PLAN

1. Insertion of Hickman Line – Appointment with Surgeon.
2. Commence Growth Factors
3. Harvest Stem Cells – Nedpark Clinic, Sunnyside, Pretoria
4. Chemotherapy Administration – Brenthurst Clinic
5. Infusion of Stem Cells
6. Discharge
7. Check-up

Certain types of cancer may require treatment with high dose chemotherapy. High dose therapy is used either when conventional dose treatment has failed or when it is known that the prognosis with conventional dose treatment is poor e.g. young patients with extensive disease. This procedure is also offered as a consolidation treatment to patients. One of the major side effects of high dose chemotherapy is that the normal bone marrow cells are also affected and their numbers are dramatically reduced. These cells are manufactured in the bone marrow and the primitive cells are known as Stem Cells. The Bone Marrow is a part of our bodies which is essential for life. It is a spongy material, which fills the bone, and it produces the correct mixture of cells in our blood.

The White Cells are essential for fighting infection. They form part of your immune system.

The Red Cells contain haemoglobin and carry oxygen around the body. This is essential to provide energy.

For this we give GCSF/Neupogen/Granocyte which encourages the production of white cells. You will be shown how to give the injection at home – it is given twice daily, morning and night. You may take two Panado prior to the injections to treat the flu like symptoms. These small injections are given subcutaneous (under the skin) daily for 6 days. They will be given for a further period after the Chemotherapy has been given if the blood count (white cell count) is slow to recover. DO NOT TAKE ASPIRIN OR DISPIRIN

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The patient is attached to a machine called a cell separator, which extracts and retains the cells. This procedure is done by trained sisters and takes about 5 hours to complete.

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This is commenced immediately after the stem cells have been collected. The patient is given a powerful anti-nausea drug followed by the chemotherapy, which is mixed in divided doses in several litres of fluid, and will take several hours to administer according to the protocol. The patient will need to pass large volumes of urine. The reason for the forced diuresis is so that the chemotherapy drugs are excreted as rapidly as possible after exerting their effects on tumour. You will be admitted to the Oncology-Ward at the Brenthurst Clinic.

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Twenty-four hours after the administration of the last chemotherapy the stem cells are given back to the patient through a drip like a blood transfusion. These cells have been kept aside and are unaffected by the chemotherapy.

They will now multiply and divide. There will still, however, be a period of haematological suppression because these stem cells have to divide and grow before sufficient of them are formed. This process can take 10-20 days after infusion of the stem cells. During this time the patient will need to be protected from anyone who has an infection. The patient is discharged after the administration of the stem cells, if condition is satisfactory and socio-economic situation favourable.

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A hickman line may be inserted prior to the procedure to facilitate the administration of the chemotherapy, blood transfusions, platelets, antibiotics etc. This is done under local anaesthetic and will remain until no longer required. The hickman line is threaded into one of the large veins of the chest and then brought out above the breast. It is a soft white flexible tube about 0,5cm in diameter. It is essential that the hickman line is adequately cared for and the patient and family will be taught how to manage the care of the line when clinic visits are less frequent.

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You must stay at home and not have too many visitors. People who have infections must not be allowed to visit.

Follow-up

You will be requested to visit Dr Rapoport’s rooms daily for a blood test.

Mouth Care

Your mouth may become very painful. Two hourly mouth care is essential i.e. rinse with a mouthwash after every meal or milky drink. Use a very soft toothbrush on teeth, not on gums. It is often helpful to suck ice if your mouth and /throat is very painful.

Nausea and Vomiting

You may continue to feel nauseous at home. If so, use the anti-nausea medication as supplied. Drink small quantities of fluid throughout the day. Cold fluids of your preference are often helpful. Should the vomiting persist, please phone the doctor.

• Wash hands before eating
• Use long life milk
• All food to be cooked
• No fresh salads
• Washed and peeled fruit e.g. oranges, bananas, avocado etc. are permissible, if they have been previously soaked in Milton
• Fruit juice in a sealed container is permissible
• Tinned or cooked fruit is allowed
• No biltong, uncooked cheese, uncooked mushrooms
• No take-aways e.g. Hamburgers, Fried chicken etc.

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Due to the effect of the chemotherapy treatment on your normal cells as well as your abnormal cells, special precautions need to be taken.

Your white cells fight against infection and form an important part in your immune system. Your platelets prevent you from bleeding.

Your red cells carry oxygen to all parts of the body.

• You are still susceptible to infection, so you should keep away from crowds until your white cell count has returned to normal.
• Visitors should not see you if they have a current infection, especially children who may be harbouring chicken pox.
• Take your temperature twice a day. Should you run a temperature above 38 C on two consecutive occasions, you must phone Dr Rapoport. Do not take panado to reduce your temperature unless ordered to do so.
• PLEASE DO NOT ASK ADVICE FROM YOUR GENERAL PRACTITIONER – HE DOES NOT WORK WITH THE DRUGS WE HAVE USED FOR YOU
• If you have a nosebleed that persists, notices bleeding in your mouth, blood in your urine, etc. phone Dr Rapoport.
• Try not to get your hickman dressing wet. If your hickman line is painful or swollen and red around the exit contact the rooms.
• If you have diarrhoea or pass urine frequently, burning urine contact Dr. Rapoport.

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FLUSHING THE LINE

You will need:

• 5ml syringes x 2
• Needles
• Heparin
• Normal Saline
• Cotton wool swabs
• Gauze
• Opp-site

1. Wash hands well.
2. Draw up Saline Solution 4ml and fill up to 5ml with Heparin.
3. Thoroughly wet swabs with hibitane solution.
4. Remove old dressing.
5. Wash hands.
6. Ensure line is clamped
7. Remove cap and attach empty 5ml syringe.
8. Clean end of line with hibitane swab.
9. Unclamp and draw blood back – approximately 4mls.
10. Clamp line.
11. Remove syringe and wipe with swab.
12. Attach Heparin filled syringe.
13. Unclamp – push 4.5mls into the line.
14. Clamp.
15. Remove syringe and replace cap.

If it is difficult to withdraw blood from the line, the patients should cough, move arms up and down and move from side to side.

If it is difficult to flush the line with the heparin solution, replace cap and come to the rooms.

1. Clean around the exit site with a hibitane swab – circular movements from inside to outside – 3 times.
2. Clean line using one swab to secure line and one swab to clean line and clamp.
3. Place small piece of gauze under the line.
4. Coil line onto gauze, make sure the line does not lie on the skin.
5. Secure with micropore.
6. Cover with opp-site.

Dressing must be renewed weekly or if damp or soiled. The line does not need to be flushed if the dressing is soiled and requires replacing. If the exit site is red, swollen, painful, report to the rooms immediately.

THE LINE HAS TO BE FLUSHED ONCE A WEEK

If a patient has a temperature, report to Dr. Rapoport immediately.

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• Physical discomfort from the insertion of the needle.
• Drop in blood pressure, possibly causing dizziness or fainting, as the blood is withdrawn into the machine.
• Reaction to anti-coagulant, causing mild numbness or tingling round the mouth and occasional nausea.

These are the main side effects that have been found. In a few instances more serious complications have occurred including bleeding, air embolisms and cardiac arrhythmia.

These are extremely rare. A trained sister will be in attendance at all times.