Oncologic emergencies pediatric Resident
tarix 25.12.2016 ölçüsü 63 Kb. #2825
Pediatric Resident Education Series ONCOLOGIC EMERGENCIES MASS EFFECTS HYPERVISCOSITY METABOLIC INFECTIONS MASS EMERGENCIES SPINAL CORD SUPERIOR VENA CAVA/TRACHEA GENITOURINARY GASTROINTESTINAL CNS SPINAL CORD COMPRESSION EWING SARCOMA 30/168 (17.9%) NEUROBLASTOMA 32/402 ( 7.9%) OSTEOSARCOMA 16/243 ( 6.5%) RHABDOMYOSARCOMA 14/287 ( 4.9%) SOFT TISSUE SARCOMA 4/102 ( 3.9%) GERM CELL TUMOR 5/130 ( 3.8%) HODGKIN DISEASE 8/404 ( 2.0%) HEPATOMA 1/69 ( 1.4%) WILMS TUMOR 2/290 ( 0.7%) OTHER 0/164 - TOTAL 113/2259 ( 5.0%) SPINAL CORD COMPRESSION: Rx ASYMPTOMATIC DEXAMETHASONE CHEMOTHERAPY (ESP. LEUKEMIA, LYMPHOMA AND NEUROBLASTOMA) IRRADIATION SURGERY SYMPTOMATIC: 24 HOUR RULE DEXAMETHASONE SURGERY (ESP. IF NO DISSEMINATED TUMOR) IRRADIATION SUPERIOR VENA CAVA SYNDROME DISEASE No. MED. MASS SVCS ALL 1,464 130 6 AML 392 9 0 HODGKIN 333 102 2 NHL 330 230 8 NBLASTOMA 332 69 3 GERM CELL 114 10 2 SARCOMAS 696 26 3 SUPERIOR VENA CAVA SYNDROME In a patient on treatment consider: relapse effusion infection thrombosis (especially if a CVL is present) SVC SYNDROME: SX, FINDINGS at DX Cough/dyspnea 11 (68) Dysphagia/orthopnea 10 (63) Wheezing 5 (31) Hoarseness 3 (19) Facial edema 2 (12) Chest pain 1 ( 6) Pleural effusion 8 (50) Pericardial effusion 3 (19) SVC SYNDROME: evaluation Pulse oximetry Chest XR: the trachea is a 3-dimensional structure. It must be evaluated with both PA and lateral views. The latter often requires a high-KV film. Pulmonary function: if considering anesthesia. Should be performed in both upright and recumbent positions. SVC SYNDROME: TREATMENT CONSULTS TREATMENT O2, IV ACCESS, IVF SURGERY IRRADIATION CHEMOTHERAPY HYPERVISCOSITY COMPLICATION ALL (161) AML (73) METABOLIC 22 4 HYPERKALEMIA 16 2 LO CA, HIGH PO4 15 3 RENAL FAILURE 5 4 RESPIRATORY 0 6* HEMORRHAGE 4 14* CNS 2 9 * p <.001 HYPERVISCOSITY: treatment OXYGEN HYDRATION TRANSFUSIONS KEEP PLATELETS > 20,000/ul AVOID PRBC UNLESS SYMPTOMATIC SINCE THEY MAY INCREASE VISCOSITY LOWER WBC EXCHANGE TFX = LEUKAPHERESIS CHEMOTHERAPY ?IRRADIATION? METABOLIC EMERGENCIES HYPERURICEMIA HYPERKALEMIA HYPERPHOSPHATEMIA HYPOCALCEMIA Due to rapid turnover of tumor cells (with or without anti-tumor therapy) HYPERCALCEMIA Due to bone metastases, PTH-like peptide production, PGE2 or calcitriol METABOLIC EMERGENCIES: hyperuricemia hypoxanthine xanthine xanthine oxidase allopurinol uric acid uric acid oxidase allantoin TUMOR LYSIS SYNDROME: Rx HYPERURICEMIA Hydration Allopurinol Uric acid oxidase Bicarbonate High PO4, low Ca Phosphate binder Calcium gluconate HYPERCALCEMIA: Dx, Rx SIGNS, SYMPTOMS: nausea, constipation, polyuria weakness, bradyarrhythmias, renal insufficiency, coma TREATMENT excretion: NSS, furosemide (not thiazide) mobilization: prednisone (acts slowly) calcitonin biphosphonates Treatment of the malignancy Tumor Primary Metastatic Hyperleukocytosis Stroke Seizure Leukoencephalopathy Post-XRT somnolence Chemotherapy Chemotherapy causing acute alterations in consciousness Corticosteroids: mood swings, hallucinations, psychosis