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Photodynamic Therapy for Bronchial and Esophageal Tumors FERIOPERATIVE IMPLICATION s Carol Kitzrow. RN ancer remains one of our most challenging health care problems, debilitating and killing thousands of people each year.’ Many new treatments and drugs appear on the horizon as we continue to search for ways to eliminate this disease. One of these new treatments, photodynamic therapy (PDT), attempts to eliminate cancer cells with minimal surgical intervention.
C
History
I
n the 1920s, researchers began to investigate this therapy when they discovered that tumor cells would produce a red-orange fluorescence when exposed to ultraviolet light. In 1961, researchers demonstrated enhanced tumor fluorescence by using an intravenous hematoporphyrin derivative dye prepared from hemoglobin.2 In 1978, researchers began to explore combinations of specific light and hematoporphyrin dye to discover what combination would produce the most impressive tumor death rates.? Currently, multi-site, phase 111, investigative clinical trials of PDT are being conducted under the guidelines of the US Food and Drug Administration (FDA).
to red laser light in the 630 nanometer (nm) range.4 This laser light activates the dye and causes tumor cell necrosis. The physician administers D H E intravenously 48 to 72 hours before the patient’s surgery date. The drug is absorbed by all the cells in the body and leaves the patient highly photosensitive for six to eight weeks following injection. Dihematoporphyrin ether has a high affinity for the tissues of the liver, skin, and cancerous tumors. It is excreted by the body in the urine and bile; however, normal cells are able to excrete it more rapidly than tumor cells. Because of this, tumor cells retain the dye at a level that causes tumor death when the tumor is exposed to red laser light.
Photodynamic Therapy
P
hotodynamic therapy is used to treat cancer by injecting the patient with IV dihematoporphyrin ether (DHE) dye, also known as Photofrin 11, and exposing him or her
Carol Kitzrow, RN, CNOR, is the surgical speciulty rnanager,for general und laser surgery at St Luke’s Medical Center, Milwaukee. She earned her diploma in nursing ut Milwaukee ( W i s ) County General Hospital School of Nursing. 1483
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Fig I . Laser used for photodynamic therapy.
Injection of DHE causes photosensitivity in all patients. It may also cause the following side effects: nausea and vomiting, fever, erythema, exudation at the injection site, and ocular photosensitivity. At St Luke’s Medical Center, Milwaukee, we use a tunable argon dye laser to generate the red light necessary for activation of DHE retained within the tumor cells (Fig 1). The light-activated dye causes destruction of the malignant cells by causing the release of singlet oxygen (ie, peroxide) within the cells. The normal cells of the esophagus and bronchus may have some slight reaction after exposure to laser light, but 48 hours after the initial laser treatment these cells appear normal, while the 1484
tumor shows obvious reaction and necrosis.
Preoperative Procedure
0
ur PDT clinical trials began under the direction of M. Mirhoseini, MD, in conjunction with Lederle Laboratories for QLT Phototherapeutics, Inc, Vancouver. Our areas of investigation have included partially and completely obstructing bronchogenic and esophageal carcinomas. We assign patients to the comparative, random study according to the guidelines developed by the FDA, and the study director assigns their form of therapy. In order to become part of the bronchial tumor clinical trial, patients must be at least 18 years of age, have inoperable bronchogenic cancer, and have a non-small-cell tumor that has been confirmed by biopsy. Conditions that
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__
exclude a patient from this group include pregnancy, tracheal or carinal lesions, previous pneumonectomy, or major blood vessel involvement by the tumor. To be involved in the esophageal tumor study, patients must be at least 18 years of age, have inoperable esophageal cancer, have refused surgical treatment of the cancer, and have no contraindications to esophagoscopy. Criteria that are used to exclude patients from this group are pregnancy, tracheal or carinal tumor involvement, complete esophageal obstruction, and previous treatment with PDT or the neodymium ytirium aluminum garnet (Nd:YAG) laser. All patients in these studies sign a special consent form that explains individual study details. The physician must explain the following to all study patients: duration of participation in the study, treatment procedure, required follow-up evaluations, possible side effects and risks of treatment, to whom their medical records will be released, and the voluntary nature of the study. After the patient decides to participate, he or she receives a booklet explaining photosensitivity and the precautions that must be taken for 4 to 6 weeks after injection of DHE.’ The booklet explains that exposure 1 o bright light will cause bums that are similar to a severe sunburn. The patient is told that he or she will need to keep room lights dim and window shades drawn. The protection of all skin ,surfaces is detailed (ie, socks, long pants, long sleeves, gloves, a broadbrimmed hat, sunglasses if leaving the hospital room for tests at any time) The booklet explains that if transported by cart, the patient must cover his or her face with a sheet while moving through the lighted hospital halls. The patient is encouraged to remain active by walking in the halls after visiting hours when the lights can be dimmed. The health care team plans an evening discharge so that it is dark when the patient leaves the hospital. The nurse explains that after dis-
