Nursing care of a patient with programmed cell death protein‑1 immunotherapy‑related myocarditis combined with coronary heart disease

ABSTRACT This report introduced and summarized the nursing care experience for a senior patient with lung cancer and developed programmed cell death protein 1 (PD‑1) immunotherapy‑related myocarditis combined with coronary heart disease (CHD) after receiving said treatment. In this case,immune myocarditis with CHD occurred shortly after implementing the PD‑1 immunotherapy, yet the patient presented no clinical symptoms.Frequent nursing attention and close observation are so required for monitoring the patient’s status and updating the physicians for a swift control of the myocarditis. For this case, nursing care procedures vital for the successful recovery of the patient included condition observation,position management, pre‑ and postcoronary angiography care, infection prevention, hemorrhage prevention, venous access port maintenance,pain care, trachea care, psychological care, diet care, environment management, and health education. After receiving effective, successful treatment and care, the patient was discharged after 13 days of treatment with generally satisfying overall conditions.

Keywords: Coronary heart disease, lung cancer, myocarditis, nursing care, programmed cell death protein 1

INTRODUCTION

Lung cancer is the most frequent type of cancer worldwide.In 2018, more than 1.7 million people died of lung cancer,comprising 18.4% of all cancer-related deaths.[1]There are basically two main histopathological types of lung cancer, which also differ clinically, i.e., nonsmall-cell lung cancer (NSCLC, 80%–85% of lung cancer cases) and small-cell lung cancer (10%–15% of cases).[2]Immune checkpoint inhibitor (ICI) therapy has revolutionized cancer treatment in the past decade. Antibodies against programmed cell death protein 1 (PD-1) or programmed cell death-ligand 1 have been used in the treatment of lung cancer and significantly improved the prognosis of NSCLC patients.[3]However, when treating patients with ICIs, immune-related adverse events (irAEs)can occur in any organ and any tissue.[4]At the same time,although cardiac irAEs are relatively rare compared to irAEs in other organs, they have a higher mortality rate.[4]The most common clinical manifestation of immunotherapy-related cardiotoxicity is myocarditis, which is associated with poor prognosis, as mortality varies between 27% and 46%.[5,6]At present, data on cardiac toxicity from ICIs in patients with lung cancer are scarce,[7]there are few cases of immune myocarditis caused by immunotherapy, and successful treatment and recovery requires close cooperation between doctors and nurses. In this paper, we reported nursing care experience for a senior patient with lung cancer and developed PD-1 immunotherapy-related myocarditis combined with coronary heart disease (CHD) after receiving said treatment.

CASE REPORT

An 82-year-old female was admitted to the hospital on September 10, 2020, after intravenous chemotherapy with micro-ossification suppression and leukopenia. She underwent invasive surgery in the lower lobe of the left lung, thyroidectomy, cataractectomy, colon polypectomy, and cesarean section. The patient had a history of hypertension for 5 years, currently under good control by taking levamlodipine besylate. After receiving a complete thyroidectomy, the patient was taking Euthyrox as a levothyroxine supplement.The patient was also under clopidogrel therapy for treating CHD. PD-1 immunotherapy (toripalimab) was initiated on July 24, August 17, 2020. After admitted, the patient complained about significant radiating pain, while physical therapy revealed edema in both lower extremities and right side in particular. Muscle strength was rated at 4+.Laboratory report suggested alanine aminotransferase at 104 IU/L, aspartate aminotransferase at 126 IU/L, creatine kinase at 3134.6 IU/L, lactate dehydrogenase at 784.6 IU/L,creatine kinase isoenzyme MB at 78 IU/L, and potassium at 3.1 mmol/L. Myocardial infarction-specific examination reported myoglobin at 894.4 ng/mL, creatine kinase isoenzyme MB at 39.41 ng/mL, troponin T at 0.238 ng/mL, and N-terminal B-type natriuretic peptide precursor at 14 pg/mL.The electrocardiogram (ECG) showed nonabsolute T-wave changes, but no clinically relevant symptoms and ECG indications, myocardial infarction was then ruled out.Coronary angiography was performed on September 18,2020, and was diagnosed as PD-1 immunotherapy-related myocarditis (ICI-related myocarditis) after a multidisciplinary consultation. Immune myocarditis was caused by immunotherapy. The patient was in critical conditions and was treated with methylprednisolone, prednisone,omeprazole, nicotinamide combined with coenzyme Q, and potassium citrate. Myocardial infarction-related markers and myocardial enzyme profile were checked on a daily basis;the patient was also on 24-h dynamic ECG. After a series of treatment and nursing care, the patient was discharged on September 23, 2020, in good condition.

