (thiamine 100mg tds and Vit
B co strong bd 2 tablets tds) for a minimum of 2 weeks.
3. Treatment of Wernickes encephalopathy IV Pabrinex , 2 pairs of ampoules tds as a 30min
infusion for 2-3 days until clinical symptoms resolved. Note anaphylactic reactions can rarely
occur with IV thiamine and IV dextrose should NOT be given before Pabrinex due to risk of
precipitating encephalopathy.
Then continue with oral vitamin supplements as above and nutritional support (high carbohydrate
diet)
Discharge arrangements and aftercare
The clinical team need to ensure that the chlordiazepoxide regiment has been completed before
discharge, vitamin supplements are prescribed and a referral made to the local community alcohol
team. If the patient leaves before full detoxification arrangements must be made for ongoing
monitoring and there is a risk of accidental drug over dosage if alcohol is resumed while taking
chlordiazepoxide.
Use of the Mental Capacity Act
A clinical assessment may reveal that a patient who declines treatment for alcohol withdrawal may
lack the capacity to make that decision. This will apply if the patient is unable to
Understand the information relevant to the decision
Retain that information
Use or weigh the information as part of the process of making a decision
Communicate that decision.
If a patient is deemed by the responsible clinical team to lack capacity then treatment should be
continued under mental capacity Act if it is in the patients best interests to do so.
Best interests decision making
In determining the patients best interests, all the patients relevant circumstances must be considered
along with his/her present and past wishes so far as they are reasonably ascertainable.
The treatment may include having to administer medicines against the patients will and in doing so
may involve having to restrain the patient or otherwise prevent him/her from leaving the ward.
Use of restraint
Under the provisions of the mental capacity Act 2005, a patient may only be restrained if the following
conditions are met:
The restrainers must reasonably believe restraint to be necessary to prevent harm to the
patient or others, and
The act is a proportional response to the likelihood of the patient suffering harm, and the
seriousness of that harm.
Record keeping
The following MUST be clearly documented the medical records:
The opinion that the patient lacks capacity to consent to treatment
Why treatment is considered to be in the patients best interests
A full description of the risk the patient poses to self should treatment be withheld and the
rationale behind this opinion
A full description of the measures being taken against the patients will
When restraint is used, a full account of why it is considered appropriate.
Page 37 of 46
Mental Health Act

This applies where there is mental illness. If it is believed that a mental illness is resulting in the
disturbed behaviour, rather than the alcohol withdrawal, the advice of a consultant psychiatrist should
be so7ght. If necessary the patient could be detained and treated under the mental health act. Note
this applies only to the treatment of the mental illness; treatment for any physical illness would still
come under the remit of the mental capacity act if the patient is refusing treatment and lacks capacity
to make this decision.
Further advice and help
Within working hours- contact the Psycho-oncology service x 8103
Out of hours provision for psychiatry is via the Wythenshawe Hospital switchboard to contact the oncall specialist registrar:
Patients under 65: ask for the on call registrar for psychiatry; If 65 and over ask for the on-call
registrar for old age psychiatry
Page 38 of 46
PAIN AND SYMPTOM MANAGEMENT

Patients on the Medical Assessment Unit
Criteria for admission
While symptoms trigger contact with the Christie and consideration of admission, the following should
NOT be admitted here:
Undiagnosed acute pain
Symptoms which are not consistent with current/recent cancer treatment ESPECIALLY if
acute surgical or medical management may be needed outside an oncology service
Symptoms associated with disease progression but the following apply
- no specific intervention is needed
- the patient is no longer on active treatment at the Christie
- and /or care may reasonably be provided in a hospital or hospice nearer to home
However staff on the MAU will need to manage pain and symptoms in patients who met the
admissions criteria.
If a patient is distressed and not responding to first line management, the situation must be escalated
to senior medical staff and obtain advice from the pain or palliative care team if necessary.
Resources (see resource folder or intranet)
Pain including use of opioids, opioid toxicity, acute pain, neuropathic pain.
Constipation.
Nausea and vomiting (causes other than chemotherapy).
Agitation and confusion.
Symptomatic management of bowel obstruction in advanced disease.
Use of syringe drivers.
Management of the dying patient.
Help and advice
1. The Pain Team
Especially severe, acute pain as the main presenting problem including pathological fractures
Monday Friday bleep pain nurse specialist or page Dr Bhaskar via switchboard.
2. Palliative Care Team
Pain and symptoms, psychological distress including carers
Especially if patient previously seen by PCST check notes/Medway or known involvement outside
palliative care services
Contact x 3072 or bleep 12634
Week-ends and Bank Holidays palliative care telephone advice available via switchboard 9am-9pm
Page 39 of 46
MANAGEMENT OF RAISED INTRACRANIAL PRESSURE

