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PHM 703: Crit Care/Heme/Onc > Onc 1: Onco Emergencies > Flashcards

Onc 1: Onco Emergencies Flashcards

1
Q

types of onco emergencies

A
  • metabolic: hypercalcemia of malignancy and TLS
  • hematologic: febrile neutropenia
  • sturcutral
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2
Q

hypercalcemia of malignancy most comon in pts with what type of cancer(s)

A
  • NSCLC
  • squamous cell cancer of head and neck
  • breast cancer
  • urolithial carcinomas
  • multiple myeloma
  • ovarian cancers
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3
Q

calcium levels in hypercalcium of malignancy

A

use corrected calcium = 0.8 (4 -albumin) + serum Ca

  • mild: Ca 10.5-11.9
  • moderate: 12-13.9
  • severe: >14
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4
Q

relevant labs in hypercalcemia of malignancy (except for Ca, that got it’s own slide)

A
  • serum phos
  • SCr
  • PTH
  • PTHrP
  • VitD
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5
Q

presentation of hypercalcemia of malignancy: renal

A
  • polydipsia
  • polyuria
  • dehydration
  • decreased GFR
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6
Q

presentation of hypercalcemia of malignancy: GI

A
  • constipation
  • anorexia
  • N/V
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7
Q

presentation of hypercalcemia of malignancy: neuro

A
  • lethargy
  • confusion
  • irritability
  • muscle weakness
  • seizure
  • stupor
  • coma
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8
Q

presentation of hypercalcemia of malignancy: cardiac

A
  • shorted QT
  • widened T wave
  • heart block
  • asystole
  • arrhythmias
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9
Q

hypercalcemia of malignancy MOA

A
  • humoral (most common)
  • bone invasion
  • rare causes: Vit D tox and ectopic PTH
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10
Q

Hypercalcemia of malignancy: humoral MOA

A
  1. increased PTHrP
  2. increased renal tubular reabsorption of Ca
  3. increased phos excretion in urine

  • PTH: decreased
  • PTHrP: increased
  • 1,25 (OH)2 D: decreased or normal
  • 25(OH)D: lol any
  • Phos: decreased
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11
Q

Hypercalcemia of malignancy: bone invason MOA

A
  1. tumor cell releases cytokines
  2. activation of osteoclasts and bone reabsorption
  3. secretion of Ca

  • PTH: decreased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: decreased or normal
  • Phos: decreased
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12
Q

Hypercalcemia of malignancy: vit D intox MOA

A
  1. malignant cells increased VitD too much
  2. increased produciton of calcitrio
  3. increased Ca reabsopriton

  • PTH: decreased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: increased
  • Phos: increased or normal
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13
Q

Hypercalcemia of malignany: ectopic PTH

A
  • PTH: increased
  • PTHrP: decreased
  • 1,25 (OH)2 D: increased
  • 25(OH)D: decreased or normal
  • Phos: decreased
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14
Q

Hypercalcemia of malignany: ectopic PTH common pts

A
  • pts with hx of head and neck irradiation
  • hx of chronic Li therapy
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15
Q

Hypercalcemia of malignany: bone invasion common pts

A
  • multiple
  • metastatic breast cacer
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16
Q

Hypercalcemia of malignancy: Vit D tox common pts

A

hodgkin
s

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17
Q

Hypercalcemia of malignany: humoral common pts

A
  • squamous cell carcinomas
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18
Q

differnet therapies for hypercalcemia of malignany

A
  • increase Ca excretion: IV NS (diuretics in pts who are fluid restricted or volume overloaded)
  • decreased intestinal absorption of Ca: glucocorticoids
  • decreased bone resorption: IV denosumab, SQ calcitonin, IV bisphosphonates (pamidronate, zoledronic acid)
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19
Q

IV NS admin in hypercalcemia of malignany

A

1-2 L bolus then infusion at 200-500 ml/hr

decreases Ca by 1-1.5 mg/dL in first 24h

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20
Q

Diuretic admin in hypercalcemia of malignany

A

lasix 20-40mg

decrease Ca by 05-1.0 mg/dL

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21
Q

GC MOA in treating hypercalcemia of malignany

A

inhibit 1-alpha-hydroxylase and decrease 1,25(OH)2 D

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22
Q

GC admin in hypercalcemia of malignany

A
  • prednisone 60mg/day 10D
  • hydrocortisone 200-400mg/day 3-4D then prendisone 10-20mg/day 7D
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23
Q

sq denosumab MOA in treating hypercalcemia of malignany

A

binds to RANKL -> inhibit interaction between RANKL and RANK -> prevent osteoclast formation

