Haem associated conditions Flashcards
TLS, mucositis, extravasation
Tumor lysis syndrome
Description
- Death (lysis) of large numbers of cancer cells leads to release of intracellular ions, nucleic acids, proteins and their metabolites into the systemic circulation. Calcium phosphate precipitates.
- characterised by hyperuricaemia, hyperkalaemia, hyperphosphataemia, secondary hypocalcaemia and uraemia
- can lead to renal failure, cardiac arrhythmias, seizures, neurological complications and potentially, sudden death
- life-threatening, can occur spontaneously or after chemotherapy or radiotherapy. More common on the first cycle of treatment.
Cairo and Bishop definition TLS:
>or=2 metabolic abnormalities on presentation / within 3days prior to therapy OR 25% derangement from baseline in first 7days therapy
- uric acid >or= 0.476 (or 25% increase from baseline)
- K+ >6.0 (or 25% increase from baseline)
- Phos >1.45 (or 25% increase from baseline)
- Ca(corr) <or></or>
<p>1 or more clinical complications</p>
<p>- renal insufficiency (serum creat >or= 1.5 x ULN for their age/gender)</p>
<p>- cardiac arrythmia/sudden death</p>
<p>- seizure</p>
<p><u>Risk factors for TLS</u></p>
<p>- high tumor proliferation rate</p>
<p>- >10cm (bulky) disease </p>
<p>- WCC >25</p>
<p>- LDH >2 x ULN</p>
<p>- chemosensitive cancers</p>
<p>- high intensity therapy </p>
<p>- novel / targeted agents </p>
<p>- aggressive cancers (Burkitt's, ALL, lymphoblastic leuk, DLBCL, solid tumors)</p>
<p>- renal impairment </p>
<p><u>Treatment</u></p>
<p>- hyperkalemia: insulin/dextrose</p>
<p>- IVFT to enhance excretion of uric acid and phosphate</p>
<p>- hypocalcemia: Ca chloride or gluconate</p>
<p>- rasburicase for hyperuricemia >0.45 (0.2mg/kg/dy or single dose 3g or 6g) IV for 5-7days. Rasburicase is recombinant urate oxidase (oxidises uric acid to allantoin, which is renally excreted). Levels normalise after 4hours. </p>
<p>- twice daily weights and strict fluid bal chart</p>
<p>- avoid sodium bicarb urine alkalisation (to treat uric acid precipitation). N/saline is sufficient urine alkaliniser. Unless pts have metabolic acidosis </p>
<p><u>Prophylaxis</u></p>
<p>Adequate hydration and maintenance of urine output</p>
<p>- if high risk, needs 24-48hrs pre-hydration (aim 3L/m2/day input; 100ml/m2/hr output; urine specific gravity <1.01)</p>
<p>- diuretics to maintain urine output, unless pt is hypovolemic</p>
<p>Hypouricaemic agents (allopurinol 300mg/day) </p>
<p>- blocks xanthine oxidase, preventing conversion of hypoxanthine and xanthine to uric acid. </p>
<p>- risk of skin rash and LFT derangement w allopurinol. </p>
</or>
Extravasation
Antineoplastic extravasation: unintentional instillation or leakage of a chemotherapy agents out of a blood vessel into surrounding tissue.
Drugs that cause irritation with extravasation: docetaxel, liposomal doxorubicin, melphalan, mitozantrone, oxaliplatin, paclitaxel and nab-paclitaxel.
Vesicant: Any drug or substance that is capable of causing tissue destruction when extravasated.
- Extravasation of a vesicant is a medical emergency.
- May cause skin blistering, ulcer formation and necrosis. Tissue destruction may extend into underlying tendons, ligaments, nerves, and bone which may require excision and skin grafting.
- esp with anthracyclines
- examples: amsacrine, dactinomycin, daunorubicin, doxorubicin, epirubicin, idarubicin, mitomycin, vincristine, vinblastine, vindesine, vinorelbine, vinflunine, Cisplatin
Risk fx for extravasation
- elderly/kids (small/fragile veins, hard/sclerosed veins)
- obese
- coagulopathy (increased vascular permeability)
- peripheral neuropathy (altered sensation)
- skin disease (eczema, psoriasis)
- prolonged infusions
- multiple cannulation attempts
Clinical features extravasation
- burning./stinging/pain/discomfort
- swelling, oedema, erythema
- slow/sluggish infusion
Assessment
- drug dose/volume
- nature of injury (size, site, appearance, extent)
- pain
Grading
1: painless oedema
2: erythema w symptoms (oedema, pain, induration)
3: ulceration or necrosis (severe damage) - OT indicated
4: life threatening - urgent OT
5: death
Management
- stop infusion, leave device in place, aspirate residual drug
- call for help
- collect extravasation kit
- assess area, photograph the area, remove the device if possible (don’t apply pressure onto skin)
- elevate limb
- analgesia
- plastic surgical referral
Antidotes
- Dimethyl sulfoxide (DSMO) 99% should be applied within 10-25mins onto dry skin
- Hyaluronidase
- IV Dexrazoxane (within 6hours). Don’t administer with DSMO. Don’t use in children
- steroids don’t work
- cold compress (unless is a vinca aalkaloid, then use warm compress)
- limb mobilisation. Elevate to provide comfort
- surgery: large volumes, damaged skin, pain worsening
Prevention
- monitor
- educate / inform about symptoms to look for (burning, pain, swelling)
- don’t insert IVC disal to previous puncture site, avoid multiple attempts
oral mucositis
Oral mucositis:
description
- Erythematous and/or ulcerative lesions of the mucosal lining of the oral cavity following antineoplastic agents, radiotherapy, high dose chemotherapy prior to BM transplant.
- due to rapid turnover of basal epithelium in GIT
risk fx
- almost all pts who receive TBI (total bod irr.), 3/4 pts getting transplant conditioning (esp melphalan), 20-40% pts on conventional chemo (aft 2-3wks), 10-40% pts on targeted therapies
- radiation induced is more severe than chemo-induced
- higher risk pts who are smokers, EtOH, malnourished
presentation
- erythema, bleeding, altered taste, xerostomia (dry mouth)
- non-uniform, fibrinous, pseudomembranous lesions
Grading (CTCAE score)
1: mild/no symptoms
2: pain/ulcer not affecting oral intake
3: severe pain interfering with oral intake
4: lifethreatening consequences
5: death
Grade (clinical exam)
1: mucosal erythema
2: patchy ulceration, pseudomembranes
3: confluent ulcerations/pseudomembranes
4: tissue necrosis, spontaneous bleeding
5: death
Prevention
- sodium bicarb or n/saline mouthwash, otherwise plain water to promote basic oral care
- sugarless chewing gum (promotes saliva)
- lidocaine mouthwash 2%
- transdermal fentanyl, PRN opiates
- ensure adequate hydration
- dental care
- avoid smoking, hot drinks, salty, fizzy, spicy drinks/food
Stomatitis:
- Any inflammatory condition of the oral tissues inc ulceration, xerostomia, altered taste and taste loss, oral sensitivity, and oral pain with or without lesions being clinically present
- secondary to targeted therapies (e.g. TKIs, mTOR inhibitors)
- single/multiple ulcers, smaller in size
- steroids (mouthwash or oral) can be used to treat stomatitis lesions