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charge, the patient can make excursions outside of the home, but these should be planned for the evening hours. The nurse also reminds the patient that although holiday lighting is not bright, his or her skin is susceptible to the light given off by red and blue Christmas bulbs. The patient is taught to check for continued photosensitivity after six weeks. If no severe reaction occurs, the patient gradually can re-expose himself or herself to sunlight over several weeks’ time. Our hospital protocol requires that any patient scheduled for general anesthesia or physician-administered IV sedation must have a chest x-ray within the previous six months, a current history and physical, a complete blood count, and a urinalysis. If the patient is more than 40 years old, an electrocardiogram (ECG) also is required. The physician uses the patient’s height and weight to determine what dosage of DHE to administer. He or she orders a computed tomography (CT) scan of the chest if the patient has a bronchial tumor or a CT of the esophagus and liver if the patient has an esophageal tumor. The patient with pulmonary involvement must undergo complete pulmonary function studies. The physician also orders a biochemical survey that evaluates the patient’s serum levels of sodium, potassium, chloride, carbon dioxide, glucose, blood urea nitrogen (BUN), calcium, phosphorus, total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lactic acid dehydrogenase (LDH), alkaline phosphotase, uric acid, cholesterol, and triglycerides. All other orders are individualized based on the patient’s condition and anesthesia preference. On the day before surgery, the perioperative nurse or the postanesthesia care unit (PACU) nurse visits the patient and completes a patient care data sheet, which includes the following information: patient allergies; past medical and surgical history; a physical assessment of height, weight, blood pressure range, and skin condition; emotional assessment; and the patient’s vision and hearing capabilities. During the preoperative assessment, the
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Fig 2 . Video system for photodynamic therapy. nurse reviews the chart for abnormal laboratory values, x-ray, and ECG results and notes any routine medications the patient is taking. If the patient will need oxygen during transport to the OR or other specialized care, the nurse notes it on the perioperative care plan. A copy of this information is distributed to the holding area, the OR, and the PACU. The nurse assesses the patient’s knowledge of the procedure and answers any questions the patient may have at this time.
Case Preparation
W
e have a case-cart system that enables OR personnel to order the appropriate c a s e c a r t t h e day before the patient’s surgery. If we are treating an esophageal tumor, arrangements are made with our outpatient department diag1486
nostic and treatment center to borrow an esophagoscope and biopsy forceps. A dualchannel bronchoscope is available in the OR for bronchial tumor procedures. On the day of surgery, the perioperative nurse sets up the flexible bronchoscope or esophagoscope and checks the light source, suction, and air jets to ensure that they are functioning correctly. The nurse connects the irrigation bottle to the esophagoscope and checks its function. He or she also sets up a rigid bronchoscope or esophagoscope, with suction available, for emergency use. If major bleeding occurs during the procedure, it may be impossible for the surgeon to gain adequate c o n t r o l of a bleeding vessel through a flexible scope. Medications used for a local procedure are 2% tetracaine hydrochloride topical (ie, 2% Pontocaine), 0.5% dyclonine hydrochloride
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Fig 3. Perioperative nurse (left), with the assistance of a biomedical laser technician (right), must tune the laser until the laser beam registers in the crosshatches of the spectroscope. topical (ie, 0.5% Dyclone), and 1% lidocaine (ie, 1% Xylocaine). Anesthesia personnel may request that midazolam (ie, Versed), fentanyl (ie, Sublimaze), alfentanyl (ie, Alfenta), or sufentanyl (ie, Sufenta) be available to sedate the patient. Phenylephrine (ie, Neosynephrine) diluted to a concentration of 0.1 mg/mL a l s o should be available. If bleeding occurs, the phenylephrine solution can be sprayed through the scope onto the bleeding site. The FDA requires that videotape records and still photos be taken of the procedure as part of this study. W e use a videotape recorder system (Fig 2) that has an in-line printer. The perioperative nurse assembles the camera and secures the adapter for the scope in use. He or she also confirms that there is adequate film in the printer. When that is accomplished, the nurse types patient 1488
information (eg, date, medical record number, area b e i n g t r e a t e d , t h e surgeon of record) onto the monitor screen, and this is recorded on the videotape. The same videotape is used to record each of the patient’s sessions in the OR and each of his or her follow-up examinations. The nurse disinfects the laser fibers by precleaning them and soaking them for 20 minutes in a 2% glutaraldehyde solution that has a 14-day use limit (ie, 14-day Cidex). Care is taken not to submerge the end of the laser fiber where it connects to the laser. While the fibers are soaking, the nurse initiates the warm-up required to use the laser. After the laser has had sufficient time (eg, 30 minutes) to warm up, the nurse prepares it for use during the treatment. Using a spectrascope and a test fiber, the nurse tunes the laser to emit a light beam at exactly 632 nm
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JUNE 1992, VOL 55, NO 6
Fig 4. The biomedical laser technician determines the laser output using the power meter.
