Oncologic Emergencies Dr Karenza Alexis

Tumor Lysis Syndrome

• Prophylaxis

• Patient at high risk: leukemia, high grade lymphma, rapidly proliferating bulky solid tumor (e.g small cell)
• Vigorous Prehydration
• Allopurinol
• Inhibits xanthine oxidase
• Can cause xanthinuria
• Prevents new uric acid formation
• Careful Metabolic monitoring

• Treatment

• Rasburicase
• (works for prevention and treatment) degrades uric acid to more water soluble form
• Contraindicated in G6PD deficiency
• Can cause hemolysis

Hyperuricemia

• Hematological disorders: leukemias, high-grade lymphomas, myeloproliferative disorders (e.g PCV)

• Aggressive tumors, extensive disease

• Treatment of malignancies

• Medications

• Renal impairment

Hyperuricemia- treatment

• Prophylaxis

• Alkalinization of urine (urine pH >7)
• Sodium bicarbonate to IVF
• Diamox
• Allopurinol

Neutropenic Fever

• Medical Emergency

• Neutropenia: ANC<1000 (multiply total wbc by percentage neutrophils and bands)

• Single temperature greater than 101.3F or sustained temperature >100.4F for more than one hour (for clnical purposes , single temo>100.4F)

• Remember there may still be infection in the absence of fever: e.g elderly patients or patients on steroids

• May present with hypothermia, hypotension, clinical deterioration

• START BROAD SPECTRUM ANTIBIOTICS ASAP!!!!

Neutropenic Fever

• Risk factors for occult infection
• Degree of neutropenia
• Rapid decline in ANC
• Prolonged duration neutropenia (> 7 to 10 days)
• Cancer not in remission
• Comorbid illness
• Peripheral lines and central venous catheters
• Use of monoclonal antibodies

Neutropenic Fever

• Infectious source identified in 30%

• 80% infection believed to arise from patient’s endogenous flora

• Risk for specific types of infection may be influenced by underlying malignancy

• Abnormal antibody production in CLL, functional asplenia: encapsulated organisms- Strep pneum.,hemophilus influenzae, Neisseria meningitidus, capnocytophaga canimorsus
• T cell defects e.g lymphoma: intracelluar pathogens- Listeria monocytogenes, Salmonella, Mycobacterium, Cryptococcus
• High dose steroids: Pneumocystis carinii

• ALWAYS COVER Gram negatives

• Fungal and viral infections also possible

Neutropenic Fever

• Patients should be pancultured including from central line as well as CXR

• Further imaging depending on symptoms

• Generally start cefipime 2g Q8 (also take into consideration signs, symptoms, recent antibiotic use)

• GROWTH FACTOR support

• Consider vancomycin if hypotension,mucositis, skin infection, presence of catheter, hx MRSA, recent quinolone

• Addition of antibiotics (including antifungal) depending on clinical response and duration of neutropenia (add antifungal if anticipate or patient has prolonged neutropenia)

• Consider catheter removal

• Oncology Consultation

• Infectious disease consultation