Oncological Emergencies Flashcards
What is neutropenic sepsis?
Life-threatening complication of anti-cancer treatment
When do you diagnose neutropenic sepsis
neutrophil count <0.5 and
temp >38 on 2 readings OR other signs/symptoms of sepsis
When does neutrophil count typically reach its lowest in sepsis?
5-10 days post chemo
What most commonly causes neutropenic sepsis?
Gram + cocci
When should you suspect a patient may have neutropenic sepsis?
Feeling unwell and having anti-cancer therapy
What questions must you ask a patient if you are worried about neutropenic sepsis?
Chemo regime - time since last dose
Recent blood products?
Lines in situ?
What do you examine on a patient with ?neutropenic sepsis?
Cardio Resp Lymph nodes Lines focus on causes - GI exam
What investigations should you ask for if you queery sepsis?
Neutrophil count Culture from vein and any lines Blood film D-Dimer - DIC? LFT U&E CRP Sputum culture Urine analysis
How is neutropenic sepsis treated?
IV Tazocin (piperacillin with tazobactam)
A patient in hospital with neutropenic sepsis has been treated with IV tazocin for 2 days without change, what do you do?
Change antibiotic
A patient in hospital with neutropenic sepsis has been treated for 5 days but there is still no change, what do you do?
Consider fungi/parasite causes
How can neutropenic sepsis be prevented?
Prophylactic fluroquinolone
Dose reduction
Prophylactic G-CSF - not routinely offered
Stop treatment
When should anti-biotics be started?
As soon as you suspect sepsis! Don’t wait for blood results
What cancers commonly cause MSCC?
Lung
Breast
Prostate
How many patients tend to get MSCC?
10% of patients with spinal mets
What are the consequences of early MSCC?
Cord compression –> oedema –> venous congestion
What are the consequences of late MSCC?
Irreversible vascular injury –> cord necrosis
What signs are indicative of metastatic spinal cord compression?
Back pain - worse on waking and aggravated by straining Spinal tenderness Limb weakness Sensory loss Incontinence Generally unwell Spasticity Babinski +ve Palpable bladder
What is the prognosis for MSCC?
30% live >1 year
How is MSCC investigated?
MRI within 24 hours
How is pain suggestive of metastases investigated?
MRI within week
How is MSCC managed?
Bed rest with neutral spine alignment need to be (log rolled)
Dexamethasone (unless lymphoma suspected)
Analgesia
Bisphosphonates (myeloma, breast and prostate mets only)
Definitive treatment: Decompression or radiotherapy within 24hrs
Supportive care - VTE prophylaxis, catheter, bed sore management, temperature checks
What is the tole of radiotherapy in MSCC management?
Relieve compression of spine and nerves - cause cell death
Pain relief and stabilise neurological deficit
When is SVCO seen?
External compression from Lung cancer but can be from lymphoma
What signs and symptoms are indicative of SVCO?
Breathlessness Face and upper limb oedema Headache Choking sensation Lethargy Neck vein distention Raised JVP Increased RR
How is SVCO investigated?
CXR - mass
CT contrast
How is SVCO managed?
Steroids
Stent
Chemo/radio - depend on cause
What is extravasation?
Leakage of IV drugs into extravascular space leading to nearby tissue damage
Why are chemo agents susceptible to causing extravasation?
Poorly soluble in aqueous media and are vesicant
How can extravasation be prevented?
Ensure IV fluid runs without resistance
Stop infusion if pain at injection site
Don’t leave infusion unattended if highly vesicant
Immediately stop infusion if suspicion
How common is hypercalcaemia in cancer patients?
Affect upto 1/3
Esp. lung, breast, renal, myeloma and T cell lymphoma
What is hypercalcaemia associated with?
Uncontrolled disease progression
Why does hypercalcaemia occur?
Osteolysis
Humoral mediators
Dehydration
Explain how cancers cause osteolysis and how this causes hypercalcaemia
Tumour cells of lytic bone mets produce cytokines to activate osteoclasts –> bone resoption –> increase calcium
Phosphate normally remain normal
Explain how cancers affect humoral mediators and how this causes hypercalcaemia
systemic release factors which activate osteoclasts (PTHrP)
Phosphate low
How does dehydration affect hypercalcaemia?
Exacerbate any underlying hypercalcaemia
How does hypercalcaemia present?
Vague, non-specific symptoms
Can be acute or over long time
What symptoms may be seen in hypercalcaemia?
N&V Malaise Drowsiness Weakness Depression Anorexia Abdo pain Constipation Pancreatitis Polydipsia and dehydration Renal colic - stones Arrhythmias
What investigations would be requested for hypercalcaemia?
Corrected serum Ca - allow for hypoalbuminaemia
Renal function
Electrolytes
How is hypercalcaemia managed?
Rehydrate
Monitor
Bisphosphonates
What electrolyte distubances are seen in tumour lysis syndrome?
Hyperuricaemia
Hyperphosphataemia
Hyperkalaemia
Hypocalcaemia
When does tumour lysis syndrome occur?
Within hours to days of chemo
What is tumour lysis syndrome?
Metabolic disturbances and renal impairment due to lysis of rapidly proliferating tumour cells
Why do patients get hyperuricaemia in TLS? What does it cause?
Nucleic acids are released and metabolised
It causes crystal deposits in renal tubules –> AKI
In TLS, what happens to phosphate and calcium and why?
Phosphate is released - high phoshpate
Phosphate precipitate with calcium - low calcium
What do calcium phosphate precipitates lead to?
Calcium phosphate deposition in:
Renal tubules - AKI
Skin - Gangrene
Heart - Arrhythmia
What complication can hyperkalaemia lead to?
Arrhythmias
What are the main risk factors for TLS?
Large volume disease
Chemosensitive
Haematological malignancy
Poor renal function
How can TLS be prevented?
Keep hydrated
Allopurinol or Rasburicase
How is TLS managed?
Correct electrolytes
Monitor fluid balance
Assess need for haemodialysis
What is the mechanism of action of allopurinol and rasburicase in regards to TLS
Allopurinol - prevents uric acid formation
Rasburicase - metabolises uric acid to allantoin which is water soluble and can be excreted by the kidneys
How could you manage a suspected line infection?
Line locks - if not systemically very poorly can give high concentration abx (commonly gentamicin) through the line to sterilise it and save it from needing removal
When would a bone scan for bony metastasis not be useful?
Multiple myeloma - bone scan works by picking up areas where there is increased uptake of radioactive traced indicating osteoblastic activity. Multiple myeloma produced purely lytic lesions so it is not useful.
What should you do in a suspected line infection?
Give Teicoplanin (provides gram +ve cover) Can do line lock with high dose Gentamicin
