Posted by Becky
So far this round of chemo is going okay. Leif has nausea and loss of appetite, and needed a unit of blood today and yesterday. His neutrophil count is still good, thanks I suspect to last week's Neupogen shots.
Today an alert nurse started to disconnect one of Leif's IV lines at the end of a chemo dose, and saw that there were little crystals of white crud inside the line. She stopped the IV, didn't flush the line, and called in another nurse. They checked further, and there was some of the same stuff in the line he was getting blood through, too. Much discussion ensued, involving the IV team, hematologists, pharmacists, and nurses.
What they think happened is that one of his chemo drugs, etoposide, precipitated out of its solution. Etoposide has a tendency to do that at concentrations higher than 0.4 mg/mL, and Leif's doses are mixed at 0.395 mg/mL. The pharmacy follows the recommended protocols; the doses are supposed to be good for 24 hours, and they make 12-hour doses within the correct time window, but for some reason (manufacturing problem?) this batch precipitated under these conditions, sometime near the end of the dose. The nurses told us this issue hadn't been seen with etoposide at DHMC for quite a long time, but it isn't unheard of. This is a drug that he gets 24 hours a day for 4 days.
Anyway, the nurses had hung the next bag of etoposide on a different line in the meantime, because the initial reaction of the doctors was that it was important not to stop his chemo. They switched the blood transfusion to his trusty port, and ran the etoposide through a line on his PICC that had only been used for normal saline and didn't show any precipitate. Then the IV team weighed in, and expressed their concern that there could be more precipitate in the ~9 to 20 inches of the PICC that are inside Leif; so they stopped everything going through the PICC until it could be replaced. More conferencing. Finally his doctor came in and gave us the plan; once his blood transfusion was done, they would remove his PICC line and put in another one, then resume his chemo, fluids, etc.
Fortunately the nurses did a good job giving him enough sedatives that he was OK through the process of putting the new line in. They had to put it in his left arm because he's had two in his right arm recently, and they need to give that side a rest. They didn't remove the old line, which they can do in his hospital room, for several more hours - the IV team was short-staffed today and very busy. As long as it was still in place, the idea of a PICC line in his vein that was full of crud was quite stressful for Leif; the sedatives were wearing off, he was experiencing extra nausea, and he had missed a couple of naps. Right about then, the awesome Mike Aaron called and distracted him for a while, which was the best medicine we could have asked for.
The doctor let us know that she doesn't think the precipitate is going to hurt him. Also, pausing the chemo for 6-8 hours is not going to be a problem. It will just run that much longer at the end of his dosing period. Only if they had to pause it for a couple of days would the effectiveness of the chemo be reduced.
Another new, fun thing Leif is discovering, as of Tuesday, is life as a diabetic. The dexamethasone steroid that they give him with his cytarabine chemo can trigger diabetes. They test his blood sugar 4 times a day, and give him insulin when necessary. Because, you know, the guy didn't have enough needles in his life.
His phosphorous levels are also high, which is caused by the lymphoma cells dying off quickly and creating a lot of crud for his kidneys to clear out of his bloodstream at once. He's been getting medication to protect his kidneys from this process (called tumor lysis) including a phosphorous binder, rasburicase (a synthetic enzyme that breaks down uric acid), allopurinol (which prevents uric acid formation), and calcium supplements, since in trying to get rid of the excess phosphorus, the body uses up a lot of calcium. They also give him lots and lots of IV fluids, and a diuretic to help flush them all out. The fluids make him look a bit puffy, but he doesn't have severe edema (swelling) in his legs like he's had in hospital visits past. He's once again wearing a sequential compression device (SCD), that inflates and deflates a pair of fancy white tyvek leg warmers.
A tall nurse helped me replace the ticking clock with our silent analog clock from home. Leif is finally getting some sleep, with music playing in his headphones. It's pretty quiet in here with only the heating pad (for his back), SCD, and a single IV pump running. His neighbors remain quiet, too, although they've changed out on either side.
