Acute Myeloid Leukemia (AML)/ Acute Non- Lymphoid Leukemia
AML starts in bone marrow (soft inner part of bones where new blood cell made).
Abnormal proliferation of monocytes and myelocytes (precursor of basophils, eosinophils, neutrophils) in bone marrow.
Types of AML
1. Acute myeloblastic leukemia
2. Acute promyelocytic leukemia
3. Acute myelomonocytic leukemia
4. Acute monocytic leukemia
5. Acute erythrocytic leukemia
Clinical features of AML
1. Recurrent chronic infection
2. Pallor
3. Bone or joint pain
4. Lymphadenopathy
5. Hepatospleenomegaly
6. Fever
7. Gingival hypertrophy
8. Frequent brushing; due to thrombocytopenia
9. Hyperuricemia
Diagnostic Evaluation
1. History taking and physical examination
2. Peripheral blood smear
3. Bone marrow examination
4. Complete blood count
5. Blood investigation
Increase serum uric acid level due to increase malignant cells.
6. Radiologic studies
Presence of mediastinal mass.
7. Liver function tests and Renal function tests; to detect leukemic cells infiltration in liver and kidneys.
8. Lumber puncture; asses CNS involvement
9. Cytochemical and Immunologic studies; to categorize disease
10. Cytogenic studies; Chromosomal abnormalities
Management
1. Chemotherapy
Chemotherapy given in three pahase;
a. Induction phase
Reduce leukemic cells to undectable level, state known as remission.
In remission, no evidence of leukemia.
Physical examination
Bone marrow examination
Peripheral blood smear
CSF examination
Drug used for induction phase; ALL
Prednisolone
Vincristine
L-asparginase with or without Doxorubicin.
Drug used for induction phase; AML
Cytarabine
Daunorubicin
95% children with leukemia achieve remission during induction, within 4 weeks.
Note-
Leukemic cell cross blood brain barrier while most chemotherapy drug doesn't cross BBB (blood brain barrier).
So, children with ALL provided CNS prophylaxis with chemotherapy drug instilled intrathecally, into cerebrospinal fluid space during lumbar puncture.
b. Consolidation phase
Eradication any residual leukemic cells.
This phase of therapy begins once remission attained.
This phase involve prophylactic treatment of CNS with cranial irradiation (reduce risk of cancer cells, spreading to brain) and or intrathecal administration of Methotrexate.
c. Maintenance phase
Aim to preventing recurrence and reducing number of leukemic cells.
Maintenance therapy begins after successful completion of induction and consolidation phase.
During this phase evaluate complete blood count and evaluate bone marrow response to drug.
2. Bone marrow transplantation
Bone marrow transplantation done successfully in treating children with AML.
Bone marrow transplantation not recommended for children with ALL because of excellent results possible with chemotherapy.
Nursing Management
Aims managing the problems of leukemia and side effects of chemotherapy.
1. Managing problems of leukemia
Infiltration of bone marrow with leukemic cells leads myelosuppression resulting in;
Reduced RBCs
Reduced WBCs
Reduced platelets production
2. Management of leukemia
Blood transfusion with packed red cells.
3. Prevention from infection
Varicella, herpes zoster, measles, mumps, rubella viruses, fungus.
a. Broad spectrum antibiotics used prophylactically
b. Live vaccine not given
Due to immunocompromised.
c. Universal precautions, aseptic techniques, handwashing
d. Fever sign of Infection
Blood, urine, stool, nasopharyngeal culture
e. Adequate protein and calories intake; better defences against infection and increase tolerance to chemotherapy.
7. Prevention and management of hemorrhage
1. Bleeding episodes
a. Prevented by Administration of platelet drug.
b. Regular mouth care essential
Prevent gingival bleeding
Provide soft tooth brush or only rinse mouth
Children develop repeated episodes of Diarrhea, prone to rectal ulceration.
Provide perineal care/ keep area dry/clean
Psychological and emotional support
Child kept away from activities; care of injury or bleeding.
2. Management of side effects of chemotherapy and problems of irradiation
1. Nausea and vomiting
Antiemetics; promethazine, chlorpromazine
Severe vomiting; metoclopramide
Antiemetics administerd before chemotherapy started and after regular interval.
2. Anorexia; Loss of appetite
Small frequent feed
Soft and easily digestible food.
Seve food in attracted manner
3. Mucosal Ulceration
Frequent mouthwash with normal saline.
Give blant, moist, soft diet
Soft tooth brush or mouth wash to clean mouth
NG started incase of severe ulceration of mouth.
Local anaesthetic Lidocaine; used to anesthetize oral ulcers, before child eats food.
4. Neuropathy
Vincristine and vinblastin; causes neurotoxic effect, leading foot drop, weakness, reduce local movement.
Use foot board to prevent footdrops.
For constipation; stool softener and laxative
Fluid intake of child increased.
5. Hemorrhagic cystitis
Cyclophosphamide
Lead hemorrhagic cystitis (inflammation in bladder)
Motivate the child to void immediately on feeling urge to urinate.
6. Alopecia; loss of hair
Hair cut short; wear surgical cap to collect fallen hair.
Earlier inform parents and child about side effect.
Encourage to parents to wear wig for child.
7. Mood change
After starting stroid therapy; children experience mood change; range from feeling of wellbeing, euphoria to depression and irritability.
8. Parental support and guidance
Guide, support, help parents to adjust.
Encourage to express feeling, fear, grief
Provide psychological and emotional support to parents.
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