Introduction
Raised intracranial pressure (ICP) in the context of a cancer patient is most commonly caused by:
Mass lesions - primary or secondary tumours +/- oedema
Haemorrhage more commonly intracerebral than extradural or subdural
Development of hydrocephalus
Cerebral venous thrombosis
In many patients the development of raised intracranial pressure due to a recurrent primary brain
tumour or the development of brain metastases indicates an extremely poor prognosis and patients
are managed to control their symptoms. More aggressive management strategies, which may include
escalation to critical care or neurosurgical intervention, may be considered in some patients e.g.
solitary metastases, chemo-sensitive disease (Germ cell tumours), etc. It is therefore important to
discuss each case at an early stage with a senior doctor.
Clinical Features
Symptoms
Headache - worse on coughing or sneezing, starting on waking
Nausea and vomiting
Impaired consciousness
Focal weakness
Seizures
Confusion
Signs
Focal neurology and visual disturbances, eye movement maybe affected
Papilloedema on fundoscopy
Cushing's reflex (bradycardia, hypertension, triad includes variable breathing which is
a late sign)
Late signs suggestive of brain stem herniation (rare unless haemorrhagic cause)
Investigations
Bloods
FBC
Coagulation screen
Blood glucose
U&E, Calcium and LFTs
Imaging
Urgent contrast-enhanced CT or MRI brain scan
Management
Stabilise patient
IV fluids to correct hypotension
Treat seizures see separate protocol
Treat pain or agitation as appropriate
CT or MRI scan will help to guide subsequent management
All cases should be discussed with a senior regarding appropriateness of escalation of
care and further management
Lumbar puncture should not be performed
If imaging demonstrates a mass lesion with associated oedema or hydrocephalus

Start dexamethasone 16mg daily (8mg at 8am and 1pm, IV or oral) with PPI cover
reduces vasogenic oedema, takes few hours to work
Review by the Critical Care team should be undertaken in selected patients who are
rapidly deteriorating and in whom escalation of care is considered appropriate after
review by oncology SpR or Consultant.
Additional management steps on Critical Care may include IV mannitol or
Page 40 of 46
hyperventilation and involvement of the neurosurgical on-call at Salford Royal

Foundation Trust (SRFT)
If imaging identifies haemorrhage extradural, subdural or intracerebral

Correct coagulation abnormalities and platelets if appropriate
Omit/ stop anti-coagulants (e.g. aspirin, clopidogrel, warfarin, LMW heparin) in the
acute setting
Discuss with Oncology SpR or Consultant
Consider whether surgical intervention by Neurosurgeons at SRFT would be
appropriate.
If imaging identifies hydrocephalus

Discuss with Oncology SpR or Consultant
Consider whether referral to Neurosurgeons at SRFT for ventricular shunt to
relieve hydrocephalus by would be appropriate.
Page 41 of 46
GUIDELINES FOR THE MANAGEMENT OF EPILEPSY IN NEURO-ONCOLOGY PATIENTS

