Clinton, F., Dowling, M., & Capra, M. (2012). An audit of chemotherapy-induced nausea and vomiting in children. Nursing Children and Young People, 24, 18–23.
To document the prescription and administration of antiemetic therapy with a secondary objective of collecting data on the effectiveness of the antiemetic medications being used when possible
After each admission, pediatric patients were interviewed to assess the degree of nausea and vomiting experienced until discharge. The antiemetic medications and chemotherapy they received were documented each day. On the day following discharge, phone calls were made to assess nausea and vomiting and to record antiemetic medications used at home.
Prospective audit
Nausea and vomiting were assessed by the Pediatric Nausea Assessment Tool (PeNAT) and the MASCC Antiemesis Tool (MAT).
Most patients received a combination of a 5HT3 antagonist and metoclopramide. One took dexamethasone. There was no apparent association between the antiemetic prescribed and emetogenic potential of the chemotherapy taken. Vomiting increased a little from days one to five of chemotherapy administration in spite of medication, but children mainly reported no or only a little nausea (PeNAT 1 or 2). Three reported more or a lot of nausea (PeNAT 3 or 4). Anticipatory vomiting occurred in two episodes, acute vomiting in 17, and delayed vomiting in 24. Of the 20 children who did not take any antiemetics after discharge, 11 were not prescribed any. Dexamethasone was prescribed for only one patient despite evidence indicating that it should be an essential part of almost all antiemetic regimens.
The discrepancies in prescriptions to manage chemotherapy-induced nausea and vomiting were obvious. The PeNAT scale was easy to manage, but it may not have been efficient for detecting previous experience with younger children. The MAT was easy to comprehend and follow.
The timely assessment and prescription of appropriate antiemetics for children is extremely important. Educational support for families regarding the assessment of delayed chemotherapy-induced nausea and vomiting is crucial for the control of symptoms.
Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . . Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368, 533–542.
The purpose of the study was to evaluate the usefulness of bathing with chlorhexidine to reduce the acquisition of multiple drug-resistant organisms and hospital-acquired infections among high-risk patients.
Six intensive care units or bone marrow transplantation units were randomly assigned to perform daily patient bathing with either nonantimicrobial washcloths (control) or washcloths impregnated with 2% chlorhexidine gluconate for six months. After six months, units were crossed over to use of the alternative approach. Infections and resistant-organism acquisition was monitored for two days after the transition in bathing treatment if the infection or organism was contracted during the bathing assignment time period. Before the study, nurses were instructed on the proper use of both washcloths. All units performed active surveillance testing for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) throughout the study period, including staff and patient swabbing for evidence of colonization.
Active antitumor treatment
This was a cluster, randomized, non-blinded crossover trial.
The incidence of overall drug-resistant organism acquisition was significantly lower in the intervention period (5.1 versus 6.6 per 1,000 patient days; p = 0.03). Vancomycin-resistant enterococci acquisitions were significantly lower during the intervention period (3.21 versus 4.38 per 1,000 patient days; p = 0.05). Hospital-acquired BSIs were lower with the intervention (7.48 versus 6.6 per 1,000 patient days; p = 0.007), as were primary BSIs (3.61 versus 5.24; p = 0.006) and central line-associated bloodstream infections (CLABSIs) (1.44 versus 3.3; p = 0.004). There were no significant differences in length of stay or central catheter days between study periods. Incidence of skin reactions among patients assigned to chlorhexidine was 2%, compared to 3.4% of those bathed with the control product. There were no differences associated with unit type, size, mean length of stay, median patient age, or gender distributions. Declines during the intervention period were seen for primary BSIs due to coagulase-negative staphylococci (p = 0.006), enterobacter (p = 0.06), and fungi (p = 0.06).
Bathing with chlorhexidine-impregnated washcloths was associated with a significant reduction in the incidence of VRE acquisition, reduction in lower rates of CVC, and general hospital-acquired BSIs. Daily chlorhexidine bathing was not associated with any serious adverse effects.
