WEEK 2 - Oncological Emergencies and Neutropenic Sepsis Flashcards
Define Oncological Emergency
- Deterioration of clinical condition caused by cancer or its treatment
- esp. immunotherapy treatment - Requires IMMEDIATE intervention
- Causes changes including:
- metabolic, structural (e.g. cardiovascular), immunologic, neurological, haematologic, infectious
List the 4 oncologic emergencies seen in practice
- Neutropenic sepsis
- Tumour lysis syndrome (TLS)
- (Metastatic) Spinal cord compression (MSCC)
- Superior Vena Cava Obstruction (SVCO)
Define Sepsis
A life threatening organ dysfunction due to dysregulated host response to infection
- caused by the presence of harmful microorgansims in the blood / other tissues AND the body’s response to their presence
Can lead to malfunctioning of organs, shock and death
= need to ACT QUICKLY if suspected
- mortality / outcome is worse in cancer patients
List the risk factors for sepsis
- Age (≥75 OR ≤1)
- Recent trauma, surgery, invasive procedure within last 6 weeks
- Recent systemic anti-cancer treatment (SACT)
- ↑ risk of neutropenia + oportunisitic infections - Impaired immunity
- Breached skin integrity
- Diabtes
- IV drug misusers
- High risk patients
- Autologous stem cell transplant <6 mths
- Allograft stem cell transplant <2 yrs
Define Neutropenia
Increased susceptibility to infection due to low neutrophil count (<1000/mm3 or 1)
- escalated risk at <500/mm3 or 0.5)
- significant risk at <100mm/3 or 0.1)
- The faster the rate of decline in neutrophils AND the longer the duration of neutropenia = risk of infection increases
- Neutropenia is more likely to be seen in cancer patients due to treatment
- GCSF (a growth factor) may be given to pt with persistent neutropenia to ↑ their neutrophil count
- GCSF acts in pelvis and femurs stimulating netrophil production within bone marrow = ↑ neutrophils in blood
- GCSF dose is weight dependant (<70kg = 300mcg if >70kg = 480mcg)
- GCSF can be given to reduce risk of neutropenic sepsis - More likely to have opportunistic infections e.g. fungal infections if had prolonged periods of neutropenia
Discuss the background, symptoms and initial management options for neutropenic sepsis
An INFECTION oncological emergency
BACKGROUND:
- Life threatening complication due to anti-cancer / immunosuppressive drug treatment
SYMPTOMS:
- temp. higher than 38ºC (fever)
- note: not all sepsis pt will have fever
- note: some cancer pt may have fever in response to cancer treatment = not infection just inflammatory response
- neutrophil count < 1 (or 0.5)
- Non-blanching rash
- Generally unwell
- SEPSIS 6
- Screen for sepsis if NEWS2 Score = ≥5
- assess HR (>90), RR (>20), BP, O2 saturation (<92%), pulse, temp, conciousness
- Lactate = ≥2mmol/L
INITIAL MANAGEMENT:
- if suspect neutropenia sepsis blood sample is sent to lab immeidately to test if cocci, bacilli or other microorganisms are present in blood
- fever cuased by either gram +ive cocci or gram -ive bacilli
Discuss treatment for neutropenic sepsis (SEPSIS 6)
An INFECTION oncological emergency
- Infection in neutropenic patients takes 2-7 days to respond to antimicrobial treatment
TREATMENT
(note: do not wait for FBC result / confirmation of sepsis, start treatment if suspect sepsis)
1. Ensure senior clinican attends
2. Give O2 if stats are <92% (AIM: 94-98%)
3. Obtain IV acces and take bloods
- i.e. FBC, blood cultures
- identifies causative organism = can have targeted antibiotic therapy
4. Start IV antibiotics = 1st line
- broad spectrum to control infection
5. Give IV fluids
- restore volume = correct shock
6. Monitor
- use NEWS2
NOTE: MUST OCCUR WITHIN 1hr to prevent mortality risk increasing
SEPSIS GUIDELINES: which antibitoics are used for treatment
NO penicillin allergy (+ SACT after 7 days):
- 1st line = Piperacillin with Tazobactam 4.5g IV QDS AND Gentamicin IV
- 2nd line = Meropenem 1g IV TDS
NON-SEVERE penicillin allergy:
- 1st line = Meropenem 1g IV TDS
SEVERE penicillin allergy:
- 1st line = Vancomycin IV AND Gentamicin IV AND Metronidazole
Patient has poor renal function OR had SACT (WITHIN last 7 days):
- 1st line = Meropenem 1g IV TDS
Discuss the background, symptoms and clinical lab dianosis for tumour lysis syndrome (TLS)
A METABOLIC oncological emergency
BACKGROUND:
- TLS = rapid breakdown of tumour cells secondary to the initiation (1st cycle) of systemic cancer treatment (within 12-72 hrs)
- large tumours have large tumour burden = more sensitive to chemo / steroids = tumour breaksdown immediately = content leaks out
- Breakdown causes uncontrolled release of ions and metabolites = ↑ uric acid, potassium, phosphate (PO4) levels
- Elevated levels cause AKI, arrhythmias, seizures and death