(Fig 3). Just before treating the patient, the nurse determines the power output by inserting the “sterile” laser fiber into the power meter and setting the laser at a predetermined wattage. To d o this, the nurse inserts the fiber into the gas-sterilized glass sleeve that fits into the power meter (Fig 4). This process is repeated with each fiber used during the PDT treatment. It also is repeated after we finish using a fiber to determine if there is any significant discrepancy in the amount of power being delivered through the fiber. T h e n u r s e m u s t r e c o r d b e g i n n i n g wattage output and ending wattage output on the patient’s record. Because OUT patients require light precautions, we provide at least three flashlights in the OR. One flashlight is for anesthesia personnel, one is for the laser technician, and one is for the circulating nurse. Everyone in the room must wear helium-neon goggles with an 1490
optical density of six at 632 nm. Operating room light is supplied via a filtered x-ray view box; all other lights in the room are tur2ed off. The OR hall lights are dimmed to decrease patient exposure that could occur from traffic entering and leaving the room.
Intraoperative Procedure
0
n the day of surgery, OR personnel transport the patient, under light precautions, to the surgical holding area. In the holding area, a room is equipped where the patient can wait safely until the surgical team is ready to begin. The lights are dimmed, a curtain is drawn across the door, and the patient is given a call light. It is here that the anesthesia personnel start the patient’s IV, if one is not already in place, and where the preoperative assessment is completed. When the OR is ready, the circulating nurse
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transports the patient to the room, and helps him or her move to the OR bed, and places the safety strap across the patient’s thighs. The anesthesiologist begins to monitor the patient; this includes the insertion of an arterial line and a central venous pressure line, and, if necessary, the insertion of a pulmonary artery catheter line. The nurse assists the anesthesiologist as needed and offers emotional support to the patient during these procedures. Every patient is monitored with an ECG, and a pulse oximeter is used to determine the patient’s oxygen saturation. The anesthesiologist draws a baseline arterial blood gas and, if the patient is a diabetic, a serum glucose level. The anesthesiologist may use general anesthesia or local anesthesia with IV sedation. The majority of patients with esophageal tumors are treated under IV sedation. If general anesthesia is used for treating a patient with a bronchial tumor, the anesthesiologist intubates the patient. After the anesthesiologist achieves adequate anesthesia, the surgical team positions the patient. The supine position is used if a bronchial tumor is being treated. The nurse tucks the patient’s left arm at his or her side and places a pillow under the patient’s knees. The nurse extends the patient’s right arm onto an arm board and covers it to protect it from exposure to laser and room light. When a patient with an esophageal tumor is being treated, the surgical team places the patient in a slightly lateral position. The nurse places a pillow behind the patient’s back for support and uses blankets between the patient’s legs and under his or her ankles to pad bony prominences. The nurse positions the patient’s arms comfortably in front of him or her. Following positioning, the surgeon inserts the flexible esophagoscope. Ice chips may be given to the patient to help him or her swallow the esophagoscope. The nurse must help the anesthesiologist monitor the patient. He or she also must explain the procedure and offer support to the awake patient. For patients with bronchial tumors, the physician passes the bronchoscope through the endotracheal tube. Initially, the physician locates the tumor
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under direct vision and connects the video camera to the endoscope. The circulating nurse begins recording the procedure. Previously performed biopsies have determined the nature of the patient’s tumor, but the physician may take more biopsies at this time. Permanent pictures are taken to document tumor size and location before the PDT. All personnel in the room are required to wear appropriate eye protection, and the door to the OR is kept closed. Signs are posted on the OR door to notify personnel in the hallway that a laser is being used. The nurse places protective goggles on the outside of the door for anyone who must enter the room while the PDT treatment is taking place. He or she helps anesthesia personnel protect the patient’s eyes by placing moist eye pads on the patient’s eyelids and covering the pads with protective goggles or aluminum foil. If the patient is alert, the nurse may place the protective goggles directly over the patient’s sunglasses. He or she covers the patient’s exposed skin surfaces to prevent prolonged exposure to the red laser light. The physician chooses the proper laser fiber for use with each tumor before surgery and calculates the laser wattage and length of exposure according to the formula established by the FDA (eg, for treatment, 400 mW [630 nm] per cm length of diffuser is applied to the tumor for 8 to 12 minutes and delivers 200 to 300 J [watts x time = J] per linear cm of diffuser tip).6 If a 1.5 cm diffuser fiber is used, the tip on the laser fiber is 1.5 cm in length. The tip is the area where the laser light will exit the fiber. The physician sets the laser at 600 mW (400 mW per cm of diffuser length) and sets exposure time on the laser for 12.5 minutes, for a total tumor exposure of 450 J. Using the video image, the physician places the laser fiber interstitially or intraluminally. The physician begins PDT treatment and times it on the laser control. The physician can pause the laser if it is necessary to interrupt exposure time. Photodynamic therapy treatment of several sights may be necessary depending on the dimensions of the tumor. Upon completion of the laser-light 1491
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exposure, the physician removes the fiber and inspects the area being treated, takes final permanent pictures, and removes the endoscope. After surgery is completed, the surgical team transfers the patient to the surgical intensive care unit (SICU), using light precautions.
