Cancer patient IMC (dyspnea, neutropenia, etc)

Question 1

Cancer patient IMC (dyspnea, neutropenia, etc)

ASAP:

Answer 1

ASAP: ABCs, IV, O2 monitor, VS (no rectal temp), EKG (↑ K in lysis syndrome)

Question 2

Cancer patient IMC (dyspnea, neutropenia, etc)

Hx/exam:

Answer 2

Hx/exam: OPQRST, fever, SOB, last chemo (ANC nadir 5-10d after); skin, mouth, lung, abd, catheter/surg sites, perirectal area, no DRE!

Question 3

Cancer patient IMC (dyspnea, neutropenia, etc)

Labs/Rads:

Answer 3

Labs/Rads: CBC, BUN/Cr, lytes, gluc, Ca/Mg/Phos, LFTs, coags, LDH, uric acid, viscosity, blood cx x 2, UA, urine cx, ± CSF, ± stool cx; CXR, ± CT scans prn

Question 4

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx:
If tumor lysis syndrome…

Answer 4

Tx:
If tumor lysis syndrome… (2-3 d post chemo; hyperK, HyperPhos, Hyperuricemia, hypoCa) - can lead to ARF, dysrhythmias and neuromuscular problems
Typically seen in hematologic cancers. Can occur spontaneously in cancers with high proliferative rates or more commonly following chemotherapy (mainly acute leukemia and in high grade lymphomas) Hyperkalemia, hyperphosphatemia, hyperuricemia (breakdown of nucleic acids), hypocalcemia (Ca-phosphate creation)

Question 5

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx:
Uric acid crystals and calcium phosphate crystals→ acute kidney injury

Answer 5

Uric acid crystals and calcium phosphate crystals→ acute kidney injury
Tx: IVFs first, correct electrolytes, may require dialysis
Allopurinol- decrease uric acid production- competitively inhibits xanthine oxidase (used if at risk of TLS)
Rasburicase- decrease uric acid levels- recombinant form of urate oxidase: uric acid→ allantoin. C/I in G6PD deficiency

Question 6

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If PE…

Answer 6

If PE … Heparin or Lovenox, ± thrombolytics

Question 7

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If SIADH …

Answer 7

If SIADH … hypoNa with euvolemia
Tx: water restriction

Question 8

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: Neutropenic Fever…

Answer 8

Neutropenic fever = single temp > 38.3 or temp > 38 for 1 hour (oral) ANC <1500, with severe < 500 or expected drop < 500 in 48h
ANC= WBC X ((PMN/100) +(Bands/100))
ANC reaches its Nadir of < 500 12-14 days after day one of chemo
Cytotoxic medications→ affect myelopoiesis, destroy integrity of GI mucosa
20-30% due to infection. Initially was gram-neg (more serious) but more recently gram-pos (due to catheters, prophylactic ABX)
Vitals, CBC, BMP, cultures, CXR, lactate, UA, ECG
If septic treat- each hour of delay in ABX increases mortality by 8%
If low risk: no hypotension, no COPD, age < 60, no dehydration, have solid tumor or hematologic malignancy, minimal symptoms, talk with Onc
MASCC > 21 low risk
empiric tx w Cipro 500mg q8 & Augmentin 500mg q8 x7. May d/c.
If high risk: shock, ANC < 500, ANC levels low for > 7 days, other organ dysfunction, MASCC < 20
empiric tx w/ Zosyn 4.5 gm IV or Cefepime 2 gm IV or Ticarcillin/clavulanate 3.1 gm IV or Imipenem/cilastatin 500 mg IV ± Vanc 1gm IV
(skin, line, PNA, mucositis, shock), ± Acyclovir 10 mg/kg IV ± anaerobic coverage (necrotizing mucositis, intra abdominal infection, sinusitis,
peri-rectal cellulitis) (only need mono coverage for pseudomonas) ± antifungal

Question 9

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If acute spinal cord compression…

Answer 9

If acute spinal cord compression… Dex 10 mg IV, stat NS consult (possible Rad/Onc), stat MRI
Intramedullary (metastasis in the dura), leptomeningeal (metastasis on top of dura), external compression (most common)
Thoracic spine most blood supply- most susceptible
Prostate → lumbar, Breast and lung → thoracic, kidney → lumbar, thoracic
MRI full spine

Question 10

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If hypercalcemia…

Answer 10

If hypercalcemia: 20-30% cancers will develop due to parathyroid-related protein production (squamous cell, lymphoma), osteoclast activating factor (multiple
myeloma, metastasis), endogenous calcitriol production (lymphomas) - poor prognosis
Dehydration, polydipsia, fatigue, confusion, nausea, vomiting, constipation, decreased UO, ECG changes (short QTc..)
Ionized Calcium, ECG
Tx: mild (<12) with no symptoms→ adequate fluid intake
12-14 with mild symptoms (usually chronic) → fluids, find cause
Severe > 14 and severe symptoms → IVF 200-300 mL/hr, loop diuretics not recommended unless renal or heart failure, calcitonin 4 units/kg (can
get tachyphylaxis), Bisphosphonates after hydration (will work in 24-72 hours), dialysis, steroids (only if due to calcitriol overproduction)

Question 11

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If hyperleukocytosis…

Answer 11

If hyperleukocytosis: WBC >50,000. Leukostasis occurs. Seen with acute myeloid leukemia or chronic myeloid leukemia with blast crisis.
Symptoms due to white cells plugging microvasculature, tissue hypoxia → respiratory and neurologic symptoms
Dyspnea, hypoxia, vision changes, headache, dizzy, ataxia, confusion, coma, fever, DIC- will have increased risk for ICH 1 week after treatment
TX: cover with antibiotics if fever
Lower WBC count by cytoreduction (chemo or leukapheresis)- chemo only thing to reduce mortality
IVF, monitor for DIC and tumor lysis syndrome
Hydroxyurea- option for asymptomatic patients

Question 12

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If Hyperviscosity syndrome…

Answer 12

If Hyperviscosity syndrome… Sludging from ↑ proteins causes fatigue, HA, Sz, AMS, MI, CHF.
Tx: IVF, phlebotomy w/ PRBC replacement.

Question 13

Cancer patient IMC (dyspnea, neutropenia, etc)

Tx: If SVC syndrome…

Answer 13

If SVC syndrome… neck veins distended, SOB, ↑RR, facial swelling, plethora
Obstruction of blood through SVC due to internal intravascular invasion or external compression. Lung cancer MCC.
CT chest w/ IV contrast
Tx: general approach chemo w/ possible stent placement; Lasix 40 mg IV and Solu Medrol 250 mg IV (if respiratory compromise, most literature does not
support lasix), anticoagulation if due to thrombus