Nursing Condition observation

Immunotherapy-related myocarditis is a side effect with a high mortality rate and currently has no generally recognized and effective treatment method, yet hormone shock therapy is usually used. The patient has no relevant clinical symptoms and requires nursing staff to be alert to whether the patient has fatigue, palpitation, nausea, chest tightness, chest pain,dyspnea, and other symptoms. Vital signs need to be checked frequently, and 24-h dynamic ECG was used to monitor the appearance of abnormal ECG. A variety of first-aid drugs and items should be kept available at all time. Intravenous port should be kept unobstructed and away from unauthorized adjustment. Drugs should be used rationally with relevant adverse reactions closely monitored.

Position management

The patient needs to maintain absolute bed rest, as exercise will increase the heart rate, requiring stronger contraction of the myocardium, which will significantly damage the myocardium. In extreme cases, significant damage may cause heart failure and arrhythmia.

Pre‑ and post‑coronary angiography care

Sufficient communication is of great importance in getting patients’ cooperation as patients may lack understandings of the procedure’s necessity and importance. Patients are required to hold their breath at times, and after the film is taken, the patients are required to cough vigorously to facilitate the discharge of the contrast agent from the coronary arteries. In this case, the patient was asked to train for breath holding and vigorous coughing before surgery, and routinely to do iodine allergy test before the procedure, and have her vitals observed. On the day of the procedure, the patient should be instructed to intake a proper amount of food, wear open-chested clothes, and not to wear any metal jewelry. After the procedure, ECG should be monitored to detect any arrhythmia on time; oxygen inhalation should be given at the rate of 1–2 mL/h. Injection site on the right hand size should be monitored closely for any possible hematoma.Special attention should also be given to the radial artery pulsation. Patients should drink much water in the early postoperative period, especially drinking 400 ml/h in the first 3 h after the operation, to promote the removal of contrast agent from the body as soon as possible.

Prevention of infection

In cancer patients, when agranulocytosis occurs due to bone marrow suppression after chemotherapy, body’s immune system is as so suppressed and making patients vulnerable to bacteria, viruses, and fungi. This type of infection is difficult to control and cannot be treated by improving the patient’s own resistance through isolation of the source of infection and vaccination. Therefore, it is of great significance to prevent such infections from happening at the beginning. It is required to strengthen the disinfection and management of the ward environment, ventilate the ward twice a day every morning and evening, keep the room temperature at 25°C–26°C and the relative humidity at 50%–60%, and use 1000 mg/L sodium hypochlorite disinfectant to mop the floor and wipe the surface twice a day. Health-care workers should operate in strictly aseptic conditions, minimize unnecessary invasive procedures,and keep maintenance of all tubes as well as catheters.

Traditional Chinese medicine theory suggests patting the back of the patient at 7:00, 11:00, and 19:00 every day for expectoration being most effective as septum excretion at the maximum quantity at said time.[8]The patient was assisted to take a comfortable lying posture, guided to take 5 deep breaths, keep the mouth open at the end of the fifth deep breath in, then cough up sputum repeatedly to the throat, and lastly cough very vigorously to excrete accumulated sputum.

Prevention of thrombosis and bleeding

The patient needs to be in absolutely bed rest due to the condition. This patient scored 9 points in the Caprini system, indicating a high risk of venous thromboembolism.Therefore, drug prevention and physical prevention for venous thromboembolism are required. The patient takes clopidogrel for a long time to inhibit platelet aggregation and prevent thrombosis. In addition, the patient is instructed to perform leg flexion and extension activities on the bed. However,because the patient has a history of bleeding, the color of the patient’s face, eyelids, lips, gums, and nail bed should be closely observed and the patient is informed that the time required to press the puncture site after injection should be extended to prevent the formation of bleeding and hematoma.The patient should inform the medical staff in time if abnormal ecchymosis, congestion, hematuria, and melena occur.

