Hello hello everybody, and thank you very much for joining me today for my presentation on nursing the oncology patient. So as nurses, we can be involved in lots of different ways and lots of different things to consider when we do have our, have our patients coming in. We tend to a lot of these, cases are picked up through nursing clinics.

We should be, so when we, when we are doing these, we should be considering all of these things. There's lots of things like outpatient care, nurse, diagnosis of these patients, any paraneoplastic syndromes, any side effects, any other conditions. That are potentially going on with that patient, regardless of if this patient has got cancer.

We also need to make sure that we are providing lots and lots of owner support, and that we are actually looking after ourselves as well, because supporting owners and looking after these patients, oncology is, is a really, really difficult, area to be in. I'm in there full time and It's such a rewarding position and so like these patients and these owners are absolutely spectacular, so we do need to remember to look after ourselves. So, as I said, a lot of these, tumours and masses and stuff that we are seeing, have been picked up by nurses, in nurse clinics, regardless of whatever age that these patients are when they're going in for the checkups.

So do remember, when you are doing these clinics, that you do a, a full body examination for every, for all ages, even if it's a 5 month old puppy. You should be looking all over, all over them, looking in their mouths, looking for any masses or any lesions. And then we should be me, if you do find anything, measure with a pair of callipers and record where that mass is.

As I said, we should be doing all these examinations for all ages. We've seen quite a few, really, really young puppies, like 5 months old, that have had confirmed mass cell tumours, which is really, really sad. As I said, malignant tumours are rare in young animals, but they can happen.

So if all of, so you're in your clinic and they say, Oh, it's had this little lump here for a little while, ask questions, ask everything you can about that mass. How long has it been present for? Has it changed shape, colour, size?

Has it become painful? Is it irritating to the patient? Has there been any discharge at any point, or has it been bleeding?

And important to remember, has that dog had any tumours previously? Has it had a mass removed that has been confirmed as a mast cell tumour or something else? Because this could be a sign of disease progression or just a reoccurrence in that same area.

Report this to your veterinary surgeon and then you can make a plan. So in these clinics, regardless of if this is the first time you've seen the pet or whether or not they're coming back and to, to you for, just for checkups, we need to keep an eye on their body weight, the body condition score, and the muscle condition score. And the WSAVA do have these lovely charts, for body condition score and muscle condition score for both cats and dogs separately.

So I find these really useful to print out and laminate, and then you can have them in the consult room, so you can, you've got a visual aid. Need to be asking about any changes to appetites, they wanted to eat more or less, how are their energy levels, and is there any vomiting or diarrhoea? So Dr.

Sue Ettinger has a wonderful website on Dr. Sue, the cancer vet, and she is the founder of the See Something, Do Something, why we aspirate programme. So if we are seeing any masking masses that have been there, for longer than a month, and it's the size of a pea or larger, we should be doing something about it.

Let's not sit and leave it and see what happens. We can, we can do a fine needle aspect, and we can get that ball rolling to actually see what's actually going on. So the wonderful Doctor Sue does have these charts on her website.

So it's a canine and feline body maps, and it means that you can accurately, note wherever these tumours are, make sure it's on the right side, and then you can, measure with them a set of callipers. So you've actually got an accurate measurement. So when, if that dog then needs to come back in a week's time to see the vet for sampling, then they can compare to see if it's actually growing, or is it shrinking, or what's going on with it.

So a lot of these patients are actually presented as clinically well, they may have actually just come in during a routine examination, such as vaccinations or maybe a a weighing worm or flea checks. And these tend to be like you know mass cell tumours. We've had a few lymphomas that the dogs have been presented just for a boost and all of a sudden the, the owners have said, Oh, actually, I've noticed maybe he's got some swelling under his, under his neck, which would be the lymph nodes.

And maybe some anal sac a no carcinomas when they've come in for anal, anal gland problems or even just at routine checkups. But the majority of our patients are presented as unwell pets, and this can be due to the perineoplastic syndromes which are, caused by the cancers, such as hypercalcemia, and we'll go through more of these in a little minute. They may be painful, they may have noticed their dog has started limping and it's not getting any better once they've started to rest, or even if they've had some analgesia prescribed a a little while ago and it's just continuing and it's not actually resolving.

It could be haemorrhage, such as if this dog has got a a splenic manrosarcoma, which has then started to rupture, and you've actually got a dog that is actually starting to bleed into its abdomen. Any GI bleeds from either ulcers or tumours as well. These patients could also have some effusions, such as a pleural effusion, pericardial effusion, or abdominal effusion, which could be compromising that that patient.

They may have also just noticed a little bit of weight loss or some a reduced body condition score. There may just be some GI signs, maybe vomiting, a little bit of diarrhoea, and that maybe just because they've just become maybe a little bit lethargic. So, before you even get started with these patients, especially these really well ones that are pinging all over the place, consider the behaviour of that patient.

We've had a few that have come in, and they've come in for the consultation, and we have been like, we can't do anything with that patient while it's conscious. It's too anxious, it's too fearful. The dog's gonna get really upset, someone's gonna get hurt.

We will send that patient home and we'll get them back a follow another day with the, with the use of gabapentin and trazodone and we found that this combination, really, really works, especially for some of the fearful dogs and the cats. And once we've got them in, and we've got them a bit more chilled out with that concoction, then we'll try and do everything when they are sedated or anaesthetized. But a lot of the times, once they've got this on board, you can actually at least examine them and get some bloods and stuff.

You have to consider anything ongoing for treatments, can that be carried out safely? And complications, if you have a complication following surgery or chemotherapy, can that patient actually be safely hospitalised? This little dog in the, in the picture, he's the sweetest dog until you try and do anything with him.

He's horribly fair aggressive, but he will let you fuss and pet him all day. You try and do anything, he's a absolutely different dog, and he comes in with gabapentin and trazodone. And we, that's just about enough for us to be able to give him, an IM injection of sedation so we can safely carry out our chemotherapy, and examinations for us and for him.

But we know if this dog becomes sick following his chemotherapy or there's a problem, we cannot hospitalise this dog, so we keep his treatment doses lower than, kind of the low end, so we hopefully don't have any complications. We need to be considering the welfare of that, the pet. So this dog, we, we know, we, we just don't mess around with him.

He comes in, he has his stuff, and he goes straight home again. We just don't do anything to mess around with him. We're not gonna force him to lie down.

We're not going to wrangle him or anything. It's just not fair. We need to consider the welfare of the owner as well, when they're backing and toing and having to deal with a, with a potentially naughty little pet when they're at home.

Can they get the medications and everything into them, safely? I know the safely of all members of staff dealing with this patient has said he's the sweetest dog and he will take biscuits and everything from you when he's awake. But once you, if you try and do anything with him, we've just got to be really careful with him.

So as discussing before, perineplastic syndromes are the results of indirect effects of the tumours. And this is due to the production and release of biologically active substances such as hormones, growth factors, and cytokines. And these are really important to consider when we are managing, any malignant tumours.

These could be detected as maybe the first indication that the animal actually has an underlying cancer, or it could be evidence that there has actually been a reoccurrence. So hypercalcemia is probably one of the most common cause, hypoplastic syndromes, and this is common with anal sac adenocarcinoma and lymphomas. So the clinical signs of this would be inapetence, nausea, PUPD and vomiting, and that's in the majority of cases.

There may be some muscle weakness or twitching which are less common. If this patient is left with a massively high blood calcium for a long time, we can then it can then lead to an acute kidney injury. So we need to treat this Regardless of the course, so we Would then go up initially for some saline diuresis.

We need to make sure that we're rehydrating these patients so we can preserve the kidneys, to keep going. And we also need to then correct the cause. So once we have a diagnosis, once we start the treatment for lymphoma, the calcium will normally then rectify.

And if once they've had surgery for their anal gland tumours, the, the calcium should normalise. You could then use diuretics to promote diuresis. Once fluid therapy, fluid deficit has been corrected.

You could use some steroids, which could increase the urinary excretion of calcium. And then we can use some bisphosphonate, such as permidronate or zoledronate. If there's, we tend to use like these lower 3, if there's no other treatment or treatment's not working or the owners kind of just want to opt for palliative care rather than, a proper treatment.

So this is, we use this as a monitoring tool for some of our, lymphoma cases who have presented as hypercalcemic. Once they have normalised, we do monitor their calcium regularly throughout their protocol. And even once they finish the protocols, we'll keep checking that causes any evidence of that returning, is probably evidence that the disease is relapsing.

Hypoglycemia is a common cause of a common side effect of insulinomas. These insulin secreting tumours and the pancreas just keeps secreting insulin, so therefore they end up with that low low blood glucose. So we're looking at the normal clinical signs associated with hypoglycemia, such as weakness, lethargy, inhabitant, and then neurological signs as well signs as well.

The treatment is basically the correction of the cause. So surgical excision of that tumour. If that is not an option, we could use some low dose glucocorticoids, for, palliative care.

And we also, we need to try and make sure we can manage that hypoglycemia, so feeding, complex carbohydrates, so it's got to be, it's gonna be nice slowly at least. And making sure the owner has got some oral glucose or dextrose syrups at home available, so should the pet show any of the clinical signs. We occasionally may have to use some IV glucose if feeding isn't practical or is not affected, especially if they are, if they're kind of, far on with that.

