Fatigue
Questions
- Is the patient post chemotherapy or radiotherapy?
- How many days has this been going on?
- Does the patient have pain and are they taking painkillers?
- Are they able to eat and drink?
- Are they short of breath – at rest and on exertion?
- Are they able to mobilise?
- Are they able to carry out ADLs?
- Are they passing usual amounts of urine?
- Are bowels functioning normally for them?
- What is their overall mood like?
Grade 1 (Green)
Increased fatigue, but not interfering with ADLs
Advice
- Assess risk of neutropenia
- Assess risk of anaemia or pancytopenia
- Advice:
- Encourage diet and fluids
- Rest, but try to take some gentle exercise
- Advise to contact the helpline if symptoms persist or worsen
- Phone/review patient in 24 hours
Grade 2 (Amber)
Moderate or causing difficulty performing some activities
Advice
- Assess risk of neutropenia
- Assess risk of anaemia or pancytopenia
- Advice:
- Encourage diet and fluids
- Rest, but try to take some gentle exercise
- Advise to contact the helpline if symptoms persist or worsen
- Phone/review patient in 24 hours
Grade 3 (Red)
Severe or loss of ability to perform some activities
Advice
As per grade 1 and 2
Admit if evidence of:
- Dehydration
- Infection
- Poor Oral Intake
- Other chemotherapy toxicities.
Contact patient’s oncology team for on-going advice and consider possible disease progression.
Grade 4 (Red)
Bedridden or disabling
Advice
As per grade 1 and 2
Admit for:
- Monitoring and on-going assessment.
- symptom management
Contact patient’s oncology team for on-going advice and consider possible disease progression.
Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding.
Arrange follow up review as necessary.
Initial assessment – patient seen in AOCU
- History of complaint/symptoms
- Check all prescribed medication and if on any thiazide diuretics, calcium, vitamin A or vitamin D supplements stop these medications
- Assessment of fluid balance status (BP, pulse etc..)
- Check bloods – Bone profile, Renal function, LFTs, Magnesium.
- ECG
Treatments
IV Fluids – Intravenous rehydration for 24 hours with 0.9% saline, 4-6L.
- Normal saline hydration corrects volume depletion from calcium-induced diuresis and decreased fluid intake; promotes renal calcium excretion.
- This intervention reduces serum calcium by a median of 0.25 mmol/L.
- The routine use of furosemide in conjunction with hydration to promote calcium excretion is not recommended, because of the risk of volume and electrolyte depletion.
- Rehydration may provoke hypokalaemia and hypomagnesaemia, so check U&Es and Mg++ daily and replace as necessary
- Consider catheterisation if patient does not pass urine for 4 hours.
Bisphosphonates – Zoledronic Acid 4mg in 50 ml 0.9% saline over 15 minutes is the standard dose.
In renal impairment dose may need to be reduced – CHECK WITH PHARMACY BEFORE GIVING
- Bisphosphonates are the mainstay of treatment of hypercalcaemia.
- These drugs are pyrophosphate analogues that bind to hydroxyapatite crystals in bone matrix and inhibit osteoclastic bone resorption.
- Resistance to bisphosphonates may occur due to the fact that bisphosphonates do not reduce PTHrP-induced renal calcium re-absorption.
- Bisphosphonates are appropriate to administer when serum calcium is ≥ 3.0 mmol/L, or when a serum calcium of < 3.0 mmol/l is accompanied by symptoms.
- Renal failure is the most serious potential adverse effect. Therefore, dehydration should be corrected and serum creatinine checked prior to administration.
Bisphosphonates will usually begin to reduce Ca++ within 48 hours and will usually normalise it within 5 days. If the Ca++ level is not falling, DO NOT REPEAT THE DOSE UNTIL AT LEAST DAY 5.
Dietary calcium does not need to be restricted. However, calcium supplements should be discontinued. Hypercalcaemia of malignancy occurs as a consequence of osteolysis and renal tubular reabsorption of calcium. The contribution of dietary calcium is negligible.
