Hematologic and Oncologic Emergencies Terzah Horton, MD/PhD - PowerPoint PPT Presentation

Title: Hematologic and Oncologic Emergencies Terzah Horton, MD/PhD


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Hematologic and Oncologic Emergencies

• Terzah Horton, MD/PhD
• Texas Childrens Cancer Center

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Four Major Categories of Heme-Onc Emergencies

• Space-occupying / mass effect

• Hematopoietic

• Metabolic

• Infectious

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Setting

• Quiet night at the Ben Taub Pedi ER
• Night Riding 4am, no charts on rack
• Attending out for a bite to eat
• Suddenly, three charts on the urgent rack (1st
  emergency)
• trouble seeing fever cough

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What to you do next?
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Night riding in Ben Taub ER

• AAP Careful data collection and synthesis
• Interpretation look through the waiting room
  door and
• Look at your patients and their VS.

What do you do next? Call for backup? (Yes), wait
for them to arrive? (No) Who do you see first?
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Patient 3 Airway complications

• What do you want to know first?
• What do questions do you want to ask now?
• What needs to be done now?

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Blue Teenager

• What do you want to know first?
• Vitals RR40, HR 140, BP 100/70, temp 101F.
• CXR (lucky for you, he came with an outside film)
• What do questions do you want to ask now?
• How long (2m, worse last 2 days)
• Whats his most comfortable position (sitting)
• What needs to be done now?
• Oxygen, keep sitting up (exacerbated by being
  supine
• Admit to PICU

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Treatment Airway Management

• Admit to PICU
• Beware supine positioning
• Avoid CT/pleurocentesis/biopsy/bone marrow exam
  without controlled environment
• Emergency XRT/chemo if unable to biopsy

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Orders for PICU

• Vital signs frequent, continuous pulse ox and
  heart monitor things can go down-hill quickly
  and you want to know
• Call ENT, anesthesia, heme-onc and surgerymay
  need controlled environment quickly (can you get
  a biopsy or not without compromise?)
• I/O npo. Fluids maintenance (only)
• Medications nothing causing drowsiness
• Activity keep him comfortable (sitting)

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Patient 2 Toddler with Neuroblastoma fever, big
belly

• Febrile for 12h
• Last chemotherapy 10 days ago
• Extremely tender RLQ
• Questions- What do you want to know now?
• What actions are needed now?

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Toddler with big belly

• Vitals HR 160, RR 22, temp 101, BP 90/60
• Labs (dont wait for them)
• ANC 0, Hb 6.5, plt 15K
• What to do now?
• ANTIBIOTICS in ER (Zosyn, Vanc, Gent)
• NS in ER (judiciously)if shocky, use what you
  need (20cc/kg boluses)
• Blood products pRBC and platelets (pRBC much
  better than NS for volume replacement).

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MAJOR POINTS infection in neutropenic patients

• Local infection may not be obvious (no redness,
  swelling, purulent drainage)
• NEVER perform rectal exams, bladder
  catheterizations, or place NG tubes without
  approval
• NEVER ID abscesses
• ALWAYS TRIAGE and have MD see patient STAT
• ALWAYS BEGIN ANTIBIOTICS IMMEDIATELY POST BLOOD
  CULTURES
• NEVER delay institution of antibiotic therapy
  until patient admitted to floor

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USUAL SOURCES OF BACTERIA

• Gut flora
• Line contamination
• Finger sticks
• Mucus membrane manipulation
• THE ENVIRONMENT

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THERAPY-Fever/neutropenia

• Immediate hospitalization
• Cultures - blood (line) urine (dont need a
  peripheral blood culture, but need both lines if
  double lumen catheter
• IV broad spectrum antibiotics
• Zosyn/ vancomycin
• Consider gentamicin if toxic
• Consider monotherapy (Ceftazidime) in low risk
  ALL or solid tumor pateint if
• - Well appearing / stable vital signs
• - No oxygen requirement
• - No source for fever
• Pressors / transfusion as indicated

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TRANSFUSIONS

• All immunosuppressed patients receive irradiated
  blood products
• Leukocyte reduced is considered CMV safe OK to
  give for CMV negative patients.
• pRBC and platelet pheresis units are routinely
  leukocyte reduced.

