Comparison of Sodium Bicarbonate and Lactated Ringers Hydration for High-dose Methotrexate Chemotherapy in Children.

BACKGROUND: High-dose methotrexate is part of the treatment of pediatric cancers. To reduce the risk of toxicity, supportive measures, including hydration and alkalinization, are recommended. At our institution, we switched from intravenous sodium bicarbonate to Lactated Ringers during a worldwide shortage. PROCEDURE: This was a retrospective cohort of children who received high-dose methotrexate from January 1, 2016 to August 31, 2018. The primary outcome was the prevalence of delayed methotrexate clearance. Secondary outcomes were proportion of cycles with delayed methotrexate clearance, time to methotrexate clearance, adverse events, risk factors for delayed clearance, and association between hydration type and delayed clearance. RESULTS: Eighty-two patients, with a total of 325 methotrexate cycles, were included. Forty-four patients received sodium bicarbonate, 31 received Lactated Ringers, and 7 received both. There was no difference in the prevalence of delayed methotrexate clearance between those who received sodium bicarbonate and Lactated Ringers (64% vs. 68%). The proportion of cycles with delayed methotrexate clearance, time to methotrexate clearance, and adverse events were similar between groups. Cancer type, methotrexate dose, and vomiting were associated with delayed clearance. CONCLUSIONS: Our study suggests that Lactated Ringers may be used in place of sodium bicarbonate for intravenous hydration during high-dose methotrexate.

Association between in-line filtration and Type I hypersensitivity reactions in pediatric oncology patients receiving intravenous etoposide.

The objective of this study was to describe hypersensitivity reactions with and without the use of in-line filters during intravenous etoposide therapy in pediatric oncology patients. This was a retrospective review of all patients treated in the Division of Oncology/Hematology/Bone Marrow Transplant at British Columbia Children's Hospital with intravenous etoposide between December 1, 2013 and February 1, 2018. Hypersensitivity reactions and anaphylaxis associated with etoposide infusions were compared over time, including 12 months prior to, 27 months during the use of, and for 12 months after the discontinuation of in-line filtration. There were 192 patients (median age 6.0 (IQR 2.8-13.0) years treated with etoposide and 486 etoposide infusions including 137 (28%) before, 261 (54%) during and 88 (18%) after use of in-line filters at our center. Twenty-six of 486 (5%) and 13/486 (3%) of infusions resulted in a type I hypersensitivity reaction and anaphylaxis, respectively. There were 2/137 (1%), 36/261 (14%) and 1/88 (1%) infusion reactions prior to, during and after in-line filter use, respectively. Infusion reactions during the in-line filter period were higher than during the pre-filter (Z = 3.978; p < 0.001) and post-filter (Z = 3.335; p < 0.001) periods of the study. These data suggest that the use of in-line filtration may be associated with increased frequency of hypersensitivity reactions to etoposide in pediatric cancer patients.

Exploring Perceptions of Education for Central Venous Catheter Care at Home.

Pediatric oncology patients with an external central venous catheter (CVC) in situ can be discharged from the hospital. Caregivers are expected to learn how to care for the CVC prior to discharge while also dealing with their child's new cancer diagnosis. This study aimed to evaluate the perceptions of a CVC education program received by caregivers to identify opportunities for improvement. A qualitative study was conducted in 3 stages, using an evidence-based co-design approach, involving caregivers and one adolescent patient discharged from the British Columbia Children's Hospital Oncology/Hematology/BMT inpatient unit. Stage I involved semi-structured interviews to gain feedback on the existing CVC education program. In Stage II, educational resources were updated or developed and implemented. For Stage III, the revised CVC education program was evaluated through a focus group and semi-structured interviews. Interview transcripts were analyzed using QSR NVivo®. The original CVC education program was overall well received. Repeated instruction and support provided by nurses was reported to have increased confidence with performing CVC skills. Participants appreciated the multimodal approach to meet learning needs and expressed interest in additional visual aids. Inconsistencies in nurses' practice and offers of "tips and tricks" were identified to be challenging for caregivers while learning a new skill. Videos depicting CVC care were developed to provide an additional visual tool, decreased inconsistencies in care, and support to caregivers at home. Caring for a CVC at home is challenging and overwhelming for caregivers. A standardized multimodal education program is required to support caregivers at home.