Heme & Onc Emergencies

Question 1

What is Tumor Lysis?

Answer 1

-Massive tumor cell lysis w/ release of large amounts of K, phos, nucleic acid in systemic circulation.
-Seen in setting of high grade lymphomas (Burkitts) & ALL, can also happen in malignancies w/ high proliferative rates, large tumor burden, high sensitivity to chemo treatment
-Severe metabolic derangements

Question 2

Clinical manifestations of TLS

Answer 2

-Increased uric acid>AKI
-Hyperphosphatemia>AKI & arrhythmias>secondary hypocalcemia>tetany & seizures
-Associated symptoms with metabolic derangements (N/V, diarrhea, anorexia, lethargy, hematuria, HF, arrhythmias, muscle cramps, tetany, syncope, stone formation occasionally)

Question 3

Definition & Classification of TLS

Answer 3

-Cairo-Bishop: 2+ lab changes w/in 3 days before and 7 days after surgery
-Uric acid >/= 8mg/dL or 25% from baseline
-K >/= 6mEq/L or 25% increase from baseline
-Phos >/= 6.5 or 25% increase
-Ca </=7 or 25% decrease from baseline
-Creatinine >1.5x upper limits of normal
-Cardiac arrhythmias
-seizures

Question 4

Management of Tumor Lysis Syndrome prophylaxis

Answer 4

-Hydration!!
-Hypouricemic agents such as allopurinol or rasburicase
-Monitor labs (high risk 4-6h, intermediate q8-12, low 24h).
-Strict I&Os

Question 5

TLS Present-Management

Answer 5

-Admit (may require telemetry pending severity of electrolyte disturbances)
-Hydration (caution in heart failure)
-Treat electrolyte disturbances
-Rasburicase (hyperuricemia > 8 mg/dL or impaired renal function) versus allopurinol

Question 6

Hyperphosphatemia in TLS management

Answer 6

-Phosphate binders *calcium acetate
*calcium carbonate
*Sevelamer

2-3 tabs/meals
1-2g/meals
800-1600mg/meals

-Dialysis (Severe)
-Low phos diet

Question 7

Hypercalcemia of Malignancy

Answer 7

-most commonly caused either by primary hyperparathyroidism or hypercalcemia of malignancy
-Occurs in both solid and hematological malignancies
-Most common cancers associated with this is breast, renal, lung, squamous cell cancers, multiple myeloma
-ionized calcium levels most accurate (if drawing total Ca-correct for albumin if low).

Question 8

Medical emergency if serum Ca is what?

Answer 8

> /= to 12.5 mg/dL or accompanied by AMS, ECG changes, dehydration, renal insufficiency, N/V.

Question 9

Hypercalcemia workup

Answer 9

-PTH
-PTHrp>elevation in hypercalcemia of malignancy
-Rule out other causes: TSH, AM cortisol, SPEP/IFE, UPEP, free light chain assay, ACE level
Skeletal survey (multiple myeloma) or nuclear bone scan (other cancers)

Question 10

What PTH level indicates hyperparathyroidism?

Answer 10

> 250 for men
200 women

Question 11

Longstanding complications with hypercalcemia of malignancy

Answer 11

-kidney stones,
-dehydration,
-kidney failure,
-arrhythmias,
-mental status changes,
-osteoporosis and/or fracture

Question 12

Denosumab

Answer 12

-FDA approved for management of hypercalcemia of malignancy that is refractory to bisphosphonates, especially if eGFR <35
-Expensive
-discontinue calcium and vitamin D supplements, calcium- containing antacids, and thiazide diuretics
-Initial dose 60 mg SQ with repeat dosing based upon response
-also approved for postmenopausal osteoporosis and prevention of skeletal related events from bone metastases

Question 13

Management of Hypercalcemia

Answer 13

-NS
-Bisphosphonates
-Calcitonin
-Furosemide
-Corticosteroids

Question 14

Neutropenic Fever

Answer 14

-Infections are common and major contributor and mortality in cancer patients
-Prompt dx and initiation of therapy is key