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24
Q

SQ denosumab admin hypercalcemia of malignany

A
  • 120mg SQ QW up to 3x (if hyperCa persists after initial 3, can wait 2 weeks then start 120mg SQ Q4W)
  • no renal adjustment needed
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25
Q

SQ denosumab ADR

A
  • increased risk of infection
  • increased bone fracture risk
  • osteonecrosis of jaw
  • musculoskeletal pain
  • HA
  • hypo Ca, phosphours
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26
Q

SQ calcitonin MOA in treating hypercalcemia of malignancy

A

inhibit osteclastic bone reabsorption and increases excretion of Ca, phosphours, Na, Mg, K

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27
Q

SQ calcitonin admin in hypercalcemia of malignancy

A
  • use in combo with IV hydration or bisphosphonates
  • 4U/kg IM or SQ Q12H (if hyper Ca persists, can increase to 8U/kg)
  • do NOT exceed use >48 hrs dt rsik of tachyphylaxis
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28
Q

SQ calcitonin ADR

A
  • hypoCa
  • face flushing
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29
Q

IV bisphophonates MOA in treating hypercalcemia of malignancy

A

iniibit osteoclast activity

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30
Q

pamidronate dose

A
  • corrected Ca 12-13.5: 60-90 mg IV over 2-24H
  • corrected Ca > 13.5: 90 mg IV over 2-4 h
  • retreatment: PRN at same dose in 7 days

not recommended if SCr >3 or CrCl < 30
- if pt is gonna use though, do so at a slower infusion rate

31
Q

zoledronic acid dose

A
  • corrected Ca >12: 4mg IV
  • retreatment PRN in 7 days

not recommended if SCr . 4.5
- if pt is gonna use though, can use a lower dose (2mg) and infuse over 30-60min

32
Q

why do the IV bisphonates have a 7 day wait period before redosing if needed in the treatmnet of hypercalcemia of malignancy

A

takes about 7 days to fully respond to that first dose

33
Q

IV bisphonates ADR

A
  • increased risk of boone fracutres
  • musculoskeletal pain
  • flu-like illness
  • osteonecrosis of jaw
  • hypo: Ca, phosphours, Ca, Mg, K
  • nausea
  • anemia
  • infusion site reaciotn
34
Q

TLS is seen in pts with what type of cancer

A
  • non-hodgkins
  • AML
  • acute lymphoblastic leukemia
  • Burkitt’s
35
Q

non-cancer TLS risk factors

A
  • elevated baseline uric acid
  • nephropathy
  • hypotension
  • left ventricular dysfunciton
  • HF
36
Q

Tumor lysis syndrome (TLS)

A

much cancer cells lyse/die at the same time ->
- increease in K, uric acid, phosphate
- decrease in Ca

cytokine release -> inflammmation 0> AKI

37
Q

presentation of increased K

A
  • fatigue
  • cardiac arrest
  • EKG abnormality
38
Q

presentaiton of icnreased uric acid

A
  • AKI
  • crystal nephropathy
39
Q

presentaiton of increrased phosphate

A
  • AKI
  • GI upset
  • AMS
40
Q

presentation of decreased Ca

A
  • AMS
  • seizre
  • arrhytmias
  • tetany/spasms
41
Q

lab TLS

A

2 or more of the following within 3 days before or 7 days after chemo

  • K: > 6 or 25% increase from baseline
  • uric acid: > 8 or ||
  • phopshate: >4.5 or ||
  • Ca: < 7.0 or 25% decrease from baseline
42
Q

clincal TLS

A

lab TLS + one of the following

  • AKI
  • seizures, neurmuscular irritability
  • cardiac arrhythmia
43
Q

treatment of hyperK in TLS

A

EKG continouosu monitoring

  • loops
  • calcium
  • insulin
  • bicarb
  • SPS
  • hemodialysis or CRR
44
Q

hyper phosphate treatment in TLS

A

IV fluids +/- diuretics

45
Q

hypo Ca treatment in TLS

A

do NOT treat unless pt is symptoatic - then give ca gluconate

usually resolves with treatment of hyperphos

46
Q

TLS ppx

A
  • lab montiroign Q4-6H
  • fluids: NS 150-300 ml/hr (do NOT use bicarb)
  • uric acid specific: allopurinol and rasburicase
47
Q

allopurinol MOA

A
  • prevent hypoxathine from turning into xanthinge
  • and prevents xanthine from turning into uric acid

prevents formation of uric acid, does NOT break down uric acid

48
Q

rasburicase MAO

A

breaks dow uric acid

49
Q

treatment of low risk TLS

50
Q

treatment of intermediate risk TLS

A
  • hydration
  • allopurinol
  • if hyper uric acid persits, can slap on rasburicase
51
Q

treatment of high risk TLS

A
  • hdyration
  • rasburicase then allopurinol
52
Q

allopurinol dose in TLS

A
  • 300mg/m^2/day or 10mg/kg/day divided Q8H
  • OR 300mg QD

no renal adjustment for TLS UNLESS pt has known kidney disease

53
Q

allopurinol ADR

A
  • SJS/TEN
  • otherwise well tolerated
54
Q

rasburicase admin in TLS

A
  • 0.15-0.2 mg/kg/dose IV QD up to 5D (OR a flat dose of 1.5mg or 3mg once with a repeat dose if uric acid remains >7.5)

when measuring uric acid level, obtain a “rasburiacse uric acid” - blood sample put in ice bath to preven further degradation of uric acid