Anaemia could be shown through chronic disease either through reduced red blood cell lifespan. Immune-mediated hemolytic anaemia, which is commonly associated with what a lot of lymphoid malignancies such as lymphoma and leukaemia. There could be a chronic blood loss, so such as the primary primary losses through GI tumours, splenic, manosarcomas, or secondary if there is ulceration, in the GI tract following if the patient has a mast cell tumour or has been on high dosteroids and that's caused ulcer ulceration that way.

It could also be due to disease progression, so you would have to look at all of the, the, the different things on the on the haematology blood results to actually think well actually is this disease progression causing all of these problems. Hyperprotemia is seen with multiple myeloma, lymphoma and leukaemia, and this is resulting from the excessive production of immunoglobulin. So these increased immunoglobulins can lead to clinical signs associated with serum hyperviscosity, and this just means that the serum has become really thickened because of all of these proteins and everything in there.

So it's a lot of neurological signs that you will see, such as retinopathy, ataxia, altered demeanour and seizures. So GI ulceration, could be, or GI problems could be caused from as a primary just for if there's any GI tumours. Any neoplastic paraneoplastic, secondary to mast cell tumours.

So malignant mast cell tumours do secrete histamine, heparin and proteolytic enzymes, and this, can create a hyperhistaminemia, condition. And this is the main factor contributing to GI ulceration. So we need to make sure that we're .

Supplying these patients with gastroprotectants as well, . For any any patients that are having treatment for mast cell tumours and making sure that they're having prescribed antihistamines as well. Cancer cachexia is probably one of the, the saddest things to have to try and deal with, when you are dealing with cancer patients.

And this is a, this is a loss of lean muscle mass and adipose tissue. And this is despite adequate nutritional intake, so it's different to starvation. So these patients will usually be eating and eating and eating normally, but their weight can absolutely fall off them.

And despite how much you're feeding them, they will still lose, lots and lots of weight. And and the condition and muscle, which is why it's really important to monitor the body condition score and the muscle condition score, especially with a lot of these patients when they're backing into during treatment. Caexia can dramatically affect these patients' quality of life, and is often seen as the end end stage of this disease and is likely to contribute to the decision for the owners to euthanize their pet, especially when this poor little lady, I think she was a lymphoma, and we just couldn't, we just couldn't get a handle on her, and she just kept progressing and progressing, and she was, she was trying, and she was, she was happy, but she just looked so, she was so weak and she's still trying to wag her tail for us, bless her, but you can see how she's literally not got an ounce of fat on her or her muscle has completely just has gone, so yeah, it was, that was a decision to euthanize for her.

So we need to consider all of the concurrent conditions that your patients are gonna be presented with alongside the cancers. So a lot of our patients in oncology are a little bit older, so there may be some concurrent problems such as kidney disease, arthritis or cardiac disease. We need to consider the MDR1 gene mutation for some of our, the, the collie breeds, our type breeds, as this may end up dose reducing or eliminating some treatments, when we, even before we started.

So with remember with arthritis, if they're on the non-steroidals, we can't use steroids. And if they've got heart disease, we're probably limited on steroid use and we probably, and the epiubicin and doxorubicin disease can be cardiotoxic. And then renal disease, so carboplatin in dogs and epiruicin in cats.

If their kidneys are kind of holding out and they're doing OK, we will tend to go ahead and then just maybe give them some fluids for maybe 4 hours or so post treatment. So to try and find out what we're actually dealing with, probably the easiest way is to actually do some FNAs, we can get some little samples, so we need to find out what we're dealing with. And then we need to determine that general health of the patient before we actually, do any sedation or anaesthesia.

And staging is the term that we, we use to determine, to try and find out what grade that the cancer actually is at. And this means we, it's helps us determine how advanced the cancer is and then to help with prognosis so we can inform the owners. So stage and assist with then determining, determining a plan of action.

So whether or not we do chemotherapy, surgery, palliative care, or no treatment at all. Mm So for lymphoma, we have basically stage 1 to 5. Stage 1 would be single lymph nodes, stage 2 is regional lymph lymphadenopathy.

And then stage 3 would be generalised lymphadenopathy, whereas you'll see most of the lymph nodes to be enlarged. Stage 4 would then be lymph node involvement, potentially with or without lymph node enlargement. But with liver and or spleen involvement.

Stage 5 is blood, bone marrow or other organ involvement. And then we classify again some stage A without systemic signs. So these patients that have got lymphoma but are pinging around all over the place.

And then stage B where they do have systemic signs. We can immuno phenotype, for lymphoma as well to determine whether or not it's a B or T cell in origin. So we need to do some FNAs of the lymph nodes, and we, we send them in a culture medium that we've prepared as well, and submit to the lab.

And that needs to go the same day. It needs to arrive at the lab within 24 hours so that the cells do not die. So there's no point in taking them on a Friday afternoon where they then sit in the fridge until Monday afternoon before they get posted.

They won't get to the lab till Tuesday at the earliest. And then themselves have probably died, so it's probably no use. Let's helped by knowing if it's a BO T cell lymphoma, actually be able to helps us give the owner, an idea of prognosis.

So B cell lymphoma has a better prognosis. It also helps us to create a better chemotherapy plan for them. So if it's a T-cell lymphoma, we will usually substitute some of the medications in the CAP protocol to for a bit more, hopefully better prognosis for them.

Anal sac adenocarcinomas, it's kind of based on tumour size, regional lymph node status, or any of the sublumbar lymph nodes, if they start to become enlarged or if there's any distant metastasis as well. And that can then help with the median medium survival time. Mast cell tumours, there is a couple of different grading schemes available for them based on cytology and histopathology, the patick system and the Kupel system, .

They will either give them a low, intermediate or high grade, . High grade, high grade, . Results, and this then this can actually That helps us actually make a plan whether or not we go ahead with surgery, we go ahead with chemotherapy, how invasive the surgery needs to be, do we need to follow up with more chemotherapy, radiation or anything else as well?

So, initially, we're probably gonna want some more blood and urine samples as well. We're gonna want a full biochemistry, electrolytes, ionised calcium, and haematology. And this is a baseline.

And quite a lot, a lot of the times, everything on this, these blood tests will be absolutely fine. They'll be right down the middle and not actually show any, any, abnormalities. I said, anal second lymphoma, there may be some hypercalcemia, anaemia patients, there may be some, if there's any GI bleeds or anything.

Lymphoma or leukaemia, if it's starting to get to kind of like the grade 5, lymphomas, leukemias, the haematology may start to show evidence of bone marrow suppression where those neoplastic cells have just completely taken over the bone marrow. So these, They it's just not actually able to, they're just not able to cope with the production and and new cells anymore. We should be checking FELV FIV status in cats as well.

This is quite common, for them to be positive for at least one of these for these lymphomas and leukemias. And if they've got GI signs, check the B folate or the B12 folate, we may need to start supplementing them as well. We want to do some clotting times if we're considering doing some biopsies or FNAs of the liver and spleen.

We may not want to blood type these patients, especially if we think we're gonna need to do some blood transfusions, if they are really anaemic. We'd want a urine sample, we ideally we want the cystocentesis, this is, this is the gold standard, and we can send that for analysis, protein protein, creatinine ratio and culture. So as I said before, for cy for any of these masses, why we aspirate, so let's get on with some FNAs of these samples.

So we're gonna need some microscope slides, pencil, 23 gauge needles for the blue needles is what we use and a 5 mil syringe. So consider before we start poking these sample these tumours, is it a mass cell tumour? Has this dog had a mast cell tumour before?

If it has, we probably want to pre-treat them with an antihistamine, so we don't have any, histamine releases and then any potential degranulation following the sampling. There's a couple of different techniques for FNA er these tumours. So you can either use the needle and the syringe attached and you use the syringe to actually try and aspirate some of the cells out and then straight onto a slide and make the smear.

We tend to use this technique, it's just a little bit easier, I think, to control the needle rather than a needle and syringe, so we just use the needle on its own, poke it in and out of that tumour a good couple of times, and then use the syringe to then pop that onto the slide. So once we've made our smears, we need to make sure the cytology slides are kept away from any formalin, so sometimes you might have a biopsy and some slides. The formalin formal cyanine can affect the cells on slides, so they should should be kept completely separately.

We allow these smears to fully dry and then store in the lab in a slide holder for lab submission. We can stay in in-house for examination. We, can be looking for, like, especially for like mast cell tumours and for lymphomas, just to confirm that we've actually got a diagnostic sample.

And we just use diff quick solutions for most in-house examinations. So for making these smears, once you've got the sample onto the slide. You can use a squash technique and this is where you just have two slides together and you just use the top one just to make the slide that makes smear the sample across the bottom slide.

Or we can use a line concentration technique where we start off as though we were going to do a blood smear, but then instead of going all the way to the end of the slide or running out a sample, we lift it up partway so so then you end up with a concentrated line of cells partway along the slide. Or you can just do the blood film technica, the way you would normally do a blood smear. So any fluid samples that you get handed, if they've taken a sample of a, an effusion or a sample out of a tumour that has, that has come back as fluid, we would collect some samples into an EDTA and plane tube, and then make some smears of that fresh fluid and make sure you label them as well.

