Venous access
|
Central line (for possible vasopressors) |
Typical
|
Double or triple lumen |
PICC line placement |
Power inject and large volume capacity |
Remove temporary lines at end of cycle |
Minimize catheter associated infection |
Variations
|
Broviac/Hickman catheter |
Subclavian/IJ catheter |
IV fluids
|
Maintenance of volume with CLS |
Typical
|
Boluses for blood pressure support |
D5NS or D5LR 10 ml - 125 ml/hr |
Administration of drugs |
PRN KCL, HCO3, Mg replacement |
Replacement of electrolytes |
Variations
|
IL-2 only compatible with D5W |
D5W, NS, 0.45% NaCl |
Infections
|
No active infections |
Typical
|
Prevention |
Gram + prophylactic antibiotic |
IV catheter likeliest source |
Variations
|
Avoid unnecessary in-dwelling catheters |
Expanded coverage per hospital |
Chills/rigors
|
Chills and rigors occur 1-2 hrs after IL-2 |
Fever-Typical
|
Prophylaxis |
Fever
|
Fever is common 2-4 hrs after IL-2 |
Acetaminophen 650 mg 30 min pre-dose, q 4-6 hrs and prn |
Indomethacin 25 mg q 6-8 hrs |
Constitutional symptoms
|
Muscle joint aches continuous and progressive during IL-2 treatment |
Fever-Variation
|
Naproxen |
Ibuprofen |
Chills-Typical
|
Meperidine 25 mg IV q 15 m prn |
Morphine 2-4 mg IV q 15 m prn |
Nausea/vomiting
|
Episodic occurrence throughout therapy |
Typical- Prophylaxis
|
Nausea > vomiting |
Ondansetron 0.15 mg/kg q 8 hrs |
Variations
|
Granisetron 1 mg daily |
Ondansetron at longer interval |
Compazine 10 mg po q 6 hrs |
Use of antinausea agents prn |
Epigastric distress
|
Gastritis induced by stress, medications |
Typical
|
H2 blocker prophylaxis |
Variation
|
PPI prophylaxis |
Mucositis/stomatitis
|
Progressive with continued treatment |
Typical
|
No prophylaxis |
Oncology mouthwash |
Diarrhea
|
Can be profuse and increases with therapy |
Typical
|
5HT-3 antagonist anti-emetic prophylaxis |
Imodium |
may have positively impacted |
Lomotil |
|
Narcotic |
|
Break between IL-2 doses |
|
Variations
|
|
5HT-3 antagonist prophylaxis |
Patient monitoring
|
I & O, Weight |
Per shift and daily |
Blood pressure, pulse, respirations, temp |
Q 2-4 hrs |
Blood work |
Daily |
EKG |
Continuous cardiac monitoring |
O2 Saturation |
Q 2-4 hrs |
Mental status examination |
Q 8 hrs |
Increase frequency as needed
|
Aldesleukin/Interleukin-2 dose and administration
|
IL-2 incompatible with salt solutions. |
Typical: 600,000 IU/kg infused over 15 minutes Q 8 hrs up to 14 doses. |
Dissolve in sterile water for injection Dilute into 50 cc D5W |
Variations: 720,000 IU/kg Q 8 hrs Q 12 hrs < 14 maximum doses |
Stop infusion, flush IV tubing with 50 cc D5W before and after each dose. |
|
Hypotension
|
Maintain systolic BP 80-90 mm hg |
Fluid boluses, 250-500 ml NS |
Blood pressure nadirs 4-6 hrs after each dose with diminished recovery with cumulative dosing |
2xday |
Increase maintenance fluid rate |
Phenylephrine 0.1-4.0 mcg/kg/min |
Hold next dose |
Prior to each dose anticipate ability to respond to next nadir |
DC IL-2 |
Variations:
|
Dopamine 1-6 ug/kg/min |
Progressive refractoriness to support measures |
Pressors with minimal fluids |
Fluids without pressors |
Cardiac arrhythmias
|
Sinus tachycardia
|
Manage BP and fever |
Common and progresses over a cycle |
