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Slide 1 SIDE EFFECTS OF CHEMOTHERAPY & ITS MANAGEMENT BY DR. NIMESH DAHIMA : Why the side effects? Chemotherapy acts on faster dividing cells Apart Slide 2 from cancerous cells they also affects the other faster diving cells in the body like GI tract lining Bone marrow Hair folicles Skin This leads : to many complications Myelosupression Anemia is when red blood cell (RBC) production is Slide 3 low or destruction is high. It is determined by the hemoglobin or : hematocrit in a CBC. Myelosuppression Symptoms include: Fatigue Weakness Slide 4 Shortness of breath Heaviness in legs Decreased stamina Inability : to concentrate Myelosuppression Ways to cope with Anemia: Advice to set shortterm goals for daily activities to conserve energy; do not over do it Slide 5 Advice to change positions slowly to prevent dizziness Maintain a healthy diet for energy production May require injection of medication : to stimulate RBC production May require transfusion of donor red blood cells to boost hemoglobin supply Slide 6 Myelosuppression Thrombocytopenia- when platelet production is low or destruction is high : Myelosuppression Ways to cope with Thrombocytopenia: Use electric razors, not razor blades Use emery board versus metal file/clippers for Slide 7 nail care Blow nose gently Use soft bristle toothbrush Use water-based : lubricant before vaginal intercourse Use prophylactic stool softeners to avoid constipation Myelosuppression Ways to cope with Thrombocytopenia continued: Do not use dental floss Do not use tampons, enemas, or rectal Slide 8 suppositories Do not engage in activity that poses high risk of falls or high impact Do not put anything up the nose Do not engage in vaginal : intercourse if platelets are < 50,000 Do not engage in anal intercourse If taking oral steroids, take with food to avoid stomach irritation MYELOSUPPRESSION Neutropenia is low amount of a type of white Slide 9 blood cell called neutrophils that fight bacterial infection. A person with neutropenia is at risk for serious infections. Neutropenia is : determined by the absolute neutrophil count (ANC) in a CBC. Slide 10 : MYELOSUPPRESSION Ways to cope with Neutropenia: Wash hands frequently Bathe daily Protect skin from cuts/burns Wear gloves when

working in garden Care for mouth after meals & bedtime Practice good hygiene after using toilet Use only an electric razor to shave Deep breathing exercises to decrease respiratory infections Wash fresh fruits & vegetables well before eating MYELOSUPPRESSION Ways to cope with Neutropenia continued: Avoid raw meat, fish, and eggs Avoid exposure to people with colds Avoid exposure to large crowded places Do not share food utensils Do not provide direct care for pets Do not use tampons, enemas, or rectal suppositories Do not receive live vaccines (oral polio, varicella, smallpox, or nasal flu) NAUSEA & VOMITING Not all chemotherapy drugs cause N/V Attempt to pre-medicate patients with anti-nausea medications based on the risk as well as supply a prescription for anti-nausea medications at home. HOW TO COPE UP WITH NAUSEA AND VOMITING Dietary Modifications Acupressure wrist bands Acupuncture for patients with normal platelet & WBC count Progressive muscle relaxation Self hypnosis Guided imagery Music therapy DIARRHEA Chemotherapy can cause inflammation or injure cells on the inside lining of the gut or can damage or destroy enzymes that digest foods PREVENTION & MANAGEMENT Drink 8-10 glasses of fluids a day including soup/broth, soda (non-caffeinated brands). Take low fat diary products (e.g. low fat yogurt) Eat smaller meals throughout the day rather than three big meals. Use BRAT diet (bananas, rice, apple sauce and toast) Eat bland, low fiber food such as white chicken meat without skin, scrambled eggs, crackers,white bread, mashed or baked potatoes and pureed vegetables. Avoid fatty, fried or greasy food. Take the prescribed medication to control diarrhea CONSTIPATION Defined as fewer than three bowel movements a week this symptom can be caused by: Vinorelbine , vincristine, and temozolomide commonly used chemotherapy drugs Inactivity Low fluid intake Low intake of dietary fiber Anti-nausea medications Opiate pain medications AVOID THE CONSTIPATION Eat plenty of dietary fiber. Grains, beans, and vegetables such as cauliflower or broccoli are good sources of fiber. Drink plenty of fluids. Make light exercise a part of your everyday schedule Number of different laxatives that are available without a prescription. Chemotherapy extravasation injury Extravasation refers to the escape of a chemotherapy drug into the extravascular space, either by leakage

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from a vessel or by direct infiltration Extravasation should be suspected when The patient complains of burning, stinging, pain or any acute change at the injection site. The patient is often the first person to become aware that something is wrong with their IV therapy, so instruct them at the beginning of treatment to inform of any acute change during treatment. Extravasation should be suspected when Induration, erythema, venous discoloration or swelling is observed at the site No blood return is obtained. A lack of blood return from the cannula is commonly quoted as a sign that extravasation has occurred. It is however, the most misleading of all signs and has been implicated in a number of serious incidences. The flow rate is reduced. A reduced rate may be observed when using an infusion pump, so close observation is necessary Extravasation should be suspected when Increased resistance to the administration, once possible changes in the position of the body e.g. bending of wrist or elbow, or cannula support e.g. the bandaging, have been excluded as possible causes of the increased resistance, then a displaced cannula and hence extravasation are the next most likely causes. This is often one of the first signs of a problem or of preextravasation syndrome. Once the alternative diagnoses have been considered and excluded and one or more of these symptoms are present, the practitioner should proceed on the basis of a diagnosis of extravasation.