Cause a lot of these might be hemorrhagic and you don't want the lab to kind of think, oh, is this a blood sample, or is this a, a sample of a fluid? Some labs might want to drop a formal and add into an EDTA sample, but remember you need to keep that away from any other smears that you make. And always get a sample for culture and sensitivity as well, just to make sure there's no infection going on concurrently.

So for a lot of these, patients will need to go on for some form of sedation or anaesthesia to get the full workup. Do we need to stabilise these patients initially? Do we need to do any blood samples, flu, fluid therapy, blood transfusions, saline diuresis before we start to anaesthetize them, depends on the condition, depends on the patient and how poorly they are.

We would always do them pre-GA sedation bloods to evaluate for any other conditions. And depending on what we actually need to do, depends on whether or not we need to sedate or anaesthetize. If we're looking for thoracics metastasis, we will need, inflated thoracic radiographs, so we will need anaesthesia.

Is that pain patient painful? If it's potentially, if it's a potentially, an osteosarcoma that has fractured, that patient's gonna be painful. So probably anaesthesia may be more appropriate than a sedation.

Is that patient got an airway compromise? Is it a brachycephalic breed that we need to go through radiography and an ultrasound, do we, or does it have something that is compromised in the airways, so we may need to intubate and actually have them anaesthetized. So we could use a CT scan for part of the diagnostic imaging for our staging, most of the time we will do this anaesthetize because we will want inflated thoracic views of that as well.

We will administer a contrast, so we need to check their blood urea, creatinine prior to administration, and then we'll give some fluid therapy for about 4 hours post just to make sure that we have managed to get rid of all of that contrast from them. And CT scans allow us to assess for metastasis, tumour size, location, and any invasion. So you can see from this one, this was a wonderful dog who had unfortunately then ended up with a thoracic metastases following his anal granddad, no carcinoma, so you can see all of these horrible nodules.

And this is another dog that had an anal grandaddenocarcinoma, and you can see his anal, sac mass is here. And this horrible creature here is the subluminal lymph nodes, that actually did start causing him some, spinal, spinal discomfort and kind of a little bit of a complication trying to pass faeces. And you could feel this node, when you kind of like palpated just under, like this in the sublumbar areas.

It was massive. Ultrasound is awesome because it's non-invasive, we can have a look at what's actually going on without actually having to do too much . So no invasive stuff really.

We can do this conscious, either sedated or under anaesthesia. It allows us to assess any masses that are internal, and then to assess any organs as well. And quite commonly they will want to have a look over, if there is a mass or like a thyroid mass or anywhere, it's not just the abdomen that we will, ultrasound.

Our awesome ultrasonographer is fantastic at sampling, so we can pretty much send her anything and she will get some wonderful FNAs or biopsies of these tumours or the organs or any fluids or anything that we need. It's common that we, if any lymphoma, especially lymphoma and mas mast cell tumour patients that we all want samples of the liver and spleen, just to assess if this has started to metastasize to there. We can also get a cystocentesis, as we've said, we can send that baseline sample, baseline analysis.

And it means we can also drain any of the effusions, so abdominal, pleural or pericardial effusions. Radiography, again, can be performed conscious, but probably not easily and not well. Sedation or anaesthesia is probably more appropriate to get what you actually need.

So for thoracic radiographs, we can probably get away with just sedation for mast cell tumours, because all we're going to look for with them is lymph, thoracic lymphadenopathy. We're not actually looking for medicine to the chest though. If we're looking for to assess for metastases, so for like anal glandocarcinomas and other sarcomas or anything, we would need them to be anaesthetized because we will need inflated, thoracic views.

We could do some abdominal radiographs as well to assess for organs and any, problems in there. It may also pick up any concurrent problems such as foreign bodies or anything else. And then we can also radiograph limbs as well.

So as you can see in this bottom picture, this poor cat has a, A a neoplastic bone lesion at the at the at the top of her humerus there. So we can take some samples of bone marrow, we will need anaesthesia if we're going to be using the humerus or the pelvis. One of our clinicians used to use the rib to get some samples just for cytology, not for a core biopsy, and we could use sedation for this as well.

This means we can evaluate for any neoplastic disease and kind of any disease, at what grade that they this disease actually is at. Such as mainly with lymphomas and leukemias, multiple myeloma as well. So this is an aseptic, procedure.

So we need to make sure that we've got everything that is done, in aseptic manner. We set for the setup of the slides. We have a couple of, glove boxes underneath the drape, and then we open pretty much an entire box of slides all the way around the front, all the way round the back.

So once the clinician has got the, there's, a fluid sample or the bone marrow sample for cytology, they will then go along all of the slides. And drop a droplet onto all of the slides, let all of the blood run down, and you can see all these little tiny bits on the slide. These are the bone marrow slide, bone bone marrow pieces, so we can then smear them and, submit them for analysis.

We can also then take a core sample using the same needle. So that can then be submitted for histopathology. And then we will always send a haematology sample as well, so that the lab can compare and give us a more accurate report.

We can get some biopsies of organs, masses, pretty much anything and we can either use a punch biopsy, chew up needles for soft tissues, jamhiy for the bone marrow or for bone. I grab biopsies if we're using the endoscopy, or we can use an incision or where we just we where we just take a small portion of that tumour via surgery. Or we can use an excisional biopsy where the whole tumour is removed, .

And then and then submitted. The only thing with this is because we're doing this without actually knowing what's going on completely, is that we may have to go back and do a revision surgery to make sure their margins are a little bit more extended. So any samples for histopathology should be kept at room temperature, and they need to be stored in formalin.

So it's 1 part tissue, it's 10 parts formalin, and any tissue that is really quite thick might need to be incised and kind of cut up a little bit, so it's gonna get suitably saturated with the formalin. We will also want usually some samples to go of the tissue to go for culture and sensitivity. We can wrap that sample in sterile swab, and then we can soak with some sterile saline, or you can just pop the sample straight into some sterile saline.

We don't want to keep that at, room temperature, so we can hopefully, if there's gonna be any bacteria or anything going on there, the, the room temperature won't, hinder any growth, which would, which is what would happen if you pop that into a fridge. So there are lots of options for these owners to consider once we have a diagnosis . We can, they can opt for no treatment at all.

So they have the dog has come in, it's got a mass . It's gonna go and they don't want to do anything. We could hospitalise it for initial stabilisation while we get the diagnosis and while we make a plan.

We could go for palliative care, chemotherapy, surgery, radiation therapy, electro chemotherapy, there's lots of different options to discuss. So if the owners don't want to go for any treatment, we, we should still give the owners all of the options of what they want to do. But quality of life for that patient must not be compromised.

If this is a suspected, say, splenic cholangiosarcoma where that patient is bleeding into its abdomen, the quality of life for that patient, is not going to be good. That patient is not going to survive very long, and it's not going to be very nice for him. So, we need to consider all of this when the owner starts to say no treatment.

So for initial stabilisation, they said some of these patients might come in as an emergency, especially say these clinic hemangiosarcomas or something that are coming in. We're gonna want an IV catheter placement, some fluid therapy depending on the hydration status or whether or not we need to actually diarse these patients. Hartman's solution is usually absolutely fine, that's what that's usually what we go for, we may need to potassium chloride supplement them as well.

We tend to use 0.9% saline if these patients are hypercalcemic, especially as they were wanting diuresis, so we, we all use saline as to over hormons. We may need to do some blood product transfusions, so we would want blood typing, potentially cross matching if this patient has already had a transfusion.

And this could be used by like whole blood, packed red cells, plasma. Auto transfusions or something I think we think, oh, could we actually use that blood? But it may not be suitable due to the neoplastic cause.

Some patients may need to go for emergency surgery, especially go back to these splenic tumours. You have these horrible, horribles hemangiosarcomas, all these splenic tumours that can rupture. Some of them might be benign, unlikely, but it can happen.

Most of these are neoplastic, but the only way to actually deal with this problem is to remove the spleen to stop the bleeding. And then we can deal with the aftermath after that, whether or not we can get a we'll get a diagnosis following that. We may need to drain some of these effusions, again, make sure you keep some samples, don't chuck for any tubes or anything that you get handed into the bin, make sure you keep some samples and get them all ready.

So pleural effusions, it might just be a one time drain and or we may end up placing some drains. Drains allow us to do some repeated draining throughout the, for the rest of the day, for a couple of days. And we've actually used the thoracic drain to administer into cavitary chemotherapy for patients as well.

Pericardial effusions will need to be drained and abdominal effusions also. So with these patients, we're gonna be needing to consider, do we need to consider feeding tubes, especially for some of these cats who haven't eaten, there's a risk of hepatic lipidosis for them. Any other dogs that are not eating, cats that are not eating and are actually starting to lose some weight.

Nasal esophageal is great because it can be placed in a conscious patient. They are only used for short term just to kind of tide you over maybe a couple of days until they start to feel better. You can only use liquid foods, no medications down these tubes, these tubes get really angry and blocked just by looking at them funny sometimes I find.

And you need to make sure that there's an abuster collar on these patients so that they don't disrupt the sutures or start to try and pull them out. Oesophageal tubes are are really good, they can be placed, they need anaesthesia to be placed, but they can be used for longer term, weeks to months, especially if they're maintained properly, and the owners actually then can pick up if the sutures are becoming loose and we can get that replaced. We can use liquid foods or slightly thicker foods, depending on the size of the tubes.

