12/10/2014 Objectives Acute Graft-Versus-Host Disease • Explain the mechanics of extracorporeal and Extracorporeal Photopheresis photopheresis (ECP) (ECP) • Review ECP side-effects, patient education and hazardous drug aspects LCDR Tracey Chinn, RN, BSN, MPM • Discuss therapy impact to the Clinical Assistant to the Chief, ETIB, NCI inpatient/outpatient Nurse Technical Considerations: Technical Considerations Apheresis Instrument • Cellex (Therakos, Inc.) ▫ Single and double venous access • Uvar XTS (Therakos, Inc.) ▫ Single venous-access only ▫ Current NIH instrument ECP: The Mechanics Technical Considerations: Venous Access 1. Blood is drawn and separated thru centrifugation; WBC are separated and • Apheresis specialist should perform venous collected assessment and make recommendations 2. Plasma and RBCs returned to patient 3. Methoxsalen (Uvadex®) added to the WBC • Peripheral Venous Access 4. Medicated WBC cells exposed to UVA light, ▫ Average needle size = 17-18 gauge which activates the medication ▫ Needle is placed and removed at time of therapy 5. Treated WBC returned to patient; prompt an immune response 1 12/10/2014 Technical Considerations: Technical Considerations: Venous Access Extracorporeal Volume (ECV) • CVAD Access • ECV = Safe mL/whole blood can be taken out of ▫ Typical catheter/size = 9.6 french single-lumen body at one period of time Hickman ▫ NURS – CVAD Flushing Guidelines: “Dialysis/Apheresis –All Purpose Use” • ECV < 15% TBV (Total Blood Volume) ▫ Preference = Use ONLY for therapy • ECV is directly related to: ▫ Safety / Bowl size / Blood prime (< 20 kg) ▫ # Cycles performed = # WBC treated Technical Considerations: Technical Considerations: Extracorporeal Volume (ECV) Extracorporeal Volume (ECV) • Average adult total blood volume = 7- 8% of • Example: body weight ▫ 55 kg (weight) x 70 mL/kg = 3850 mL (TBV) • TBV = patient weight (kg) x body build (mL/kg) ▫ 3850 mL (TBV) x 0.15 = 577 mL (ECV) ▫ Normal build = 70 mL/kg of body weight ▫ Varies based on body build (i.e. Muscular, Normal, Thin, Obese) Technical Considerations: Technical Considerations: Extracorporeal Volume (ECV) Anticoagulant • Reduces potential of blood clotting within the circuit • Mixes with whole blood at specified ratios ▫ (i.e.) 10:1 = 10 parts blood: 1 part anticoagulant • Type of anticoagulant medication varies ▫ Patient weight ▫ Clinical status (i.e. bleeding risk) ▫ Platelet count 2 12/10/2014 Technical Considerations: Technical Considerations: Anticoagulant Plasma Issues • ACD-A (Anticoagulant Citrate Dextrose) • Neon-Yellow Plasma ▫ Routine practice @ NIH ▫ Elevated bilirubin (Liver GVH, infection) ▫ Low platelets ▫ Manual procedure mode ▫ DTM/Minimum platelet threshold = 20 K/uL • Standard-dose Heparin (10,000 U / 500 mL NS) • Cloudy plasma ▫ Used with citrate sensitivities ▫ Lipemic (due to diet or lipids w/TPN) ▫ Normal platelet levels ▫ Avoid high-fat diet ~ 24 hours prior to ECP ▫ Weight > 40 kg ▫ Avoid intra-lipids at least 7 hours in advance • Low-dose Heparin (5,000 U / 500 mL NS) ▫ Manual procedure mode ▫ Low patient weight (<40 kg) Technical Considerations: Contraindications ECP: Logistics Hematologic Non-Hematologic • Procedure length = 2 – 5 hours • Hct ≥ 28% Exclusion • Sepsis • Platelets ≥ 20 K/uL • Severe Cardiovascular • Therapy location: • Severe Renal Impairment ▫ Inpatient therapies performed at bedside • WBC Count = Variable Risk/Benefit ▫ Outpatient at DTM, Dowling Apheresis Clinic • Severe Infection • Severe diarrhea (> 1 L/day) ECP: Typically Well-Tolerated Common Side-Effects ECP: Patient Education ▫ Drop in blood pressure Dizziness • Day prior to therapies: Weakness ▫ Drink plenty of fluids Intravenous - Albumin ▫ Avoid caffeine/alcohol ▫ Slight chill with blood return ▫ Avoid high-fat foods Warm blankets • Day of procedure: ▫ Hypocalcemic ▫ Eat low-fat diet Anticoagulant / ACD-A binds to Ca+ Tingling/numbness around lips, nose, mouth, fingertips Slowing procedure, Intravenous - Ca+ if needed 3 12/10/2014 ECP: Patient Education ECP: Impact to the CC Nurse • 24-Hours after therapy: Inpatient: ▫ Coordination of care with Clinical Team and DTM ▫ Methoxsalen (Uvadex®), causes photosensitivity ▫ Therapy performed at bedside ▫ Wear UVA-protective, full-coverage sunglasses and sunscreen ECP Nurse at bedside for length of therapy ▫ Lab value thresholds ▫ Avoid sunlight Hct ≥ 28% Platelets ≥ 20 K/uL • Hazardous Drug Precautions ▫ Procedure length (2-5 hours) ▫ Methoxsalen (Uvadex®) ▫ Bedside commode ▫ CVAD dressing care/flushing with unit nurse ▫ Hazardous drug precautions ECP: Impact to the CC Nurse ECP: Documentation Outpatient: ▫ Coordination of care with Clinical Team and DTM CRIS ▫ Therapy performed at Dowling Apheresis Clinic • Worklist Manager ▫ Lab value thresholds ▫ Methoxsalen (Uvadex®) Hct ≥ 28% ▫ CVAD Flushing Platelets ≥ 20 K/uL • Apheresis structured note ▫ CVAD dressing care with unit nurse ▫ Procedural specifics ▫ CVAD flushing with patient ▫ Patient Education ▫ Hazardous drug precautions ▫ Hazardous drug precautions • Total fluid given = approximately 450-550 mL + ▫ Inpatient/Intake ECP: Conclusions Acknowledgements • ECP has multiple technical challenges with the aGVH patient • NCI - ETIB ▫ Dr. Gress, Chief, ETIB, NCI • ECP well-tolerated ▫ Dr. Halverson, Head, Clinical Care, ETIB, NCI • Patient education ▫ ETIB, NCI Clinical and Research Team • Hazardous drug aspects • CC - Department of Transfusion Medicine • Therapy impact to the CC Nurse • NCI Oncology Nursing - Brown Bag Lunch Series • Clinical Center Nursing - 3NE, 3NW, 3SE • Sky’s the limit…. 4 12/10/2014 Extracorporeal Photopheresis (ECP) Questions… 5.