Posted by Becky
Leif's done with chemo until Day 12 (this is Day 6) when he gets one more dose of Rituxan.
This morning Leif found more precipitate in his etoposide line. He'd been checking it pretty compulsively since the snafu on Thursday. The line was clear when he checked it at 6am, but contained precipitate around 9am. The nurse stopped his drip and called the IV team, and the IV nurse tried changing the cap and flushing the line with no luck; the new PICC line, that he got Thursday afternoon, needed to come out. She kindly waited until they were able to get Leif his sedative, but it was still a stressful procedure for him. He doesn't need a new PICC for now; they can use his port, since he's done with his chemo regimen and is unlikely to need a large number of things infusing at once, like he has been getting.
Since he'd gotten some extra etoposide from a new bag on Thursday before they decided it was OK to stop the infusion until his PICC was changed out, and there was a roughly equivalent amount left in the bag (his final bag) when they stopped it this morning, the doctor decided it was safe to call the entire dose done when the precipitate turned up.
The pharmacists said that the etoposide that precipitated was from the same manufacturing lot # as the doses Leif had received without problems for the previous 3 days. There is still no answer as to why this problem has cropped up. The pharmacy & nurses changed their procedures after Thurday, to mix the dose within an hour of starting to infuse it, so it won't sit for longer than 13 or 14 hours total (it's supposed to be stable for 24 hours); that was the case with this latest batch that precipitated. We were told that DHMC will probably infuse etoposide in 6-hour increments instead of 12-hour increments from now on, to prevent this from happening to other patients. Switching the infusion from a PICC line to an IV (which would obviate needing to remove an entire PICC in case of problems) was not an option, because etoposide is hard on the veins; it needs to go into a central line with a high volume of blood flow. And of course, they didn't want to risk gunking up Leif's port, which is more invasive to remove than a PICC.
After the PICC removal, Leif's mom, brother, and sister-in-law came in to visit him, after driving over from Maine last night. That was a nice way for him to relax and recover, seeing them one at a time since he's been getting fatigued easily. It was great to see them. He wasn't able to see much of his nephews since preschoolers are such active little germ vectors, but he at least got to say hi to them. Since he had company today, I spent a lot of the day out of the hospital doing a little shopping, eating good meals, and visiting my aunt. I'm staying at the apartment tonight, with a mystery book and a long winter's nap on the agenda.
Leif was looking good when I left. They've stopped the IV fluids, so the puffiness should start going down. The expectation is that his blood counts will continue to decrease from here on out, so they'll be giving him transfusions as necessary and monitoring him closely for infections. Nearly all patients on this regimen get infections because their neutrophil count goes to zero for so long that normally-benign microbes, already existing in their bodies, get out of hand. So the team will be watching Leif closely and treating whatever flares up. He's already on a lot of antibiotics, some prophylactic and others targeted toward the microbes that had been infecting his abscess. The surgery site continues to look okay; it's no longer oozing at all, and he is diligently taking sitz baths four times a day until the surgery team tells him it's okay to cut back.
Leif's done with chemo until Day 12 (this is Day 6) when he gets one more dose of Rituxan.
This morning Leif found more precipitate in his etoposide line. He'd been checking it pretty compulsively since the snafu on Thursday. The line was clear when he checked it at 6am, but contained precipitate around 9am. The nurse stopped his drip and called the IV team, and the IV nurse tried changing the cap and flushing the line with no luck; the new PICC line, that he got Thursday afternoon, needed to come out. She kindly waited until they were able to get Leif his sedative, but it was still a stressful procedure for him. He doesn't need a new PICC for now; they can use his port, since he's done with his chemo regimen and is unlikely to need a large number of things infusing at once, like he has been getting.
Since he'd gotten some extra etoposide from a new bag on Thursday before they decided it was OK to stop the infusion until his PICC was changed out, and there was a roughly equivalent amount left in the bag (his final bag) when they stopped it this morning, the doctor decided it was safe to call the entire dose done when the precipitate turned up.
The pharmacists said that the etoposide that precipitated was from the same manufacturing lot # as the doses Leif had received without problems for the previous 3 days. There is still no answer as to why this problem has cropped up. The pharmacy & nurses changed their procedures after Thurday, to mix the dose within an hour of starting to infuse it, so it won't sit for longer than 13 or 14 hours total (it's supposed to be stable for 24 hours); that was the case with this latest batch that precipitated. We were told that DHMC will probably infuse etoposide in 6-hour increments instead of 12-hour increments from now on, to prevent this from happening to other patients. Switching the infusion from a PICC line to an IV (which would obviate needing to remove an entire PICC in case of problems) was not an option, because etoposide is hard on the veins; it needs to go into a central line with a high volume of blood flow. And of course, they didn't want to risk gunking up Leif's port, which is more invasive to remove than a PICC.
After the PICC removal, Leif's mom, brother, and sister-in-law came in to visit him, after driving over from Maine last night. That was a nice way for him to relax and recover, seeing them one at a time since he's been getting fatigued easily. It was great to see them. He wasn't able to see much of his nephews since preschoolers are such active little germ vectors, but he at least got to say hi to them. Since he had company today, I spent a lot of the day out of the hospital doing a little shopping, eating good meals, and visiting my aunt. I'm staying at the apartment tonight, with a mystery book and a long winter's nap on the agenda.
Leif was looking good when I left. They've stopped the IV fluids, so the puffiness should start going down. The expectation is that his blood counts will continue to decrease from here on out, so they'll be giving him transfusions as necessary and monitoring him closely for infections. Nearly all patients on this regimen get infections because their neutrophil count goes to zero for so long that normally-benign microbes, already existing in their bodies, get out of hand. So the team will be watching Leif closely and treating whatever flares up. He's already on a lot of antibiotics, some prophylactic and others targeted toward the microbes that had been infecting his abscess. The surgery site continues to look okay; it's no longer oozing at all, and he is diligently taking sitz baths four times a day until the surgery team tells him it's okay to cut back.
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