Postoperative Care
I
n the SKU, heavy shades protect the patient from bright lights. The patient is kept in the SICU to monitor for difficulties in breathing or swallowing that may occur from edema induced by the PDT. After 48 hours, the SICU nurse transfers the patient to the OR for debridement of the tumor and, if necessary, retreatment of any residual tumor with the laser. This is performed under the same conditions as the first surgery. Under direct vision or by viewing the video screen, the physician inspects the treated area and debrides any necrotic tissue. In addition to videotaping this procedure, still photos are taken to document any tumor change. If the patient receives a second PDT treatment, he or she will return to the OR 2 to 3 days later. At that time, the physician will perform endoscopy for video documentation and to debride the necrotic tumor. Following this surgery, the physician discharges the patient from the hospital when the patient’s medical condition permits. If the patient did not receive a second PDT treatment during his or her second visit to the OR, the physician will schedule the patient to return to the OR within 24 to 48 hours. The final PDT treatment in a series must be given within one week of DHE injection. During the final visit to the OR, the physician debrides the tumor mass, videotapes and photographs the procedure, and sends the debrided tissue to histology for microscopic examination. After discharge from the hospital, the patient returns for follow-up endoscopies as dictated by FDA guidelines. These guidelines include follow-up endoscopies one week after treatment and then monthly for three months. The patient 1492
then has endoscopies at six, 12, and 18 months after treatment.
Summary
A
lthough still under investigation, clinical applications of PDT appear to have positive results. The success of PDT is being confirmed as investigative sites throughout the world are reporting remarkable result^.^ Researchers hope that this will be one of the bright spots in the treatment of cancer. 0
Notes 1. D M Oleske, “Epidemiologic principles for nursing practice: Assessing the problem and planning its control,” in Cancer Nursing: A Comprehensive Textbook, ed S B Baird, R McCorkle, M Grant (Philadelphia: W B Saunders Co, 1991) 95-96. 2. R L Lipson, E J Baldes, A M Olsen, “Hematoporphyrin derivative: A new aid for endoscopic detection of a malignant disease,” Journal of Thoracic and Cardiovascular Surgery 42 (November 1961) 623-629. 3. K A Ball, Lasers: The Perioperative Challenge (St Louis: The C V Mosby Co, 1990) 1.53. 4. J S McCaughan, Jr et al, “Photodynamic therapy for esophageal tumors,” Archives of Surgery 124 (January 1989) 74-80. 5. Information for Patients Receiving Photodynamic Therapy (Milwaukee: St Luke’s Medical Center/Aurora Health Care, 1990). 6. T J Dougherty, “Photodynamic therapy: Status and potential,” Oncology 13 (July 1989) 6773. 7. Ball, Lasers: The Perioperative Challenge, 1.53. Suggested reading McCaughan Jr, J S, et al. “Photodynamic therapy of endobronchial tumors.” Lasers in Surgery and Medicine 6 (1986) 336-345. Professional nurses are invited to submit clinical or managerial manuscripts for the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal, I01 70 E Mississippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal, papers submitted for home study programs should not have been previously published or submitted simultaneously to any other publication.
hxamination PHOTODYNAMIC THERAPY FOR BRONCHIAL AND ESOPHAGEAL TUMORS
1. Photodynamic therapy (PDT) combines hematoporphyrin dye and red laser light to destroy cancer cells. How is this accomplished? a. Tumors are painted with the dye and exposed to laser light, which causes q m o r necrosis. b. , ematoporphyrin dye is injected IV.It is ’ absorbed by all cells but retained in cancer cells in high concentrations, which, when activated by exposure to red laser light, causes the cells to necrose. c. Tumors are injected with hematoporphyrin dye and are unable to excrete the dye. When these tumors are exposed to red laser light, tissue necrosis occurs. d. The hematoporphyrin dye causes the tumors to fluoresce, thus making their identification easier. When identified, the laser is used to excise the tumor. 2. Injection of hematoporphyrin dye causes in all patients. a. sensitive hearing b disorientation L, ’c2hotosensitivity d. hypersensitivity 3. Photodynamic therapy first was investigated when it was discovered that tumor cells would produce a red-orange fluorescence when exposed to /;t sunlight ( p. ultraviolet light c. black light d. lasers 4. The hematoporphyrin dye used in PDT has a high affinity for which tissues? a. heart, lungs, brain
”--
1494
?liver, skin, tumors LJ ,
c. skin, hair, liver d. eyes, connective tissue, bones 5. The light-activated dye causes destruction of malignant cells by causing the release of
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AORN JOURNAL
Photodynamic Therapy for Bronchial and Esophageal Tumors FERIOPERATIVE IMPLICATION s Carol Kitzrow. RN ancer remains one of our most challenging health care problems, debilitating and killing thousands of people each year.’ Many new treatments and drugs appear on the horizon as we continue to search for ways to eliminate this disease. One of these new treatments, photodynamic therapy (PDT), attempts to eliminate cancer cells with minimal surgical intervention.
