Amifostine: drug profile and nursing implications of the first pancytoprotectant.

PURPOSE/OBJECTIVES: To review the drug profile and nursing implications of amifostine, a new cytoprotective agent. DATA SOURCES: Published articles, abstracts, professional communications, drug manufacturer, and personal experience with amifostine clinical studies. DATA SYNTHESIS: Amifostine increases the selectivity of specific anticancer agents for neoplastic cells by protecting normal tissue. It is indicated for reduction of the cumulative renal toxicity associated with repeated administration of cisplatin, in radiation therapy, and in several types of chemotherapies in patients with a variety of malignancies. Studies of amifostine used as a radioprotective and cytotoxic chemoprotective agent have demonstrated results against nephrotoxicity, neurotoxicity, hematotoxicity (granulocytopenia, leukopenia, and thrombocytopenia), and ototoxicity without adversely affecting tumor response or patient survival. The most common side effects are hypotension, nausea and vomiting (which may be severe), and a decrease in serum calcium concentrations. CONCLUSIONS: Amifostine is a new cytoprotectant, the first such agent with pancytoprotection. With appropriate management and premedication, amifostine is generally well-tolerated. Side effects are reversible following treatment discontinuation. IMPLICATIONS FOR NURSING PRACTICE: Nurses need to be knowledgeable about cytoprotectants, a new class of drugs, in order to teach patients and their families about the need for cytoprotection so they can comply with and participate in treatment plans and to identify the need for and management of amifostine administration. Patient-care concerns include the risk of decreased systolic blood pressure that requires fluid infusion and postural management and potentially severe nausea and vomiting.

Chronic myelogenous leukemia and acute promyelocytic leukemia: new bone marrow transplantation options.

PURPOSE/OBJECTIVES: To describe new bone marrow transplantation (BMT) options for chronic myelogenous leukemia (CML) and acute promyelocytic leukemia (APL), as well as their applications and prognoses, and to describe the role of the oncology nurse in caring for the BMT recipient and options for future nursing research. DATA SOURCES: Published articles, book chapters, and personal experience. DATA SYNTHESIS: Various pretransplant agents and methods are under investigation to improve the outcome and reduce the costs of allogeneic and autologous BMT and peripheral blood progenitor cell (PBPC) transplants. Preliminary results of current studies indicate that autologous BMTs and PBPC transplants have merit as a treatment option in patients with AML and require further research. For patients with APL, BMT usually is reserved for those who fail to achieve or relapse after achieving remission with chemotherapy. Preliminary data show that patients with CML and APL who receive a PBPC transplant engraft more rapidly with decreased morbidity and mortality. CONCLUSIONS: BMT options for patients with CML and APL continue to evolve as advances in pretransplant methods and symptom management become capable of improving the outcome, decreasing costs, and shifting patient care to the outpatient and homecare settings. IMPLICATIONS FOR NURSING PRACTICE: Understanding the marrow transplant options available to patients with CML and APL is essential for nurses. They must stay informed about ongoing improvements in pretransplant processes and symptom-management procedures that reduce BMT morbidity and mortality. Inpatient and outpatient nurses need to collaborate and participate in nursing research to find better ways of providing the best care possible for patients.

Nursing management of the nonhospitalized patient receiving recombinant interleukin-2.

Clinical trials have demonstrated that rIL-2 can be safely administered in an outpatient setting. A thorough nursing assessment ensures patient safety and effective toxicity management. Because it is becoming more economically advantageous to treat patients on an outpatient basis, nurses will need to become involved in all aspects of managed care. Outpatient administration of rIL-2 challenges nurses to be both technologically expert and clinically proficient.

Comparison of perceived symptoms of patients undergoing bone marrow transplant and the nurses caring for them.

This study describes the symptomatology of patients hospitalized for bone marrow transplant (BMT) (n = 30) and compares their perceptions of these symptoms to those of nurses (n = 28). Patients and nurses responded to the Symptom Distress Scale (SDS) four times: within 48 hours of BMT day one (T1); day 7-10 post-BMT (T2); day 20-23 post-BMT (T3); and day 30-34 post-BMT (T4). Patients also completed the Profile of Mood States at T1. Each time, the investigators completed a Karnofsky Performance Status evaluation of each patient. Patients perceived significantly more distress from their symptoms at T1 than their nurses perceived that they were experiencing. Over time, patients' SDS scores did not change significantly. However, nurses' SDS scores indicated significant differences, with their SDS scores at T1 less than those at T2 and T3. The results indicate the importance of nurses exploring the perceived symptom experiences of patients undergoing BMT. Any incongruence between nurses' and patients' perceptions potentially could prevent patients' symptoms from being managed effectively.

Home support of patients with end-stage malignant bowel obstruction using hydration and venting gastrostomy.

Palliative terminal care of patients with malignant bowel obstruction is a major clinical and ethical challenge. These patients are often mentally alert and ambulatory, but are kept in the hospital for hydration, nasogastric suction, and pain control. Parenteral nutrition requires frequent metabolic monitoring, is expensive, and is ethically questionable. We have used an alternative method of home management for 27 patients who met the following criteria: inoperable bowel obstruction due to untreatable cancer, an estimated life expectancy of between 2 weeks and 3 months, and understanding of the goals and limits of therapy. Hydration was provided by 10 percent dextrose and electrolyte solutions administered as overnight infusions through long-term central venous catheters. Thirteen patients with complete bowel obstruction required a venting gastrostomy which, when connected to passive drainage, relieved nausea and vomiting. The mean duration of survival was 64 days (range 9 to 223 days). Acceptance by patients and families was excellent, although most acknowledged increased costs due to limited insurance coverage for outpatient care. Seven patients returned to the hospital for terminal care (average stay 3.2 days), and 20 chose to die at home. The mean daily expense for fluids and supplies was +73.50, with an overall cost decrease of $900,000 compared with inpatient care. Home support with fluids and gastric venting is a humane, cost-effective alternative to in-hospital care for selected patients.

Recommendations for handling cytotoxic drugs in hospitals.

Recommended procedures for handling cytotoxic drugs in hospitals are presented. The recommended procedures are designed to reduce the number of opportunities for unnecessary contact with cytotoxic agents (CYTAs) by hospital personnel and to prevent contamination of the hospital environment and staff with cytotoxic agents. The recommendations incorporate elements of previously published and unpublished guidelines; they admittedly are based on informed judgment as well. Three sets of recommended procedures are presented, each offering a varying degree of protection. The number of cytotoxic drug doses prepared and administered is suggested as the determinant of which level of protection is followed. The cytotoxic workload index, defined as the number of CYTAs prepared or administered (or both) divided by the number of available staff hours, is proposed as a quantitative method of deciding which level of protection is required for a particular work station or work shift. The recommended procedures cover the following seven topic areas: general guidelines; apparel, equipment, and facilities; drug preparation; drug administration; housekeeping, waste disposal, and management of spills and contamination; medical surveillance of staff; and legal and personnel considerations. The recommended procedures and associated equipment are considered to be practical and to adequately protect hospital personnel from risks associated with handling cytotoxic agents.