Cytosine arabinoside: cerebellar dysfunction, seizures, coma Methotrexate: encephalopathy, seizures Ifosfamide: somnolence Retinoic acid: pseudotumor CNS EMERGENCIES: seizures Tumor Primary Metastatic Hyperleukocytosis Stroke Leukoencephalopathy Chemotherapy GI EMERGENCIES OBSTRUCTION tumor vincristine, narcotics HEMORRHAGE INFECTION typhlitis perirectal abscess “treat the rectum with respect” PANCREATITIS corticosteroids, asparaginase infection GI EMERGENCIES: VOD VENOCCLUSIVE DISEASE ETIOLOGY: POST-TRANSPLANTATION : DACTINOMYCIN : THIOGUANINE CLINICAL : WEIGHT GAIN : HEPATOMEGALY : HYPERBILIRUBINEMIA GU EMERGENCIES: OLIGURIA PRERENAL: dehydration, sepsis, low albumen RENAL: tumor, tumor lysis products, antibiotics, SIADH, chemotherapy POST RENAL: tumor, narcotics, v-zoster Treatment depends upon etiology GU EMERGENCIES: HEMATURIA THROMBOPENIA: MARROW DISEASE, DIC, CHEMOTHERAPY INFECTION: BACTERIAL, VIRAL (CMV, BK, ADENO) CHEMOTHERAPY: CYCLOPHOSPHAMIDE AND IFOSFAMIDE RARELY LIFE-THREATENING PER SE DIAGNOSE, TREAT UNDERLYING PROBLEM GU EMERGENCIES: SIADH ETIOLOGIES CNS INFECTION TUMORS CHEMOTHERAPY VINCRISTINE CYCLOPHOSPHAMIDE IFOSFAMIDE IATROGENIC HYPERTENSION RENAL: VASCULAR COMPRESSION/OCCLUSION, TUMOR LYSIS, PARENCHYMAL DISEASE/TUMOR HUMORAL: CATECHOLAMINES, RENIN, CORTICOSTEROIDS (TUMOR, TREATMENT) CNS: TUMOR (CUSHING TRIAD), INFECTION OTHER: MEDICATION , FLUID OVERLOAD, PAIN INFECTIOUS EMERGENCIES RISK FACTORS NEUTROPENIA (ANC or APC < 500/ul) IMMUNE SUPPRESSION FOREIGN BODIES The usual signs of infection may be subtle or absent in patients unable to mount an effective inflammatory response due to neutropenia, lymphopenia or corticosteroid therapy INFECTIOUS EMERGENCIES If a central access line is present, cultures through each CXR rarely helpful in the absence of clinical signs or symptoms Urine culture may be useful in females Single, broad-spectrum antibiotic coverage is adequate for most patients (cefipime) Add vancomycin if sick, recent foreign body insertion, or site suggestive of staphylococcal infection Double gram negative/anaerobic coverage for suspected GI focus INFECTIOUS EMERGENCIES Perirectal pain (treat the anus with respect) Look Palpate Test tube proctoscopy better than rectal exam Fever, tachypnea, hypoxemia, clear lungs Sepsis Pneumocystis carinii pneumonia Pulmonary embolism SHOCK IN CHILDREN WITH CANCER HYPOVOLEMIC SEPSIS HEMORRHAGE MESIS PANCREATITIS ADDISONIAN DIABETES HYPERCALCEMIA OTHER EMERGENCIES: RETINOIC ACID SYNDROME FEVER RESPIRATORY DISTRESS WEIGHT GAIN PLEURAL/PERICARDIAL EFFUSIONS HYPOTENSION TREATMENT: HOLD ATRA : DEXAMETHASONE : ?LOWER WBC? OTHER EMERGENCIES INFILTRATION OF THE OPTIC NERVE can lead to rapid, permanent loss of vision emergency irradiation +/- chemotherapy SKIN EXTRAVASATION OF VESSICANTS rare since central access device use can cause severe ulceration, scarring No good clinical trials of treatment. Alkylating agents: Na thiosulfate, topical DMSO DNA intercalators: cold, ?topical DMSO? Alkaloids, podophyllotoxins: hyaluronidase Credits
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