Some of these mass tubes that we can use for larger dogs, you could blend up some canned food, and maybe get that down there. Some medications can also go, go down there as long as the, as long as they're crushed into a proper powder. And we need to make sure that we're doing wound, proper wound management, and with once to twice a day, redressing of that stoma site.

So with nutrition, I get asked this lots about what should I be feeding? Should I change this? Should I change that?

And what we normally advise is make sure that everyone a good quality food, and that they're eating plenty as well. We tend, we advise them to avoid raw feeding, especially if we're going to use chemotherapy. We just don't want the added potential complications of, any, any, any other infections.

Balanceit.com is awesome. I've used this loads of times for medicine patients and oncology patients.

And it is just an online programme, it's designed by a veterinary nutritionist, and you can kind of type in what you want, and then it will create a balanced home cooked plan for an owner to follow. They must buy the supplement that comes with them to make it balanced, but it's, I found this has been really, really useful. We may need to feed for any concurrent diseases such as kidney disease.

But again, if the patient isn't going to eat the kidney diet and it's not eating anything at all, it's better to eats something rather than nothing. So I'm, I am a big fan of just making sure that they are actually eating, and then once they're eating really well, then we can transition on over to an appropriate, disease, disease style food. We need to avoid force feeding because we don't want to end up with an aversion to food and get these owners to keep a food diary so you can actually they can actually see how much the pet pet is eating and if it's actually starting to increase or get reduced.

We can monitor fluid intake. And then we need to monitor body weight and body condition score as well, especially if they're when they're coming back in for their checkups. So as a palliative care, is one of the options, and this is described by the World Health organisation as improving the quality of life of patients and that of their families who are facing challenges associated with life-threatening illnesses.

This can be offered at any point following the diagnosis of cancer, and it can be utilised, if the patient isn't to go in, isn't gonna undergo any form of treatment and can give the owners a bit, a little bit of time to come to terms with their pet's condition as well. So people may choose to go for a palliative care if their primary cancer or the metastasis are too advanced for any treatments. There's any presence of any other life limiting conditions as well.

The patient's behaviour or emotional health as well. If there's simply just no treatment options, a lot of our treatment, treatments that we use a lot, a lot, not many of these are actually licenced for animals, with only a few treatments that are available and everything is all off licence, so there might just simply not be anything available. Some patients who are no longer responding to treatments or chemos, which tends to be quite common once they've got to the end and once the disease starts progressing and is becoming resistant to chemotherapy.

It may simply just be the owner's wishes that they don't want their pet to have to go through all this chemotherapy and surgery and everything it's hardcore, it's it's hard on the pet, it's hard on the owner. And it could simply be costs also, pet insurance is amazing, but chemotherapy and chemotherapy protocols can be quite expensive, especially if there's end up being complications and if the disease starts to progress and you need to start chopping and changing what you're doing, especially with lymphomas. So palliative care won't slow down the disease progression or prolonged life.

We're not treating that, the disease, we're looking after the pet, and it's essentially to restore and maintain a really good quality of life. Again, it shouldn't be offered if the patient is already suffering or if we're not actually going to improve that quality of life. The goals and expectations of the palliative care should be discussed with the owner, and we, it's important to then discuss an end point for treatment.

As this can, this can help if the owner starts to lose sight of what is actually going on, if the pet seems to be doing OK, and then we start needing to add this and add that and add all sorts of stuff into it when we've already discussed actually, we, we weren't gonna do all of this, you decided you didn't want to do all of that. We need to make sure that you keep in touch with these owners, and this is something probably really important for nurses to do, especially if you're seeing them, on a, on a weekly, two weekly, monthly basis, just to kind of just touch base with them and actually see how they're getting on, how are the pets getting on. I remember to advocate for your patient as well and if we're thinking actually it's getting to the point that euthanasia should be offered, we should maybe get the vets involved and get them kind of coming back to see, to see the vets for regular checkups.

So every day should be a great day. I remember hearing this at a, another wonderful talk that I went to a little while ago, and it's actually true. If we're doing palliative care, we want every day to be awesome for these guys, and they should be able to kind of carry on and just do the normal thing without any complications due to their illness, or because of the treatment that we're actually giving them as well.

There are lots, lots of quality of life scales that you can follow, there's loads of different ones. And this is, this allows us and the owners to monitor their pets for like hygiene, pain, happiness, motility, and there's there's actually more good or good or bad days. And by doing this regularly, the owners can actually then detect, or actually maybe a pet isn't wanting to go for his walks quite as long or quite as far, or he doesn't want to go at all, or he's not eating.

Actually something's changing, we need to be, we need to be thinking about what we're doing now. So for pain, for analgesia as well is an important part of the palliative care. So pain does cause anxiety, fear and helplessness and it also does have a negative emotional, this negative emotional state lowers the body's immune resistance to cancer and does enhance tumour cell growth and metastasis, so.

Direct pain can be caused by the tumours just growing and expanding and causing some tissue damage or invasion of these surrounding tissues, or even just obstruction of like the normal flow of urine or faeces, or even just infection as well. Infection and anything can be, can be super painful. Or it can be from indirect pain as well.

Some of these tumours can release inflammatory mediators that can stimulate pain. So we need to make sure that we're using pain scoring charts as well, but remember to take into account any the acute pain and any chronic pains, or the pains that they may have such as like for arthritis. Pain plans might need to be multimodal, so we might need to be using opioids, non-steroidals, anything, and lots of different medications.

Non-steroidals, we can't use if the patient is on steroids, unfortunately, but we can use them for osteoarthritis. And it is used in some tumours for an anti for their anti-cancer effects, such as, anal gland adenocarcinomas, and we tend to, use the non-steroidals, such as meloxicam, mixed in with the chemotherapy protocols, but we would only administer the non-steroidals on the chemotherapy off days. We could also consider some like acupuncture or physiotherapy and hydrotherapy to to help with pain relief.

And remember, we need to trust what the owner's telling us about how their pet is actually at home. We've all seen these dogs that come pinging all around the consult room and the waggy tail, they're jumping all over the place, and yet the owner's saying, Oh, he's just really miserable at home, or he's really painful, and we'd be looking at the pets going, are you sure, really? So trust what they're telling you as well.

So maybe that an analgesia trial is suitable and then the owners can then report, the response to you. So bisphosphonates are, useful for analgesia for bone lesions. They inhibit osteo osteoclast activity and reduce bone reabsorption and turnover.

So therefore they can alleviate bone pain. It's also useful for hypercalcemia of malignancy, such as with anal sac tumours, as it can then reduce, calcium levels because of the, Well I actually just for the the bone lesions too. These can be administered ivy, and we can administer these every 28 days.

So with palliative care, we can end up using some steroids, these can help with altering the transcription of DNA leading to alteration and cellular metabolism. We also need to make sure that we're using gastro protection, so we're usually using a quite high dose of steroids, palliative care plans, and some of the treatment plans as well. So we need to make sure that we're protecting their intestines as well.

We need to use some antiemetics to alleviate the side effects of vomit side effects of either the primary disease or any of the treatments that we're using. Lots of this tend to be just self-limiting, but we should make sure that the owners are prepared as well. Laxatives or stool softeners could may end up needing to be used, especially in cases of someone like the constipation or obstructions.

Appetite stimulants can be used, but we need to make sure that we've covered all other reasons for why that pet isn't eating, vomit, nausea, pain, fear, either in the hospital or at home. Are they worried about something in the hospital? Is there too many cats, too many dogs in the ward, they're worried about that.

Are they just, yeah, cover all of these options, before you start using them. Mirtazapine is available in a couple of different sizes now it's been reformulated, and then Tice is now available is available, it's a licenced product in America, and we can get it in I can get it over here, but we need a VMD special import certificate to be able to access that. So we could opt for surgery as a treatment.

So we're gonna aim for the full removal of that tumour. It may require a quite, quite a decent size margin around that tumour. So this is why we want to go for maybe a biopsy or even just FNA so we can actually determine how aggressive is that tumour, what grade it is, depending on, and then that can then lead the surgeon to then say, actually, we need a margin of this size or that size.

Some of these really nasty tumours, such as the fibrosarcoma, may require, the like the injection sites, cat tumours. They can, require massive, massive surgical sites, really, really wide excision involving more than one surgical plane going down as well. And the surgeon may want to change kit, gloves, gowns, everything else.

Once that tumour is out, he'll want they, or he, she, they will then want a fresh kit before they start to suture up just to try and avoid any spread, of the tumour that we might be left behind on little bits of that old kit. We can also place cystostomy tubes for patients who've got a like a bladder, bladder neck or urethral tumour that is compromising the the urination. So surgical palliative care can be used for quality of life.

We can look at debulking tumours just to make them a little bit more comfortable, can they if they're well and they can carry on with their life as normally as possible. Or even just limb amputation to remove that pain. We've had many owners say, I didn't realise how painful he was until we removed that limb.

And then he's gone back to his normal, happy self. OK, it may be just for a very short period of time, but if we've managed to improve that quality of life for that patient, even if it's just for a couple of months, absolutely, we can go ahead and do that. And post-op as well, we need to make sure we're doing lots of TLC for these guys, nutrition, do we consider placing a feeding tube at the time, time of surgery, so we've literally on top of it straight away.