Question 15

Definition of neutropenic fever

Answer 15

-Fever is defined as single oral temp >/= 38.3 or >/= to 38 sustained for more than 1 hour
-Neutropenia is defined as absolute neutrophil count (ANC) < 0.5 x 109 or an ANC that is expected to decrease to < 0.5 x 109 during the next 24 hours. Profound neutropenia is an ANC < 0.1 x 109
Nadir 5-10 days after last chemo dose
WBC recovery 7-10 days after nadir

Question 16

Pathophysiology of neutropenic fever

Answer 16

-Those with acute leukemia
-Bone marrow dysfunction (MDS, acute leukemia, aplastic anemia)
-Patients with drug or radiation induced neutropenia
-Less common in patients with solid tumors
-Hematologic cancers

Question 17

Chemo disrupts mucosal barrier making risk for what type sepsis greater?

Answer 17

-Gram negative

Question 18

Indwelling devices serve as a port of entry for what type of skin colonizers

Answer 18

gram positive cocci

Question 19

Presentation of neutropenic fever

Answer 19

-Fever often only symptom +/- localizing symptoms
-Neutropenia leads to atypical presentation of common infections
-Careful physical exam is crucial
-May not see infiltrate on CXR, absence of pyuria on UA, absence of leukocytosis in CNS fluid, purulence and swelling are frequently absent

Question 20

Workup for neutropenic fever

Answer 20

-Labs: CBC with diff, BMP, Hepatic function panel, lactate, INR
-2 sets of blood cultures of a peripheral vein and one from central line if present. Fungal blood cultures if risk factors or if prolonged neutropenia

Question 21

Workup for neutropenic fever

Answer 21

-Labs: CBC with diff, BMP, Hepatic function panel, lactate, INR
-2 sets of blood cultures of a peripheral vein and one from central line if present. Fungal blood cultures if risk factors or if prolonged neutropenia
-Urine and stool sample of clinically indicated
-Sputum cx, BAL infiltrates
-CXR may be normal and CT chest if high suspicion for lung infection
-LP for CSF culture and serology is suspected meningitis
-Skin aspiration cultures if abscess, biopsy if rash

Question 22

Common pathogens in neutropenic fever

Answer 22

-Bacterial pathogens are isolated in <30% of patients
-Gram positive cocci: coag neg staph most common
-Gram negative
-Fungal infections most common in prolonged severe neutropenia
-Viral

Question 23

Examples of Gram Positive Cocci with Neutropenic Fever

Answer 23

-Coag negative staph (most common)
-Staph aureus
-Streptococci
-Enterococci
-Risk factors include skin or central lines

Question 24

Examples of gram negative organisms with neutropenic fever

Answer 24

-E Coli
-Klebsiella Enterobacter (common from GI tract)
-Pseudomonas aeruginosa (typically health care associated)-most common isolaed

Question 25

What fungal infections are most common in prolonged in severe neutropenia

Answer 25

-Candida Species-with routine use of prophylaxis disseminated candida infections are infrequent
-Aspergillus-most common mold infection in neutropenic patients

Question 26

Treatment of neutropenic fever

Answer 26

-Initiate empiric treatment without delay once cultures are obtained
-Low risk patients could be considered for outpatient treatment (with oral or IV therapy)—–*must have prompt access to healthcare
-High risk patients should be considered for inpatient treatment: if any signs of comorbid conditions or presence of organ dysfunction
-MASCC Risk index for febrile neutropenia

Question 27

Outpatient oral therapy for neutropenic fever

Answer 27

ORAL THERAPY
-Combination of Augmentin + Cipro
-Fluroquinolones (except if already on them as prophylaxis)
IV THERAPY for high-risk group
-Broad spectrum monotherapy (covering pseudomonas) with cefepime, meropenem, Zosyn
-Gram positive coverage with patients with hypotension, sepsis, PNA, known colonization of gram +, mucositis or suspect of line infection should get Vanco as well
-Emperic antifungal or antiviral therapy not routinely recommended»Usually considered after 4 days if fever persists
—-Okay to stop IV abx after 48 hours of being afebrile

