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24 Cards in this Set
- Front
- Back
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Tumor lysis syndrome:
Tumor lysis syndrome (TLS) refers to the ... abnormalities resulting from massive tumor cell death at the onset of therapy, with associated complications Leukemias/lymphomas are associated with TLS: -T-cell ALL -Lymphoblastic lymphoma -Burkitt’s lymphoma -AML with ... WBC count High S phase cell fraction in lymphomas and leukemias -Massive death of tumor cells at ... of therapy -Release of cellular contents into the bloodstream |
electrolyte
high onset |
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Electrolyte disturbances in tumor lysis syndrome:
... -Rapid increase in potassium may lead to cardiac arrest ... -Uric acid crystals form in renal tubules --> renal failure ... -Precipitates out in small vessels and renal tubules (CaPO4) Hypocalcemia - secondary |
Hyperkalemia
Hyperuricemia Hyperphosphatemia |
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Minimizing tumor lysis syndrome:
Hydration - ... at least twice the maintenance rate Alkalinization - Addition of ... to IV fluids - Goal urine ph 7.0-7.5 Drugs that help reduce uric acid levels - Allopurinol – blocks formation of uric acid - ... – enzyme that breaks down uric acid to allantoin No chemotherapy until: - Existing abnormalities are at least improved - Good output of alkaline urine Frequent monitoring of electrolytes |
IV fluids
sodium bicarbonate Uricase |
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Tumor lysis syndrome: additional considerations:
Patients with signs of tumor lysis syndrome require ... monitoring No ... in the IVF for the first few days Poor ... function at presentation (marked uremia, oliguria) = indication for hemodialysis prior to starting chemotherapy ... is a consequence of hyperphosphatemia -Should not be treated unless symptomatic |
ICU
potassium renal Hypocalcemia |
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Hyperleukocytosis:
Presence of >100,000 WBCs/microliter Factors in leukostasis -Hyperviscosity -... to damaged endothelium High cell counts in ALL or AML associated with: -... accidents (strokes) -... disturbances (as in tumor lysis syndrome) -Pulmonary hemorrhage |
Adherence
Cerebrovascular Electrolyte |
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Hyperleukocytosis:
Symptoms -CNS *Confusion *Blurry vision *Headache *Lethargy -Pulmonary *Difficulty breathing (...) *Hypoxia Management -... – filtering off WBC’s -... - take out blood, put in blood -Prompt onset of chemotherapy |
dyspnea
Leukapheresis Exchange transfusion |
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“categories” of oncologic emergencies:
...-associated -Superior vena cava syndrome -Pleural effusions -Hyperleukocytosis -Cord-compression -Obstructive hydrocephalus ...-associated -“ATRA” syndrome -Tumor lysis syndrome -Hemorrhagic cystitis -Veno-occlusive disease ...-associated -Sepsis -Typhlitis |
Tumor
Therapy Infection |
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Cardiorespiratory emergencies: Superior vena cava syndrome:
Definition -Constellation of symptoms arising from external ... or thrombosis of the SVC -“Superior ... syndrome” *Refers to compression of the trachea in addition to the SVC Occurrence in cancer patients -Most common in the ... and ... -Often the presenting sign in childhood lymphoblastic lymphoma |
blockage
mediastinal leukemias and lymphomas |
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Cardiorespiratory emergencies: Superior vena cava syndrome:
Predisposition of the SVC to compression -Thin, compliant endothelial wall -Adjacent ... of mediastinum/thymus Mechanism -External compression of the SVC by tumor cells leads to restriction of venous return from the head and neck -Tracheal compression can also occur *More pronounced in ... patients |
lymph nodes
younger |
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Cardiorespiratory emergencies: Superior vena cava syndrome:
Clinical presentation -Cough -Difficulty ... -Visible swelling of soft tissues of head/neck -... lying down! Imaging -CXR *Mediastinal mass *Tracheal deviation -CT scan of neck/chest (if able) |
breathing
Worse |
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Cardiorespiratory emergencies: Superior vena cava syndrome:
Management -... should be your prime consideration *Anesthesia consultation *Avoid ... as much as possible Specific therapies -Emergent radiation to area of tumor -Steroids +/- chemotherapy -Surgery in some cases required Need for ... prior to treatment -If possible -Thoracentesis if pleural effusion -Peripheral lymph node biopsy -Marrow aspirate/biopsy |
Airway
sedation biopsy |
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Cardiorespiratory emergencies: Pleural/pericardial effusions:
Effusions -Fluid collecting in potential spaces -Responding to some underlying trigger Cancer patients may present with -... effusions (cancer cells) -... effusions (infection) -... effusions (fluid overload/CHF) Treatment -For malignant effusions, ... provides both relief and helps with diagnosis -May not recur once patient starts therapy -Some patients may require chest tube placement -Sclerosing agents can be used for recurrent fluid accumulation |
Malignant
Purulent Transudative thoracentesis |
