I. Standard hospitalization process of ALL clinical pathway for primary care children
(I) The standard hospitalization day is within 35 days.
(B) The criteria for entering the pathway.
1.The first diagnosis must meet the standard risk and intermediate risk group of patients with childhood acute lymphoblastic leukemia (ALL) disease code (ICD10: C91.002).
2.When the patient has other disease diagnoses at the same time, but does not require special treatment during hospitalization nor affect the implementation of the clinical pathway process for the first diagnosis, he/she can enter the pathway.
(C) Clear diagnosis and routine examination for admission takes 3-5 days (referring to working days).
1. Required examination items.
(1) Blood routine, urine routine, stool routine;
(2) Liver and kidney function, electrolytes, coagulation function, blood type, pre-transfusion examination;
(3) Chest X-ray, electrocardiogram, ultrasonography (including neck, mediastinum, heart and abdomen, testicles, etc.), fundus examination;
(4) Fever or suspected infection can be selected: pathogenic microbial culture, imaging;
(5) Bone marrow examination (morphology including histochemistry), immunophenotyping, cytogenetics, leukemia-related genetic testing;
(6) Cerebrospinal fluid routine, biochemical and cytomorphological examinations, intrathecal injection of chemotherapeutic drugs within 4 days of the start of treatment;
2.Selectable tests according to the situation: MRI or CT of the head, neck and chest, lateral spine films, EEG, blood gas analysis, etc.
3.The patient and family members sign the following consent forms: notice of serious or critical illness, consent form for bone puncture, consent form for lumbar puncture and intrathecal injection, informed consent form for chemotherapy, informed consent form for blood transfusion, and consent form for intravenous cannulation (when available).
(D) Pre-chemotherapy preparation.
1.Patients with fever are recommended to have immediate pathogenic microbial culture and use antimicrobial drugs. Cephalosporins (or penicillins) can be used for anti-inflammatory treatment, and those whose fever does not remit after 3 days can be considered for replacement with carbapenems and/or glycopeptides and/or antifungal treatment; patients with clear organ infections should choose the appropriate antimicrobial drugs according to the site of infection and pathogenic microbial culture results.
2. For patients with Hb80g/L, PLT20×109/L or with active bleeding, transfusion of concentrated red blood cells, single or multiple platelets, respectively. If you have cardiac insufficiency, you can relax the indication of blood transfusion.
3. Patients with coagulation abnormalities, transfuse relevant blood products. Fibrinogen 1.5g/L, transfusion of fresh plasma or concentrated fibrinogen.
(E) Chemotherapy is started on day 1-5 of diagnosis.
(F) Chemotherapy regimen.
VDLP(D) regimen.
Vincristine (VCR) 1.5 mg・m-2・d-1 once a week for 4 times, with a maximum absolute dose of no more than 2 mg each time.
Zolpidem (DNR) 30mg・m-2・d-1 once a week for 2-4 times.
L-asparaginase (L-asp) 5000-10000u・m-2・d-1 for 6-10 times.
Prednisone (PDN) 45-60mg・m-2・d-1, d1-28, decreasing to stop on day 29-35. Or PDN 45-60mg/m-2/d-1, d1-7,dexamethasone (DXM) 6-8mg/m-2/d-1, d8-28, tapered to stop on day 29-35.
PDN trial d1-7, starting from 25% of the full dose, gradually increase to full dose according to clinical response, cumulative dose >210mg・m-2 in 7 days, for patients with large tumor load, the starting dose can be reduced (0.2-0.5mg・kg-1・d-1) to avoid tumor lysis syndrome, assessed on day 8.
(VII) The examination items that must be reviewed after chemotherapy.
1.Blood routine, urine routine, stool routine.
2.Naive cell count in peripheral blood smear on day 8 of chemotherapy.
3.Bone marrow morphology on the 15th and 33rd day of chemotherapy, and micro residual lesion detection if available.
4.Cerebrospinal fluid examination.
5.Liver and kidney function, electrolytes and coagulation function.
6.Organ function assessment.
7.All examinations with leukemic cell infiltration changes before treatment.
8.In case of infection, various body fluid or secretion cultures, pathogenic examinations, and relevant imaging examinations need to be repeated several times.
(H) Treatment during and after chemotherapy.
1.Infection control.
(1) Give compound sulfisofazole to prevent Pneumocystis carinii pneumonia.
(2) Patients with fever are recommended to have an immediate pathogenic microbial culture and use antibacterial drugs. Cephalosporins (or penicillins) can be used for anti-inflammatory treatment, and those whose fever does not resolve after 3 days may be considered for replacement with carbapenems and/or glycopeptides and/or antifungal treatment; patients with definite organ infections should choose the appropriate antibacterial drugs according to the site of infection and pathogenic microbial culture results.
(3) Intravenous infusion of gammaglobulin is available for severe infections.
2. Corresponding prevention and treatment of organ function damage: antiemetic, hepatoprotective, hydration, alkalinization, prevention and treatment of uric acid nephropathy (allopurinol), acid suppressant, etc.
3.Component transfusion: for patients with Hb80g/L, PLT20×109/L or active bleeding, transfusion of concentrated red blood cells, single or multi-collected platelets respectively, if there is a tendency of DIC, then PLT50×109/L should be transfused with platelets, and use other DIC treatment drugs such as heparin. If there is cardiac insufficiency, the indication for transfusion can be relaxed.
4. Hematopoietic growth factor: If the absolute value of neutrophils (ANC) is ≤1.0×109/L after chemotherapy, granulocyte colony-stimulating factor (G-CSF) 5μg・Kg-1 ・d-1 can be used.
(ix) Discharge criteria.
1.Generally good condition.
2. No complications and/or comorbidities that require hospitalization.
(J) Variation and cause analysis.
1, Those with infection, anemia, bleeding and other comorbidities before, during and after treatment need relevant diagnosis and treatment, which may prolong hospitalization and lead to increased costs.
2. Those who do not achieve complete remission with induction remission therapy withdraw from the pathway.