55
Q

rasburicase ADR

A
  • hemolysis in pts with G6PD deficiency
  • peripehral edema
  • skin rash
  • abdominal pain
  • consptation/diarrhea
56
Q

definition of a fever

A
  • 38.3 C
  • or > 38C for over an hr
57
Q

definition of neutropenia

A
  • ANC < 500
  • ANC < 1000 and expected to drop to < 500 in 48h
58
Q

when does febrile neutropenia usually occur

A

1 week after chemo admin

59
Q

febrile neutropenia risk factors

A
  • > 65 receiving full chemo
  • pre-existinng / persistent neutropenia
  • bone marrow infltration with tumor
  • recent surgery and/or open wounds
  • liver dysfunction (bili > 2)
  • renal dysfunction ( CrCl< 50)
  • gender: female
  • low BMI or BSA
  • hx of chemo or radiation
  • poor performance status
  • comorbiditeis
  • genes
60
Q

neutropenia antimicrobial ppx: when to give

A
  • cancer pt with low risk for infection: only if hx of HSV
  • at intermediate risk: consider bacterial, fungal (and PJP), and give viral during neutropenia
  • at high risk: consider fungal (and PJP), and give bacterial and viral during neutropenia

remember that this is (neutropenia) ppx for before febrile

61
Q

bacterial (febrile neutropenia) ppx for pts with neutropenia

A
  • levofloxacin
  • cefopodoxime
  • cipro
  • penicillin K
62
Q

fungal (febrile neutropenia) ppx for pts with neutropenia

A
  • fluconazole
  • posaconazole
  • voriconazole
  • isavuconazole
  • micafungin

PJP: bactrim

63
Q

viral (febrile neutropenia) ppx for pts with neutropenia

64
Q

what to do when a pt presents with febrile neutropenia

A

collect the following
- CBC
- cxray
- urinalysis: if abnormal -> urine culture
- blood culture: 1 from periphery the other from central (helps identify source of infection)
- viral diagnostics

65
Q

MASCC score

A

used to determine if a pt risk level for complicatios (high score = lower risk)

66
Q

febrile neutropenia - MASCC score >21: treatment

A
  • if NOT on fluoroquinolone ppx: levaquin, moxifloxacin, or augmentin + cipro
  • if ON fluoroquinolone ppx: cefepime
67
Q

febrile neutropenia - MASCC score <21: treatment

A

give empriric IV ABX: zosyn, cefepime or meropenem (reserve meropenem if hx of ESBL)

68
Q

when to do MRSA coverage for febrile neutropenia

A

only if pt has
- catheter-related infusion
- PNA
- mucosititis
- skin/soft tissue infection
- hemodynamic insufficiency
- sepsis

69
Q

febrile neutorpenia MRSA agents

A
  • vanco
  • linezolid
  • dapto
70
Q

when to do fungal coverage for febrile neutropenia

A
  • hematologic malignancy
  • hemodynmically unstable
  • s/s sepsis
  • if neutropenia expected ot last > 7days

don’t forget to collect fungal markers/collectors

71
Q

febrile neutorpenia fungal agents

A

same as ppx + liposomal amphotericin B

72
Q

cancer pts who are at low risk for infection

determines if they get microbial ppx for neutropenia (NOT febrile yet)

A
  • standard chemo regimens for most sold tumors
  • anticipated neutropenia < 7 days
73
Q

cancer pts who are at intermediate risk for infection

determines if they get microbial ppx for neutropenia (NOT febrile yet)

A
  • autologous hematopoietic cell transplant
  • lymphoma
  • multiple myeloma
  • CLL
  • purine analog therapy
  • anticipate neutropenia 7-10D
  • Car T-cell therapy
74
Q

cancer pts who are at high risk for infection

determines if they get microbial ppx for neutropenia (NOT febrile yet)

A
  • allogenic hematopoietic cell transplant
  • acute leukemia
  • alemtuzumab therapy
  • moderate to severe graft versus host disease
  • anticipate neutropenia > 10 days

PHM 703: Crit Care/Heme/Onc (16 decks)

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