305. Leukeamia Flashcards
How do you approach a leukeamic patient that feels unwell?
Take seriously, can deteriorate quickly
Bloo dcultures, FBC, U&E’s, LFt’s, Ca2+, glucose and clotting
Consider CNS bleeding
Discuss with patient aims of treatment
What neutropenic regimen should they abide by when in hospital?
Full barrier nursing
Avoid IM injections
Look for infection (mouth, axillae, perineum, IVI site)
Check FBC, platelets, INR, U&E, LFT, LDH,CRP, cultures, CXR
Wash perineum after defication
Oral hygiene (mouthwash every 2 hours)
Check vital signs 4 hourly
How do you use antibiotcs in those who are neutropenic
If fever then give piperacillin tazobactam and vancomycin
If fever persists despite antibiotics consider CMV or Fungi
What is tumour lysis syndrome?
Results in a high potassium, high urate and AKI. Low calcium
What is Hyperviscocity in those with leukaemia?
WCC can exceed 100 leading to thrombi forming in the brain, lung and heart.
Lower WBC with hydroxycarbamide or leukapheresis
What is DIC
Release of pro coagulants into the circulation causes widespread activation of coagulation consuming factors
Fibrin strands fill small vessels
What are the causes of DIC
What are the signs of DIC
Malignancy, Sepsis, Trauma, obstetric events
Bruising, bleeding, renal failure
What are the tests for DIC
Plateltes, prthrombin time, APTT, decreased fibronogen. Increase of fibrin
Schisctocytes
How is DIC treated?
Treat the cause
Replace platelets if <50.
Cryoprecipitate
How should sepsis be prevented in those with neutropenia?
Can give fluoroquinolone before neutropenia gets serious
Granulocyte colony stimulators can increase production of WBC
Herpes,pneumocystis and CMV prophylaxis has a role
What are the four main classes of leukemia?
Acute lymphoid luekemia- affects young and under 40’s
Acute myeloid leukemia-high mortality
Chronic myeloid leukemia- three stages
Chronic lyphoblastic leukemia- most common
What is acute myeloid leukemia?
A malignancy of lymphoid cells affecting B or T lymphocytes causing uncontrolled maturation of blast cells
What are the important associations with acute lymphoid leukemia?
Ionizing radiation dueing pregnancy
Down’s syndrome
What are the signs of Acute lymphoblastic leukemia?
Marrow failure- pancytopenia
Infilatration- hepato/splenomegaly, lymphadenopathy, CNS, Orchidomegaly
What are common infections that those with ALL might encounter?
Chest, mouth, perineum and skin
Bacterial septicaemia
Zoster
CMV
measles
Candidiasis
Pnemocystis pneumonia
What tests are undertaken in ALL?
Blast cells seen on blood film
CXR and CT scan for mediastinal and abnormal lymphadenopathy
Lumbar puncture for CNS involvement
What support can you give to those with ALL?
Blood/platelet transfusions
IV fluids
Allopurinol
Subcutanous port/hickman line
Discuss the treatment for ALL?
4 chemotherapy stages:
Remission inducing
Consolidation
CNS prophylaxis
Maintenance
Matched related allogenic marrow transplantation
What indicates a poor prognosis in ALL?
Adult, male
Philadelphia chromosome (chromosomes 9 and 22)
Presentation with CNS signs
low Hb, low WCC
What is chronic myeloid leukemia?
Uncontrolled proliferation of myeloid cells.
Occurs mainly in those 40-60
What is different about CML and ALL with regards to genetic
Those with the Philadelphia chromosome do better in CML
What are the stages of chronic myeloid leukemia?
Chronic phase- lasts months or years, hardly any symptoms-30% detected by chance
Accelerated phase- increasing symptoms of spleen size and difficulty controlling counts
Blast transformation features of acute leukemia and death
What are the signs and symptoms of CML?
Weight loss Tiredness Fever Sweats gout splenomegaly hepatomegaly bruising anaemia
What are the tests involved in chronic myeloid leukemia?
Increased white blood cells
Increased spectrum of myeloid cells- increased neutrophils, monocytes, basophils, eosinophils
Increased urate and b12
Hypercellular bone marrow
How is CML treated?
Imatinib, specifically targeted biologic to BCR-ABL
2nd generation bcr-abl drugs e.g. dasatinib and nilotib
Similar treatment to ALL, chemo (doesn’t have good outcomes), allogenic transplant (better in younger patients)
