Oncologic Emergencies Flashcards
What are metabolic/hormonal cancer related complications?
Tumor lysis syndrome
Hyperglycemia of malignancy
SIADH
Paraneoplastic syndrom
What are structural cancer related complications?
Superior vena cava syndrome
Pleural or pericardial effusion
Spinal cord compression
What are chemotherapy-related cancer related complications?
Extravasation
Diarrhea/Constipation
What are hematologic cancer-related complications?
Febrile neutropenia
Hyperviscosity syndrome
Thromboembolic risk associated with cancer
What is TLS?
Tumor lysis syndrome
Metabolic complications resulting from abrupt release of cellular components into the blood
What may TLS result in?
Acute renal failure
What are the typical electrolyte abnormalities of TLS?
Hyperphosphatemia
Hyperkalemia
Hypocalcemia
What is the pathophysiology of TLS?
Release of nucleic acids –>
Hyperuricemia–>
Uric acid crystal ppt in renal tubules –> –>
Acute obstructive nephropathy
What are the tumor related toxicities of TLS?
Type of malignancy - more common with acute hematologic malignancies
High tumor burden
Chemotherapy-sensitive disease
What are the patient related risk factors of TLS?
Pre-existing renal dysfunction
Elevated uric acid, WBC, serum LDH
Dehydration
What is the cairo-bishop classification?
2 or more lab changes up to 7 days after chemotherapy
What is an elevated uric acid level per cairo-bishop classification?
8.0+
25%+ increase from baseline
What is an elevated potassium level per cairo-bishop classification?
6.0+
25%+ increase from baseline
What is an elevated phosphorous level per cairo-bishop classification?
6.5+ (children)
4.5+ (adults)
25% + increase from baseline
What is an elevated calcium level per cairo-bishop classification?
Less than 7.0
25% decrease from baseline
What are the clinical presentations of TLS?
Non-specific complaints** Acute renal failure Arrhythmias Neuromuscular weakness Tetany
What is the treatment outline for TLS?
Aggressive emergency care Fluids and hydration Management of hyperuricemia Management of electrolytes Monitor and follow-up
How do we manage hyperuricemia in TLS?
Allopurinol (to prevent remission)
Rasburicase (treatment)
How is Allopurinol administered?
IV
PO
How must allopurinol be adjusted?
Renal dysfunction
Does allopurinol affect uric acid produced prior to initiation?
No
What are the AEs of allopurinol?
N/V
Precipitate gout flare
Increased LFTs
What is the indication for Rasburicase?
Patients with hyperuricemia secondary to leukemia, lymphoma or solid tumor malignancies; indicated for a single course of treatment
How is rasburicase administered?
IV
What is the BBW of rasburicase?
Anaphylaxis
Hemolysis
Methemoglobinemia
What are monitoring issues with rasburicase?
Collect blood in prechilled heparinized tubes
Immerse in ice water
Analyze samples w/in 4 hours
What is the management of hyperkalemia?
Insulin and glucose
Albuterol
Diuretics/dialysis
Bicarbonate
What is the treatment of hyperphosphatemia?
Phosphate binds
IV fluids
Dialysis
What is the treatment of hypocalcemia?
Treat phosphorous levels
How do we monitor pts with TLS?
Renal function I&Os SCr Electrolytes EKG
What range is severe hypercalcemia?
14+
What is the corrected calcium equation?
Observed Ca + 0.8 (4 - albumin)
What is the pathophysiology of hypercalcemia of malignancy?
Increased bone resorption
Enhanced renal tubular and intestinal reabsorption
What medications may cause hypercalcemia?
Calcium supplements
HCTZ
Lithium
What are the clinical presentations of hypercalcemia of malignancy?
"Stones, bones, ab groans, psychiatric moans" Renal GI Neurologic CV
What are the renal presentations of hypercalcemia of malignancy?
Kidney stones Polyuria Polydipsia Dehydration Decreased GFR
What are the GI presentations of hypercalcemia of malignancy?
Constipation
N/V
Anorexia
What are therapies for hypercalcemia of malignancy?
D/c exogenous sources of calcium
Hydration (watch CV status)
Diuresis (after establishing rehydration)
Bisphosphonate therapy
What is a follow up therapy if bisphosphonates do not fix calcium after the second dose?