Analgesia, making sure our pain's growing and that we are not being shy with the pain relief should these guys need it. And making sure that there's plenty of lights out time, sleep time for these guys when they're in the hospital. We could opt for radiation therapy as a treatment, and with this tends to come with a higher risk of side effects because of the higher doses and frequencies of treatment compared to like palliative care plans.

So we can use, radiation as part of a palliative care plan, especially for bone cancer, osteosarcoma treatments, or palliative care patients, to help with pain. We need to make sure that the owners are, warned regarding the risk of pathological fractures, especially after they've had some palliative care radiation, because these, if the pain is gone, they're gonna start wanting to go, go crazy again. But all we've dealt with is the pain, and we haven't actually dealt with the tumour.

Electro chemotherapy is another option. It's a targeted treatment for tumours. So what we do is administer chemotherapy intravenously, and then we will use either some prongs or some plates to administer a voltage to the actual tumour, the tumour previous tumour site along the scar tissue.

This then actually enables the cells in that area to open up and allow that chemotherapy to enter the cells, so it's actually targeting that specific area. So we can use, with, for like non-surgical cases, we use it with a lot of nasal tumours, where the owners are not wanting to go ahead with radical surgery. We've used it intraoperatively, as you can see here, this was a Rottweiler with a massive, massive myosarcoma.

This, this tumour was enormous and had grown really, really quickly. So, a surgeon came in, she did her thing. She removed as much of the tumour as we could.

We were never ever in a million years going to get clean margins because of the size of this tumour. So along we came partway through the surgery, and we provided electro chemotherapy to this whole, surgical, tissue bed, and then underneath all of the skin, and the, on the underside of the skin as well to try and do as much as we could, for this, for this dog. So then on to chemotherapy, when will we use chemo?

So only when there has been a confirmed diagnosis of cancer, we don't wanna go wielding chemotherapy if there's no diagnosis because some of these treatments are, they are nasty. So we have got lots of treatment protocols in place for like lymphomas or mast cell tumours or anything else, so there's actual plans that we could then follow. We could use a neoadjuvant chemotherapy.

So this is when we're doing this pre-operatively, and we're using this to shrink a tumour, ideally. So we use this quite commonly with, mast cell tumours, and the tumours are kind of in an awkward place, or it's a little bit large, so we'll maybe give some steroids and maybe a dose of blastin, get them back then a week later, we'll mark the tumour, give them the treatment, and then when they come back, hopefully a week later, the tumour is a little bit smaller, so that then the surgeon can go ahead and actually do. Surgery a little bit, a little hopefully a little bit more effectively.

Or we can do adjuvant chemotherapy, and this is following surgery and especially if there is a risk of recurrence or metastasis. So again, we have protocols for like soft tissue sarcomas or . Mast cell tumours, nal gland tumours as well.

So for the chemotherapy, we need to make sure that everyone involved is aware of all of the risks, especially because the chemotherapy comes with some serious side effects for people as well, if you're exposed. So any pregnant women breastfeeding women and immunocompromised people should not be involved at all. Chemo agents pose a serious risk to patient welfare if it's not used or administered correctly.

And we should only be using this when it's absolutely indicated. So if there is any contamination, you managed to flick some chemo onto you, if you by accident, we need to make sure that any contaminated clothing or gowns or anything is removed immediately, and then the affected area should be washed with copious amounts of water and eyes flushed with some saline for at least 10 minutes. So the facilities where your chemotherapies are kept, everything should be kind of ideally kept separately from all of the other medications.

I'm lucky enough to have a, a separate safe and a fridge in my little chemo rooms. So nothing else is in there, that is just our chemo stuff. But.

Before we had this available, I used to have to use, I had, a Tupperware tub that I labelled, and I put signs all over it, and it was sealed and it would go into our lab fridge. And everyone who could, it was no, you could see it. As soon as you open the door, there's chemotherapy in there, don't go messing with this tub.

And access to where you are administering or preparing the chemotherapy should be restricted espe especially at them times just so that there's no no one getting potentially exposed. We make sure that we've got patient alerts on kennel doors. You don't know if there's people in your practise who are pregnant, trying to have, trying to get pregnant, and we want to make sure that they are fully aware, and notified, just in case we don't want any problems to happen there.

We ID ID these patients. We, we tend to use the yellow paper tags, around their neck so people can see that it's got a yellow tag on. It's potentially had probably had chemotherapy.

We have designated bedding for chemotherapy patients, and that making sure that all of any, any excretia, so it's like saliva or vomit or anything, is treated as potentially hazardous after this animal has had the, had treatment. So PPE, we should be wearing the full lot whenever we're dealing with any chemo. So gloves, Nitrile offers a better level of protection compared to latex.

And you should really be using a chemotherapy specific glove that have, has a long cuff. The, the gloves, there's a couple of different brands available now, and they've got the cuff maybe about 34 inches longer than a normal glove. So it means it just will actually tuck, allow your gown to be tucked into them.

The gowns need to be chemotherapy specific and with an impermeable front and arms as well. Just to make sure that if anything does happen, it's not going to go through the front of the gown. Material, surgical gowns or anything like that are not suitable at all.

And we need to be using our face or eye protection, so goggles or a full face mask, plus a respiratory mask as well. So for cleaning, we should be using, in that, so any kennels, litter trays, food bowls, we will use a detergent to clean away any traces of chemotherapy first and then we disinfect afterwards. Some chemos may react with disinfectants, which is, and cause a reaction, which is why we want to make sure it's all cleaned away first.

Bedding we always double wash them, and we have because our bed, we have blue bedding instead of white fat beds, for chemo patients, we know that these beds need to be double washed. So for fume cabinets or the surface used where you've prepared the chemo or if there's been a spill, you can either just use the detergent to clean there and then disinfect. And we have these HD clean wipes.

This is a hazardous drug cleaning wipe and it's a two part process that removes the hazardous drug, if there's been any contamination or just the general cleaning. I do the, I do our fume cabinet every evening with these just to make sure that there's no contamination there. Cat litter trays, we can use either a cat litter tray liner or these disposable leak and shred proof, hopefully, litter trays as well if we've got patients that are gonna be staying in for a couple of days.

We have a spill kit available just in case anyone drops a syringe or drops a vial or anything happens. We have this available ready. We have a fume cabinet in our hospital.

We're dealing with, chemotherapy every single day. We're drawing up multiple, lots of chemotherapy treatments every single day. So we, we do need this cabinet.

But if you're only dealing with maybe one every now and again, these are not essential as long as you're wearing your full PPE kit, and you're doing it in a kind of a restricted area. Chemo pet are awesome, they can provide you with all with all of the chemotherapy pre-drawn, they can supply you with all the kit, whatever you need, so then you're not having to draw stuff up yourself or even hold lots of medication as well. So for preparing your drugs, we use a needle-free system, so with the syringes, we make sure that we make sure that we don't overfill the syringes, so a maximum of 3/4 full, so you may end up needing multiple syringes.

We shouldn't be using needles at all to, administer chemotherapy, especially intravenously. There's a couple of, there's one other reason where we might use like, chemotherapy subco. And we'll go through that in a little minute, but anything that is going intravenously, it should be IV catheter should be placed, and then a needle-free system should be used.

We don't use fluid pumps for routine chemotherapy, such as like epiruicin or doxorubicin, because we want to monitor that infusion, that, administration. But there's a few times that we can use them, and if we are using them, we do monitor our patients really closely. Some of them are sedated for the duration of their treatment, so we can monitor them closely.

So for these needle-free systems, there is the chemolave system, which is what we use, and then we need lu lock syringes, and that attaches to the spin inspiros, and it's, and the spin inspiros, well, actually it has like a valve inside. So if you're, if it's not attached to another file adapter or to a given set of te connector, it will not let you squeeze that, medication out. It's a safety device on there.

And there's there's the for seal system as well, which is another needle-free system, and they come with like the whole kit that you need to be able to do this safely. I found this Miller bag spike is absolutely, absolutely incredible. It's like probably one of the best things I've got in the, in my little chemo room.

And it means that we can actually introduce the, we can add it to a bag of fluids, a bag of saline. And then on the side port, we can introduce the chemotherapy that goes straight back into the bag. This is if we're needing to dilute treatments.

And then you can add a given set into the bottom. It means you're not having to mess around with Brettes or multiple bag spikes going in or needles or anything. I found this is probably one of the best finds for my oncology er room.

So for calculations, a lot of these meds are based on metre squared or the body surface area and not on their actual body weight. And we need to make sure that we're working it all out in lean body weight as well to minimise side effects. I do love a good calculation, so I try and work it out every single time.

But then there are also charts, that chemo have kindly provided, and it's widely available online, so that we can use them too. So by dosing on the metabolic basis, as in the body surface area, we hopefully reduce the risk of risk of toxicity. But this does sometimes mean that smaller dogs will get a larger dose compared to, larger dogs, in proportion to kind of like their body weight and metabolism and everything else as well.

So some of the medications for small cats and dogs may end up actually being dosed on body weight rather than body surface area. We always get someone to double check the body surface area that we've worked out, and then the drug calculation as well. And once you've been doing this for a little while, you get used to knowing kind of how much drug is suitable for a cat or for a dog, or for a patient of that size or that type of drug.