C
History
I
n the 1920s, researchers began to investigate this therapy when they discovered that tumor cells would produce a red-orange fluorescence when exposed to ultraviolet light. In 1961, researchers demonstrated enhanced tumor fluorescence by using an intravenous hematoporphyrin derivative dye prepared from hemoglobin.2 In 1978, researchers began to explore combinations of specific light and hematoporphyrin dye to discover what combination would produce the most impressive tumor death rates.? Currently, multi-site, phase 111, investigative clinical trials of PDT are being conducted under the guidelines of the US Food and Drug Administration (FDA).
to red laser light in the 630 nanometer (nm) range.4 This laser light activates the dye and causes tumor cell necrosis. The physician administers D H E intravenously 48 to 72 hours before the patient’s surgery date. The drug is absorbed by all the cells in the body and leaves the patient highly photosensitive for six to eight weeks following injection. Dihematoporphyrin ether has a high affinity for the tissues of the liver, skin, and cancerous tumors. It is excreted by the body in the urine and bile; however, normal cells are able to excrete it more rapidly than tumor cells. Because of this, tumor cells retain the dye at a level that causes tumor death when the tumor is exposed to red laser light.
Photodynamic Therapy
P
hotodynamic therapy is used to treat cancer by injecting the patient with IV dihematoporphyrin ether (DHE) dye, also known as Photofrin 11, and exposing him or her
Carol Kitzrow, RN, CNOR, is the surgical speciulty rnanager,for general und laser surgery at St Luke’s Medical Center, Milwaukee. She earned her diploma in nursing ut Milwaukee ( W i s ) County General Hospital School of Nursing. 1483
JUNE 1992, VOL 5 5 , NO 6
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Fig I . Laser used for photodynamic therapy.
Injection of DHE causes photosensitivity in all patients. It may also cause the following side effects: nausea and vomiting, fever, erythema, exudation at the injection site, and ocular photosensitivity. At St Luke’s Medical Center, Milwaukee, we use a tunable argon dye laser to generate the red light necessary for activation of DHE retained within the tumor cells (Fig 1). The light-activated dye causes destruction of the malignant cells by causing the release of singlet oxygen (ie, peroxide) within the cells. The normal cells of the esophagus and bronchus may have some slight reaction after exposure to laser light, but 48 hours after the initial laser treatment these cells appear normal, while the 1484
tumor shows obvious reaction and necrosis.
Preoperative Procedure
0
ur PDT clinical trials began under the direction of M. Mirhoseini, MD, in conjunction with Lederle Laboratories for QLT Phototherapeutics, Inc, Vancouver. Our areas of investigation have included partially and completely obstructing bronchogenic and esophageal carcinomas. We assign patients to the comparative, random study according to the guidelines developed by the FDA, and the study director assigns their form of therapy. In order to become part of the bronchial tumor clinical trial, patients must be at least 18 years of age, have inoperable bronchogenic cancer, and have a non-small-cell tumor that has been confirmed by biopsy. Conditions that
JUNE 1992, VOL 55, NO 6
__
exclude a patient from this group include pregnancy, tracheal or carinal lesions, previous pneumonectomy, or major blood vessel involvement by the tumor. To be involved in the esophageal tumor study, patients must be at least 18 years of age, have inoperable esophageal cancer, have refused surgical treatment of the cancer, and have no contraindications to esophagoscopy. Criteria that are used to exclude patients from this group are pregnancy, tracheal or carinal tumor involvement, complete esophageal obstruction, and previous treatment with PDT or the neodymium ytirium aluminum garnet (Nd:YAG) laser. All patients in these studies sign a special consent form that explains individual study details. The physician must explain the following to all study patients: duration of participation in the study, treatment procedure, required follow-up evaluations, possible side effects and risks of treatment, to whom their medical records will be released, and the voluntary nature of the study. After the patient decides to participate, he or she receives a booklet explaining photosensitivity and the precautions that must be taken for 4 to 6 weeks after injection of DHE.’ The booklet explains that exposure 1 o bright light will cause bums that are similar to a severe sunburn. The patient is told that he or she will need to keep room lights dim and window shades drawn. The protection of all skin ,surfaces is detailed (ie, socks, long pants, long sleeves, gloves, a broadbrimmed hat, sunglasses if leaving the hospital room for tests at any time) The booklet explains that if transported by cart, the patient must cover his or her face with a sheet while moving through the lighted hospital halls. The patient is encouraged to remain active by walking in the halls after visiting hours when the lights can be dimmed. The health care team plans an evening discharge so that it is dark when the patient leaves the hospital. The nurse explains that after dis-
