Haem - Viva - Haem Malignancies Flashcards
Why might you admit a haem cancer to ICU
May develop critical illness as their first presentation of the disease
May develop complications as part of treatment - chemo, bone marrow etc
Give some causes of critical illness that may be from a haem cancer
Neutropenia and sepsis
TLS
GvHD
Resp failure - infection, oedema, haemorrhage, disease infiltration
Complications of chemo
CNS dysfunction - bleeds, thrombosis, hyper viscosity, electrolytes
GI - neutropenic enterocolitis
Renal - nephrotoxics, sepsis, hypoperfusion, underlying disease
Define neutropenia and neutropenic sepsis
NICE -
Neutrophil < 0.5 x 10.9/L
Sepsis - Neutrophil < 0.5 plus clinical signs of infection OR temp > 38
Precautions with neutropenic patients
Reverse barrier nursing Positive pressure side room Avoid invasive procedures - bladder, CVP Good oral hygeine Avoid rectal exams/temperature probes (risk of haematogenous spread)
Principles of neutropenic sepsis management
ABCDE
Hx - pets and animal exposure, hobbies, recent foreign travel, TB risk, in dwelling lines
OE - oropharnx, skin, perirectoal areas for abscesses
Follow Surviving Sepsis Guidelines, immediate Abx (tazocin)
Bloods including lactate, cultures including in dwelling sites
Fluids and vasopressors
Image, CXR - abdomen CT etc
Empirical Abx for Febrile Neutopenia
Tazocin
Consider gentamicin/aminolycosides if gram negative suspected or presence of hypotension or pulmonary infection
Alternative to pen allergy - ciprofloxacin and clindamicin, or vanc and aztreonam
Describe TLS
Tumour Lysis Syndrome
Metabolic abnormalities caused by the lysis of a large volume tumour load. Spontaneous or after chemo.
Assoc with leukamias and high grade lymphomas (Burkitts)
Features of TLS
High K
High Phosphate
High Uris Acid
High LDH
Low Ca
High Cr
Renal failure
Metabolic acidosis
Treatment of TLS
ABCDE
Aggressive fluid resus Treat hyperkalaemia (may need RRT) Rasburicase (recombinant urate oxidase, enzyme with catalyse the oxidation or urate so it can be excreted
Calcium used only for K treatment not to correct a low calcium
Complications of allergenic haemopoiestic cell transplanation
Early (<100 days) or late >100 days
Early Infection Haemorrhage Acute GvHD Aplastic anaemia after graft failure
Late Chronic GvHD Chronic pulmonary disease Infection Autoimmune disorders
What is Graft versus host disease
Immune mediate
Follows allogenic transplant results in complex interaction between donar and recipeint immunity. Antigen presenting cells of recipient interact with the T cells of the donor. Can occur even when donor is perfectly matched and HLA identical.
Features of acute GvHD
<100 days
Enteritis
Hepatitis
Dermatitis
Diagnosed by histology or clinically using Seattle Glucksberg Criteria
What is the Seattle Glucksberg criteria
Stages acute GvHD
Skin changes, bilirubin level and GI fluid losses (mls/day)
1 - risk under 25% of body. Bilirubin 26-60. GI loss 500-100
2 - Rash 25-50
3 - Rash> 50%, erythroderma
4 - Bullous desquamation of skin. Bilirubin>257, fluid > 2500 with lieu’s
Bilirubin and GI losses increase with each stage
What is chronic GvHD
> 100 days
Diverse syndrome resembling auto immune illnesses such as scleroderma, primary biliary cirrhosis, and chronic immunodeficiency. May occur as an extension of acute.
Treatment of GvHD
High dose steroids
Immunosuppressants (cyclosporine)
TPN to facilitate gut rest
Octreotide for diarrhoea