So I know if someone calculated 3 mLs of Christin, I would know for a for a cat, I would know that is really, really wrong, and you're probably going to cause that cat significant damage. Whereas 0.3 mLs is more suitable for a cat.

So going back to kind of how, like patient behaviour and kind of like having to be able to get these some of these medications into these patients, we, we do need to, again, we need to be considering the patient, considering ourselves, consider the medication that patient is receiving. Is it gonna be, is it a quick injection? Is it a tablet?

Is it a 30 minute injection? And then remember that this patient is coming back weekly. So, Even if you end up kind of going, OK, right, we can get through one treatment.

OK, you've got, you've potentially got to get through another 6 months' worth of treatment for that patient. And if you upset them stress them out, to the point where they're getting fearful and upset, you're not gonna get away with that more than once. So.

We will always try for any any, anything to try and make it nice for these patients. Food is always a good way to start. Some patients like to sit on, nurses' knees for the treatments.

We like to feed them. We, some of them, we might actually need to sedate completely. And as I said, like gabapentin and trazodone for cats and dogs is awesome.

And especially for cats, we've had to, we've avoided sedating properly cats by just using gabapentin. And make sure you're not gonna get disturbed, lock the door, turn off the ringer on telephones, and make sure that people are not in and out while you're trying to do a chemotherapy. So, there are some incompatibilities for chemotherapy drugs.

So we only use saline to flush catheters or for the infusions. If you potentially make some chemotherapies with either like Hartman solution or heparin flush, it can cause a precipitate, And this picture at the bottom was doxorubicin interacting with serenia and you can see this precipitation that has formed in the syringe. So this precipitation can cause a drug embolization into the pulmonary circulation, which is what no one wants ever.

So I like to have every when I'm preparing the medications, I obviously work full PPE. I have my, syringe and my vile adapter, everything all labelled, all opened and attached before I even get my drug out. I'm wearing two pairs of gloves when I'm preparing chemotherapy, so trying to run wrap wrappers with two pairs of gloves on can be quite difficult.

So when we're administering these drugs, it should be, the IV should be placed as a first stick, IV catheter or a clean stick. So this means you're going straight into the vein, straight in. You're not going, oh, I've hit it, I'm coming back out.

I've got to advance a little bit, or it won't go, it won't feed. It needs to literally hit the skin, hit the vein, go straight on him. We use Ela cream for our patients, if they're not gonna jump and feel the catheter going in, it makes it makes my life a heck of a lot easier, because they're not gonna jump at that point.

And make sure you secure them catheters in really well as well. So when we come to administering these treatments, once I've got that catheter in, I will, double check that that catheter's in placement so you can feel the saline, running up the leg. Drawback to make sure you get a nice blood flashback, flush again.

And I always get someone else to double check as well before we administer the chemo. So I'll check, they'll check, and then before I administer the drug again, I will check again. .

The risk of extrovisation or complications is is is enough to keep me, keep me a little fearful to make sure I want to double triple check. So when we're gonna administer that bolus, once you've double checked and triple checked that catheter, you can administer that chemo that syringe to the tea connector. I draw back again just to make sure I'm getting a good flash of blood.

So then inject, I draw back, inject, draw back, making sure that you're monitoring for any signs of that vein blowing, disconnect and then flush with saline all the way through. If it's got two ports on it, flush both ports. Then if you don't need that catheter anymore, take the catheter out.

It doesn't need to stay in the vein any longer than necessary. So for some of the shorter infusions, say 2030 minutes, we'll have some saline just running in through a given set just at a nice slow rate. And then you can attach the give the syringe of chemotherapy down to the .

To the port, and every now and again I will just draw back again just to make sure that I'm getting a nice flashback in that T connector. For oral administration, tablets, we should never crush or split tablets or open capsules. We should be adjusting the dosing or having medication reformulated.

These companies are, have been absolutely awesome and they've started, Have it, they've got lots of different formulations available, lots of different sizes. Nova can actually pretty much reformulate any size that you ask for. So if we're gonna, if we're doing all of this, we, we can try and get a bit, and it means we can actually accurately dose a little bit more as well.

We should wear double nitrile gloves for administration and face protection as well. I try and administer it in food. I give them all a little bit of a test dose of food, and if they eat it really well and swallow it whole, perfect tablet can go in there.

If they're a little bit fussy and you can see them going, hm, I'm a bit suspicious, tablet goes straight down the hatch, and we end up having to hand tablet them as well. These gelatin capsules are pretty good because sometimes you can get a couple of the chemotherapy tablets inside the gel capsule, so you only have to maybe tablet them once instead of maybe 3 times. So cytarabin is a chemotherapy, that can go subcut.

We tend to do it as an IV infusion, but occasionally, you guys in, in general practise may be doing it as a sub-cut injection. We should have an assistant to hold the patient, and then administer it as a sub-cut injection. Needle catch should be removed.

Drugs should be administered, so, do not recap the syringe, or the needle, just because of the risk of accidental injury or self-injection. We've all done that where it's come through the side of the, the cap and straight into your finger. So put the needle syringe, everything should go into a hard sided plastic cytotoxic waste bin.

Espirogenase is, is not a chemotherapy, but it's really expensive, sores care is needed when you are administering the subco. We could administer some directed chemotherapy, but even in a referral setting it's not something that we do very frequently. So all the cytotoxic waste should be treated as infectious or contaminated waste, and follow your .

Your, the guidelines that you're Company provides you for any of your like your waste company provides, as for the colour of the bags, how you should label them, maybe they need double bagging, maybe they're kept separately from just kind of normal clinical waste. Purple, or we can use like the hard top bags, the hard top boxes as well, the plastic tubs and make sure that it is labelled as chemotherapy. I've got a lovely pack to safe bin, which actually creates lots of little, can create little pockets to get all of the, to stash all of the chemotherapy waste in.

So moving on to side effects, the veterinary, the veterinary cooperative Oncology Group came up with a whole, a whole document, I think it's about 50 pages long of side effects, adverse events, and then graded all of them between 1 to 5. So I've included this in the, in the handouts for you guys as well, so you can have a look. But it, it goes through literally every side of every side effect that you could potentially need.

So move, starting with extravasation. So this is when there is accidentally administration of the medication outside that blood vessel. And this can be caused by the catheter going in and out of the vein, leaking at the site, the insertion site.

This is a medical emergency. If you notice that this does happen, it can cause some awful tissue necrosis, and I've got some awful pictures to show you. Not to scare people, but to kind of make everyone, it makes me, makes me extra careful when I'm administering certain medications.

So we have an extrovisation first aid kit ready to go, just in case anything does happen, I'm hoping it wards off evil spirits. And we've got the guidelines, doses, literally everything there that we should ever need, should anything happen. So for Ben Christian or Ben Baston, .

We should be applying warm compresses, and then we may need to inject some hyaluronidase and some saline into that area as well. There will be wound management as well and analgesia and antibiotics. Signs for this drug, these drugs may show about 1 to 7 days, and they may be full thickness.

So they do look pretty grotty, but then they can take a little while, they can take quite a long while to actually heal up as well. So doxorubicin or epiubicin are the ones that . Can cause some awful necrosis and can actually lead to some absolutely awful complications.

So we need to apply cold packs, some dextrosone injections, topical DMSO. And we need to consider surgical debridement or intervention, which may end up actually leading to amputation pretty soon after this happens. There's gonna be some extensive wound management, so we need to be considering lots of analgesia for these patients and antibiotics for infection.

So this is one dog, this showed that signs will start to show at about 7 to 10 days. It is progressive and we do need surgical intervention. So this was 10 days post-extrovisation of 1 mL.

And then this was 20 days post 1 mL and you can see how awful that this is. And this is a different dog. So this was 5 weeks post-extrovisation with no treatment.

It was presented to a referral hospital 2 days. Oh, it was presented 2 days to the, after the treatment to the primary vet. And then they, they followed up with wound management for 5 weeks before they referred this patient onto this, this technician's hospital.

And this actually did lead to amputation. So, I don't, I'm not sure, I'm not sure how this actually happened, whether or not whoever administer it hadn't realised what had happened. And then there was no treatment ongoing.

But I think once it's happened, I'm not sure how, if, how, if this would have progressed to this extent, had treatment been followed. But this dog ended up needing to have her leg amputated. And knowing the drug that she was on, she was probably on drug, maybe on a course for lymphoma, which for the whole time of this going on, she then wasn't able to actually have any chemotherapy, so then that could that's a massive risk for then disease progression.

So acute tumour lysis syndrome can occur for patients with high tumour burden, such as like high grade lymphomas or acute lymphoblastic leukemias, and it's commonly seen with about 48 hours of treatment, . So what happens is that there's a massive tumour cell death, because there's lots of tumours, tumour cells around. We've given it some chemotherapy, we've blasted all of them, and then there's a massive cell death.

So this, all of these cells dying releases lots of intracellular substances such as phosphorus, potassium, and all these purines. If the release is extensive, it can overwhelm the renal excretory mechanisms. So with all of this happening, can lead to acute kidney injury, metabolic acidosis, disseminated intravascular coagulation, and death.