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charge, the patient can make excursions outside of the home, but these should be planned for the evening hours. The nurse also reminds the patient that although holiday lighting is not bright, his or her skin is susceptible to the light given off by red and blue Christmas bulbs. The patient is taught to check for continued photosensitivity after six weeks. If no severe reaction occurs, the patient gradually can re-expose himself or herself to sunlight over several weeks’ time. Our hospital protocol requires that any patient scheduled for general anesthesia or physician-administered IV sedation must have a chest x-ray within the previous six months, a current history and physical, a complete blood count, and a urinalysis. If the patient is more than 40 years old, an electrocardiogram (ECG) also is required. The physician uses the patient’s height and weight to determine what dosage of DHE to administer. He or she orders a computed tomography (CT) scan of the chest if the patient has a bronchial tumor or a CT of the esophagus and liver if the patient has an esophageal tumor. The patient with pulmonary involvement must undergo complete pulmonary function studies. The physician also orders a biochemical survey that evaluates the patient’s serum levels of sodium, potassium, chloride, carbon dioxide, glucose, blood urea nitrogen (BUN), calcium, phosphorus, total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lactic acid dehydrogenase (LDH), alkaline phosphotase, uric acid, cholesterol, and triglycerides. All other orders are individualized based on the patient’s condition and anesthesia preference. On the day before surgery, the perioperative nurse or the postanesthesia care unit (PACU) nurse visits the patient and completes a patient care data sheet, which includes the following information: patient allergies; past medical and surgical history; a physical assessment of height, weight, blood pressure range, and skin condition; emotional assessment; and the patient’s vision and hearing capabilities. During the preoperative assessment, the
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JUNE 1992, VOL 55, NO 6
Fig 2 . Video system for photodynamic therapy. nurse reviews the chart for abnormal laboratory values, x-ray, and ECG results and notes any routine medications the patient is taking. If the patient will need oxygen during transport to the OR or other specialized care, the nurse notes it on the perioperative care plan. A copy of this information is distributed to the holding area, the OR, and the PACU. The nurse assesses the patient’s knowledge of the procedure and answers any questions the patient may have at this time.
Case Preparation
W
e have a case-cart system that enables OR personnel to order the appropriate c a s e c a r t t h e day before the patient’s surgery. If we are treating an esophageal tumor, arrangements are made with our outpatient department diag1486
nostic and treatment center to borrow an esophagoscope and biopsy forceps. A dualchannel bronchoscope is available in the OR for bronchial tumor procedures. On the day of surgery, the perioperative nurse sets up the flexible bronchoscope or esophagoscope and checks the light source, suction, and air jets to ensure that they are functioning correctly. The nurse connects the irrigation bottle to the esophagoscope and checks its function. He or she also sets up a rigid bronchoscope or esophagoscope, with suction available, for emergency use. If major bleeding occurs during the procedure, it may be impossible for the surgeon to gain adequate c o n t r o l of a bleeding vessel through a flexible scope. Medications used for a local procedure are 2% tetracaine hydrochloride topical (ie, 2% Pontocaine), 0.5% dyclonine hydrochloride
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JUNE 1992, VOL 55, NO 6
Fig 3. Perioperative nurse (left), with the assistance of a biomedical laser technician (right), must tune the laser until the laser beam registers in the crosshatches of the spectroscope. topical (ie, 0.5% Dyclone), and 1% lidocaine (ie, 1% Xylocaine). Anesthesia personnel may request that midazolam (ie, Versed), fentanyl (ie, Sublimaze), alfentanyl (ie, Alfenta), or sufentanyl (ie, Sufenta) be available to sedate the patient. Phenylephrine (ie, Neosynephrine) diluted to a concentration of 0.1 mg/mL a l s o should be available. If bleeding occurs, the phenylephrine solution can be sprayed through the scope onto the bleeding site. The FDA requires that videotape records and still photos be taken of the procedure as part of this study. W e use a videotape recorder system (Fig 2) that has an in-line printer. The perioperative nurse assembles the camera and secures the adapter for the scope in use. He or she also confirms that there is adequate film in the printer. When that is accomplished, the nurse types patient 1488
information (eg, date, medical record number, area b e i n g t r e a t e d , t h e surgeon of record) onto the monitor screen, and this is recorded on the videotape. The same videotape is used to record each of the patient’s sessions in the OR and each of his or her follow-up examinations. The nurse disinfects the laser fibers by precleaning them and soaking them for 20 minutes in a 2% glutaraldehyde solution that has a 14-day use limit (ie, 14-day Cidex). Care is taken not to submerge the end of the laser fiber where it connects to the laser. While the fibers are soaking, the nurse initiates the warm-up required to use the laser. After the laser has had sufficient time (eg, 30 minutes) to warm up, the nurse prepares it for use during the treatment. Using a spectrascope and a test fiber, the nurse tunes the laser to emit a light beam at exactly 632 nm
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JUNE 1992, VOL 55, NO 6
Fig 4. The biomedical laser technician determines the laser output using the power meter.