Daily bathing with chlorhexidine may prevent some BSIs and reduce the acquisition of drug-resistant organisms among hospitalized patients at high risk for infection.
Clemons, M., Bouganim, N., Smith, S., Mazzarello, S., Vandermeer, L., Segal, R., . . . Dranitsaris, G. (2016). Risk model-guided antiemetic prophylaxis vs physician's choice in patients receiving chemotherapy for early-stage breast cancer: A randomized clinical trial. JAMA Oncology, 2, 225–231.
To test the clinical utility of a chemotherapy-induced nausea and vomiting (CINV) risk model to improve patient outcomes compared to usual care
Patients were randomly assigned to the risk model group (RMG) or physician choice group (PCG) (control). Those in the RMG group had acute and delayed emetic risk scores calculated prior to each cycle of chemotherapy. Patients with low risk (acute risk score < 7, delayed score ≤ 16) received dexamethasone and ondansetron regimens. Those at high risk by the models were given triplet antiemetics according to highly emetogenic chemotherapy (HEC) guidelines. Patients assigned to the PCG were given whatever regimen their oncologist decided upon. Patients rated their control of nausea and vomiting on a 4-point Likert-type scale, and need for intravenous fluids was recorded. Patients were contacted by phone on days 1 and 5 after chemotherapy.
In cycle 1, 94.1% in the PCG group and 15.6% in the RMG group were given 5-HT3 and dexamethasone prophylaxis, and 81.2% in the RMG group and 4.1% of controls were given triple drug regimens. In the RMG group, 90% received aprepitant by cycle 4 and 40% had olanzapine added to cycles 3 and 4. In the control group, aprepitant was added to about 25% of cycles 2–4. Significantly fewer patients in the RMG group required prochlorperazine (p = 0.02) or methotrimeprazine (p = 0.001) for rescue. No differences existed in the need for IV fluids between groups. In both the acute and delayed phases, significantly more patients in the RMG group reported no vomiting and no nausea (p < 0.001). FLIE scores were consistently better in the RMG group, but differences from control patients were not statistically significant.
The use of the emetic risk model for prophylaxis decision making was shown to be more effective than physician antiemetic choice for the prevention of both acute and delayed CINV.
The findings support the use of emesis risk prediction in treatment decision making for antiemetic prophylaxis. Nurses can advocate for the consideration of emetic risk and the appropriate prescription of antiemetics for patients with breast cancer receiving chemotherapy.
Clemens, K.E., Quednau, I., & Klaschik, E. (2009). Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: A prospective study. Supportive Care in Cancer, 17(4), 367-377.
The objective of the study is to compare the effects of oxygen application and use of opioid treatment on ventilation and palliation of chronic dyspnea in hypoxic and non-hypoxic palliative care patients.
Four liters per minute of oxygen were given via nasal cannula. After 60 minutes, patients rated dyspnea, and respiratory parameters were recorded for comparison to baseline. Patients initially received immediate release opioids every four hours and rescue doses as required for breakthrough dyspnea. Patients who had been pre-treated with opioids were switched to oral morphine equivalent doses, and the opioid dose was titrated to achieve a tolerable and stable level of symptoms. When stable, patients were changed to sustained release opioids.
The study reported on a sample of 46 patients. The median age was 66.5 years, with a range of 40-90 years, for hypoxic patients and a median age of 70.5 years, with a range of 40-86 years, for non-hypoxic patients. Twenty-three patients were females; 9 were hypoxic, and 14 were non-hypoxic. Twenty-three patients were males; 9 were hypoxic, and 14 were non-hypoxic. In the hypoxic group, participants were diagnosed with end-stage cancer of multiple types. Participants were included if they experienced dyspnea at rest, had a hemoglobin level of greater than or equal to 10 g/dl measured within 2 weeks, and had normal cognitive function. Of the participants included, 18 were noted to have been pre-treated with opioids for pain control, while 28 were opioid naive. In addition, four participants were noted to have a medical history of chronic obstructive lung disease. Seventeen patients reported intermittent pre-treatment with oxygen therapy (2-6 L/min).
