Page 53 Complete Your CE Test Online - Click Here Damage to sensory nerves can cause [179]: ● ● Tingling, numbness, or “pins-and-needles” in feet and hands. ● ● Inability to feel heat or cold in extremities. ● ● Inability to feel pain in the extremities. ● ● Hyperesthesia (increased sensitivity to heat, cold, or pressure) [17]. Damage to motor nerves can cause: ● ● Weak or achy muscles, loss of balance, difficulty with fine motor function (buttoning shirts or opening jars). ● ● Twitching, cramping, or muscle wasting. ● ● Dysphagia or dyspnea if chest or throat muscles are affected. Damage to autonomic nerves can cause: ● ● Gut motility problems such as constipation or diarrhea. ● ● Hypotension with dizziness and lightheadedness. ● ● Sexual problems: Men may have erectile dysfunction and women may not reach orgasm. ● ● Sweating too much or too little. ● ● Urinary issues, such as leakage or incomplete bladder emptying. Injury prevention is important after CIPN develops. Advise affected patients to take actions to [179]: 1. Prevent falls: ○ ○ Get help moving rugs out of pathways to reduce the risk of tripping. ○ ○ Wear sturdy shoes with soft soles, not slippers that feet can accidentally slide out of. ○ ○ Home care services may be needed to put rails along the walls and in the bathroom. ○ ○ Use “gripper” bathmats in the shower or tub. ○ ○ Get up slowly after sitting or lying down, especially if the patient reports dizziness. 2. Take extra care in the kitchen and shower: ○ ○ Use potholders in the kitchen to protect hands from burns. ○ ○ Be careful when handling knives or sharp objects. ○ ○ Use oven gloves to handle hot pans, oven racks, and dishes. ○ ○ Ask someone to check the water temperature, or use a thermometer to make sure bath or shower water is not too hot. Set hot water heaters between 105° and 120°F to reduce risk of scalding when washing hands or dishes. 3. Protect hands and feet: ○ ○ Wear shoes, both inside and outside. ○ ○ Wear protective gloves when gardening, cleaning, or doing repairs. ○ ○ Check arms, legs, and feet for cuts or scratches every day. ○ ○ When the weather is cold, wear warm clothes, gloves, and socks to protect hands and feet. 4. Slow down and ask for help: ○ ○ Let others help with difficult tasks. ○ ○ Slow down and allow more time to do things. For patients with long-term CIPN, nurses may also want to ask the doctor to offer a referral to occupational therapy to help the patient with safety and mobility in the home and community [17]. Pain management for CIPN In 2014, the American Society of Clinical Oncology put out a review of evidence and a recommendation noting that no agents have been proven to prevent CIPN, and recommended duloxetine as a proven pain reliever for CIPN. They further added that tricyclic antidepressants (such as nortriptyline), gabapentin, and a topical gel containing baclofen, amitriptyline HCL, and ketamine, might all be offered because there is data that supports their efficacy in other types of neuropathic pain [101]. However, more research is needed on these agents for CIPN. The ASCO also had a long list of medications and supplements that they specifically recommended against, including amifostine, amitriptyline, calcium and magnesium infusion, vitamin E, glutathione, all-trans-retinoic acid, nimodipine, acetyl-L-carnitine, and others. Some patients with incomplete pain relief may be helped somewhat by distraction and practices such as massage, physical therapy, yoga, guided meditation, acupuncture, and other modalities [179]. Neutropenia Chemotherapy, radiation therapy, and stem cell transplants (which usually involve both chemo and RT) can lower the white blood cell count [208]. Especially important are the granulocytes or neutrophils that have an important role in fighting infection. Many chemotherapy drugs can depress the entire bone marrow production, not just white cells but also red blood cells (erythrocytes) and platelets. This leads to defects in fighting infection as well as oxygenation and blood clotting. Practice note: Look on the lab report for the white blood count differential (most often done with a complete blood count, CBC): sometimes neutrophils show up listed as “segs,” which refer to segmented neutrophils, or mature neutrophils; “bands,” which are less mature neutrophils; or to “polys,” which are polymorphonuclear leukocytes, yet another term for neutrophils. An absolute neutrophil count (ANC) of 500-1,000 is considered mild- moderate neutropenia, 100-500 is severely neutropenic, and an ANC less than 100 is profoundly so. To calculate the ANC, add together the percentage of bands plus segs, polys, or neutrophils, then multiply by the number of total number white blood cells. For example, a person with a total white blood count of 550 with 60% segs and 4% bands would have an ANC of 352 (550 x 0.64 = 352). This person has neutropenia and should be watched for any signs of infection because an immediate fever workup and antibiotics would be indicated. This is especially important if the patient’s white count is still dropping after a cycle of chemotherapy. In people with cancer, there is some urgency to completing this sequence because infection can sometimes progress to septic shock and death very quickly. Fever workups: Make ‘em stat A fever workup in the neutropenic patient usually starts with two sets of blood cultures. If the patient has a port or a CVL, one set of blood cultures is taken from the line and the other from a peripheral site. However, given that many people with cancer have very poor peripheral venous access it is sometimes necessary to take both from the line. Generally, a CBC with differential is taken as well, along with electrolytes, BUN, creatinine, and liver function tests. A chest X-ray, sputum cultures, and pulse oximetry would typically be conducted if the patient had respiratory symptoms. If the patient has skin lesions/ drainage, UTI symptoms or a urinary catheter, additional cultures are taken from these sites. Stool for enteric pathogens may be done if the patient has diarrhea, with a probe for Clostridium difficile toxins if the patient has had antibiotics in the past few weeks (see “Diarrhea”). Additional history is taken to find out if the person has any other new symptoms such as sore throat, skin or mucosal ulcers, etc., which are then usually cultured or tested for viruses. People with localizing symptoms such as abdominal pain or a new headache, stiff neck, etc., might need additional scans or tests. As soon as cultures are completed, broad- spectrum antibiotics are typically administered until more information becomes available from the cultures and scans to focus the antibiotic therapy on the causative organism [208]. Case study: A 54-year-old woman with acute myelogenous leukemia has a WBC of 400 with 40% segs and 5% bands near the end of her first treatment (intended to induce remission). This calculates out as an ANC of 180 (0.40+0.05=0.45; 400 x 0.45 = 180). You note that her