Evaluation of a pediatric pre-chemotherapy rapid hydration protocol: A quality assurance project.

INTRODUCTION: Intravenous hydration may be utilized to prevent nephrotoxicity and facilitate drug elimination in patients receiving high-dose chemotherapy. Prolonged hydration protocols may lead to delayed initiation and completion of therapy, lengthening hospital admissions. Rapid hydration protocols have been implemented to reduce the time required for patients to meet parameters for chemotherapy administration. This study aims to evaluate a rapid hydration protocol implemented at the Alberta Children's Hospital (ACH). METHODS: Starting January 2018 through May 2018, data was prospectively collected for pediatric oncology acute care and ambulatory patients at ACH receiving methotrexate (MTX), cisplatin, cyclophosphamide, or ifosfamide. The primary outcome was the time to achieve pre-determined urine parameters prior to chemotherapy administration. Secondary outcomes included the proportion of cycles that achieved urine parameters and the efficacy of each rapid hydration step. RESULTS: A total of 22 cycles were included, 13 for MTX and 9 for non-MTX chemotherapy. Median time to meet all urine parameters was 120 min (range 30-600 min). Two cycles (15%) failed rapid hydration in the MTX group, while no cycles required further hydration in the non-MTX group. Adverse events potentially attributable to hydration were mild and did not require intervention. CONCLUSION: The ACH rapid hydration protocol resulted in reduced time to meet target urine parameters. The results of this quality assurance review support the continued use of rapid hydration prior to chemotherapy administration.

Oral sodium bicarbonate protocol for high-dose methotrexate urine alkalinization: A pediatric experience.

INTRODUCTION: Methotrexate (MTX) is a cytotoxic antimetabolite. Intravenous (IV) hydration and urine alkalinization with sodium bicarbonate (NaHCO3) can mitigate nephrotoxicity associated with high-dose MTX (HDMTX, doses ≥500 mg/m2). A shortage of IV NaHCO3 in 2017 prompted Alberta Children's Hospital (ACH) and Stollery Children's Hospital (SCH) to adopt an alternative protocol including oral NaHCO3 and IV hydration with Lactated Ringer's (LR). METHODS: A retrospective chart review was conducted for ACH and SCH inpatients who received HDMTX between January and December 2017. The primary outcome was the proportion of cycles with delayed HDMTX clearance within the IV and oral cohorts. Secondary outcomes include NaHCO3 administered until clearance, NaHCO3 required to reach pH ≥7, time to reach pH ≥7, incidence of pH <7, time to clearance, and time to discharge. Adverse effects associated with delayed clearance or NaHCO3 administration were also reported. RESULTS: 112 MTX cycles were included, 50 and 62 from the IV and oral cohorts, respectively. Clearance delays beyond protocol expectations occurred in 10 cycles (8.9%), 5 from each cohort (p = 0.72). Differences between cohorts were not statistically significant, except the amounts of NaHCO3 required until clearance (383 vs. 277 mmol/m2, p = 0.005) and to reach pH ≥7 (52 vs. 40 mmol/m2, p = 0.004) were lower in the oral cohort. Incidences of adverse effects were not different. CONCLUSIONS: Oral NaHCO3 with LR is a feasible alternative for urine alkalinization. The total dose of NaHCO3 utilized was lower in the oral cohort, with no additional delays in clearance.

Integration of a nausea and vomiting assessment tool into antineoplastic management of pediatric oncology patients.

BACKGROUND: Antineoplastic-induced nausea and vomiting (AINV) is a treatment-related issue that can have significant negative influences on the cancer patient's quality of life. Assessment of nausea is challenging in children as few studies include the perception of nausea as an outcome, and the severity is rarely evaluated with the use of a validated instrument. We describe our experience of integrating an AINV tool into patient care at the Alberta Children's Hospital.Procedure: The Pediatric Nausea Assessment Tool (PeNAT) was adapted to create a standardized tool that could be used by the clinical pharmacists for AINV assessment. From February to August 2017, 74 patients receiving 217 cycles of highly or moderately emetogenic chemotherapy (HEC or MEC) were eligible to use the AINV tool. Patients that completed the AINV tool were contacted to complete a satisfaction survey. RESULTS: AINV tool uptake was low: 47 (22%) eligible chemotherapy cycles utilized the tool (24 (32%) and 23 (16%) cycles of HEC and MEC, respectively, (p < 0.01)). Ifosfamide-containing cycles received the highest nausea ratings, with nausea severity correlated with agent emetogenicity. Mean nausea rating was 2.07 versus 1.76 for patients receiving HEC or MEC, respectively. Clinical pharmacists performed 1.24 AINV interventions per day. Patient satisfaction with AINV care overall was high; however, 51% of patients indicated that the tool led to no changes in nausea symptoms. CONCLUSIONS: AINV tool uptake was low with limited value in improving outcomes. Incorporation of nausea assessment into the electronic health record and potential use of a mobile application may improve uptake.

Adherence to pediatric acute chemotherapy-induced nausea and vomiting guidelines in Canadian hospitals.

BACKGROUND: Chemotherapy-induced nausea and vomiting (CINV) impacts quality of life for patients. Guidelines for emetogenicity classification and prevention of CINV in children were recently published and endorsed by pediatric oncology organizations. PROCEDURE: A multicenter chart review was performed at four Canadian pediatric oncology centers examining rates of prescribing adherence to CINV guidelines between January 2012 and December 2015. Eligible patients received their first chemotherapy course of highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). RESULTS: Guideline adherence was described in 204 patients as antiemetic-only guideline adherence (AGA; examined medication/class prescribed only) and complete guideline adherence (CGA; examined medication/class, dose, frequency, and duration prescribed). Adherence was 29% (HEC 30%, MEC 19%, P = 0.1) and 2% for AGA and CGA patients, respectively. Vomiting in the first 24 h was experienced by 24% of AGA and 34% of non-AGA patients (P = 0.13), with mean breakthrough medication doses similar between AGA and non-AGA groups (HEC 1.8 vs 1.5, P = 0.45; MEC 3 vs 1.42, P = 0.35). In the first 24 h, HEC AGA patients achieved a complete control rate of 37% vs 45% for non-AGA patients (P = 0.31), while patients receiving AGA therapy for MEC achieved a complete control rate of 80% vs 24% for non-AGA patients (P = 0.02). CONCLUSIONS: Adherence to guidelines was low across all four pediatric institutions. Each center used different approaches to implement pediatric CINV guidelines. Complete CINV control was low, with reports of emesis high, indicating that patients are not receiving optimal treatment.