The single-site study was conducted on a palliative care unit in Germany.
Patients were undergoing end-of-life and palliative care.
Prospective non-randomized study
During 60-minute oxygen insufflation with the 4 L/min nasal cannula, no decrease in dyspnea was noted among the hypoxic and non-hypoxic patients. No significant correlation was seen between intensity of dyspnea and oxygen saturation. A significant increase was seen in SaO2 in hypoxic patients after opioid application (P < 0.0001), and a significant decrease was seen in respiratory rate in both groups. In non-hypoxic patients, respirations in the opioid naïve ranged from 38 (SD = 5.6) per minute to 27 (SD = 4) per minute (P = <0.0001) after 120 minutes, while patients who were pre-treated with opioids ranged from 37 (SD = 4.5) per minute to 27 (SD = 3.4) per minute (P = 0.003) after 120 minutes.
The study had a small sample of less than 100. Baseline measurement of dyspnea intensity, SaO2, PaCO2, and tcpaCo2 during 60-minute oxygen administration obtained from the 17 participants who were known to have used as much as 6 L/min nasal cannula at home calls into question the accuracy of comparative data because study intervention used only 4 L/min nasal cannula. The results only pertain to patients experiencing “chronic” dyspnea and do not relay or compare the effects of increasing oxygen concentration or modes of oxygen delivery (i.e., greater than 4 L/min, face mask, FiO2, etc.) in management of acute, chronic, or breakthrough dyspnea in hypoxic and non-hypoxic patients.
Oxygen therapy for the management of chronic dyspnea in patients with cancer with advanced disease may not be a cost-effective intervention and has no established long-term benefits for symptomatic relief of work of breathing. Intermittent use of opioids for the safe improvement of symptomatic dyspnea may be a better alternative with minimal likelihood of resulting respiratory depression.
Clemens, K.E., Jaspers, B., Klaschik, E., & Nieland, P. (2010). Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in palliative care patients. Japanese Journal of Clinical Oncology, 40(11), 1068–1072.
To determine the effectiveness and frequency of manual lymphatic drainage (MLD) in patients with lymphedema secondary to advanced stage cancer undergoing palliative care
Patients were included in the study if they had lymphedema-related symptoms, pain, and dyspnea. The intervention strategy consisted of utilizing demographic information and disease-related data to calculate and compare the effects of MLD on lymphedema-related symptoms. MLD was performed daily on patients until discharge, and the effects were documented.
The study took place in an in-patient setting in a palliative care unit from January to December 2007.
Patients were undergoing active treatment for lymphedema. The study has clinical applicability for palliative care.
The study used a retrospective, reflexive control design.
Sixty-seven patients reported pain (59 somatic, 8 somatic and neuropathic) and 23 patients reported dyspnea. Patients in the study received an average of seven MLD treatments. MLD treatment lasted an average of 41.3 minutes. The treatment was tolerated well in 92.2% of patients. Ninety-four percent of patients reported a reduction of pain and 73.9% of patients reported a reduction of dyspnea post-treatment. Four of the eight patients with reported neuropathic pain had to discontinue the MLD intervention because of increased intensity of pain during treatment. The patient self-report of lymphedema reduction on the Likert scale was reported as 18.9% as little, 64.4% as good, and 16.7% as good.
The study suggests a positive correlation between a significant decrease in pain and dyspnea after MLD in patients with advanced disease or cancer undergoing palliative care but increased pain with MLD in patients with neuropathic pain.
In patients undergoing palliative care, the top priority is comfort. Given the positive outcomes of the study, nurses may recommend that their patients partake in MLD as a mechanism to alleviate burden because of their disease process, if the pain is not of neuropathic origin. It should be recognized that some patients experienced increased pain with MLD, so nurses need to be aware of assessing these effects if MLD is used. Further studies should be completed using a more rigorous study design and larger sample size to further support findings reported in the study.
Clemens, K.E., & Klaschik, E. (2010). Dyspnoea associated with anxiety-symptomatic therapy with opioids in combination with lorazepam and its effect on ventilation in palliative care patients. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 19(12), 2027-2033.
