Oncological Emergencies Flashcards
Neutropenic Sepsis clinical features
potentially life threatening complication of chemotherapy (chemo has been very toxic e.g. lacks an enzyme to properly excrete the chemotherapy)
- metabolic acidosis (high lactate)
- neutrophils = <0.5 x 109
- pyrexia >38’C (call if >37.5’C)
Neutropenic sepsis management
admission to hospital
IV antibiotics upon arrival (within 1 hr)
fluid balance (catheter)
Symptoms and signs to look for neutropenic sepsis
pyrexia >38 mucositis cough, SOB diarrhoea urinary symptoms signs of sepsis (GCS, hypoxia, hypotensive, shock) TEP rash, lines, cellulitis, UTI, LRTI, prev hx of MRSA Blood pressure Confusion / LOC Tachycardia
if they do not have neutrophils they might not have the symptoms of an infection e.g. no sputum
no immune system so random infections: Mucositis Cough SOB Diarrhoea TEP (treatment escalation plan) **Rash** Lines (PIC line) Cellulitis UTI LRTI Previous hx of MRSA or C.Diff
Management of neutropenic sepsis
A-E and correct as you go
Arrange for nurse be drawn up IV antibiotics if no penicillin infection
MASCC score
risk index for patients with neutropenic fever to work out if needs abx
scoring system
>21/26 indicates likely at low risk of significant bacterial illness
What are the investigations for Neutropenic Sepsis
bloods: FBC, U+E, LFT, CRP Blood cultures (peripheral and culture TIVAD) swabs urinalysis- MSU CXR sputum culture stool culture covid swab
What is the 1st line treatment for neutropenic sepsis
Tazocin 4.5g TDS
+ gentamicin if severe sepsis
penicillin allergy:
ascertain the allergy status
- anaphylaxis from penicillin give:
levofloxacin +/- gentamicin _/- metronidazole - non severe allergy: meropenem
Further mx/ix if no improvement after 3 days from neutropenic sepsis
atypical or fungal infection
PCP if been on dexamethasone or steroids for a long time (haematology chemotherapy)
investigations:
CT scan
echo (infective endocarditis)
osteomyelitis ( (staph aureus infection)
discitis ('')
repeat bloods culture when spiking
discuss with microbiology
anti fungals
Neutropenic enterocolitis / typhlitis
fever
abdominal pain
diarrhoea
common in haematological malignancies
affects the ileocecal region to ascending colon
often caused by polymicrobial ifnection- candida, aspergillus.
higher risk with certain chemotherapies e.g. taxanes, vinorelbin…
Typhlitis mx
non surgical - bowel rest, NG, IVF, broad spec antibiotics
surgical mx if perforation or bowel resection necessary
Diarrhoea- IO toxiciy
Pembrolizumab
Iplilmumab
Iplilimumab and nivolumab
fatigue, pruritus, rash, diarrhoea, arthralgia
toxic drugs= pembroliumab, ipilimumb, nivolumab
any potential auto immune effect:
pneumonitis, uveitis, colitis, neuropathy, hepatitis, adrenal dysfunction, thyroid dysfunction..
History and examination for diarrhoea (toxicity)
blood
dehydration
hypotensive
tachycardia
fluid balance
electrolyte imbalances
Immune mediated diarrhoea management
Steroids (to suppress T cell activation)
moderate 0.5-1mg/kg prednisolone OD
severe 1-2mg/kg methyl prednisolone/OD
Involve relevant specialist teams
Persistent >3 days steroids- sigmoidoscopy, infliximab a steroid sparing agent.
do not give loperamide or codeine- the risk of perforation.
stool diary
irAEs
Immune-related adverse events
can occur up to 12 months after completion of treatment
fluid assessment
cap refill mucous membranes heart rate UO BP JVP peripheral oedema creatinine and urea
resuscitation of fluid
IV sodium chloride 500ml bolus in 15 minutes
Metastatic spinal cord compression
older age gradual onset severe unremitting pain aching night pain localised spinal tenderness no symptomatic improvement after 4-6 weeks conservative bowel back pain therapy unexplained weight loss past hx of cancer
Urine incontinence Back pain (cervical / thoracic back pain) saddle anaesthesia (cauda equina syndrome)
Cauda equina syndrome
severe progressive bilateral neurological deficit in legs
major motor weakness
knee extension, ankle eversion, foot dorsiflexion weakness
recent onset of urinary retention urinary incontinence (loss of sensation) faecal incontinence perianal or perineal sensory loss unexplained laxity of the anal sphincter.
metastatic spinal cord compression investigations
MRI of the whole spine within 24 hours
if planning neuro/radio want to be able to identify where in the spine there is cancer. treat one vertebra above and one below.
Metastatic spinal cord compression management
pain relief- oramorph 10mg PO
improve neurological symptoms
dexamethasone at least 16mg per day PO or IV (then 8mg morning, 8mg evening with PPI cover)
gradually reduce / wean off slowly
laxatives- enema every 3 days
catheterise if necessary
definitive treatment starts quickly- neurosurgery, radiotherapy
prognostic factor- walking.
nursed in beds if spine looks unstable and not mobilised until after definitive treatment
Hypercalcaemia
CCa >2.6 and symptoms
20-30 % of pt with malignancies
corrected calcium (low albumin so very high ca2+)
causes of hypercalcaemia
- osteolytic bone mets
- PTHrP- SCC’s (cancer is - secreting a protein which is mimicing parathyroid hormone)
increased calciriol (hodgkins disease, non hodkgins lymphoma)
production - primary hyperparathyroidism- higher incidence amongst patients with malignancy
- ca2+ supplementation. (bisphosphonates reduce ca2+ so pt are put on supplementation which can sometimes increase the caa2+)
hypercalcaemia signs and symptoms
“stones, bones, groans and moans”
confusion muscle weakness polyuria and thirst anorexia nausea/vomiting constipation abdominal pain fatigue/lethargy mood disturbance cognitive dysfunction
investigations for hypercalcaemia
- cancer diagnosis?
- taking anti cancer drugs?
- previous hx of hypercalcaemia
- meds
ECG (shortened QT conduction)
vitamin D
U+E’s
pathophysiology of hypercalcaemia
bone disease
los of bone resorption
dehydrated patients
PTH hormone related peptide acts like PTH causes more ca2+ to be taken from bone into blood and more resorption from the kidneys
hypercalcemia mx
rehydrate
3-4L of 0.9% saline over 24 hours
stop thiazides (benzo) ca2+ supplements
if cca>3 following hydration
- pamidronate 90mg in 500ml saline over 2 hours
60mg if less severe or zolendronate
if renal impairment- reduce dose and prolong infusion
caution if eGFR <30ml/min
treat underlying malignancy
most causes of cancer hypercalcaemia
prostate
lungs (paraneoplastic)