Nursing care of complete implantable venous access ports

The patient’s immune system is low due to her advanced age and chemotherapy, which increases the risk of infection.When maintaining the venous access ports, medical staff should operate in a strictly aseptic environment and follow standard operating procedures. When performing noninvasive needle puncture, medical staff should always wear sterile gloves and disinfect the skin with 75% ethanol first and then use povidone–iodine solution to disinfect the skin three times in a spiral pattern from inside to outside,clockwise, and then counterclockwise with a range of 12 cm × 12 cm to reduce the occurrence of local infection,in addition, guide the patients to keep the skin clean and dry around the infusion port.

Pain management

In the process of pain management, the primary responsibility of nurses was to screen, evaluate, and record the pain of the patient and report to the doctor for timely treatment as required. As for radiation pain in the lower extremities caused by degenerative spine, it is recommended for the patient to stay in bed absolutely to prevent compression,take analgesics according to the doctor’s advice, and ask her family to press Weizhong acupoint for relieving the pain. We used the visual analog scale to assess the degree of pain and encouraged the patient to express her feelings.

Psychosocial support

The diagnosis and treatment of cancer are stressful events,patients might face fears, uncertainties, distress, and have certain psychosocial needs.[9]When serious irAEs such as myocarditis occur during PD-1 treatment, immunotherapy must be stopped, which may cause fear, anxiety, and disappointment to patients and their family members. On the one hand, they worry about the serious consequences of myocarditis. On the other hand, stopping immunotherapy means stopping cancer treatment. Through comfort and encouragement, nurses mobilize family members to provide strong support and do a good job of psychological counseling for patients. In performing various procedures, nurses should be both stable and swift as to secure a trusted relationship with the patient. The responsible nurses should make effective communication with patients, pay much attention to their needs, as well as feedback illness-related treatment and nursing information to them, to help them to keep abreast of illness, build up the confidence, and maintain a good mental state to overcome the disease.

Nutrition support

Tumor consumption could cause nutritional problems for patients.[10]The patient stayed in bed for a long time, resulting in poor body activity and gastrointestinal peristalsis, and inadequate diet. It is recommended for patients to eat small and frequent meals to reduce gastrointestinal burden, intake of nutritious and high-protein foods, such as milk and eggs,to avoid irritating foods, and to choose the patient’s favorite diet when her appetite is poor. To avoid a bland and boring diet, new foods can be tried as the conditions permit.

Discharge guidance and follow‑up

The patient was instructed to follow the doctor’s advice to continue hormone therapy and make regular outpatient follow-up reviews. The patient should seek medical attention when symptoms worsen. In a dietary perspective, the patient was instructed to eat nutritious and easy-to-digest diets, especially foods rich in Vitamin C. Resting is also of great significance, the patient should rest at least about 3 months. Necessary and proper exercise is encouraged to enhance resistance. It is recommended to prevent all kinds of infections, especially to avoid cold.

CONCLUSION

For this patient with myocarditis caused by immunotherapy,nurses need to maintain a high degree of vigilance since admission, keep close cooperation with the doctor to make relevant examinations and preparations for rescue according to the patient’s condition, and closely observe the condition to ensure the patient’s vital signs to be stable, while giving the patient’s psychology nursing, paying attention to pain care, diet care, and prevention of bleeding and infection. After treatment and careful nursing care by medical staff, the patient’s condition was basically stable without infection and bleeding in the hospital. At the same time, for patients with advanced age, cancer metastasis,CHD, and myocarditis, caregivers are prone to fatigue due to the greater need for care. Therefore, hospitals and community medical staff should increase education to the patient’s family members, inform relevant knowledge and pay attention to changes in the patient’s condition at home,and respond in time.

Declaration of patient consent

The author certifies that she had obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.