Paediatrics: Acute care: other

Acute care: other

The acute abdomen

Possible causes in the oncology patient include the following.

·Gastric haemorrhage: s to gastritis or ulceration. Risk factors include high dose steroids and raised ICP.

·Pancreatitis: complicating treatment with steroids or L-asparaginase.

·Neutropenic enterocolitis or typhlitis (Greek typhlon = caecum): bacterial invasion (clostridium, pseudomonas) leads to inflammation, full thickness infarction and perforation, sepsis, and bleeding. It is associated with leukaemia. Symptoms of pain +/– fever may be masked by concomitant steroids (e.g. in ALL induction). The key to management is early, appropriate antibiotic cover on first suspicion and early involvement of surgeons. Mortality is high.

Haematological support

Blood products should be leucodepleted to reduce viral transmission and incidence of reactions. The latter are treated with antihistamine and/or steroid. Irradiated products should be used to prevent transfusion asso-ciated GVHD around the time of stem cell harvesting, following trans-plant, during treatment with fludarabine, and for patients with Hodgkin’s disease.

·Threshold for blood transfusion: usually a haemoglobin level of 7 or 8g/ dL, but teenagers are often symptomatic at higher levels. (Caution if high count leukaemia, longstanding anaemia, or heart failure).

·Platelets: should be maintained above 10 × 10⁹/L if well, 20 × 10⁹/L if febrile or for minor procedure (e.g. LP), 30 × 10⁹/L if brain tumour, and 50 × 10⁹/L after significant bleed or for major surgery. These thresholds should be overridden where there is bleeding.

Nausea and vomiting

Chemotherapy varies in its emetogenicity: oral antimetabolites and vin-cristine require no prophylaxis; cisplatin and ifosfamide require multiple agents. Aim to prevent severe symptoms.

·First-line: domperidone or metoclopramide.

·Second-line: ondansetron (5HT antagonist).

·Dexamethasone: useful adjunct, but not in ALL/NHL induction or CNS tumours.

Other agents: cyclizine useful in children with CNS tumours. In severe cases, nabilone, methotrimeprazine or chlorpromazine can help.

Nutrition and mucositis

Good nutritional status is essential for recovery, but is compromised by the presence of malignancy, direct effects of treatment, and mucositis and infection:

·  A dietitian is central to successful nutrition. Support should include making appetizing meals available at all times, calorie supplementation, treatment of mucositis, and use of parenteral nutrition when enteral route inadequate.

Chemotherapy-induced mucositis leads to oral ulceration, pain, and diarrhoea. Good mouth care (involving basic oral hygiene and antiseptic mouthwashes) helps prevent some infective complications. Prompt treatment with analgesia allows maintenance of oral intake for as long as possible.