Red Book - Haem Cancer In The ICU

Question 1

Why do haem cancer pts end up in ICU

Answer 1

Critical illness relating to disease

Illness relating to treatment

Something else unrelated to their cancer

1) Neutropenia and sepsis
2) Resp failure —> infection, oedema, haemorrhage, infitltrates

3) TLS
4) GvHD
5) Chemo complications
6) CNS dysfunction —> hyperviscosity, venous thrombosis, intracerebral bleed, cancer, electrolytes
7) GI - neutropenic enterocolitis - typhilitis
8) AKI - nephrotoxics, sepsis

Question 2

Define neutropenia

Neutropenic sepsis

Answer 2

Neutro - Neutrophil count < 0.5 x 10.9/L

Sepsis - Neutropenia plus temp >38C OR signs of infection

Question 3

Precautions in neutropenic patients to reduce sepsis risk

Answer 3

Reverse barrier nursing
Positive pressure side room
Avoid invasive things - bladder cathter, CVP
Avoid rectal exam/temp probes

good oral hygiene

Question 4

Principles of managing neutropenic sepsis

Answer 4

ABCDE etc

History and exam -
pets, animal exposure, hobbies, foreign travel, TB exposure
Indwelling lines
Look for absesses in skin, oropharynx, perirectal areas

Sepsis Tx
	Immediate Abx as per protocols
	FBC, U&E, LFT, CRP, Lactate
	Blood cultures, culture lines, and sites
	Atypical tests
	FLuid and vasopressor

Images
CXR +/- AXR

Question 5

Empirical treatment

Answer 5

ANti-pseudomonal b-lactam e.g tazocin

Additional - gent/quinolones if gram negative or resistant

Alternatives to pen allergy - cipro and clindamycin

Question 6

What is Tumour Lysis Syndrome

Answer 6

Metabolic abnormalities with large volume tumour cells lyse and release contents

Usually with chemo, but can be spontaneous.

Associated with acute leukeamias and high grade lymphomas (Burkitt)

Question 7

Features of TLS

Answer 7

Life threatening Hyperkalemia
Metabolic Acidosis
Renal Failure

Hypocalcaemia
Hyperphosphataemia

Increasaed serum and urinary urate

Question 8

Treatment of TLS

Answer 8

ABCDE etc

Goals:
Aggressive fluid resus
?forced alkaline diuresis - questionable, risk of fluid overload

Treat hyperkalaemia (including RRT)

Rasburicase (urate oxidase enzyme reduces uric acid concentrations)

Question 9

What is graft vs host disease

Answer 9

Immune mediated

Follwing allogenic HCT

Results in complex interaction between donor and recipient adaptive immunity

Question 10

Complications of stem cell transplant

Answer 10

Early <100 days or late >100 days

Early:
	Infectioni
	Haemorrhage
	Acute GvHD
	Interstitial pneumonitis
	Aplastic anaemia due to graft failure

Late:
	Chronic GvHD
	Chronic pulmonary disease
	Infections
	Autoimmune disorders

Question 11

How does acute GvHD present

Answer 11

Less than 100 days post HCT

Enteritis
Hepatitis
Dermatitis

Question 12

Diagnosis of GvHD

Answer 12

Histology - skin rectal or liver biopsy

Clinical by staging system - Seattle Glucksberg system

Question 13

Describe the Seattle Glucksberg system

Answer 13

Stage 1 - Skin rash < 25% of body, Bili 26-60 and GI fluid loss 500-100

2 - 25-50%. 61-137. 1 to 1.5 litres

3 - >50% and erythroderma >138. >1500

4. Bullous desquamation. >257. >2500 ileus

Question 14

Treatment of GvHD

Answer 14

High dose steroids

Immunsuppressants - ciclosporin

Parental nutrition for gut rest (consider octrotide)

Question 15

Features of Chronic GvHD

Answer 15

> 100 days post HCT

Diverse range of autoimmune disorders
Scleroderma
PBC
Bronchiolitis obliterans

Question 16

What is typhilitis

Answer 16

Neutropenis enterocolitis

GI complication of chemo

N/V/abdom pain and distention, chills and fever

Poor prognosis

High index of suspition and CT imaging

Elective right hemi to prevent recurrent