KC Onc and Special Pop Flashcards
*What are 2 Definitions of fever in febrile neutropenia
A single temperature at or above 38.3° C
A sustained temperature of at least 38.0° C for at least 1 hour
*What are 2 Definitions of neutropenia
ANC less than 500 cells/mm 3
An ANC expected to drop below this threshold within 48 hours
*4 biochemical changes in tumour lysis syndrome
- HYPERuricemia (i.e. high uric acid, source is DNA, which is metabolized to uric acid)
- HYPERphosphatemia (phosphate primarily intracellular electrolyte)
- HYPOcalcemia (due to binding of phosphate)
- HYPERkalemia
*2 reasons to treat hypocalcemia in TLS
Hypocalcemia with 1) cardiac (e.g. dysrhythmia, heart block) 2) neurologic (e.g. seizure, coma) instability
- Can also give calcium if hyperkalemia with ECG changes
Otherwise should avoid giving calcium just for hypocalcemia; supplemental calcium will only increase calcium-phosphate deposition in the viscera
*What are 5 non-infectious causes of fever in an oncology patient
VTE, drug side effect (ex. chemo), tumor burden, transfusion reaction, inflammation
*what is the classic triad of hyperviscosity?
Classically presents with the triad of neurological deficits, visual changes, and mucosal bleeding.
*Treatment of hyperviscosity
Plasmapheresis (temporizing measures: hydration, phlebotomy, hydroxyurea)
*What are high risk criteria in patients with febrile neutropenia?
Opposite of MASCC score:
Severe symptoms
Hypotension
COPD
Heme cancer with prev. fungal infection
Dehydration
Inpatient
Over 60yo
*What are the indications for IV vancomycin in a patient with febrile neutropenia?
Hypotension or CVS unstable
Clinically suspected catheter infection
Positive culture for gram+ organisms
Known colonization MRSA (or ceph resistant pneumococcus)
?other: skin/soft tissue infection, pneumonia (page 1498)
*What is the appropriate PO antibiotic regimen for a patient with febrile neutropenia being discharged home?
Amox/Clav + cipro
“moxifloxacin monotherapy has shown similar outcomes”
*Lymphoma patient on chemo presents with increasing SOB and pleuritic CP, afebrile. 5 Differential Diagnoses
- Pulmonary embolism
- Pericardial effusion/tamponade
- Pericarditis/myocarditis
- Pneumonia
- Pneumothorax
- Mass/airway obstruction
- Acute heart failure
*3 treatments of tumour lysis syndrome
- Intravenous fluids, as high as 5-6 L daily
- Prevent/treat hyperuricemia (allopurinol and rasburicase)
- Correct other electrolytes
consider dialysis)
Caveats: - Calcium: To minimize risk of calcium phosphate nephropathy, calcium should only be given in setting of cardiac (e.g. dysrhythmia, heart block) or neurologic (e.g. seizure, coma) instability
- Potassium: Management of hyperkalemia same as any other etiology, including use of calcium
- Uric acid: Allopurinol to decrease production, rasburicase to increase elimination
List 5 features associated with low risk febrile neutropenia
[Box 115.1] - MASCC criteria
Hx: age <60, fever while outpatient, no hx of prior fungal infection, no hx of COPD
O/E: asymptomatic or mild symptom burden, no dehydration, no hypotension
Which with febrile neutropenia can be treated as an outpatient
1) meet low risk criteria (MASCC score => 21)
2) no evidence of PNA, line infection, cellulitis, or organ failure
3) have reliable follow up with their oncologist
4) have demonstrated clinical stability during an observation in the emergency department that lasts at least 4 hours
Which cancers are most likely to cause spinal cord compression
Prostate, breast, lung
List 4 ultrasound findings of cardiac tamponade
pericardial fluid, RV diastolic collapse, RA systolic collapse, plethoric IVC
What is pulsus paradoxus
> 10 mmHg change in systolic blood pressure between the inspiratory and expiratory phases of the cardiac cycle
What is Kussmaul’s sign
paradoxically increased JVP with inspiration
List 3 cancers associated with hypercalcemia
Lung, lymphomas, esophagus, head and neck, cervical, endometrial
What diuretic should be avoided in hypercalcemia
Thiazides (increase calcium reabsorption)
List 5 risk factors for tumor lysis syndrome
Tumor related: high proliferation rate, large tumor burden, increased WBC, bone marrow involvement, kidney involvement, high sensitivity to chemo agents
Host related: low urine output, CKD
List 2 cancers at a particular risk for tumor lysis syndrome
lymphoma, leukemia