Supportive Care Flashcards
What is tumor lysis syndrome?
result of massive breakdown of tumor cells; intracellular content is released faster than the body can eliminate them
When does TLS happen?
spontaneously OR result of treatment
What are risk factors for TLS?
Bulky, chemosensitive disease
Lymphoproliferative malignancy (blood cancer)
Elevated WBCs
High serum urate
Elevated LDH
Volume depletion
Renal insufficiency
Acidic urine pH
What electrolyte imbalances are the result of TLS?
Hyperkalemia
Hyperuricemia
Hyperphosphatemia
Hypocalcemia
What is the most important intervention for TLS?
Hydration; ~2-3 L/m2/day
Loop diuretics can be added after volume replacement
Which agent is given prior to chemo to prevent hyperuricemia?
Allopurinol
Which agent breaks down uric acid into a soluble form and can be used to treat hyperuricemia?
Rasburicase
What is the result of hyperkalemia?
arrhythmias
neuromuscular abnormalities
What is given for mild hyperkalemia (no arrhythmias)?
Sodium Polystyrene Sulfonate (KAYEXALATE)
What is given for severe hyperkalemia (EKG changes)?
Regular Insulin+ dextrose
What is a local allergic reaction (red blotches along vein) without pain?
flare reaction
What is an agent capable of causing tightness, achiness, and phlebitis (inflammation of vein)?
irritant
What is an agent that is known to produce severe tissue damage and/or necrosis when infiltrated?
vesicant
What is the administration of solution/ medication into tissue surrounding an IV?
infiltration
What is the administration of a vesicant into surrounding tissues?
extravasation
Why is extravasation a medical emergency?
blistering and sloughing off of tissue begins 1-2 weeks after injury; tissue necrosis follows
What agents have the highest vesicant potential?
Daunorubicin
Doxorubicin
Epirubicin
Idarubicin
Vinblastine
Vincristine
Vinorelbine
What is treatment of vinca alkaloid extravasion?
Apply warm compress around area QID for 48-72 hours;
Antidote: hyaluronidase injections x 1 day
What is treatment of anthracycline (rubucin) extravasation?
Apply cool compress around area QID for 48-72 hours;
Antidote: dimethyl sulfoxide topically QID x 14 days OR
IV Dexrazoxane
Where is IV Dexrazoxane administered?
large vein other than one affected by extravasation
Why does Dexrazoxane have 2 different brand names?
ZINECARD- anthracycline-induced cardiotoxicity
TOTECT- anthracycline extravasation
What is myelosuppression?
decreased production of cells made by bone marrow
What is the result of myelosuppression?
neutropenia (decreased WBC)
anemia (decreased RBC)
thrombocytopenia (decreased platelets)
What is considered neutropenic?
ANC < 1000
What is considered absolutely neutropenic?
ANC < 100
What is a normal ANC (neutrophil count)?
ANC = 2000-5000
What is considered febrile neutropenic?
neutropenic AND
oral temperature > 38.3C (101F) or multiple oral temperatures >38C (100.5F) over 1 hour
What medications should NOT be used when febrile neutropenia is suspected/ present?
Tylenol
NSAIDs
Steroids
What medications can be used for pain with febrile neutropenia?
opioids
What medications can be given after chemo to reduce the incidence, magnitude, and length of neutropenia?
Colony Stimulating Factors (CSFs)
When are CSFs used to prevent neutropenia?
chemo regimen associated with >/= 20% incidence of febrile neutropenia
When should CSFs be started to prevent febrile neutropenia?
24-72 hours after chemo competed
Granulocyte CSF
Filgrastim (NEUPOGEN)
Pegylated CSF
Pegfilgrastim (NEULASTA)
When would we treat for febrile neutropenia?
< 20% incidence of febrile neutropenia but patient gets it anyway; would prevet every time after indecent
When should CSFs not be given?
During chemo/ radiation
What are the side effects of CSFs?
Bone pain (means its working)
injection site reaction
fever
What is mucositis?
ranges from mild inflammation and erythema to bleeding ulcerations in oral cavity
What is the prevalence of mucositis?
75% of those receiving chemo
Nearly all patients receiving chemo + radiation of head and neck
What are risk factors for mucositis?
Chemo containing alkylating agents or Topoisomerase II inhibitors;
Radiation to head/ neck;
Poor dentation;
Tobacco use;
Alcohol use
What are the complications of mucositis?
Decreased oral intake–> malnutrition;
Infection;
N/V;
Pain;
Dose delay/ reduction–> negative tx outcome
What is mucositis closely related to?
neutropenia
When does mucositis usually occur?
5-7 days after start of chemo/ radiation
How is mucositis prevented?
Dental assessment prior to tx;
Oral hygiene;
Ice (cryotherapy) for 30 mines before, during, and after chemo
What are treatment options for mucositis?
Topical lidocaine, magic mouthwash
Opioids
Parenteral Controlled Analgesia (PCA)
TPN/ feeding tube
What is an indication of poor prognosis (50% die within 30 days)?
hypercalcemia of malignancy
What clinical presentations are common for hypercalcemia of malignancy?
polyuria and polydipsia (body trying to flush out calcium)
What types of cancer are associated with local osteolytic hypercalcemia?
hormonal cancers like to goto bone and turn them into dust
What type of hypercalcemia of malignancy is most common?
Humoral hypercalcemia
Why do we need to correct calcium lab values?
calcium is usually bound to albumin in the blood; low albumin does not mean low calcium
What is the corrected calcium equation?
Measured calcium +
[0.8 x (4 -albumin level)]
How is hypercalcemia treated?
Hydration with normal saline +/- furosemide
1st line meds
2nd line meds
What are the 1st line meds for hypercalcemia?
Bisphosphonates (Zoledronic Acid, Pamidronate)
RANKL inhibitor (Denosumab)
What is the mechanism of Bisphosphonates?
“stun” osteoclasts to prevent bone degradation
What rare but serious side effect is associated with bisphosphonates, usually with long-term use?
osteonecrosis of the jaw (ONJ)
What is the mechanism of RANKL inhibitors?
destroys osteoclasts
When are RANKL inhibitors typically used?
hypercalcemia refractory to bisphosphonates
What side effect is related to the mechanism of RANKL inhibitors?
severe hypocalcemia
What is the 2nd line tx of hypercalcemia, usually for emergency treatment?
Calcitonin
How does calcitonin work to treat hypercalcemia?
drives calcium intracellularly
What problems are seen with calcitonin?
transient (short) response duration and tachyphylaxis (less effective over time)
What are the goals of hypercalcemia therapy?
restore mental functioning so patient can make tx decisions; NOT to restore normal calcium