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Slide 22 : procedure management of extravasation Seek experienced assistance from someone used to looking at extravasation. Stop infusion, disconnect the drip but.DO NOT REMOVE THE VENFLON. Aspirate the extravasated drug, trying also to draw some blood back from the cannula/venflon. This may be facilitated by s.c. injection of either 0.9% sodium chloride, to dilute the drug, or 1500 units of hyaluronidase in 2ml water for injection, to open up the intracellular space. Remove the venflon. Give hydrocortisone (2ml) as 0.1-0.2ml sc injections at about 6 to 8 points around the circumference from the extravasation site. PROCEDURE AND MANAGEMENT OF EXTRAVASATION Give 100mg hydrocortisone IV if large-scale inflammation, flare or fracturing along the vein has occurred. This should be administered via a new venflon, resited remotely from the extravasation area. Instruct the patient on the correct care of the site and on the use of any ongoing treatment. Analgesics may be required for pain management. Ensure that the extravasation is followed up. Counsel the patient that if the

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symptoms worsen in the following days then they should promptly contact their clinic or ward. http://www.extravasation.org.uk/CEG.htm Slide 25 : Slide 26 : Most Importantly Act in a manner that will not aggravate the injury but a manner that offers prompt first aid treatment Bleeding Chemotherapy drugs can affect the ability of the bone marrow to produce platelets that help stopping bleeding and forming blood clots. Some tips that help you avoid problems Avoid falls or other injuries (e.g. avoid participating in contact sports and activities). Use an electric razor rather than a plain one. Use a nail clipper or a file rather than scissors. Avoid blowing nose. Use a soft toothbrush for mouth care. Never use medications that affect the platelet functions nerve & muscle related symptoms Tingling, numbness and weakness felt. Patient felt tiredness. Stomach pain, heart burn Constipation Jaw pain Loss of balance, clumsiness, having trouble with coordination (e.g difficulty picking up objects and buttoning your clothes) Fatigue Dizziness Feeling colder than normal Pain when walking Depression Ways to cope and manage If you do not feel well, be careful when grasping objects. Avoid falls or other injuries by moving carefully using handrails whenever possible. Wear gloves when gardening, cooking, washing the dishes, etc.. Wear shoes or other footwear with rubber soles. Skin and Nail Chemotherapy can cause minor skin problems such as rashes, redness, acnes, itching, peeling and even a dry looking or dry feeling skin. Tips to prevent skin problems For itching, avoid scratching to prevent irritation. To avoid dryness, use creams or lotions when your skin is moist after bath. Avoid products that contain perfumes as well as deodorants and powders. Avoid using tapes and adhesive dressings on your skin. Avoid extremes in temperature. Wear comfortable clothes. Drink plenty of fluids. Avoid direct sunlight. Alopecia Hair loss occurs very often and is the most visible side effect of chemotherapy. The actual extent of hair loss depends on the person and the anticancer drugs being given. Hair may fall out gradually, in clumps, or even all at once. Facial, underarm, and pubic hair may be lost. Recommendation in managing hair loss Cut hair short to make it look thicker and fuller Use mild shampoo and conditioner Use soft hairbrush Avoid excessive shampooing and hair combing Infections Most chemotherapy drugs affect the bone marrow and

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thereby decrease its ability to produce white blood cells that fight infections Signs of infections Fever >38 C. Chills. Loose bowel (which can also be a side effect of the chemotherapy itself). Burning during urination. Severe cough, sputum or sore throat. Unusual vaginal discharge or itching. Redness, swelling or tenderness of a wound, sore, pimple or intravenous catheter site. Personal Hygiene Wash hands with an antibacterial soap Gently pat your skin dry after a warm bath or shower. Clean the anal area thoroughly after bowel movement (Women: cleanthe anal area front to back) To prevent any injury be careful with grooming (e.g. clipping nails). Do not tear or cut cuticles Clean any cuts or niches on the skin immediately by using soap and warm water followed by an antiseptic. Do not squeeze or scratch blemishes. Oral / Dental Hygiene When brushing teeth, use a soft toothbrush and avoid using dental floss. Avoid using commercial mouthwashes containing alcohol. Clean dentures with fresh water. Dental procedures should not be performed when White Blood Cells is low. Safety Precautions Avoid people who have cold, flu, open sores or any type of infection. Avoid crowded areas. Avoid exposure to direct sun light. Wear shoes to prevent cuts or burns in your feet. Nutrition Awareness Proper diet is very important. Food must be cooked adequately. Maintain good nutritional intake and drink plenty of fluids. Avoid vegetables that cannot be peeled (e.g. salad vegetables) and peel fruits before eating them. General Recommendations Maintain good nutrition and a healthy lifestyle. Exercise. Take plenty of rest. Learn how to deal with stress. Encourage to discuss r fears and feelings with family members, support group and health care professionals. Learn about your disease. Lets Live Longer! Live Better!

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