Question 28

VRE Infection Treatment considerations

Answer 28

-Linezolid
-Daptomycin

Question 29

MRSA Coverage

Answer 29

-Vancomycin
-Linezolid
-Daptomycin (not for PNA)

Question 30

Prophylaxis for Neutropenic Fever

Answer 30

-Fluoroquinolones: Levaquin 500 mg PO daily while neutropenic
-Candida prophylaxis: with antifungal
-Aspergillus prophylaxis: intensive chemo for AML, MDS
-Antiviral: acyclovir

Question 31

Malignany Spinal Cord Compression

Answer 31

-All cancers can cause MSCC-Most often seen in breast, lung and prostate cancer which accounts for 2/3 of all cases
-AKA Bone metastases, high tumor burden and recent onset of symptoms such as back pain
-May see motor deficits
-Can be seen in MM and non-Hodgkin lymphoma
-Can result in neuro deficits

Question 32

Treatment for MSCC

Answer 32

-Don’t delay
-Start Dexamethasone 10-16 mg IV while waiting for imaging followed by 4mg every 6 hours. Followed by taper during or after completion of radiation
-Spinal surgery (decompression)
-Treat the cancer

Question 33

Malignant Bowel Obstruction

Answer 33

-Associated with colon, ovarian, gastric, pancreas, cancers causing peritoneal carcinomatosis
-Abdominal pain, N/V, lack of gas or stool output, bowel distention, hypovolemia, third spacing, excessive digestive secreations

Question 34

Malignant Bowel Obstruction

Answer 34

-Associated with colon, ovarian, gastric, pancreas, cancers causing peritoneal carcinomatosis
-Abdominal pain, N/V, lack of gas or stool output, bowel distention, hypovolemia, third spacing, excessive digestive secretion’s

Question 35

What is the gold standard for MBO?

Answer 35

-Contrast CT of abdomen pelvis
-abdominal Xray is easily accessible, low cost, has reasonable sensitivity

Question 36

Management of MBO

Answer 36

-Surgery
-Bowel rest
-IV fluids
-Combo therapy such as antiemetics, analgesics, corticosteroids, octreotide
-PPIs
-Somatostatin analogues (octreotide)
-Dexamethasone
-Anti-emetics

Question 37

Hyperviscosity Syndrome

Answer 37

-Intrinsic resistance of fluid to flow- elevated levels of circulating serum immunoglobulins coat the cells, causing increased blood viscosity, sludging of blood and hypoperfusion.

Question 38

Diagnosis of hyperviscosity

Answer 38

-Physical exam: retinal venous engorgement, retinal hemorrhage, papilledema, retinal vein occlusion, bleeding complications
-Complete a blood smear
-CT head to rule out other CNS issues
-Serum viscosity
-IgG levels

Question 39

Treatment of hyperviscosity

Answer 39

-Phlebotomy (removal of red cells)
-NS
-Plasmapheresis
PEARLS
-Avoid RBC transfusions before initiating disease directed therapy to avoid hyperviscosity
-Consult hematology

Question 40

What disorder is caused by a leukocyte count of 100x

Answer 40

-Hyperleukocytosis and leukostasis

Question 41

What is the rapid proliferation and disrupted cell adhesion resulting in large number of leukemic blasts?

Answer 41

-Hyperleukocytosis and leukostasis
-This is a medical emergency»can cause respiratory failure, intracranial hemorrhage and early death
-Risk for developing TLS and DIC

Question 42

Leukapheresis is a treatment for what disorder?

Answer 42

-Hyperleukocytosis and leukostasis

Question 43

Hydroxyurea can be used for what disorder when immediate induction of chemotherapy is not available?

Answer 43

–Hyperleukocytosis and leukostasis