So clinical signs, kind of weakness, GI signs, bradycardia, other cardiac arrhythmias and syncope, shock, tech and seizures, petia nehymosis, and death. So for treatment, we're looking at fluids, aggressive fluid therapy and correction of the electrolytes and metabolic abnormalities and symptomatic treatment as well. So for some of these guys that when we've, I it was like, if they, they do have a high grade lymphoma, we will hospitalise maybe 24, 48 hours afterwards, and we will monitor their electrolytes and keep a really close eye on them.

Some fluid therapy, monitor their electrolytes just to make sure that nothing is happening before we send them home. So GI toxicity, such as diarrhoea is a common side effect from chemotherapy. But could it be the chemotherapy, or could it be the diet changes and all the treats that these guys are getting fed at home because they've now got cancer?

I'm very guilty of feeding our patients lots of biscuits, but it could, most of the time, it can be just due to the chemotherapy. Usually self-limiting and resolving quickly, so we can use probiotics, such as like procol andalin. We supply our owners, with metronidazole for 5 to 7 days.

If that dog is starting the chemo protocol, we start, we give them some metronidazole. They sit, that, that box of metronidazole can sit in the cupboard, and if it doesn't get used during the course, that's fine. If they need to use it straight away, that's fine too.

It means that they can start that antibiotic straight away if there's ongoing diarrhoea without having to contact us, contact you guys, They can start that straight away and we, we do advise, we, we educate them on that too. We only need to hospitalise them if it's kind of ongoing or it's making them quite poorly. We may need to look at some like barrier creams and just keeping them clean as well.

If the diarrhoea is hemorrhagic, we may need to add in a broad spectrum antibiotic as well as there's a risk of bacterial translocation which can then lead to sepsis if the patient is also then neutropenic. So if any of your clients call up and say, my dog is on palladia and he's starting to have some diarrhoea with GI bleeding, we need to advise them to stop their treatment immediately and seek, either come to your practise or send them back to your the referral hospital that they're going to. There is quite, it's not common, but it's quite rare it's quite rare, that they can end up being a GI perforation that is occurring in dogs with treated with pelagia.

So we, we stop that straight, straight away. If this GI any of these GI problems are suspected, it's not whether or not it's due to palladia or the mast cell degranulation, we do need to stop the administration of palladia and monitor. We may start it again at a reduced dose, or we may just discontinue it and swap it to something else.

Commonly with palladia, we may add in non-steroidals to be used in conjun conjunction. So we, to reduce the side effects of the, of the both of these drugs. We administer the non-steroidals on the palladia off days.

Vincristin can cause ileus and constipation in cats, less commonly in dogs. So we may need a prokinetic treatment if this does happen. Something like metoclopramide, some, some clinicians will use this prophylactically starting on the day of increase in administration, we don't use that.

It may require further intervention such as food therapy and tube feeding, feeding, feeding, or stool softeners, dietary changes, enemas, or manual evacuation, but thankfully I don't think we've actually come across that, commonly. Vomiting or nausea, is vomiting is a common side effect with chemotherapy. So we always pre-treat with Mirropotin prior to each chemotherapy, either an IV or subcut dose or tablets at home.

We make sure that they've got, always got some serenia at home to use following the chemotherapies, and we treat regardless, for a couple, for say 3 to 4 days following treatment with medications such as epiruicin or like carboplatin. And if the owners have got plenty of this meropotin at home, they will give a treatment on the morning of the chemotherapy, so it's, it's working by the time they've come to see us. We may need to hospitalise if we're unable to control the clinical signs.

So we normally start off with Mirropotin, then move on maybe to metoclopramide and ondansetron, and or we may end up using all three of them at some point as well. We have a couple of patients whose nausea and vomiting can't be controlled by Mirropotin, but we give them one dose of ondansetron instead of Mirropotin, and they're much better with that. And it's the same for nausea and and salivation as well.

We make sure that we give the we on board with the moppotent before we do the chemotherapy and that the owners have got a stash of that at home. So if the patient, if their dog is a little bit off colour, they can administer it straight away. So hyperexia, anorexia, we need to make sure that we, again, we're controlling everything else that could cause a problem.

So nausea and vomiting is probably the main reason why these patients don't want to eat after chemotherapy. And once they've had some Sereia within an hour or so that they can, they're normally doing better again. But if they're just needing a little bit of a dietary change, some coaxing, we could then consider the use of appetite stimulants as long as everything else has been dealt with, and as I said, we've got Mirtazapine or the Nice, that is a little bit, it is sort of is available.

So prednisolone can cause lots of side effects. Steroids are amazing things, but they do come with all of the problems. PUPD, polyphasia, we've seen some of these really, really high, beginning of like the lymphoma protocols, or some of these neurological conditions that we're having with treating with prednisolone.

They are hungry all of the time. So we, they have to learn how to deal with that. And hopefully, as the, the prednisolone starts to wean down, that becomes a little bit easier to manage.

So GI ulceration can be caused by primary GI tumours, causing all sorts of other, or as a paraineoplastic syndrome, secondary to the mast cell tumours, which is a, a degranulation could be caused by the non-steroidals that they're getting, or from steroids because of this gastric acid increased gastric acid secretion. It can lead to GI perforation. So if there's any any suspicion that we need to be treating that straight away.

We, if any of these dogs and cats are on high dose steroids or for mast cell tumours, we will always, administer some GI protectants such as the motadine or omeprazole as well. So, as I said, once these mass cell tumours start to degranulate, these can result, this, this, these can degranulate, as a result of tumour manipulation. If we've done some FNA's or handling, chemotherapy, radiation.

And once they start, once they start degranulating the histamine and the heparin and everything starts going, everywhere and causing all sorts of problems, such as like the ulcers or, local side effects as well. So local side effects can include so like erythemia, swelling at the site or some poor wound healing as well. So this was a, some pictures I, I, I, I, I got from a, on a Facebook page, and this lady, her dog has a mast cell tumour.

This wasn't a confirmed mast cell tumour when this happened. She didn't know what this was. Her dog just had the, had this little lump, a large lump, and he'd been playing and messing around with the other dogs.

They'd been fighting, play fighting. And she thinks that because the other dogs maybe have knocked this, he then end ended up with degranulation which was then confirmed that it was a mass cell tumour, and you can see he's got all of this bruising here and the, the wound actually did swell, and actually bled quite a lot afterwards as well. So some of these lymph nodes or masses can become necrotic.

Once we start chemotherapy, some of these, lymph nodes, especially for lymphomas, can be massive. And once we start giving them chemotherapy themselves inside their dye, and they can actually then start just to become necrotic and abscessy. So we want some culture and sensitivity, wound management, and we may end up actually needing some surgical intervention as well.

Sterile hemorrhagic cystitis is a side effect of cyclophosphamide. This is metabolised by the liver and excreted in the urine. So the metabolite of cyclophosphamide is aquiline, and this has an effect on the bladder mucosa causing sterile hemohagic cystitis.

So if we're, if these guys are on a like a chemotherapy protocol for lymphoma, it's it's a massive dose that we gave them as part of this protocol. We try to administer this in the morning, if possible. And we give them freezamide alongside, we give 3 doses over 20.

24 hours to encourage drinking and urination. And once they go home, we tell the owners, make sure they've got plenty of opportunity to go outside. We don't want you to take them home, shut them in for 8 hours and you go off to work.

We need them to actually be urinating all of this out. We always check a urine sample prior to administration of cyclophosphamide, and then following, like the, maybe the week after, administration, just to look for any, well, all we're looking for is signs of blood. If there are any signs of UTI or blood on the test strip, don't use.

And then we need to look for supportive care if this happens. I've probably seen one or two cases over the last 55 years or so that this has happened to. And they can be really nasty to try and actually resolve, the bladder end, the bladder wall ends up horribly thickened and, we need lots of analgesia, maybe some fluid therapy if it's caught early enough, and then some, nutraceuticals to try and help that bladder out as well.

So some of these guys may end up on metronomic chemotherapy, metronomic cyclophosphamide, so we will, we educate these owners on how to do the urine test strips. I have a, this is how you process a urine sample at home strip, test, . Information leaflet for these, for owners, but this is something again that nurses can really be involved with to actually educate the owners on how to use these test strips, what to be looking out for.

And if the owners are then detecting any signs of UTI or blood on the test strip, we need to again, supportive care and discontinue that use. So some drugs are cardiotoxic, such as epiubicin and doxorubicin, so the acute signs can manifest. So cardiac toxicity manifests as transient, or it can be just for maybe just a short time.

So this is associated with arrhythmias, and mainly because I think maybe the treatment has been administered too quickly, as this then it, it increases circulating histamine and catecholamines, which then causes the arrhythmias. So if we administer it slower, it should be administered over 15 to 30 minutes. There should be no, no arrhythmias, and it's usually of little, little clinical significance.

Cumulatively, they are cardiotoxic over long term, so there is a, kind of a maximum amount that they can have in their entire lifetime. After that, they, we need to look at a dis discontinuing and trying with a different medication instead. It can lead to congestive heart failure, and the damage is irreversible and just carry a grave prognosis.

We will always do a, focal, a cardiac echo before administering epiubicin or the first dose of epiubicin, just to check the cardiac contractility. Some medications can be nephrotoxic, especially doxorubicin or recorubicin in cats, so we need to be careful if we're gonna continue using these, we need to monitor their renal function, . Oh, sorry.

