Haematological Malignancy (Sources: Revision notes)

Question 1

What factros are associated with a worse outcome on haematological malignancy patients admitted to ICU?

Answer 1

Mechanical ventilation

Greater than 2 organ failure

Question 2

What is neutropenic sepsis?

Answer 2

Development of a fever (>38) in a patient rendered neutropenic by chemotherapy
Threshold varies from 0.5-1.0

Question 3

Post-chemotherapy at what point are patients most likely to be neutropenic?

Answer 3

5-7 days post-chemotherapy

Question 4

What are the most common causative organisms in neutrpenic sepsis?

Answer 4

Gram positive cocci

Gram negative bacili

Question 5

In neutropenic patients with respiratory symptoms, what additional test might you consider to look for opportunistic infection?

Answer 5

Bronchial washings - Pneumocystis jirovecii, CMV, Mycobacterium and fungal infections
CT imaging

Question 6

In neutropenic patients with diarrhoea, what additional tests might you consider to look for opportunistic infection?

Answer 6

Stool sample for Cryptosporidium

Endoscopic biopsy for CMV

Question 7

In neutropenic patients with neurological symptoms, what additional test might you consider to look for opportunistic infection?

Answer 7

CSF for toxoplasma and India ink stain - Cryptococcus

Question 8

In neutropenic patients with skin lesions that appear hepetic in nature, what additional test might you consider to look for opportunistic infection?

Answer 8

Swabs for Herpes simplex and Varicella zoster

Question 9

How is neutropenic sepsis managed?

Answer 9

Reverse barrier nursing
Positive pressure isolation
Taz/gent is the most common regimen, with the addition of vancomycin if CVC in situ
Consider anti-viral and anti-fundal if not improving within 3-5 days
Consider removing long-term lines

Question 10

What is tumour lysis syndrome?

Answer 10

A metabolic syndrome
Caused by the break down of malignant cells
Characetrised by hyperkalaemia, hypocalcaemia, hyperphosphataemia
Lysis of the tumour cells results in release of the potassium and phosphate. The phosphate binds to calium resulting in crystalisation of the resulting calcium phosphate in soft tissues and renule tubules
Metabolism of released nucleic acid results in raised plasma urinc acid
Uric acid crystals are deposited in the renal tubules leading to renal impairment

Question 11

What clinical features may result from tumour lysis syndrome?

Answer 11

AKI
Cardiac arrythmias
Seizures
Death

Question 12

What are the risk factors for tumour lysis syndrome?

Answer 12

High tumour load
High turnover of tumour cells
High tumour sensitivity to chemotherapy agents
High LDH
Pre-existing renal dysfunction and/or low urine output

Question 13

How is tumour lysis syndrome prevented?

Answer 13

Adequate hydration 3L/24 hours is recommended
Avoid other agents which may precipitate uric acid formation - caffeine, alcohol, diuretics
Prevention of converting nucleic acid to uric acid - allopurinol (xanthine oxidase inhibitor)
or Rasburicase (IV recombinant urate oxidase)

Question 14

How is tumour lysis syndrome managed?

Answer 14

Adequate hydration - 3L/M2 BSA per 24 hours
Aim u/o 100ml/m2 BSA
Avoid furosemide
Rasburicase ctalyses breakdown of uric acid therefore benficial
Manage electrolyte abnormalities as standard
RRT may be required