Oncologic emergencies

Question 1

How is febrile neutropenia defined

Answer 1

Single oral temperature of over 38.3 degrees celsius or temp of 38 degrees sustained over 1 hour period
plus
Absolute neutrophil count below 500 or below 1000 with an expected decrease to 500 within the next 48 hours

Question 2

How to calculate absolute neutrophil count? How do we use this info?

Answer 2

3.5 times (Segments + Bands)/100

If it’s below 500, they’re neutropenic

Question 3

What is included in initial assessment of febrile neutropenia patients?

Answer 3

Labs, 2 or more blood cultures (from different sites), and chest xray if you suspect pneumonia

Also add culture specimens as indicated, ie urine culture if UTI pain

Question 4

What is the MASCC score?

Answer 4

Used to determine empiric treatment risk levels

Low risk is MASCC over 21
High risk is MASCC below 21

Question 5

Who is at low risk when treating febrile neutropenia? How do we treat?

Answer 5

MASCC over 21, duration brief (less than 7 days)

Give outpatient therapy:
Cipro plus augmentin
Cipro/levo
Cipro plus clindamycin

Treat until ANC is over 500 and hemodynamically stable

Question 6

Who is at high risk when treating febrile neutropenia? How do we treat?

Answer 6

MASCC less than 21, anticipated prolonged (7 days or more) neutropenic period, with comorbidities like hypotension, pneumonia, etc

Treat with inpatient IV antibiotics

Monotherapy: Cifepime, Piperacillin/tazo, Meropenem, Imipenem

Combination: Cipro/levo or a -mycin PLUS any of those listed above

Penicillin allergy: Cipro plus clinda OR Aztreonam plus vanco

Question 7

When do we use vanco?

Answer 7

Risk of MRSA
Septic shock
Catheter related infection
SSTI

Question 8

How do we monitor tx response?

Answer 8

Days 2-4: d/c vanco if stable, median time to loss of fever is 5 days

ONLY modify if hemodynamically unstable
Can still have fever if hemodynamically stable, keep going

Question 9

What do we do if a pt has a fever after 4 days?

Answer 9

Look for fungal, add antifungal therapy

Do PE/CT scan, C/s for resistant bacteria, etc

Question 10

When should antifungal coverage be added?

Answer 10

If patient is continuously febrile on broad spectrum antibiotics at 96 hours (4 days)

Yeast - see at 72-96 hours
Mold - see at 2-3 weeks

Question 11

When do we give antiviral therapy for FN?

Answer 11

Positive skin or mucous membrane lesions due to HSV or VZV

Add acyclovir or valacyclovir

Goal is to heal lesions to prevent entry of bacteria

Question 12

How long should we treat FN?

Answer 12

Until ANC is over 500 or if infection is documented, 7-14 days

Question 13

Who gets prophylaxis for FN?

Answer 13

If they’ve had infx with previous chemotherapies, or expected duration is over 7 days (levo 750)

Risk for PCP: Bactrim, dapsone, pentamidine

Question 14

Antifungal PPX for FN

Answer 14

Candida: Fluconazole (plus any of those below)

Aspergillus Voriconazole, posaconazole, echinocandin, amphotericin B

Question 15

How to diagnose tumor lysis syndrome?

Answer 15

2 or more Laboratory TLS abnormalities within 3 days before or 7 days after cytotoxic therapy:
High uric acid
High potassium
High phosphorous
Low calcium (all of these should be 25% change at least)

Clinical TLS would be lab finding plus 1 of the following:
Renal insufficiency, cardiac arrhythmias, seizures

Question 16

How to prevent/manage TLS?

Answer 16

TLS labs every 8-12 hours (Scr, PO4, Ca, K, UA)

Fluids and hydration

Allopurinol, rasburicase (anti-hyperuricemic agents)

Correct electrolyte abnormalities

Question 17

How to monitor fluid/hydration?

Answer 17

Make sure UOP is over 2 mL/kg

Use diuretics but not sodium bicarb!!

Question 18

When do you use anti-hyperuricemic agents when managing TLS?

Answer 18

Allopurinol: Start at least 1-2 days prior to treatment (can’t help if uric acid already elevated), stay hydrated, adjust levels of 6-mercaptopurine/azathioprine

Rasburicase: Only use for 5 or less days, can reduce elevated levels(?!), blood samples taken after using it must be in chilled tube with heparin!!!

Question 19

How to treat electrolyte abnormalities: Hyperphosphatemia

Answer 19

Moderate (over 4.5): Phosphate binder (sevelamer 800 mg TID)

Severe: Dialysis

Question 20

How to treat electrolyte abnormalities: Hyperkalemia

Answer 20

Moderate (over 6 but asymptomatic): Sodium polystyrene sulfonate 15 g 1-4 times/daily

Severe (over 7 mEq and/or symptomatic): Calcium gluconate to protect the heart and 10 units regular insulin to push potassium back into the heart

Question 21

How to treat electrolyte abnormalities: Hypocalcemia

Answer 21

Calcium gluconate 50-100 mg/kg slow IV infusion

Question 22

How to treat hypercalcemia of malignancy

Answer 22

Mild (corrected less than 12):
Asymptomatic: Hydration
Symptomatic: Hydration plus bisphosphonate (pamidronate, zoledronic acid)

Moderate/severe (Corrected over 12):
Hydration plus bisphosphonate
Calcitonin if symptoms are severe/very high calcium

Question 23

Symptomatic presentation of hypercalcemia of malignancy?

Answer 23

Bones Stones Moans Groans

Question 24

Describe treatment options for hypercalcemia of malignancy

Answer 24

Pamidronate 60 mg IV over 2-24 hours
If renal dysfunction: should be done over duration longer than 2 hours

Zoledronic acid 4 mg IV over 15 mins
Renal dysfunction do over 30 mins

Question 25

How to manage spinal cord compression?

Answer 25

Relieve pain and preserve/improve neurologic function (could result in irreversible paralysis if not treated!!!)

Use surgery, radiation, steroids (dexamethasone 8-10 mg IV x 1 then 16 mg/day IV/PO q6h)