Epilepsy is common in patients with brain tumours, especially those with primary low-grade tumours.
Management is individualised, based on patient factors and toxicities.
The full epilepsy guidelines are available within the Management of CNS Tumours document on the
intranet; this excerpt from that document is intended to cover only acute management.
Additional advice can be sought from the Neurology team @ Salford Royal NHS
Foundation Trust
The On-call Neurology SpR is available for 24 hour advice via Salford Royal switchboard
0161 789 7373 they cover the Greater Manchester and Cheshire area
The Neurology Consultants/Epileptologists are Dr Mohanraj, Dr Cooper & Dr Clough at
Salford Royal NHS Foundation Trust to whom patients can be referred
Strategies for managing prolonged / serial seizures / status epilepticus
Patients with structural brain lesions are at increased risk of experiencing status epilepticus or serial
seizures.
Serial seizures:
Patients may experience increasing frequency of partial seizures before suffering a generalised
convulsive seizure, which evolves into status epilepticus. If this pattern of seizures has occurred once,
patients and their families should be given the option of using Clobazam 10mg BD for 3 days to abort
the episode of status.
Prolonged generalised seizure:
If seizures persist for >5min, or 2 min more than the usual duration of seizures for the patient,
intervention is required.
Out of hospital management:
Some patients have rescue medication available at home (buccal midazolam or rectal diazepam)
which has been supplied by the epilepsy service.
If no rescue medication available, or if it does not work then in most cases this would require a 999
call.
In hospital management of status epilepticus:
Status epilepticus can be defined as:
Generalised convulsive seizure lasting >5min
or 2 convulsions without complete resolution between events1 (ie patient does not regain
consciousness)
or Nonconvulsive Status Epilepticus difficult to diagnose but keep it in mind for patients
who have had an unexpected alteration in mental state 2. If this is suspected, contact the
neurologist on call as an urgent EEG is indicated
These events should all be managed as follows:
Initial treatment
ABC and consider requesting senior support
Airway support via adjuncts eg guedell airway or naso-pharyngeal airway + oxygen via non
rebreather mask.
Monitor and maintain blood pressure
Check blood glucose and correct where applicable especially if low
Medication
Patient has IV Access
Page 42 of 46
Either 1. Lorazepam 4mg given over 2 minutes

Or
2. Diazepam 10mg IV (if Lorazepam unavailable)
No IV access
Either 1. Rectal Diazepam 20mg
Or
2. Buccal midazolam 10mg (can give Hypnovel the IV preparation 10mg/1ml bucally open
the vial and squirt onto buccal membrane)
Repeat dose after 5 minutes if no resolution and obtain senior support (outreach team via CCU and/or
own team seniors if available)
If seizures continue 5 min after the initial medication, management is either:
Valproate
10mg/kg (ie 500-800mg, up-to 800mg maximum)
Administered as IV bolus over 3-5 minutes
Followed by intravenous infusion of valproate 20 mg/kg ie 1g-1.6g up-to 1.6 gram over
24 hours.
Bolus over 3- Infusion over
Weight
5 minutes
24 hours
50kg
500mg
1g
60kg
600mg
1.2g
70kg
700mg
1.4g
80kg upwards
800mg
1.6g
OR
Phenytoin (or Phosphenytoin if available same dose)
18mg/kg iv over minimum of 20 minutes.
Patient should be on a cardiac monitor during infusion and blood pressure checked every 5
minutes due to risk of hypotension and bradycardia.
Should the patients blood pressure drop significantly or they become bradycardic stop the
infusion and review. Recommencement at a slower rate is possible but if remaining
bradycardic, atropine may be required.
Levels should be checked after 2 hours then daily for 1 week. The clinically effective serum
level is usually 10-20 mcg/mL.
Maintenance therapy of 100mg TDS for 1 week and then 300mg at night(3-4mg/kg ~300mg).
However it is better to change to a first line AED such as lamotrigine for the longer term. The
neurology SpR on call should be contacted before medication is altered
Weight
50kg
60kg
70kg
80kg
100kg
Bolus rate not exceeding 50mg/min

