Oncological emergencies Flashcards
What is the definition of neutropenic sepsis
- pt undergoing systemic anticancer treatment
- with a temp of >38
- and neutrophil count of <0.5x10^9g/L
Describe the clinical features of neutropenic sepsis
- variable depending on source- cough, sob, abdo pain, meningism, dysuria
- may present generally unwell w/ reduced GCS, fever, confusion etc
- often have tachycardia/ opnoea, hypotension
- check indwelling catheters, central lines, skin wounds and mouth ulcers for source
- staph a, staph e, enterococcus and strep are usual causes but 30% have no source identified
When are neutrophils lowest after chemotherapy (and so at highest risk of neutropenic sepsis)
- 10-14 days post chemo
- important to consider in all that have had chemo in the last 6 weeks
What investigations should be done when neutropenic sepsis is suspected
- FBC, U&E, LFT, lactate, CRP
- Blood (central and peripheral), urine, sputum cultures
- lines and wound swabs
- ABG
- CXR, AXR, CT/ MRI, LP if clinically indicated
Give 3 differentials for neutropenic sepsis
- malignancy related fever
- PE
- chemo related fever
How should neutropenic sepsis be managed?
- empiric IV abx within an hour- give piperacillin and tazobactam, dont wait for FBC to confirm neutropenia
- fluid resus
- consider catheter
- may switch to oral abx after 48 hrs if low risk
- consider granulocyte colony stimulating factor if profoundly septic/ neutropenic
How can neutropenic sepsis be avoided/ harm be reduced
- written and oral pt info on when and how to contact 24hr specialist oncology advice and emergency care
- antibiotic prophylaxis
- dose reduction, prophylactic GCSF and stoppage of chemo may be considered
- avoid IM injections
- barrier nursing and strict handwashing when in pt
- all pts get alert card
What cancers most commonly cause spinal cord compression
- breast
- prostate
- lung
account for 60% of cases
By what mechanism can cancer cause spinal cord compression
- vertebral collapse
- compression of vertebral body
- only 10% caused by direct tumour extension into vertebral column
- initially causes oedema, venous congestion and demyelination which is reversible, prolonged compression causes vascular injury, cord necrosis and permanent damage
Describe the clinical features of cord compression
- 90% have back pain for a couple months before other symptoms
- Pain is spinal or radicular pain exacerbated by SLR, cough, sneeze or straining, night pain, worry if thoracic or cervical
- Most have limb weakness
- Many have sensory level (not in CES)
- Some have bladder and bowel dysfunction, saddle anaesthesia
- Spasticity (increased tone, clonus, hyperreflexia) below MSCC
- Plantar reflexes
- Palpable bladder due to urinary retention
How should spinal cord compression be managed?
- If pain suggestive of mets MRI within 1 week
- If signs suggestive of MSCC MRI within 24 hrs
- Admit
- Bed rest with log rolling
- Dexamethasone 16mg + PPI
- Radiotherapy is commonly used to treat and must be given within 24hrs
- Decompressive surgery is preferred if fit and good prognosis
- Chemo is used rarely for cancers which are very responsive
- If motor function hasn’t returned within 48hrs of treatment, it is unlikely to
- Analgesia, laxatives, bladder care, BM monitoring, VTE prophylaxis, physio and OT all have a role also
Which cancers respond well to chemo, and so it can be used to treat MSSC
- lymphoma
- SCLC
- teratoma
How can malignancy cause hypercalcaemia?
- PTHrp production by tumour (usually lung, oesophagus, skin, cervix, breast, kidney)
- Local osteolysis around mets due to cyotokine release eg with myeloma
- Tumour production of calcitriol eg with lymphomas
Describe the clinical features of hypercalcaemia
(Decrease NMJ excitibility)
- weakness, constipation
- N+V
- Anorexia
- Thirsty
- Polydipsia and polyurea
- Fatigue and weakness
- Confusion
- Poor concentration
- Drowsy
- Seizure
- Coma
- stones
- bone pain
- arrhythmias- asytole
Describe the management of hypercalaemia
- Aggressive rehydration for first 24 hrs
- Bisphosphonates (IV zolendronic acid) can then be used but can cause renal failure so need to be properly rehydrated first and take up to a week to work
- Denosumab can be used for refreactory hypercalcaemia
- Definitive management is better systemic treatment of the malignancy
How can malignancy cause SVO obstruction?
- 90% extrinsic compression from intrathoracic primary eg lung ca, mesothelioma or mediastinal lymphoma/ met
- 5% due to occlusion of SVC by thrombus on central catheter
- Rarely due to fibrosis from radiotherapy
Describe the clinical features of SVCO
- Breathlessness
- Swelling of face and neck, trunk and arms
- Chocking sensation
- Fullness in head
- Headache
- Lethargy
- Distended chest and neck veins
- Chest pain, cough, dysphagia less common
How should SVCO be investigated?
- CXR
- CT contrast
How should SVCO be managed?
- sit up with high flow O2
- 16mg IV dexamethasone (poor evidence but usually given anyway)
- balloon valvuloplasty and SVC stenting if not radio or chemo sensitive or need rapid relief
How is bowel obstruction managed?
- drip and suck
- give ++ fluids and stabilise as much as possible
- emergency bowel resection and stoma creation
What is tumour lysis syndrome?
- massive tumour lysis leading to release of K=, phosphate and uric acid
- leads to AKI from uric acid and calcium phosphate crystals in the renal tubules
- and hypocalcaemia due to hyperphosphateaemia
When does tumour lysis syndrome most commonly occur?
- usually in haematolgical maligancies which respond very well to treatment- eg lymphoma, leukaemia, myeloma
- renal disease, hypovolaemia, high LDH and uric acid pretreatment will predispose to it
How does tumour lysis syndrome present?
3-7 days post chemo with N+V, diarrhoea, anorexia, lethargy, haematuria/ oliguria, heart failure and arrhythmias
How can tumour lysis syndrome be prevented?
- vigorous hydration before and during treatment
- monitoring of electrolytes and and fluid balance
- prophylactic rasburicase and allopurinol if high risk
How is tumour lysis syndrome treated?
- allopurinol and rasburicase used to reduce uric acid levels
- dialysis if refractory
- cardiac monitoring
- calcium gluconate if hypoglycaemia