- Most likely to occur in bulky / rapidly proliferating cancers like AML or lymphoma
- lymphoma cells = large mass = has many WBC
SYMPTOMS:
- ↑ K = nausea, diarrhoea, weakness, cramps
- ↑ PO4 = renal impairment, oligura and anuria (low urine) output
- ↑ Uric acid = renal impairment + renal failure (due to precipitaion of uric cryrals in renal tubules), oedema, altered mental state, oligura and anuria
- ↓ Ca = cramps, BP, seizures
LAB TLS DIAGNOSIS:
(2 or more):
- Uric acid ≥ 476µmol/l or 25% ↑ from baseline
- K ≥ 6.0mmol/l or 25% ↑
- PO4 ≥ 1.45 mmol/l or 25% ↑
- Ca ≤ 1.75 mmol/l or 25% ↓
CLINICAL TLS DIAGNOSIS:
- Creatinin ≥ 1.5x upper limit of normal
- Cardiac arrhyrhmias
- Seizures
Discuss prophylaxis for tumour lysis syndrome (TLS)
A METABOLIC oncological emergency
PROPHYLAXIS:
- if suspect tumour to have large tumour burden prophylatically treat (before starting cancer treatment) to prevent TLS (immedeiate tumor breakdwon)
- Need to perform RISK STRATIFICATION incuding:
- details of tumour hostology
- recent blood results
- renail function (GFR or CrCl)
- size of largest tumour lesion
LOW RISK of TLS:
- NO prophylaxis
- normal oral hydration
- NO additional blood monitoring
INTERMEDIATE RISK:
- Prophylaxis - Allopurinol 300mg oral OD for 7 days
- its a xanthine-oxidase inhibitor
- inhibition of oxidase lowers level of uric acid in plasma
- it prevents xanthine from being converted into uric acid
- ↑ oral hydration (2-3L daily)
- hydration prevents renal function deteriorating (remove K, PO4, uric acid)
- NO additional blood monitoring
HIGH RISK:
- Prophylaxis - Rasburicase 3mg IV for 2 days
- is a potent uricolytic agent
- catalyses enzymatic oxidation of uric acid into allantoin (water solublee product) which is easily excreted (in urine) by kidneys
- IV hydration ≥3L daily (saline + dextrose)
- 2x day blood monitoring
Discuss treatment for tumour lysis syndrome (TLS)
A METABOLIC oncological emergency
TREATMENT:
1. Rasburicase 0.2mg/kg IV daily (max. 15mg daily)
2. Hydration with IV fluids (≥3ml daily)
- aim for urine output of ≥100ml/m2 hr)
3. Regular monitoring (ECGs, bloods twice daily)
Treat hyperkalaemia as per BNF
Treat hyperphosphataemia with aluminium hydroxide 950mg QDS orally
Treat hypocalcaemia with calcium gluconate
- ONLY if symptomatic or <1.75
Additional info. about medication for TLS
Rasburicase:
- given PRIOR to chemo (if not possible, gievne immediately after)
CONTRAINDICATED (= use allupurinol):
- if have allergy to rasburicase
- in G6PD deficiency
Allopurinol:
- if CrCl <20ml/min = reduce dose to 100mg OD
NOTE: DO NOT USE both TOGETEHR (allupurinol inhibits rasburicase)
- dont add K to IV fluids unless K <3
- dont use sodium bicarbonate to alkalise urine, can cause CaPO4 crystals = exacerbate AKI
Discuss the backgroud, symptoms and initial management options for metastatic spinal cord compression (MSCC)
A NEUROLOGICAL oncological emergency
BACKGROUND:
- MSCC is caused by compression of the dural sac and its content by extradural or intradural mass (primary or metastases)
- MSCC leads to irreversible neurological damage
- MSCC can be caused by any cancer BUT MOST COMMON = prostate, breast and lung
- May be first symptom of cancer
EARLY SYMPTOMS:
- Back pain / tenderness (occurs 2 months before diagnosis)
- motor weakness
- sensory changes
LATER SYMPTOMS:
- Loss of strength
- Loss of sensation
- Poor bladder control
- Destroyed vertebra
INITIAL MANAGEMENT:
- Remain BED BOUND ~ too much movement may break spinal cord = paralysis
Discuss treatment for metastatic spinal cord compression (MSCC)
A NEUROLOGICAL oncological emergency
USE GUIDELINES
TREATMENT:
- Neurosurgery OR Radiotherapy (RT) are the ONLY interventions
What occurs after diagnosis:
1. Patient has MRI scan of whole spine
2. Patient given 3 medications:
- High dose corticosteroid stat (DEXAMETHASONE 16mg) followed by 8mg BD ~ weening patients down over 5 to 15 days
- PPI (gastroprotection)
- Analgesia
3. Refer patient for neurosurgery or RT or both
- If MSCC is confirmed after steroids patient given RT to specific area
- ALTERNATIVES: diff. type of chemo or surgeru
Discuss the background and symptoms for superior vena cava obstruction (SVCO)
A CARDIOVASCULAR oncological emergency
BACKGROUND:
- SVCO is when tumour is found within lung
- Tumour pushes on SVC causing oedema in face, neck and upper chest
SYMPTOMS:
- ↑ RR (cant get O2 required into body)
- Dizziness
- Swelling of face, neck and arms
- Confusiion
- Headaches
- Chest pain
- Coma
- Visual changes
- Dilated anterior chest wall veins
- Dyspnoea (difficulty breathing)
- Non-pulsatile JVP (jugular venous pulse)
- Stridor (high pitched sound)