So far this round of chemo is going okay. Leif has nausea and loss of appetite, and needed a unit of blood today and yesterday. His neutrophil count is still good, thanks I suspect to last week's Neupogen shots.
Today an alert nurse started to disconnect one of Leif's IV lines at the end of a chemo dose, and saw that there were little crystals of white crud inside the line. She stopped the IV, didn't flush the line, and called in another nurse. They checked further, and there was some of the same stuff in the line he was getting blood through, too. Much discussion ensued, involving the IV team, hematologists, pharmacists, and nurses.
What they think happened is that one of his chemo drugs, etoposide, precipitated out of its solution. Etoposide has a tendency to do that at concentrations higher than 0.4 mg/mL, and Leif's doses are mixed at 0.395 mg/mL. The pharmacy follows the recommended protocols; the doses are supposed to be good for 24 hours, and they make 12-hour doses within the correct time window, but for some reason (manufacturing problem?) this batch precipitated under these conditions, sometime near the end of the dose. The nurses told us this issue hadn't been seen with etoposide at DHMC for quite a long time, but it isn't unheard of. This is a drug that he gets 24 hours a day for 4 days.
Anyway, the nurses had hung the next bag of etoposide on a different line in the meantime, because the initial reaction of the doctors was that it was important not to stop his chemo. They switched the blood transfusion to his trusty port, and ran the etoposide through a line on his PICC that had only been used for normal saline and didn't show any precipitate. Then the IV team weighed in, and expressed their concern that there could be more precipitate in the ~9 to 20 inches of the PICC that are inside Leif; so they stopped everything going through the PICC until it could be replaced. More conferencing. Finally his doctor came in and gave us the plan; once his blood transfusion was done, they would remove his PICC line and put in another one, then resume his chemo, fluids, etc.
Fortunately the nurses did a good job giving him enough sedatives that he was OK through the process of putting the new line in. They had to put it in his left arm because he's had two in his right arm recently, and they need to give that side a rest. They didn't remove the old line, which they can do in his hospital room, for several more hours - the IV team was short-staffed today and very busy. As long as it was still in place, the idea of a PICC line in his vein that was full of crud was quite stressful for Leif; the sedatives were wearing off, he was experiencing extra nausea, and he had missed a couple of naps. Right about then, the awesome Mike Aaron called and distracted him for a while, which was the best medicine we could have asked for.
The doctor let us know that she doesn't think the precipitate is going to hurt him. Also, pausing the chemo for 6-8 hours is not going to be a problem. It will just run that much longer at the end of his dosing period. Only if they had to pause it for a couple of days would the effectiveness of the chemo be reduced.
Another new, fun thing Leif is discovering, as of Tuesday, is life as a diabetic. The dexamethasone steroid that they give him with his cytarabine chemo can trigger diabetes. They test his blood sugar 4 times a day, and give him insulin when necessary. Because, you know, the guy didn't have enough needles in his life.
His phosphorous levels are also high, which is caused by the lymphoma cells dying off quickly and creating a lot of crud for his kidneys to clear out of his bloodstream at once. He's been getting medication to protect his kidneys from this process (called tumor lysis) including a phosphorous binder, rasburicase (a synthetic enzyme that breaks down uric acid), allopurinol (which prevents uric acid formation), and calcium supplements, since in trying to get rid of the excess phosphorus, the body uses up a lot of calcium. They also give him lots and lots of IV fluids, and a diuretic to help flush them all out. The fluids make him look a bit puffy, but he doesn't have severe edema (swelling) in his legs like he's had in hospital visits past. He's once again wearing a sequential compression device (SCD), that inflates and deflates a pair of fancy white tyvek leg warmers.
A tall nurse helped me replace the ticking clock with our silent analog clock from home. Leif is finally getting some sleep, with music playing in his headphones. It's pretty quiet in here with only the heating pad (for his back), SCD, and a single IV pump running. His neighbors remain quiet, too, although they've changed out on either side.
No comments:
Post a Comment