Page 183 - Essential Haematology

Chapter 12 Haematological malignancy: management / 169

occasionally be required. Inadequate communica- morbidity and mortality. Immunosuppression may
tion is perhaps the most common failing of medical result from neutropenia, hypogammglobulinaemia

teams. The immediate family should be kept and impaired cellular function. These can be second-
’
informed of the patient s progress whenever possible ary to the primary disease or its treatment.
and appropriate. Neutropenia is a particular concern and in many
patients neutrophils are totally absent from the blood

Reproductive issues for periods of 2 weeks or more. The use of granulo-
cyte colony - stimulating factor (G - CSF) to reduce
Men who are to receive cytotoxic drugs should be
periods of neutropenia is discussed on p. 112 . One

offered sperm storage, ideally before treatment com-

potential protocol for the management of infection
mences or, if impossible, within a short period of
in an immunosuppressed patient is illustrated in
time thereafter. Ethical issues relating to storage or
Fig. 12.2 .
potential usage of tissue in the event of treatment
failure will need to be addressed. Permanent infertil-
Bacterial i nfection
ity in women is less common after chemotherapy

although premature menopause may occur. Storage This is the most common problem and usually
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of fertilized ova is usually impractical and storage of arises from the patient s own commensal bacterial
unfertilized ova is currently very diffi cult and, fl ora. Gram-positive skin organisms (e.g.

despite some recent progress, is not offered as a Staphylococcus and Streptococcus ) commonly colo-
routine service. nize central venous lines, whereas Gram - negative
gut bacteria (e.g. Pseudomonas aeruginosa , Escherichia
Nutritional support coli , Proteus , Klebsiella and anaerobes) can cause
overwhelming septicaemia. Even organisms not
Some degree of weight loss is virtually inevitable
normally considered pathogenic, such as Staphyloccus
in patients undergoing inpatient chemotherapy
epidermidis , may cause life - threatening infection. In
because of the combination of a poor nutritional
the absence of neutrophils, local superfi cial lesions
intake, malabsorption caused by drugs and a cata-
can rapidly cause severe septicaemia.
bolic disease state. If a weight loss of > 10% occurs,
support with total nutrition is often given, either Prophylaxis of b acterial i nfection
enterally via a nasogastric tube or parenterally
Protocols used to limit bacterial infection vary from
through a central venous catheter.
unit to unit and may include the use of a prophy-
lactic antibiotic such as ciprofl oxacin. During
Pain
periods of neutropenia, topical antiseptics for
Pain is rarely a major problem in haematological bathing and chlorhexidine mouthwashes and a
malignancies except myeloma although bone pain ‘ clean diet ’ are recommended. The patient is nursed

can be a presenting feature. The mucositis that in a reverse - barrier room. The severity and length

follows intensive chemotherapy can cause severe of mucositis may be reduced by treatment with
discomfort and continuous infusions of opiate anal- recombinant human keratinocyte growth factor
gesia are often required. Pain is often a considerable (palifermin) which reduces the severity of oral
issue in patients with multiple myeloma and can be mucositis. Oral non - absorbed antimicrobial agents
managed by a combination of analgesia and such as neomycin and colistin reduce gut commen-
chemotherapy/radiotherapy. Advice from palliative sal flora but their value is unclear. Regular surveil-

care teams or specialist pain management practi- lance cultures are taken to document the patient s
’
tioners should be sought when required. bacterial flora and its sensitivity.

Prophylaxis and treatment of infection Treatment of b acterial i nfection
Patients with haematological malignancy are at great Fever is the main indication that infection is present
risk of infection which remains the major cause of because if neutropenia is present pus will not be