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GENERAL RECOMMENDATIONS

• pRBC -10-15 cc/kg
• Expected rise in Hb 2 g/dL
• PLTS lt10kg 5-10 cc/kg
• gt10 kg 1 random unit/10 kg
• Max 6 pooled units or 1 pheresis unit.
• FFP 10-15cc/kg over 2-4 hrs
• Jumbo units 400-600cc (contact blood bank)
• cryoprecipitate 1-2units/10kg

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Case 2 TYPHLITIS

• Necrotizing colitis
• Agranulocytic
• Cecal involvement
• Gram negative organisms
• KUB enlarged cecal wall sometimes with
  railroad tracks air in luminal wall (not good)

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TYPHLITIS

• Symptoms
• - Fever, RLQ pain, abdominal distention,
• dilated loops of bowel
• Treatment
• - Early recognitionmake NPO
• - Aggressive IV antibiotics
• - Rarely surgical candidates

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Space Occupying lesions

• Can be in multiple locations
• Head and neck
• Chest/abdomen
• Urologic
• Neurologic
• Orbital mass
• Threat to vision
• Compression of optic nerve
• ?Other CNS involvement?

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Space occupying lesions
Orbit
Paranasal sinuses
Brain tumor with hydrocephalus
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Tx Space occupying lesions

• Treatment
• Neuro vital signs q2h, strict I/O, CBC
  (bleeding?) Chem7 (SIADH, acidosis)
• Neurosurgery and heme-onc consults may need
  mannitol, hyperventilation for hydrocephalus
• Biopsy if possible
• Immediate XRT/chemotherapy
• Steroids very helpful with symptom control

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Meanwhile on the TCH floor
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Unresponsive patient with HbSS

• What do you want to know now?
• What assessments should be performed now?
• How do you manage this patient?

Phone skills Assume you have or youre going to
call 1) the heme-onc fellow, 2) the rapid
response team, 3) the upper level, and 4) the
PICU.
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Unresponsive patient with Hb SS

• What do you want to know?
• Vitals HR 110, RR 15, BP 130/90, temp 98.7F
• What assessments/treatments should be performed
  now?
• Glascow coma scale (GCS)
• Oxygen, vitals q15m, IVFavoid overhydration
  (1500-1800 cc/m2/day), avoid hyperglycemia,
  control hypertension. Airway contol (RRT will
  help with this)
• RRT assess--what is needed for safe for transfer
  to DI?
• CT scan without contrast

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Unresponsive patient with Hb SS

• How do you manage this patient?
• Pheresis in ICUarranged through renal attending
  (fellow usually calls, but)
• RBC apheresis Renal will need to know
• Weight, M2, last Hb profile? how much blood to
  order to get target Hb Slt30
• What size catheter to order
• What surgeon to help with catheter placement

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Unresponsive patient with Hb SS

• Stroke- At risk patients
• Sickle cell patients
• Hyperleukocytosis (AML or ALL)
• Hypercoagulable syndrome (need w/u one
  stabilized)
• Brain tumors
• Consults neurology (in am), neurosurgery if
  hydrocephalus

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Stroke in Hb SS

• Due to acute occlusion of ICA branch(es)
• Most common in 2-15 yr olds
• Hemorrhagic strokes may occur in teens
• Tx Emergent exchange transfusion!
• 70 recurrence rate without intervention
• Chronic transfusions reduce risk to 10
• TCD can predict risk of future stroke

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Labs not right in newly-diagnosed leukemia
patient

• 2yo with T-cell ALL, WBC 350K, started treatment
  12h ago.
• What do you want to know?
• Labs Na 135, K 7.5, uric acid 9, phosphorus 8,
  Ca 6.5
• Management?

