Oncologic Emergencies Flashcards
Metabolic Onco Emergencies
Hypercalcemia of Malignancy
Tumor lysis syndrome
Hematologic Onco Emergencies
Febrile Neutropenia
Tumor lysis syndrome: definition
large number of cancer cells rapidly die -> cell contents released in the blood
- DNA
- phosphate
- potassium
- cytokines
TLS: Cairo-Bishop definition
laboratory TLS: >/= of the following within 3 days before or 7 days after initiation of treatment
- hyperkalemia (>/=6)
- Hyperuricemia (>/=8)
- hyperphosphatemia (>/=4.5)
- Hypocalcemia (</= 7)
TLS: presentation
Hyperkalemia
- ECG abnormalities
- cardiac arrest
- fatigue
Hyperuricemia
- AKI
- crystal nephropathy
Hyperphosphatemia
- AKI
- GI upset
- AMS
Hypocalcemia
- AMS
- seizures
- arrhythmia
- tetany, spasms
TLS prevention
hold causative agents
- diuretics
- Ca / K / Phos supplements
- ACE
- nephrotoxic agents
Hydration
TLS Management
High risk
- hydration
- rasburicase
- allopurinol
Intermediate risk
- hydration
- allopurinol
- consider rasburicase
Low risk
- observation
- normal hydration
Allopurinol
Xanthine Oxidase inhibitor
for TLS prevention: initiate 24 hrs before chemo
Dose:
- 10 mg/kg/day div Q8H
- 300 mg PO QD
Caution:
- severe hypersensitivity rxn
- will not lower current uric acid levels
Rasburicase
Induces uric acid metabolism
Indication:
- pre-existing hyperuricemia
- high risk TLS
- spontaneous TLS
Dosing:
- 0.15-0.2 mg/kg/dose QD for up to 5d
- flat dose 1.5 or 3mg
Caution
- G6PD deficiency
- $$$
TLS: Hyperkalemia managment
Hydration
Severe or symptomatic ->
- calcium chloride 1g IV
- regular insulin 10U + IV dextrose 25g
- Sodium bicarb 50 mEq IV
- Sodium polystyrene 15-60 g PO
- Hemodialysis or CRRT
TLS: Hyperphosphatemia management
1st line IV hydration
decrease exogenous phosphate intake
last line: dialysis
phosphate binders
- calcium acetate
- calcium carbonate
- aluminum hydroxide
- lanthanum
- sevelamer
TLS: Hypocalcemia management
Typically resolves after hyperphosphatemia
only treat symptomatic (cardiac arrhythmias, seizures, tetany)
Febrile neutropenia definition
Febrile
- single temp >/= 38.8 C
- temp > 38 C for over 1 hr
Neutropenia
- ANC < 500
- ANC < 1000 and expected to be < 500 within 48h
FN: Low risk
standard chemo for most solid tumors
anticipated neutropenia < 7d
prophylaxis: nope
FN: Med risk
autologous HCT
lymphoma
multiple myeloma
CLL
purine analog therapy
anticipated neutropenia 7-10 days
Prophylaxis: consider bacterial, fungal or viral
FN: High risk
Allogenic HCT
Acute leukemia
Alemtuzumab therapy
GVHD therapy treated with high dose steroids
Anticipated neutropenia > 10 days
Prophylaxis: bacterial, fungal, viral
FN: Antimicrobial prophylaxis
Levofloxacin
Ciprofloxacin
FN: Antifungal prophylaxis
Fluconazole
Posaconazole
Voriconazole
FN: Pneumocystitis jirovecci pneumoniae prophylaxis
Bactrim
FN: Viral prophylaxis
Acyclovir
FN prevention: colony stimulating factors
Pegfilgrastim
Filgrastim
FN Risk assessment
MASCC score
High risk: < 21
- inpatient
- IV abx
Low risk: >/= 21
- outpatient management
- PO abx
FN: MRSA coverage not recommended unless…
- catheter related infections
- SSTI
- Pneumonia
- Hemodynamic insufficiency/sepsis
- mucositis
FN: fungal coverage only added if…
no response to therapy within 4-7 days
positive fungal markers / culture
Hypercalcemia of malignancy severity
Mild:
- corrected calcium 10.5-11.9
Moderate:
- corrected calcium 12-13.9
Severe:
- corrected calcium >/= 14
Corrected calcium formula
Corrected Ca = measured Ca + [0.8 x (4 - albumin)]
Hypercalcemia of malignancy: symptoms
Renal
- polyuria
- polydipsia
- dehydration
- decrease in GFR
GI
- constipation
- anorexia
- N/V
- acute pancreatitis
Neurologic
- lethargy
- confusion
- irritability
- muscle weakness
- seizure
- stupor
- coma
Cardiac
- shortened QT interval
- widened T wave
- heart block
- asystole
- atrial and ventricular arrhythmia
Hypercalcemia of malignancy treatment
Hold Vit D, Ca, thiazide diuretics
Hydration: NS +/- furosemide
IV bisphosphonates
RANK-L inhibitors
2nd line:
- calcitonin
- glucocorticoids
- calcimimetics
- dialysis
Hypercalcemia of malignancy: IV bisphosphonates
Agents:
- zoledronic acid
- pamidronate
Renal dose adj NOT RECOMMENDED
Can take 7 days to full effect
ADE:
- flu like sx (APAP prophylaxis)
- fevers
- arthralgias
- nephrotoxicity
Hypercalcemia of malignancy: RANK-L inhibitors
Denosumab
can take 9-10 days to full effect
used for hypercalcemia refractory to bisphosphonates