(Fig 3). Just before treating the patient, the nurse determines the power output by inserting the “sterile” laser fiber into the power meter and setting the laser at a predetermined wattage. To d o this, the nurse inserts the fiber into the gas-sterilized glass sleeve that fits into the power meter (Fig 4). This process is repeated with each fiber used during the PDT treatment. It also is repeated after we finish using a fiber to determine if there is any significant discrepancy in the amount of power being delivered through the fiber. T h e n u r s e m u s t r e c o r d b e g i n n i n g wattage output and ending wattage output on the patient’s record. Because OUT patients require light precautions, we provide at least three flashlights in the OR. One flashlight is for anesthesia personnel, one is for the laser technician, and one is for the circulating nurse. Everyone in the room must wear helium-neon goggles with an 1490
optical density of six at 632 nm. Operating room light is supplied via a filtered x-ray view box; all other lights in the room are tur2ed off. The OR hall lights are dimmed to decrease patient exposure that could occur from traffic entering and leaving the room.
Intraoperative Procedure
0
n the day of surgery, OR personnel transport the patient, under light precautions, to the surgical holding area. In the holding area, a room is equipped where the patient can wait safely until the surgical team is ready to begin. The lights are dimmed, a curtain is drawn across the door, and the patient is given a call light. It is here that the anesthesia personnel start the patient’s IV, if one is not already in place, and where the preoperative assessment is completed. When the OR is ready, the circulating nurse
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transports the patient to the room, and helps him or her move to the OR bed, and places the safety strap across the patient’s thighs. The anesthesiologist begins to monitor the patient; this includes the insertion of an arterial line and a central venous pressure line, and, if necessary, the insertion of a pulmonary artery catheter line. The nurse assists the anesthesiologist as needed and offers emotional support to the patient during these procedures. Every patient is monitored with an ECG, and a pulse oximeter is used to determine the patient’s oxygen saturation. The anesthesiologist draws a baseline arterial blood gas and, if the patient is a diabetic, a serum glucose level. The anesthesiologist may use general anesthesia or local anesthesia with IV sedation. The majority of patients with esophageal tumors are treated under IV sedation. If general anesthesia is used for treating a patient with a bronchial tumor, the anesthesiologist intubates the patient. After the anesthesiologist achieves adequate anesthesia, the surgical team positions the patient. The supine position is used if a bronchial tumor is being treated. The nurse tucks the patient’s left arm at his or her side and places a pillow under the patient’s knees. The nurse extends the patient’s right arm onto an arm board and covers it to protect it from exposure to laser and room light. When a patient with an esophageal tumor is being treated, the surgical team places the patient in a slightly lateral position. The nurse places a pillow behind the patient’s back for support and uses blankets between the patient’s legs and under his or her ankles to pad bony prominences. The nurse positions the patient’s arms comfortably in front of him or her. Following positioning, the surgeon inserts the flexible esophagoscope. Ice chips may be given to the patient to help him or her swallow the esophagoscope. The nurse must help the anesthesiologist monitor the patient. He or she also must explain the procedure and offer support to the awake patient. For patients with bronchial tumors, the physician passes the bronchoscope through the endotracheal tube. Initially, the physician locates the tumor
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under direct vision and connects the video camera to the endoscope. The circulating nurse begins recording the procedure. Previously performed biopsies have determined the nature of the patient’s tumor, but the physician may take more biopsies at this time. Permanent pictures are taken to document tumor size and location before the PDT. All personnel in the room are required to wear appropriate eye protection, and the door to the OR is kept closed. Signs are posted on the OR door to notify personnel in the hallway that a laser is being used. The nurse places protective goggles on the outside of the door for anyone who must enter the room while the PDT treatment is taking place. He or she helps anesthesia personnel protect the patient’s eyes by placing moist eye pads on the patient’s eyelids and covering the pads with protective goggles or aluminum foil. If the patient is alert, the nurse may place the protective goggles directly over the patient’s sunglasses. He or she covers the patient’s exposed skin surfaces to prevent prolonged exposure to the red laser light. The physician chooses the proper laser fiber for use with each tumor before surgery and calculates the laser wattage and length of exposure according to the formula established by the FDA (eg, for treatment, 400 mW [630 nm] per cm length of diffuser is applied to the tumor for 8 to 12 minutes and delivers 200 to 300 J [watts x time = J] per linear cm of diffuser tip).6 If a 1.5 cm diffuser fiber is used, the tip on the laser fiber is 1.5 cm in length. The tip is the area where the laser light will exit the fiber. The physician sets the laser at 600 mW (400 mW per cm of diffuser length) and sets exposure time on the laser for 12.5 minutes, for a total tumor exposure of 450 J. Using the video image, the physician places the laser fiber interstitially or intraluminally. The physician begins PDT treatment and times it on the laser control. The physician can pause the laser if it is necessary to interrupt exposure time. Photodynamic therapy treatment of several sights may be necessary depending on the dimensions of the tumor. Upon completion of the laser-light 1491
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exposure, the physician removes the fiber and inspects the area being treated, takes final permanent pictures, and removes the endoscope. After surgery is completed, the surgical team transfers the patient to the surgical intensive care unit (SICU), using light precautions.