• Should really be in the PICU, but
• its winter and everyones on vents.
• He doesnt meet criteria for
• leukapheresis (if gt2y, need to be gt400K)
• You can watch him carefullycall if
• you need help, remember ABC

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TUMOR LYSIS SYNDROME (TLS)

• Complication of rapid cell replication lysis
• Mechanism Rapid release of intracellular
• metabolites exceeding excretory
• capacity of kidneys
• Hyperuricemia
• Hyperphosphatemia
• Hyperkalemia
• Hypocalcemia
• RISK OF ACUTE RENAL FAILURE

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TLS HIGH RISK DISEASES

• Large cell burden / rapid responders
• Burkitts lymphoma
• T-cell leukemia / lymphoma
• B-cell leukemia (WBCgt400K)
• AML
• Neuroblastoma

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TLS MANAGEMENT of hyperuricemia

• Decrease uric acid production
• - Allopurinol Competitive inhibitor of
• xanthine oxidase reducing degradation
• of purines to uric acid
• - Urate oxidase (rasburicase) enzyme
• responsible for the oxidation of uric acid
  to
• allantoin (10 x more soluble at renal
• tubular pH)

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RASBURICASE

• What you need to know about rasburicase
• Severe hypersensitivity reactions and anaphylaxis
  can occur
• Hemolysis in patients with G6PD- contraindicated
• Methemoglobinemia may occur
• Enzymatic degradation will occur in blood samples
  left at room temp. Blood must be collected in
  chilled heparinized tubes, put on ice, and
  immediately sent to lab for assay
• Dose 0.15-0.2 mg/kg QD x 5 over 30 min

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TLS MANAGEMENT

• Hyperuricemia
• Extracellular volume expansion
• IVF 2400-3600 cc/m2/day
• Hyperkalemia
• EKG (peaked T waves and widened QRS?arrhythmias)
• Kayexalate (permanent), albuteral (temporary fix)
• IVF, Lasix, bicarbonate (already getting)
• Insulin, glucose, IV calcium if severe (central
  line)

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TLS MANAGEMENT

• Hypocalcemia Treat hyperphosphatemia if not
  critically low. Ca Gluconate in ICU if lt6.0.
• Hyperphosphatemia
• Low PO4 diet
• Phosphate binders (aluminum hydroxide)
• Renagel

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TLS HEMODIALYSIS

• Consider hemodialysis if
• - Acute renal failure develops
• - Neurologic sx develop
• - Uncontrolled volume overload /hyperkalemia
• Contact Renal early they can help with
  electrolyte management

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Sickle-cell chest pain

• What do you want to know now?
• What assessments need to be made now?
• What is the treatment plan?

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Sickle cell with chest pain

• What do you want to know now?
• VS RR, pulse ox, ABG if severe
• What assessments need to be made now?
• CRS score
• CXR (new infiltrates) portable if unstable
• What is the treatment plan? Depends on CRS
• IVF IV oral limited to maintenance fluids
• Xopenex 4-8 puffs depending on CRS
• Methylprednisolone q8-12h depending on CRS

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CRS score
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Acute Chest Syndrome

• Chest pain, cough, fever, hypoxemia, new
  infiltrate on CXR
• Is it infection or infarction?
• Management
• Hydrate, but dont overhydrate
• Antibiotics (GPCs and atypicals)
• Control pain (but dont oversedate)
• AGGRESSIVE PULMONARY TOILET
• Simple or exchange transfusion
• At risk for future episodes

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Management of chest pain in patient with sickle
cell disease
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Summary

• Collect needed information quickly and call the
  heme-onc fellow.
• Most important assess the patient, get their
  vital signs, CRS, GCS, relevant labs that you
  already have available
• If necessary, call upper-level and/or RRT if need
  PICU support