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Cardiorespiratory emergencies: Cardiac tamponade:
Mechanism -Compression of ... ventricle from: *Pericardial malignant effusion *Post-radiation constrictive ... *Infection/inflammation of pericardium Clinical picture -Cough, difficulty breathing, chest pain -Hypotension, tachycardia, pulsus paradoxus -CXR may reveal large heart shadow -EKG may show low voltage complexes Therapy -Immediate: Oxygen, ... positioning -Definitive: Pericardiocentesis under radiologic guidance |
left
fibrosis upright |
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Therapy-related emergencies: ATRA syndrome:
ATRA = ... -Part of standard induction therapy for APL Biologic effects of ATRA -Induces proliferation/differentiation of leukemic blasts -Secondary ... Clinical manifestations -Respiratory distress *Pulmonary infiltrates *Pleural effusions -Fevers -Renal insufficiency Treatment - Dexamethasone - Hold ATRA |
All-trans-retinoic acid
hyperleukocytosis |
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Abdominal emergencies in cancer patients:
Related to immunosuppression -... (neutropenic enterocolitis) --> perforation -Pseudomembranous colitis Related to the underlying neoplasm -Ascites -Acute bowel obstruction *Burkitt’s lymphoma *Sacrococcygeal teratomas -Intussusception -Massive hepatomegaly *Infants with neuroblastoma Related to therapy -Severe ... (vincristine, opiates) -... disease (6-TG) |
Typhlitis
constipation Veno-occlusive |
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Hemorrhagic cystitis:
Most common causes in cancer patients: -Cyclophosphamide (Cytoxan) -Ifosfamide Mechanism -Breakdown metabolite of both agents (acrolein) -Caustic to bladder epithelium -Leads to bladder ... -Blood losses may be very large! Treatment -Co-administration of MESNA with either of the above drugs -Vigorous .../diuresis -Supportive care – transfusions, Foley with bladder irrigation |
hemorrhage
hydration |
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Neurologic emergencies in cancer patients: Elevated ICP (intracranial pressure):
Usually from ... Clinical signs -Infants/toddlers: Lethargy, vomiting, seizures, rapidly increasing head circumference with scalp vein prominence -Older children/adults: *Progressively worsening headaches ^Characteristically ... ^Present upon awakening Vomiting, 6th cranial nerve palsy *Late findings: Ataxia, lethargy, seizures |
obstructive hydrocephalus
occipital |
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Neurologic emergencies in cancer patients: elevated ICP:
Evaluation -Emergent ... Management -Neurosurgical consultation -IV dexamethasone -Mannitol -Hyperventilation |
brain CT
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Neurologic emergencies in cancer patients: Altered mental status:
... -Meningitis, encephalitis -Septic shock ... -Patients in the hospital are at risk (iatrogenic) -Naloxone (opiate reversal) -Flumazenil (benzodiazepine reversal) ... -Ensure doses given are appropriate -Accidental intrathecal vincristine |
Infection
Opiates Chemotherapy |
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Neurologic emergencies in cancer patients: Cord compression
May be the main presenting sign at diagnosis Can occur with almost any neoplasm ... pain in any patient with cancer should always be taken seriously -May reflect ... disease (adults) -May reflect ... tumor (children) Clinically presents as back pain (80%) -Advancing weakness, parasthesias, over time -Once overtly symptomatic, changes may be permanent |
Back
metastatic primary |
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Cord compression:
Management -High-dose ... (usually IV) *Given based on history/physical *Unavailability of prompt imaging not a reason to defer Prompt imaging of spinal cord via MRI Definitive therapies -Surgery: (especially if diagnosis not known) -...: (if diagnosis known and tumor responsive) -...(for leukemias/lymphomas) |
dexamethasone
Radiation Chemotherapy |
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Hypercalcemia of malignancy:
Levels above ... mg/dl --> multiple toxicities -GI: Vomiting/dehydration -Neurologic: Weakness, hypotonia -Cardiac: Bradycardias -Renal insufficiency Mechanisms -Deficient excretion by the ... -... resorption of bone *Abnormal osteoclast activation *PTH-like factor secreted by tumor (adults) Treatment -IV hydration/diuretics – Enhance calcium excretion -Prednisone/biphosphonates – Reduce calcium resorption |
12
kidneys Increased |
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Sepsis in the immunocompromised patient:
Multiple risk factors for serious infections: -Patients often immunocompromised from both therapy and underlying disease -Prolonged periods of ... with current multidrug regimens -Presence of indwelling central venous catheters -Prolonged hospitalization --> increased risk of nosocomial ... -Rapid progression of infection in neutropenic patients |
neutropenia
infections |
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Sepsis in the immunocompromised patient:
“Overattention” to fevers, even if otherwise well Prompt institution of IV ... -Ceftazidime -Vancomycin -Antifungals Management of shock -Adequate fluid resuscitation -ICU monitoring -“Call ahead” |
broad-spectrum antibiotics
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