Calcitonin
Denosumab (if refractory to zolendronic acid)
Glucocorticoids (in steroid responsive diseases)
Mithramycin (chemo)
Gallium nitrate (chemo)
Dialysis
What are the causes of superior vena caca syndrome?
SVC obstruction
Malignancy - lung cancers most common
Non-oncologic
What are the s/sx of vena cava syndrome?
Facial/neck swelling Upper extremity swelling Dyspnea Cough Dysphagia/stridor Syncope Sensation of fullness in head Distended neck/chest veins Facial, neck, arm edema Facial plethora Cyanosis
What are the classifications of vena cava syndrome?
0-5
0=asymptomatic
5=death
How is vena cava syndrome diagnosed?
Made with s/sx and imaging studies
How is vena cava syndrome managed?
Treat underlying cause (chemo/radiation)
Endovascular revascularization
Supportive measures (elevate head of the bed/O2)
Corticosteroids/diuretics (controversial
Anticoagulation for thrombosis-related obstruction
What cancers are the most common causes of pleural effusions?
Lung
Breast
Lymphoma
What cancers are the most common causes of pericardial effusions?
Lung Breast Leukemia/lymphoma GI Sarcomas Melanoma
What is the pathophysiology of pleural/pericardial effusions?
Impaired balance between normal fluid production and elimination
What is the clinical presentation of pleural and pericardial effusions?
Dyspnea
Cough
Chest pain
What is on the PE of pleural and pericardial effusions?
Decreased breath sounds
Dullness to percussion
Decreased fremitus
Pericardial rub
What is the treatment for plerual/pericardial effusions?
Treat the underlying cause Diagnostic tap (may turn into therapeutic tap) Thoracentesis/chest tube drainage Pleurodesis/sclerotherapy Doxycycline/bleomycin/talc
What is pleurodesis?
Put talc into space where fluid was so that it won’t fill back up and closes it like a glue
What are AEs of using doxycycline in pleural/pericardial effusion?
Pain
Fever
What are AEs of using bleomycin in pleural/pericardial effusion?
Pain
Fever
Alopecia
Dyspnea
What are the AEs of talc in pleural/pericardial effusion?
Pain
Hypotension
Infection
What cancers commonly cause spinal cord compression (SCC)?
Prostate cancer
Breast cancer
Lung cancer
RCC, NHL, MM, CRC, sarcoma
What is the clinical presentation of SCC?
Pain - mainly back
What are the motor findings of SCC?
Weakness
Hyperreflexia below level of compression
+Babinski sign
Diminished LE deep tendon reflexes
What are sensory findings of SCC?
Paresthesias (ascending numbness most common)
What autonomic dysfunction does SCC cause?
Urinary retention
What are the therapy options for SCC?
Tailored to patient severity
HD dexamethasone (LD + 4-24 mg q6h)
Surgery and radiation
Supportive care
What is extravasation?
Accidental leakage of chemotherapy from the vein into the surrounding tissue
What are irritants that cause extravasation?
Cisplatin Oxaliplatin Irotecan Topotecan Paclitaxel
What vesicants cause extravasation?
Anthracyclines
Vinca
Paclitaxel
Mitomycin
What are patient related RFs for extravasation?
Age
Unable to communicate
Impaired circulation
What are procedure related RFs for extravasation?
Administration technique
IV/port site
Drug itself (cellular toxicity)
Mobility of patient
What are preventative measures for extravasation?
Patient and staff education
Check patency of lines, appropriate veins and equipment
Avoid easily “dislodged” lines
Flush line before and after administration
Use thin cannulas with high gauges
Monitor closely
Recognition of patient sx
What is the management of extravasation?
Stop infusion - leave needle/cannula/catheter in place Slowly aspirate as much drug as possible Apply antidote (if applicable) Withdraw IV access Elevate area to minimize swelling Mark affected area and photograph Plastic surgery may be necessary
What is the localize and neutralize method?
Application of cold pack to affected area
How does localize and neutralize method work?
Cold causes vasoconstriction to localize the extravasation
DMSO
Dexrazoxane
Sodium thiosulfate
What is the disperse and dilute method?
Application of warm compress to affected area
For which agents is disperse and dilute used?
Vincas
Oxaliplatin
How does disperse and dilute work?
Warm causes decreased local drug concentrations
Hyaluronidase - pharmacological dispersing agent sometimes used, but limited evidence