900mg
1,080mg
1,260mg
1,440mg
1,800mg
If seizure continues for >5-10 minutes after administration of bolus:

the patient should be reviewed by critical care and considered for escalation of care eg
suitability for general anaesthesia and transfer to an itu.
the critical care unit @ the christie cannot manage intubated patients so they would
require transfer to an itu facility.
consider phenobarbital (a controlled drug) which should only be given in HDU due to
possibility of respiratory depression and request advice from neurology spr on call, in
addition to critical care involvement.
if patient is not suitable for escalation of care, call neurology spr on call for advice on
management.
Page 43 of 46
MANAGEMENT OF PERICARDIAL EFFUSIONS AND CARDIAC TAMPONADE

Aetiology
In the population of patients treated at the Christie Hospital pericardial effusions are highly likely to be
malignant in nature. There are however numerous other causes which should be considered
including:
Mediastinal/ Chest radiation
Acute pericarditis (viral, bacterial, tuberculous, or idiopathic in origin)
Post-myocardial infarction
Drugs
Chest trauma including cardiac diagnostic and interventional procedures
Renal failure with uraemia
Hypothyroidism
Autoimmune disease
Aortic dissection
Clinical features
Symptoms
Effusion often asymptomatic but may have symptoms of underlying condition.
Effusions leading to tamponade will cause symptoms of impaired cardiac function i.e.
fatigue, dyspnoea, oedema
Signs
Sinus tachycardia
Hypotension, Raised JVP, muffled heart sounds (Beck's triad)
Pulsus paradoxus (an exaggeration of the physiological drop in blood pressure on
inspiration)
Pericardial rub (in the early stages)
Signs of right and, eventually, left heart failure
Large effusions can cause compression of local structure resulting in dyspnoea,
dysphagia, hoarseness (recurrent laryngeal nerve), hiccups (phrenic nerve) and
nausea
Investigations
Bloods
FBC
Coagulation
U&Es
Thyroid function
Troponin
Autoimmune screen in selected cases
ECG
Low voltage QRS complexes
Saddle-shaped ST elevation
Variable amplitude of QRS complexes (electrical alternans)
Sinus tachycardia
Imaging
CXR large effusions may result in globular cardiomegaly
Transthoracic Echocardiogram will be needed to confirm the presence of an effusion
suspected on CXR.
Management
Assess the haemodynamic status of the patient
Asymptomatic effusions
This is a common scenario in oncology patients with a pericardial effusion noted on
a routine re-staging CT scan.
Discuss case with Consultant regarding further management.
Page 44 of 46
Diagnostic sampling can be considered but needs to be weighed against the

associated risk, the diagnostic information it will provide and the context of the
patient. In many patients diagnostic sampling will not be required unless it would
alter a patients management i.e. alter cancer management or to assess for a nonmalignant cause.
Treatment
Based upon management of the underlying condition i.e. chemotherapy if
appropriate for malignant effusions
Monitoring may be required to ensure the effusion does not enlarge and
subsequently become symptomatic. Decisions on the appropriateness and
frequency of echocardiogram monitoring will vary dependent upon
individual patient circumstances.
Symptomatic patients
Stabilise the patient fluid resuscitation/ Oxygen
Needs senior review and discussion with Cardiothoracic team at Wythenshawe
Hospital regarding urgent pericardioscentesis.
Note the volume of effusion does not correlate with symptoms with acute
symptomatic effusions often being small.
Page 45 of 46
CONSULTATION, APPROVAL & RATIFICATION PROCESS

All documents must be involved in a consultation process either locally within a department or division
or throughout the trust at relevant board/committee meetings before being submitted for approval.
VERSION CONTROL SHEET
Version Date
Author
V1
05/05/12 Michael Braun
V2
15/05/12 Michael Braun
Catherine McBain
Steve Wardell
V3
16/05/12 L Lawrence
V4
23/05/12 Louise Lawrence
Paula Hall
Anne Moreman
Lena Richards
Wendy Makin
V5
16/05/13 Wendy Makin
Edit
V6
16/05/13
Louise Lawrence
Edit
Updated SUSPECTED OR DIAGNOSED