The objective of this study was to assess the safety of opioid and benzodiazepine combination for dyspnea management in patients receiving palliative care.
Patients in a palliative care unit were provided morphine or hydromorphone and lorazepam enterally every four hours, and rescue doses were given as needed every 15 minutes according to a titration schema. All patients were given 1 mg lorzepam sublingual with the first opioid dose during the clinical stay. Ratings of dyspnea were recorded at rest and on light exertion. PaCO 2 and SaO2 were monitored with earlobe sensors. Measurements were taken at baseline for 15 minutes after patients were admitted to the palliative care unit and for at least 240 minutes after starting the opioid and lorazepam combination.
This single-site study was conducted in an inpatient setting in Germany.
The study was a prospective, nonrandomized trial.
Mean morphine dose was 8.4 (SD = 7.2), and mean hydromorphone dose was 30 (SD = 35) morphine equivalents. Respiratory rate was significantly reduced 60 minutes after the combination of medications was delivered (from 40–30, p < .001), and dyspnea at rest declined from mean of 6.2 to 4.1 after 30 minutes and to 1.2 after 120 min (p < .001). No significant changes were seen in paCO2 or SaO2.
The medication regimen used here was helpful in reducing symptoms of dyspnea in these patients.
This study adds little new in terms of symptom management for dyspnea. The study design did not help to further define the role of anxiolytics versus opioids for dyspnea management.
Clemens, K.E., & Klaschik, E. (2008). Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Supportive Care in Cancer, 16(1), 93-99.
The objective of this study was to assess the safety and effectiveness of hydromorphone for the improvement of ventilation and intensity of dyspnea in palliative care patients.
Baseline intensity of dyspnea was recorded at rest and during exertion during a light physical activity. Baseline data, including arterial pressure of carbon dioxide (tcPaCO2), peripheral oxygen saturation (SaO2), and pulse frequency (PF) were measured continuously via a noninvasive calibrated digital sensor (i.e., the SenTec Digital Monitor) attached to the patients’ earlobe. They then were initiated on orally administered hydromorphone every four hours and titrated to at least 50% dyspnea reduction. Rescue doses of one-sixth of the calculated daily dose were made available for relief of breakthrough dyspnea.
The single-site study was conducted in an inpatient setting on a palliative care unit at the Center for Palliative Medicine in Germany.
Patients were undergoing end-of-life and palliative care.
The study was a prospective, nonrandomized trial.
Use of oral hydromorphone potentially could reduce dyspnea with minimal risk of respiratory depression to patients with advanced or terminal cancer.
Use of hydromorphone in the palliative care setting may serve as an effective treatment alternative for patients with renal impairment or intolerance to morphine in the management of dyspnea and work of ventilation. Hydromorphone may reduce dyspnea even in patients who already are receiving opiates for other symptoms.
Clemens, K.E., & Klaschik, E. (2007). Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. Journal of Pain and Symptom Management, 33(4), 473–481.
The objective of this study was
One opioid dose of morphine (mean dose 9.4 mg [SD = 8.8 mg]) or hydromorphone (morphine equivalent dose of 10.8 mg [SD = 3.8 mg])
The sample was comprised of 11 patients with dyspnea (5 severe, 4 moderate, and 2 mild), 8 patients with lung cancer, 2 patients with breast cancer, and 1 patient with acute lymphoblastic leukemia. None of the patients had a history of chronic obstructive pulmonary disease.Two patients were pretreated with opioids for pain control.
The study was conducted on an inpatient palliative care unit.
The study was a prospective, nonrandomized, uncontrolled trial.
After opioid administration
Patients’ ratings showed no significant decrease in dyspnea intensity with nasal oxygen.
Decreased respiratory rate and decreased dyspnea scores with opioid dose were evident.
Cleeland, C. S., Body, J. J., Stopeck, A., von Moos, R., Fallowfield, L., Mathias, S. D., . . . Chung, K. (2013). Pain outcomes in patients with advanced breast cancer and bone metastases: results from a randomized, double-blind study of denosumab and zoledronic acid. Cancer, 119, 832–838.
