Oncologic Emergencies Flashcards
In which groups of patients is incidence of hypercalcemia most common in?
- NSC lung cancer
- Breast cancer
- Multiple myeloma
- Squamous-cell cancers of the head and neck
- Urothelial carcinomas
- Ovarian cancers
What corrected calcium level defines mild hypercalcemia?
10.5 to 11.9 mg/dL
What corrected calcium level defines moderate hypercalcemia?
12 to 13.9 mg/dL
What corrected calcium level defines severe hypercalcemia?
14+ mg/dL
What other laboratory values should be tested for in hypercalcemia?
- Serum phosphorous
- PTH
- Vitamin D
What is the formula for corrected calcium?
0.8*(4 - albumin) + serum calcium
What are some S/S of hypercalcemia?
- AKI
- N/V
- Lethargy/muscle weakness
- Shortened QT interval
- Arrhythmias
Which etiology accounts for most cases of hypercalcemia?
Humoral (PTH-related peptide increased)
- increased calcium tubular reabsorption and phosphorus excretion
What are the rare causes of hypercalcemia?
- Vitamin D toxicity
- Ectopic PTH production by tumor
What treatment do we use to increase calcium excretion?
NS bolus of 1-2L, followed by 200-500 mL/hr infusion
Furosemide 20-40 mg (fluid overloaded or HF patients)
What treatments do we use to inhibit bone resorption?
- Pamidronate (bisphosphonate)
- Zoledronate (bisphosphonate)
- Denosumab (RANKL-RANK binding inhibitor)
- Calcitonin (direct inhibition and increased Ca2+ excretion)
What dose of pamidronate should we give to a patient with a corrected calcium >12?
90 mg IV
What dose of zoledronic acid should we give to a patient with a corrected calcium >12?
4 mg IV
Should you use bisphosphonates in renal impairment?
NO
How many days do we wait before repeating bisphosphonate doses for hypercalcemia?
7 days
T/F: Denosumab should be avoided in renal impairment
FALSE
Why do we limit calcitonin treatment to 24-48 hours?
Tachyphylaxis
What possible reserved options do we have if main therapies fail for hypercalcemia?
- Steroids
- Cinacalcet
- Dialysis
What labs are characteristic of tumor lysis syndrome?
↑ K
↑ Uric acid
↑ Phosphate
↓ Calcium
What are risk factors for TLS?
- High uric acid at baseline
- Nephropathy
- Hypotension
- HF
T/F: Low WBC leads to a higher risk of TLS
FALSE: High WBC is associated with TLS risk
What is the treatment approach to TLS?
- Monitor labs q4-6 hours
- NS 150-300 mL/hr (NOT SODIUM BICARB)
- Allopurinol / Rasburicase
Which uric acid treatment comes first in high risk TLS patients?
Rasburicase
Which uric acid treatment comes first in intermediate risk TLS patients?
Allopurinol
Generally allopurinol has no renal considerations unless what is present?
CKD
How do we treat hyperphosphatemia?
IV fluids + diuretics
Maybe phosphate binders
T/F: We do not always correct hypocalcemia
TRUE: usually resolves when hyperphosphatemia is addressed
Correction may introduce complications and hypercalcemia
What are risk factors for febrile neutropenia?
- Age >65
- Previous chemo or radiation
- Pre-existing neutropenia or bone marrow tumor
- Gender
- Low BMI
- Poor performance status
- Comorbidities
- Genetic polymorphisms
How is neutropenia defined?
ANC < 500
OR
ANC <1000, expected to drop below 500 within 48 hours
How is fever defined?
Temperature >38.3 C
OR
Temperature >38 for over 1 hour
When do we give prophylaxis for LOW risk neutropenia?
Previous HSV infection
Which prophylaxis treatments should we consider/give for high or intermediate risk patients?
- Bacterial
- Fungal
- Viral
- PJP
A MASCC score of at least WHAT indicates a low infection risk in febrile neutropenia?
21
What bacterial prophylaxis should be given to a low risk patient with febrile neutropenia?
Fluoroquinolone
Cefepime if they’re already taking a quinolone
What bacterial prophylaxis should be given to a high risk patient with febrile neutropenia?
Empiric IV options
- Pip-tazo
- Cefepime
- Meropenem
When do we consider MRSA coverage?
- Catheter-related infections
- SSTI
- Pneumonia
- Mucositis
- Hemodynamic insufficiency or sepsis
When do we give fungal coverage in patients with febrile neutropenia?
- Hematologic malignancies
- Hemodynamically unstable
- Signs of sepsis
- 7+ days of febrile neutropenia
What are the three ways we can treat hypercalcemia (mechanisms)?
- Increasing calcium excretion
- Decreasing bone resorption
- Reduced intestinal absorption of calcium