Peaks 2-4 hrs after dose with fever and hypotension |
Must resolve prior to next dose |
Supraventricular tachycardia, atrial fibrillation
|
Medical Conversion |
Less common |
Cardizem as needed |
Atrial fibrillation
|
Digoxin |
Ventricular tachycardia
|
Medical Conversion |
Acute treatment |
Discontinue IL-2 |
Renal function
|
|
Typical
|
Oliguria
|
Output less than 50-100 cc/8 hrs Fluid bolus, if no improvement next shift hold IL-2 dose |
Rising creatinine
|
Creatinine >3-4 |
Stop NSAIDS and nephrotoxic antiobiotics |
Urine output and creatinine resolve after discontinuation of IL-2 |
Hold overnight dose |
If am creatinine improved continue |
If only one kidney always consider obstruction of ureter |
Variations
|
Dopamine 1-6 mcg/kg/min |
Furosemide |
Pulmonary
|
Tachypnea/Dyspnea |
Typical
|
Diagnose etiology and treat |
Oxygen 2-4 L nasal cannula, increasing up to 35% rebreather |
Hypoxic causes-Fluid overload, capillary leak, bronchospasm |
Reassurance or sedative for anxiety, treat bronchospasm or acidosis if appropriate |
Non hypoxic causes |
Hold IL-2 dose if O2sat < 95% |
Anxiety, fever, acidosis |
Maintain O
2
sat > 92-5%
|
Variation
|
Furosemide |
Bronchodilators |
Monitor bicarbonate |
Peripheral edema
|
Expect to gain 5-10% body weight |
Elevation, compression, limit fluid support in subsequent cycles |
Treat edema symptomatically |
Diuretics upon conclusion of IL-2 dosing are not necessary but may speed process |
Entrapment of peripheral nerves in upper extremity may need therapy |
Treat peripheral nerve pain |
Neurotoxicity
|
|
Typical
|
Protean manifestations |
Formal neuro checks |
Gradual onset with sudden worsening near end of cycle |
Enlist family evaluation |
May persist after cessation of therapy |
Lorazepam and Haloperidol |
Delusions, Visual hallucinations |
Hold IL-2 liberally for suspected neurotoxicity |
Warn patient of vivid dreams after discharge |
Dermatologic
|
|
Typical
|
Rash, erythema, dry desquamation |
Emollient lotions and creams Oatmeal bath |
Pruritus |
Antihistamines |
Moist dermatitis |
Hold IL-2 dose |
Variations
|
Crisco |
Gabapentin |
Naloxone |
Narcotics |
Nonalcohol, no steroid topicals
|
Metabolic
|
Hypomagnesemia, hypocalcemia (but low albumin - so corrected may be WNL), Hypokalemia- |
Daily electrolyte panels |
Acidosis due to diarrhea, hypoperfusion |
Correct electrolytes cautiously prn |
Hypothyroidism a slow onset problem |
Magnesium and HCO3, particularly if diarrhea a problem |
HCO3 < 18 meq/L hold dose of IL-2 |
Check TSH at beginning of cycle |
RL as support fluids may decrease need for HCO3 |
Hepatic
|
↑Bilirubin (up to 10) |
Monitor daily |
↓Albumin (down to 1.8) |
No intervention except if SGOT SGPT are >5x |
↑Hepatic aminotransferases |
Resolves spontaneously |
|
Stop acetaminophen if bilirubin > 5 |
Hematologic
|
↓Platelets |
Transfuse platelets if < 20 K |
Lymphs ↓during IL-2, ↑post therapy |
Other abnormalities require no intervention |
Eosinophils progressively ↑with several cycles |
Significant anemia needs evaluation for cause |
Endocrine
|
Hypothyroidism - slow onset after completion of treatment |
Check TFTs at beginning of cycle and monitor TFTs with subsequent visits |
Requires serial monitoring |