Resources to prep for Liquid NF?

[knightstale4]

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I'm starting on liquid night float as an intern and was wondering if any of you knew a good resource I can read up before I get on the ward or any specific topics I should absolutely know/ articles to read up on?

So far have only received feel good advice, which is great but I actually need some educational materials.

 

[visari]

what does "liquid" include?

 

[gutonc]

what does "liquid" include?

This was my question as well.

Acute leuks?
Transplant?
Inpatient lymphoma/myeloma chemo?
All of the above?

High yield stuff?
Tumor lysis
Infection prophylaxis/treatment in the immunocompromised patient (note that this will vary from institution to institution and probably attending to attending so don't get too worked up about this one)
Immune reconstitution syndrome
Acute toxicities of the major chemo drugs in this setting (anthracyclines, cytarabine, ATRA, ATO, rituximab)

If you know any one of those things on day 1, you're golden.

 

[HelpPleaseMD]

I'm starting on liquid night float as an intern and was wondering if any of you knew a good resource I can read up before I get on the ward or any specific topics I should absolutely know/ articles to read up on?

So far have only received feel good advice, which is great but I actually need some educational materials.

i am sure others here can provide more topics than I can, but i'd read up on

-tumor lysis syndrome: labs to look out for, when to suspect it. what do you use for ppx, what you use when you suspect patient is going into it acutely.
-premedication for patients who need transfusion but may develop rashes from transfusion
-dic-labs to follow. how do you know if a patient is going into it. when to give cryo
-neutropenic fever- definition. which abx are first line. when do you need to add gram positive coverage. when to add double gram negative coverage. when to add fungal coverage. atypical coverage. coverage for c. diff
-meaning of neutropenic precautions

-APML- know about differentiation syndrome with ALTRA. now its symptoms. when to use dexa to treat

practical things
-things you use to control fever if tylenol not working
-things you use to control nausea if zofran not worknig

i am sure there is more, this is off the top of my head.

edit: look above. advice is better.

 

[QuizzicalApe]

If the last few hours of my shift are any indication, rig up some sort of system that automatically throws some acetazolamide in the general direction of patients with stubborn urine pHs and a body full of methotrexate.

I suggest a modified clay pigeon thrower capable of reading lab info from epic.

 

[QuizzicalApe]

In all seriousness, though, most of what I'm doing is symptom management: Nausea, pain, fever control. I react to neutropenic fevers per unit protocol; familiarize yourself with yours (empiric antibiotics of choice, culturing, imaging, etc), I monitor and react to tumor lysis, I transfuse everyone all the time.

As has been mentioned, knowing key side effects of the common chemotherapies you'll encounter is important, and just as important is knowing what medications to avoid due to interactions. This is mostly important for antibiotics and comparable medications that you otherwise might be tempted to order without thinking too much in an unstable patient (IE, know that azoles + vincristine = bad). Generally if people are doing their jobs and being mindful, they'll mention the key things to you at sign out and have good forward-looking progress notes that tell people to look out for these things. That means you don't have to learn this in advance, but you will learn it if you're paying attention.

EDIT: While I was writing this I was paged to give someone acetazolamide. Called it.

 

[gutonc]

In all seriousness, though, most of what I'm doing is symptom management: Nausea, pain, fever control. I react to neutropenic fevers per unit protocol; familiarize yourself with yours (empiric antibiotics of choice, culturing, imaging, etc), I monitor and react to tumor lysis, I transfuse everyone all the time.

I forgot about this one. Figure out what protocols are used and expected on that unit...and use them.

My Leuk/BMT unit had protocols for bowel, pain, K and Mg replacement, transfusion and neutropenic fever (that I can remember off the top of my head anyway). The MAR and nursing order sheets were a complete horror show to look at (14 pages of PRN meds, 10 pages of if/then RN orders). But it was expected and it got s*** done in a timely fashion. It also kept the moonlighters from getting paged every 45 seconds for basic stuff.

Also...make friends with your charge nurses. On day 1. Every acute leuk and transplant patient is a sneeze away from the ICU and the only surprises on their labs are that there might be a non-critical value. If there are protocols in place to mange routine things as above, and you make nice with the charge RN, you won't get paged for every critical value the second it comes in.

When I used to moonlight on our BMT service, I had a pretty good relationship with the nurses in general. When the critical labs rolled in at 2am (you mean the acute leuk on day 7 of induction chemo has a critical WBC and plt count?...I'm shocked...shocked!), the charges would generally have the nurses review the results, make sure it wasn't a dramatic change from previous values, follow replacement/transfusion protocols, and then page me at 6am with all the FYIs from 4 hours earlier. Even if I wasn't sleeping, it was nice to be able to get new admits done without being constantly interrupted with BS.

 

[visari]

A lot of good advice up there ...

Almost all BMT units now don't have residents primarily managing patients so I doubt this is what the OP is asking about.
I'm also not sure if the OP is finishing his internship on NF on a hem service or he's going to be starting internship in July on NF. I hope it's not the later because having a July intern on NF on a malignant hem service is trouble waiting to happen ... I can think of a 100 things that can go wrong

 

[knightstale4]

what does "liquid" include?

I unfortunately don't know the specifics.

A lot of good advice up there ...

I'm also not sure if the OP is finishing his internship on NF on a hem service or he's going to be starting internship in July on NF. I hope it's not the later because having a July intern on NF on a malignant hem service is trouble waiting to happen ... I can think of a 100 things that can go wrong

I 100% agree, but I guess the chiefs have more faith than I do (or they're highly understaffed and we're cheap labor).

Thank you for the advice everyone. I will look up all of these topics before starting. If anyone can think of anything else or any specific articles that would be good to read, please let me know. Hoping for the sake of pts that everything works out.

 

[gutonc]

Hoping for the sake of pts that everything works out.

I assume that you're going to have a senior with you...and a fellow and/or attending available by phone. It'll be fine.

 

[visari]

It sucks but no need to panic ... They will probably send you some orientation email that would include the common scenarios and protocols you will have to deal with .. make sure you know them well and keep that email in your favorites ...

And I'm sure they won't just wish you a good night and leave you to handle everything on your own. know all your resources and ,at least in July, use them all (senior resident, fellow, attending, pharmacist, charge nurse ...etc). In the first couple of weeks, nobody expects you to know anything in medicine... let alone malignant hematology, so don't be over-confident and just ask for help.