The purpose of this study was to compare the effects of denosumab to those of zoledronic acid on the pain of patients with advanced breast cancer and bone metastases.
Patients were randomly assigned to receive one of two treatments. One group received monthly subcutaneous denosumab 120 mg and intravenous (IV) placebo. The other group received monthly IV intravenous zoledronic acid with standard dosing and adjustments. Investigators assessed pain severity and the extent to which pain interfered with daily function at baseline and monthly.
This study was a double-blind, double-dummy, active, randomized, controlled trial.
The pain of all patients worsened throughout the study. Compared to patients receiving zoledronic acid who had no or mild pain at baseline, fewer denosumab-receiving patients with the same pain profile progressed to severe pain (p = 0.002). Median time to improvement, among patients reporting worst pain, was similar between groups. Median time to decrease in pain was similar between groups, but patients receiving denosumab waited slightly longer for relief.
Fewer patients in the denosumab group progressed to severe pain than did patients in the zoledronic acid group. Patients in the denosumab group took longer to progress to higher levels of pain.
Both denosumab and zoledronic acid have been shown to reduce skeletal events and bone pain in patients with bone metastases. Findings from this study suggest that denosumab may extend the time that patients have before pain progresses to severe levels. Because denosumab does not require IV administration, it may be a practical alternative for some patients.
Clarkson, J.E., Worthington, H.V., Furness, S., McCabe, M., Khalid, T., & Meyer, S. (2010). Interventions for treating oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews, 8, CD001973.
To assess the effectiveness of interventions for treatment of oral mucositis or its associated pain for patients receiving chemotherapy or radiation therapy
Databases searched were MEDLINE, CancerLIT, EMBASE, CINAHL, LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Oral Health Group and PaPaS Trials Registers, Cochrane Central Register of Controlled Trials (CENTRAL), OpenSIGLE, and Current Controlled Trials. Handsearching carried out by the Cochrane Collaboration was included. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.
Search keywords were (neoplasm* OR leukemia OR leukaemia OR lymphoma* OR plasmacytoma OR “histiocytosis malignant” OR reticuloendotherliosis OR “sarcoma mast cell” OR “LettererSiwe disease” OR “immunoproliferative small intestine disease” OR “Hodkin disease” OR “bone marrow transplant*” OR cancer* OR tumor* OR malignan* OR netropeni* OR carino* or Adenocarcinoma* OR radioth* OR radiat* OR radiochemo* OR irradiat* OR chemo*) AND (stomatitis OR “Stevnes Johnson syndrome” OR “candidiasis oral” OR mucositis OR (oral AND (cand* OR mucos* OR fung*)) OR mycosis OR mycotic OR thrush. Extensive appendices are provided with specific search strategies used for each database.
Studies were included in the review if they
The final assessment incorporated 32 studies. Out of an initial 95 eligible studies, 64 were excluded because of study design issues, protocol violations, lack of useable data, or no relevant outcomes.
Treatment of mucositis
Summary of data from single trials showed the following interventions to demonstrate statistically significant benefit (p < 0.05).
Other interventions for treatment of mucositis evaluated included chlorhexadine versus salt and soda, Gelclair verus sucralfate and mucaine,”Magic” mouthwash versus salt and soda, sucralfate versus placebo and versus salt and soda, and tetrachlorodecaoxide.
Management of pain with mucositis
The following interventions demonstrated statistically significant benefit in managing pain (p < 0.05).
Other findings
The lack of independent duplication of studies investigating the same intervention limits the strength of evidence and ability to generalize results.
Most studies reviewed had small sample sizes and may have been underpowered to demonstrate significant differences in outcomes.
Different scoring systems for mucositis were used, and, in some studies, the method of scoring was not defined.
The need for further well-designed trials to evaluate the effectiveness of interventions continues.
Adoption of standard clinical outcome measures should be considered, including patient-based measures and inclusion of the cost of interventions.