Page 182 - Essential Haematology

168 / Chapter 12 Haematological malignancy: management

significant problem in stem cell transplant recipi- Antiemetic therapy

ents (see p. 309 ).
Nausea and vomiting are common side - eff ects of
5 Red cell transfusions should be avoided if at all

chemotherapy. A key objective is to try to prevent
possible in patients with a very high white cell nausea occurring early in the treatment as it is more
9
count ( > 100 × 10 /L) because of the hypervis-
difficult to control once problems have arisen. Th e

cosity and the risk of precipitating thrombotic
5 - HT 3 (serotonin) receptor antagonists such as
episodes as a result of white cell stasis.
ondansetron or granisetron can control nausea from
6 Large volume transfusions, such as 3 units of
intensive chemotherapy in over 60% of cases and
blood or more, can precipitate pulmonary
the addition of dexamethasone can increase this by
oedema in older patients and should be given
approximately 20%. Metoclopramide, prochlorper-
slowly and with clinical monitoring. Diuretics
azine or cyclizine, benzodiazepines (e.g. lorazepam),
such as frusemide (furosemide) are often given.
domperidone or cannabinoids (e.g. nabilone) can

7 Febrile reactions with blood products are not
all have a role.
uncommon and should be managed by slowing
the infusion and administration of drugs such as
antihistamines, pethidine or hydrocortisone. Th e Tumour lysis syndrome
dosage of steroids should be limited because of Chemotherapy may trigger an acute rise in plasma
concerns with immunosuppression. uric acid, potassium and phosphate and cause
8 Blood products given to highly immunosup- hypocalcaemia because of rapid lysis of tumour
pressed patients (e.g. from chemotherapy, such as cells. This syndrome is seen most commonly with

fludarabine, with aplastic anaemia, Hodgkin rapidly dividing tumours such as lymphoblastic
lymphoma or post - allogeneic SCT) should be lymphoma or acute leukaemia and can cause acute
irradiated prior to administration to prevent renal failure. Allopurinol, intravenous fl uids and
graft - versus - host disease (see p. 306 ). electrolyte replacement are the mainstay of preven-
9 The use of recombinant erythropoietin to reduce tion and alkalinization of the urine is sometimes

the need for blood transfusion and improve used. Rasburicase, an enzyme that oxidises uric acid
patient well - being (e.g. in myeloma or myelod- to allantoin, is highly effective in controlling

ysplasia) is discussed on p. 18 . hyperuricaemia.
Haemostasic support Psychological support
A coagulation screen should be performed regularly Patients with a diagnosis of malignant disease com-
on patients undergoing intensive chemotherapy and monly feel concerns about such issues as the dis-

support with vitamin K or FFP may be required. comfort of treatment, finance, sexuality and fear of
Cryoprecipitate may be needed for fi brinogen defi - mortality. Even when patients achieve a clinical
ciency (e.g. precipitated by asparaginase in the man- remission there is understandable concern about
agement of acute lymphoblastic leukaemia; ALL). the chance of disease relapse. Psychological support
Antiplatelet drugs such as aspirin or clopidogrel are should be an integral part of the relationship
usually discontinued in patients undergoing inten- between physician and patient, and patients should
sive chemotherapy and patients on long - term war- be allowed to express their fears and concerns at the
farin can be switched to low molecular weight earliest opportunity. Most patients value the oppor-
heparin, which can then itself be stopped if the tunity to read more about their disorder and many
9
platelet count falls below 50 × 10 /L. Progesterones excellent booklets or websites are now available.
are given to premenopausal women undergoing Teamwork is also crucial and the nursing staff and
intensive chemotherapy to prevent menstruation. trained counsellors have a vital role in off ering
Tranexamic acid can be given to reduce haemor- support and information during inpatient and out-
rhage in patients with chronic low - grade blood patient care. Many units have specialist input from
loss. clinical psychologists and psychiatric help may