Procedures

1
Procedures In Pediatric Oncology Venous Access
INTP - PPO, PHO, IAP. SS A - 23 Slides
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Aims

• Diagnosis
• Staging
• Treatment
• Special Studies /Research

INTP - PPO, PHO, IAP. SS A 2/23
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Diagnosis

• Confirmation of malignancy
• HPE / Cell type and grade
• Special studies - stains,
• immunohistology, cytogenetics,
• flowcytometry
• Research studies

INTP - PPO, PHO, IAP. SS A 3/23
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Staging

• Involvement of procedure site by
• the disease will confirm the
• stage, prognosis and treatment
• strategy
• e.g Positive CSF cytology in acute
• leukemia, NHL, round cell tumours,
• retinoblastoma

INTP - PPO, PHO, IAP. SS A 4/23
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Treatment

• Administration of Chemotherapy
• drugs
• e.g. IT MTX, IP Bleomycin etc
• Relief of the symptoms
• e.g. Pleural tapping

INTP - PPO, PHO, IAP. SS A 5/23
6
Dos And Donts

• Dos Pre Procedure Check Points
• Explanation to pt./parents
• Consent, pre-procedure work up,
• pre-medication checking of
• contraindications
• Equipment, containers, sedation
• analgesia / anaesthesia

INTP - PPO, PHO, IAP. SS A 6/23
7
Bone Marrow Biopsy

• Indication Suspected acute leukemias,
• Lymphomas, Round cell tumours, ITP, Bone
• marrow suppression, Cytogenetic study
• Contraindications
• Technique of Aspiration and Trephine Biopsy
• Delivering and processing the material for
• morphology, HPE immunological study,
• cytogenetics

INTP - PPO, PHO, IAP. SS A 7/23
8
Lumbar Puncture

• Indications
• - CSF cytology in acute leukemias,
• lymphomas, round cell tumours,
• retinoblastoma, brain tumour etc
• - Intrathecal adminstration of drugs
• Eg. IT, MTX
• Technique and precautions

INTP - PPO, PHO, IAP. SS A 8/23
9
Thoracocentesis/ Pleural Tapping

• Indications
• Diagnostic - lymphoma/solid tumours
• Therapeutic - to relieve the symptoms
• of breathlessness, to administer
• intrapleural drugs
• Technique and precautions
• Guided procedure (USG, CT scan)
• Use of vacuum evacuated bottle

INTP - PPO, PHO, IAP. SS A 9/23
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Liver Biopsy

• Indications
• Diagnosis / staging of lymphoma,
• hepatoblastoma, round cell tumour,
• storage disorder, abscess etc
• Special precautions, Vitamin K if
• prolonged PT
• Biopsy needles - Menghini, Vim
• Silverman, Tru cut
• USG guidance.

INTP - PPO, PHO, IAP. SS A 10/23
11
Abdominal Paracentesis / Ascites Tapping

• Indications
• Diagnosis - lymphoma,solid tumours
• Therapeutic - to relieve the symptoms of
• abdominal distension, to administer
• Intraperitonial drugs
• Technique and precautions

INTP - PPO, PHO, IAP. SS A 11/23
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Fine Needle Aspiration Biopsy

• Indications
• Diagnosis / staging of lymphoma,
• round cell tumour, abscess etc.
• Site lymphnode or any accessible
• mass/swelling
• Special precautions bleeding
• tendency or local infection
• USG / CT assistance - SOS

INTP - PPO, PHO, IAP. SS A 12/23
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Importance Of Venous Access

• Longer survival and higher cancer cure
• rates in Paediatric Malignancies
• Intensive combination chemotherapy and
• Intensive supportive care
• - Blood and Blood products
• - Antibiotics
• - Nutrition.
• Able to maintain prolonged vascular access
• with Vascular Access devices (VAD)

INTP - PPO, PHO, IAP. SS A 13/23
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Types Of VAD

• External devices
• Hickman
• Broviac Single, Double Triple
• Groshong lumen
• Implanted port
• Peripherally Inserted Central Catheter (PICC)

INTP - PPO, PHO, IAP. SS A 14/23
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Long Term Indwelling Catheter

• Hickman Or Broviac
• To use for months to years.
• Insertion is a minor surgical procedure
• Daily to weekly site care - frequent flushing,
• cap changing etc.

INTP - PPO, PHO, IAP. SS A 15/23
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Implantable Ports
Advantages Disadvantages Risk of infection is
low Minor surgical procedure Less interference
with Repeated pricks normal daily
activities Requires little site care and minimal
flushing.
INTP - PPO, PHO, IAP. SS A 16/23
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PICC

• For intermediate duration IV Rx
• ( e.g antibiotics short term chemo)
• Safe and cheap
• Simple bedside insertion
• Comfortable / no restriction of arm
• movement.

INTP - PPO, PHO, IAP. SS A 17/23
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Catheter Care

• Insertion site
• Catheter flushing
• Injection port changes
• Catheter exit site .

INTP - PPO, PHO, IAP. SS A 18/23
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Complications

• Occlusion ? Thrombosis ? heparin urokinase
• Infection ? appropriate antibiotics
• Catheter migration ? reposition ? removal
• Catheter damage ? repair kits are available.

INTP - PPO, PHO, IAP. SS A 19/23
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Complications

• Phlebitis
• Sepsis
• Thrombosis
• Catheter migration.

INTP - PPO, PHO, IAP. SS A 20/23
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Catheter Selection

• Age of the child
• Physical condition
• Therapy planned.

INTP - PPO, PHO, IAP. SS A 21/23
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Catheter Removal

• Completion of therapy
• Uncontrollable catheter infection
• ( candida / S. aureus)

INTP - PPO, PHO, IAP. SS A 22/23
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Catheter Counselling

• Diagnosis
• Type and duration of chemotherapy.
• Need and the advantages of indwelling
• catheter for venous access.
• Procedure in brief.
• When to get in touch with the doctor.

INTP - PPO, PHO, IAP. SS A 23/23