And for, dogs as well, carboplatin can be nephrotoxic. So we do monitor renal function before we administer. And then some of these guys, we may just keep in for maybe 46 hours post administration so that we can diurese these as well, just to try and help them kidneys out.

Epi and doxorubicin do have the risk of cause potential anaphylactic reactions if it's been administered too quickly, as I mentioned with the cardiac arrhythmias. But if we're administering it slowly enough, there shouldn't be any problems, and some suggest maybe we should be pre-treating with an antihistamine, we, we never have. Easpirogenase is a rescue therapy that we can use for lymphoma, .

It is super expensive and we keep it in stock. But it is something that can cause a hypersensitivity reaction, either after one or repeated doses. It should be administered soup, and we always administer this with an antihistamine such as chlorophenamine and potentially dexamethasone as well.

I like to administer the antihistamine and the dexamethasone, maybe about 1 hour before half an hour to 1 hour or so before I then give the allospirogenase. It just makes me feel a little bit better. And we then hospitalise them for a couple of hours post treatment.

If it's just the first one, if they, if it's their second treatment, we may keep them maybe for 46 hours or so just to make sure that there's no complications. So probably one of the most significant, side effects is bone marrow suppression, neutrope, so the bone, the cancer, the chemotherapy is gonna target all of these, rapidly dividing cells, and unfortunately the bone marrow is as awesome as it is, is one of these rapidly dividing areas. So chemotherapy can have such a significant problem for these.

Neutropenia or reduced neutrophils will occur first, followed by thrombocytopenia, and then, less commonly, anaemia as a side effect is, isn't quite as common for chemotherapy side effects. So it's just tend to be the dose limiting toxicity of many chemotherapy agents. Most patients are absolutely fine, don't show any clinical signs and you only pick it up because they've come in for either the next dose of chemotherapy or we're doing it at a set point following the treatment.

Severe neutropenia can be complicated by sepsis and may be life-threatening. We treat this as an emergency. So if any of our chemo patients ring up and kind of say, my dog was had, had treatment, say, 5 days ago, he's now, pyre, but like now anorexic, he's lethargic, he looks really miserable.

He's kind of, he looks really poorly. We have them, we, we treat this as an emergency. And we'll get them to the hospital straight away and, a haematology blood sample run straight away.

So treatment for these guys is supportive care, so barrier nursing, make sure everyone is aware that this patient has got no immune system. These white blood cells, the neutrophils are MIA, and we are waiting for them to come back so he can, they can fight off any infections, so we need to protect that patient from anything else that we could admin, give it to. We want some fluid therapy, potentially with some flu potassium supplementation, IV anti-emetics, antibiotics, gastroprotectants, and potentially a nasal esophageal feeding tube as well.

Some patients that are persistently neutropenic, we can use a medication such as Neupogen. But this is really expensive. And usually by the time we've started with all of this supportive treatment, and the neutrophils will normally come back up within 24, 48 hours anyway.

We would only consider this if it was, if they were really not responding. Owners should be made aware of the clinical signs of neutropenia, so that if they know this, if they notice any change in their patient and their pet, that they can contact us straight away. We've got a few, and we've, some owners, we've advised them to check their pet's temperature as well, and supplied them with a thermometer.

So we'll run haematology blood tests on our patients before each chemotherapy treatment. And then, as I said, at a set point following some medications, and this is, this is the Nadia. So the Nadea is the is usually the lowest point that the neutrophils will get to, and it's usually 7 to 10 days following treatment.

It's different for different drugs and different for different patients. So it can, where you would expect them to be low at a certain point, they might not do that until they come back a little bit later on. So depending on what level of the neutrophil count actually is, depends on what the actual course of action is, depending on whether or not it was where they do their next treatment.

Were they just in following the, a week later after their treatment. It depends on whether or not they have a, have a, are pyrexic or they're not pyreexic or if they're showing clinical signs. If they are neutropenic, but they're not pyorreexic, they're not showing clinical signs, we will boot them out of the hospital as quickly as possible so that they don't pick up any infections in the hospital.

And we will supply them with some antibiotics and tell them to kind of maybe just keep your pet at home for a couple of days while they get over this. So hair loss and colour change to the hair as well tends to be one of the things that upsets a lot of people, they kind of know it's gonna happen, but when it actually does start, it can take some owners a little while to actually get round, . So it tends to be like the poodles and like the, the doodle breeds that are, we, we see that we've trashed their coats a little bit.

And, we've seen some colour changes with, mainly poodles, where they've been like a beautiful white colour. And when we've stopped chemotherapy, they've come back an apricot colour. It's, it's really bizarre.

As you can see, this is little Bella. She's beau she was beautiful and white until we got our hands on her, and she's now apricot. And this is Barney.

He, it's really bizarre with him. It was his white hair that came out, that, that stopped. And the black hair stayed.

It was really strange. But I kind of mentioned it to the owners cause it's one of the first things as well that they can ask. And I'll say, it might happen, it might not happen.

And I said, it does tend to be the poodle crosses or the poodles that do seem to have the most, significant hair changes. So kind of we're coming to the end and we just kind of just, mentioning about Stephonta, which is a new treatment for mast cell tumours that are non-metastatic, and they need to be, a certain size and location as well. If you do a webinar, a webinar vet search, you can look at mass cell tumours, and there's loads of new webinars that I've gone on, discussing this new treatment.

So with this one we need to be super careful with the dosing and administration, I said these these tumours we cannot administer these to large tumours, they've got to be a certain size and in a certain area. We should be considering whether or not we hospitalise these patients for that, at least the first night because of the pain that can be caused. And that, and to warn these owners, there will be a wound.

There's, there's no doubt this, this tumour is going to cause a wound once we have finished with this treatment. It is an injection that goes directly into the tumour. There is going to be a wound, so they need to be educated and even showing them pictures of what is actually going to happen.

So, this, lady was on a, Facebook page, and she kindly let me use these pictures of her dog. She documented it lovely for me. So you can see what actually happens over the course of like 3 weeks.

And you can see that this is a, this is, this wound, there will be a wound. So this is why that we're only able to actually use this for certain size tumours. We can't use this on a massive mast cell tumour because there will just be such a deficit that will probably never heal.

So for any, any part of the oncology treatment, regardless of what is actually going on, quality of life is the most important thing to consider during treatment. We need to consider all of the joys of life and looking at, at the, the quality of life charts and all of the kind of the things that these that these owners know that their pets enjoy. They, if they're eating and drinking, they're like, can they get up and move around?

Are they still being sociable? Are they wanting to play? Are they actually happy dogs?

Are they expressing how they would normally behave? If things are starting to change, and maybe 2 or 3 of these things are starting to change, or the score on the quality of life charts are actually changing, that's when we need to start thinking, actually, what are we need to be considering whether or not euthanasia is becoming an option for these guys. So, teamwork makes the dream work, and this is not just between the, the team and the hospital, it's a team that you create, with you, the patient, and with the owner.

You need these owners to be on, well, everyone is on each other's side, and looking after, you're looking after their pet, they're looking after their pet, if we're all in it together, and if they're worried about anything that they can, they know they can call, my owners know that they can call any time. And even if they, if they want just a little bit of a chat, or if they, need just a bit of a chat about what's going on, or they're just worried about a side effect or something. I've spent many, I've spent quite a lot of time on the phone to some owners about discussing quality of life.

And this is, I think, what's such an important role for the nurses is, is that client contact, and just being able to support the owners, as well. We provide all of our owners with lots of leaflets, kind of like all the information on how to handle the pet following the administration of chemotherapy for side effects. Make sure we're providing Mropotin and metronidazole so that they can start that straight away.

If their dog is a little bit off colour on a Saturday night or Sunday morning, and then they it's difficult to try and get hold of an out of hours provider sometimes, so that they know they've got medication to start straight away. And if this this dog or cat is on protocols that would require urine samples, send them home with urine pots, makes your life a heck of a lot easier in the long run, I'll tell you. So I often wonder sometimes about rabbits and guinea pigs eating the grass outside where cats and dogs are potentially urinating.

I asked around, I've asked the oncologist, I've asked on other groups about whether or not this is actually a thing, but it's probably something worth considering, maybe keeping rabbits and small grass-eating creatures off the area where the dogs are going to urinate and, defecate as well. So if you do need any help, give your local friendly oncologist a call. They will usually be happy to discuss any cases or if you as nurses need any help with .

Sourcing equipment or medications or anything else. I'm happy to do that. My email is on the notes, so at the end of this presentation, I'm always happy for a call or for an email, plus chemo and chemo pet are also fantastic, if you do need any help as well.

There's a little bit of light further reading as well for you, there's plenty there. And this, this is Harvey, and what I really love doing is a congratulations or like a graduation certificate as well for these guys, once they have finished their chemotherapy protocol. I love it.

The owners love it. And the dogs usually get a little bit of dogs and cats get some biscuits and some treats out of it as well. So it's a really nice way to kind of end the protocol.

And it's like a, well done. These owners are awesome. Some of these owners are awesome.

So if anyone has any questions, my email address is is there, or you can contact the hospital, I'm happy to answer any questions. Just remember to look after yourself as well. Thank you.