RENAL / BILIARY OBSTRUCTION
Ratification template.
V7
24/10/13
V8
12/3/14
Louise Lawrence
Wendy Makin
Andrew Wardley
John Murray
Lena Richards
Phil Hajimichael
Phil Haji-Michael
Louise Lawrence
Wendy Makin
Edit
Review
Review
Review
Review
Review
Edit
Review
Review
Revised document
Revised Hypercalcaemia
Reviewed content
Revised Management of Sepsis
Revised MSCC
Reviewed content
Added Hyperkalaemia
Reviewed document
Reviewed document
Status
Creation
Review
Comment
Update
Review
Page 46 of 46

Acute Oncology Handbook R8 PDF

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ACUTE ONCOLOGY HANDBOOK

Acute Oncology Group

4th Nov 2013

Management of Suspected Sepsis

Nausea and vomiting post chemotherapy

Management of problems related to central venous catheters

Acute radiotherapy complications

Dose conversion chart for strong opioids

Management of head and next cancer patients on the MAU

Metastatic Spinal cord compression

Deteriorating renal function / acute renal failure

Suspected or diagnosed renal / biliary obstruction

Management of alcohol withdrawal

Pain and symptom management

Management of raised intracranial pressure

Guidelines for the management of epilepsy in neuro-oncology patients

Management of pericardial effusions and cardiac tamponade

Consultation, approval and ratification process

Responsibilities for continuity of care

MANAGEMENT OF SUSPECTED SEPSIS

NAUSEA AND VOMITING POST CHEMOTHERAPY

MANAGEMENT OF PROBLEMS RELATED TO CENTRAL VENOUS CATHETERS

ACUTE RADIOTHERAPY COMPLICATIONS

Grade 3 oesophagitis is indicative of hospitalisation, but naso-gastric tube feeding is not

Oral morphine solution 10mg/5ml (oramorph )

If unstable pain commence continuous subcutaneous driver infusion of morphine or

Alternatively, if patient is hospitalised, intravenous morphine 1mg/1ml administered by

2. Mucosal coating agents

3. Proton pump inhibitors (PPI)

All patients with grade 4 oesophagitis should receive intravenous PPI.

MANAGEMENT OF HEAD AND NECK CANCER PATIENTS ON THE MEDICAL ADMISSIONS

3. Patients admitted with nausea and vomiting

METASTATIC SPINAL CORD COMPRESSION (MSCC) ASSOCIATED WITH MALIGNANT

DETERIORATING RENAL FUNCTION / ACUTE RENAL FAILURE

Common causes of new renal impairment/failure in cancer patients:

Renal ultrasound to exclude obstruction.

Optimize Fluid Balance

GUIDELINES FOR THE MANAGEMENT OF HYPERKALAEMIA IN ADULT PATIENTS

SIGNS & SYMPTOMS

Managing mild and moderate hyperkalaemia

FIVE STEP APPROACH TO TREATING SEVERE HYPERKALAEMIA

Hyperkalaemia Flow Chart

Urgent Repeat ECG

ECG changes present

Repeat ECG and repeat

Repeat bloods in 4-6

SUSPECTED OR DIAGNOSED RENAL / BILIARY OBSTRUCTION

Contact interventional radiology team ASAP to discuss:

Zoledronic acid dose

dose is two capsules bd (4 mmol/tablet).

Instigate medical management as soon as possible (see box below).

H&N CNS Ext 8041, bleep 12610

MANAGEMENT OF ALCOHOL WITHDRAWAL

Mental Health Act

PAIN AND SYMPTOM MANAGEMENT

MANAGEMENT OF RAISED INTRACRANIAL PRESSURE

If imaging demonstrates a mass lesion with associated oedema or hydrocephalus

hyperventilation and involvement of the neurosurgical on-call at Salford Royal

If imaging identifies haemorrhage extradural, subdural or intracerebral

If imaging identifies hydrocephalus

GUIDELINES FOR THE MANAGEMENT OF EPILEPSY IN NEURO-ONCOLOGY PATIENTS

Either 1. Lorazepam 4mg given over 2 minutes

Bolus rate not exceeding 50mg/min