ส่วนที่ 1 ข้อมูลเอกสาร

ส่วนที่ 2 Chemotherapy Safety

2.1 Pre-chemotherapy Verification

• Double-check: 2 nurses verify order independently
• Patient identification (2 identifiers)
• Drug, dose, route, rate, schedule
• Drug calculation: BSA (body surface area) or weight-based
• Lab values (ANC, platelets, LFT, renal) — hold if below threshold
• Informed consent documented
• Pre-medications given (anti-emetic, steroid, antihistamine)

2.2 PPE for Handling Chemo

• Chemo gown (low-permeability, long sleeves)
• Double gloves (nitrile, changed q 30 min or if contaminated)
• Mask (N95 for aerosolizing)
• Eye/face protection
• Closed-system transfer devices (CSTD)

2.3 Spill Management

• Chemo spill kit readily available
• Evacuate area, restrict access
• Don PPE
• Contain with absorbent pads
• Clean with detergent → 2% sodium thiosulfate (if indicated)
• Dispose in yellow cytotoxic waste
• Document incident

ส่วนที่ 3 Vascular Access

3.1 Types

3.2 Extravasation Prevention & Management

• Vesicants (high risk): Anthracyclines (Doxorubicin), Vinca alkaloids (Vincristine), Mitomycin
• Irritants: Cisplatin, Etoposide
• Use central line for all vesicants when possible
• Check patency before every dose (blood return + flush)
• If extravasation:
  • Stop infusion immediately
  • Aspirate residual drug (don't flush!)
  • Remove IV
  • Mark area, photo
  • Antidote per protocol: DMSO, Dexrazoxane, Hyaluronidase
  • Cold vs warm compress (depends on drug)
  • Elevate limb
  • Plastic surgery consult if severe

ส่วนที่ 4 Common Toxicities Management

4.1 Nausea & Vomiting (CINV)

Prophylaxis based on emetogenicity:

• 5-HT3: Ondansetron 8-16 mg IV/PO
• NK1: Aprepitant 125 mg day 1, 80 mg days 2-3
• Breakthrough: Metoclopramide, Prochlorperazine, Lorazepam

4.2 Myelosuppression

• Neutropenia (ANC < 500): Neutropenic precautions
  • Private room, no visitors with illness
  • Hand hygiene strict
  • No raw fruits/vegetables (unpeeled), no flowers/plants
  • Daily oral care (chlorhexidine)
  • Fever > 38°C = emergency (febrile neutropenia)
• Thrombocytopenia (Plt < 50): Bleeding precautions
  • Soft toothbrush, electric razor
  • No IM injections, rectal temps
  • Fall prevention
  • Platelet transfusion if < 10 or bleeding
• Anemia: ESA (erythropoiesis stimulating agents) if Hb < 10, transfusion

4.3 Febrile Neutropenia ⚠️

Fever + ANC < 500 = Medical emergency

1. Blood cultures × 2 (one from central line)
2. Urine culture, CXR
3. Broad-spectrum antibiotic within 1 hour:
   • Piperacillin-tazobactam 4.5 g IV q 6h, or
   • Cefepime 2 g IV q 8h, or
   • Meropenem (severe)
4. Add Vancomycin if: severe mucositis, hypotension, known MRSA, catheter infection
5. Add antifungal if no improvement after 4-7 days
6. G-CSF for high-risk

4.4 Mucositis

• Oral care protocol: saline/soda rinses q 2-4 hr
• Avoid alcohol-based mouthwash
• Cryotherapy (ice chips) during 5-FU infusion
• Magic mouthwash (lidocaine + antacid + diphenhydramine)
• Nutritional support (soft foods, nutritional supplement)
• Opioid for severe pain

4.5 Diarrhea

• Loperamide 4 mg → 2 mg after each loose stool (max 16 mg/day)
• Hydration, electrolyte replacement
• Stool culture if severe (rule out C. diff)
• Octreotide for refractory

4.6 Tumor Lysis Syndrome

• Risk: rapid cell turnover (ALL, Burkitt lymphoma, bulky tumors)
• Labs: hyperK, hyperuricemia, hyperphos, hypoCa, ↑ LDH, AKI
• Prevention: IV hydration 2-3 L/m²/day, allopurinol or rasburicase
• Monitor: labs q 6-8 hr × 72 hr

ส่วนที่ 5 Patient Education & Psychosocial

• Written chemo calendar
• Side effects to report
• When to call: fever > 38°C, uncontrolled vomiting, bleeding, chest pain, SOB
• Pregnancy/contraception counseling
• Fertility preservation (before chemo)
• Psychological support, depression screening
• Support groups
• Advance care planning

ส่วนที่ 6 Immunotherapy

6.1 Immune-related Adverse Events (irAEs)

• Dermatitis: topical/systemic steroid
• Colitis: steroid, rule out infection first
• Pneumonitis: stop drug, steroid, CXR/CT
• Hepatitis: LFT monitoring, steroid if severe
• Endocrine: thyroid, adrenal, pituitary dysfunction
• Management: Steroids (prednisone 1-2 mg/kg/day), tapered slowly

KPIs

References

• Oncology Nursing Society (ONS). Chemotherapy Biotherapy Guidelines.
• NCCN Clinical Practice Guidelines in Oncology.
• Hesketh, P.J., et al. (2020). Antiemetics: ASCO Guideline Update.
• Haanen, J., et al. (2022). ESMO Guidelines for management of irAEs.

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