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.