Postoperative Care
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n the SKU, heavy shades protect the patient from bright lights. The patient is kept in the SICU to monitor for difficulties in breathing or swallowing that may occur from edema induced by the PDT. After 48 hours, the SICU nurse transfers the patient to the OR for debridement of the tumor and, if necessary, retreatment of any residual tumor with the laser. This is performed under the same conditions as the first surgery. Under direct vision or by viewing the video screen, the physician inspects the treated area and debrides any necrotic tissue. In addition to videotaping this procedure, still photos are taken to document any tumor change. If the patient receives a second PDT treatment, he or she will return to the OR 2 to 3 days later. At that time, the physician will perform endoscopy for video documentation and to debride the necrotic tumor. Following this surgery, the physician discharges the patient from the hospital when the patient’s medical condition permits. If the patient did not receive a second PDT treatment during his or her second visit to the OR, the physician will schedule the patient to return to the OR within 24 to 48 hours. The final PDT treatment in a series must be given within one week of DHE injection. During the final visit to the OR, the physician debrides the tumor mass, videotapes and photographs the procedure, and sends the debrided tissue to histology for microscopic examination. After discharge from the hospital, the patient returns for follow-up endoscopies as dictated by FDA guidelines. These guidelines include follow-up endoscopies one week after treatment and then monthly for three months. The patient 1492
then has endoscopies at six, 12, and 18 months after treatment.
Summary
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lthough still under investigation, clinical applications of PDT appear to have positive results. The success of PDT is being confirmed as investigative sites throughout the world are reporting remarkable result^.^ Researchers hope that this will be one of the bright spots in the treatment of cancer. 0
Notes 1. D M Oleske, “Epidemiologic principles for nursing practice: Assessing the problem and planning its control,” in Cancer Nursing: A Comprehensive Textbook, ed S B Baird, R McCorkle, M Grant (Philadelphia: W B Saunders Co, 1991) 95-96. 2. R L Lipson, E J Baldes, A M Olsen, “Hematoporphyrin derivative: A new aid for endoscopic detection of a malignant disease,” Journal of Thoracic and Cardiovascular Surgery 42 (November 1961) 623-629. 3. K A Ball, Lasers: The Perioperative Challenge (St Louis: The C V Mosby Co, 1990) 1.53. 4. J S McCaughan, Jr et al, “Photodynamic therapy for esophageal tumors,” Archives of Surgery 124 (January 1989) 74-80. 5. Information for Patients Receiving Photodynamic Therapy (Milwaukee: St Luke’s Medical Center/Aurora Health Care, 1990). 6. T J Dougherty, “Photodynamic therapy: Status and potential,” Oncology 13 (July 1989) 6773. 7. Ball, Lasers: The Perioperative Challenge, 1.53. Suggested reading McCaughan Jr, J S, et al. “Photodynamic therapy of endobronchial tumors.” Lasers in Surgery and Medicine 6 (1986) 336-345. Professional nurses are invited to submit clinical or managerial manuscripts for the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal, I01 70 E Mississippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal, papers submitted for home study programs should not have been previously published or submitted simultaneously to any other publication.
hxamination PHOTODYNAMIC THERAPY FOR BRONCHIAL AND ESOPHAGEAL TUMORS
1. Photodynamic therapy (PDT) combines hematoporphyrin dye and red laser light to destroy cancer cells. How is this accomplished? a. Tumors are painted with the dye and exposed to laser light, which causes q m o r necrosis. b. , ematoporphyrin dye is injected IV.It is ’ absorbed by all cells but retained in cancer cells in high concentrations, which, when activated by exposure to red laser light, causes the cells to necrose. c. Tumors are injected with hematoporphyrin dye and are unable to excrete the dye. When these tumors are exposed to red laser light, tissue necrosis occurs. d. The hematoporphyrin dye causes the tumors to fluoresce, thus making their identification easier. When identified, the laser is used to excise the tumor. 2. Injection of hematoporphyrin dye causes in all patients. a. sensitive hearing b disorientation L, ’c2hotosensitivity d. hypersensitivity 3. Photodynamic therapy first was investigated when it was discovered that tumor cells would produce a red-orange fluorescence when exposed to /;t sunlight ( p. ultraviolet light c. black light d. lasers 4. The hematoporphyrin dye used in PDT has a high affinity for which tissues? a. heart, lungs, brain
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?liver, skin, tumors LJ ,
c. skin, hair, liver d. eyes, connective tissue, bones 5. The light-activated dye causes destruction of malignant cells by causing the release of
