Oncologic emergencies Flashcards
(25 cards)
How is febrile neutropenia defined
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
How to calculate absolute neutrophil count? How do we use this info?
3.5 times (Segments + Bands)/100
If it’s below 500, they’re neutropenic
What is included in initial assessment of febrile neutropenia patients?
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
What is the MASCC score?
Used to determine empiric treatment risk levels
Low risk is MASCC over 21
High risk is MASCC below 21
Who is at low risk when treating febrile neutropenia? How do we treat?
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
Who is at high risk when treating febrile neutropenia? How do we treat?
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
When do we use vanco?
Risk of MRSA
Septic shock
Catheter related infection
SSTI
How do we monitor tx response?
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
What do we do if a pt has a fever after 4 days?
Look for fungal, add antifungal therapy
Do PE/CT scan, C/s for resistant bacteria, etc
When should antifungal coverage be added?
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
When do we give antiviral therapy for FN?
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
How long should we treat FN?
Until ANC is over 500 or if infection is documented, 7-14 days
Who gets prophylaxis for FN?
If they’ve had infx with previous chemotherapies, or expected duration is over 7 days (levo 750)
Risk for PCP: Bactrim, dapsone, pentamidine
Antifungal PPX for FN
Candida: Fluconazole (plus any of those below)
Aspergillus Voriconazole, posaconazole, echinocandin, amphotericin B
How to diagnose tumor lysis syndrome?
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
How to prevent/manage TLS?
TLS labs every 8-12 hours (Scr, PO4, Ca, K, UA)
Fluids and hydration
Allopurinol, rasburicase (anti-hyperuricemic agents)
Correct electrolyte abnormalities
How to monitor fluid/hydration?
Make sure UOP is over 2 mL/kg
Use diuretics but not sodium bicarb!!
When do you use anti-hyperuricemic agents when managing TLS?
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!!!
How to treat electrolyte abnormalities: Hyperphosphatemia
Moderate (over 4.5): Phosphate binder (sevelamer 800 mg TID)
Severe: Dialysis
How to treat electrolyte abnormalities: Hyperkalemia
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
How to treat electrolyte abnormalities: Hypocalcemia
Calcium gluconate 50-100 mg/kg slow IV infusion
How to treat hypercalcemia of malignancy
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
Symptomatic presentation of hypercalcemia of malignancy?
Bones Stones Moans Groans
Describe treatment options for hypercalcemia of malignancy
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
