Emergencies In Oncology

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Emergencies In Oncology
Neutropenic fever
SVCO
Malignant pericardial tamponade
Hypercalcemia
Tumour lysis syndrome
Cord compression
Brain metastases
Pain

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Emergencies In Oncology

  1. 1. Emergencies in Oncology
  2. 2. 1. Neutropenic fever 2. SVCO 3. Malignant pericardial tamponade 4. Hypercalcemia 5. Tumour lysis syndrome 6. Cord compression 7. Brain metastases 8. Pain
  3. 3. Neutropenic fever
  4. 4. • Fever • Single reading >38.3ºC • Sustained (> 1 h) reading >38ºC • Neutropenia • ANC <500 cells/uL (pedantic) • ANC 500 to 1000 cells/uL with a predicted nadir of <500 (pragmatic) • Risk is inversely proportional to ANC
  5. 5. high index of suspicion • Signs of inflammation may be absent • Erythema, induration, pus • Pulmonary infiltration • Pyuria • Pleocytosis • Fever is not always present • Elderly, pts receiving steroids • May present with hypothermia and hypotension
  6. 6. Most common causes • Majority are bacterial in origin • 30% have bacteremia • 80% are endogenous • Gram (-) used to predominate • Gram (+) are on the rise
  7. 7. Bacterial infection • Gram (-) • E coli • Klebsiella • Pseudomonas • Enterobacter • Gram (+) • Staphylococcus species • Streptococcus species • Enterococcus • Corynebacterium
  8. 8. Anaerobic infection • Represents 3.4% of cases • Routine cover is not necessary • Except for special sites • Oral and sinus infections • Intra-abdominal or pelvic infection • Perirectal infection • Anaerobic becteremia
  9. 9. Fungal infection • Usually a secondary infection • Prolonged neutropenia • Prolonged antibiotic use • Candida and Aspergillus species • One-third of febrile neutropenic pts who fail to respond after 7 days of antibiotic have systemic fungal infection
  10. 10. Viral infection • Predominantly in BMT and hematologic cancer patients • Predominantly herpesviruses (HSV, VZV, CMV, EBV) • Sometimes respiratory viruses • There is usually no indication for empiric anti-viral therapy without evidence of viral infection
  11. 11. Treatment • evaluation for subtle signs & symptoms of infection • Full blood count • Liver and renal panels • CXR • Blood and urine cultures
  12. 12. Treatment • Perform blood culture from ALL PORTS and the peripheral vein • Start antibiotic therapy IMMEDIATELY!
  13. 13. Monotherapy • Broad spectrum b-lactams with anti-pseudomonal coverage • Ceftazidime 2 g q8 hrly • Cefepime 2 g q8 hrly • Imipenam 500 mg q6 hrly • Meropenam 1 g q8 hourly • Tazocin 4.5g q8 hourly
  14. 14. Two-drug therapy • The addition of an aminoglycoside to • Tazocin • Ceftazidime or Cefepime • Imipenam or Meropenam • Synergistic against gram (-) bacilli with less risk of emergence of resistance • Indicated when severe sepsis, septic shock, high prevalence of multi-drug resistance gram (-) bacilli
  15. 15. ? Vancomycin • Addition to initial empiric antibiotic regimen has not been shown to decrease mortality • Considered when • Clinically suspected serious catheter related infection • Known MRSA colonization • Gram (+) bacteremia • Hypotension
  16. 16. CVC-related infection • Classification • Exit wound infection • Tunnel infection • CVC-associated bacteremia • Septic thrombophlebitis
  17. 17. CVC-related infection • Most commonly • Coagulase-negative staph • S aureus • Less commonly • Gram (+) bacilli (Corynebacterium and bacillus specie) • Candida • Mycobacteria
  18. 18. Catheter removal • Tunnel infection • Septic thrombophlebitis • Septic emboli • Culture (+) after 72 hrs of therapy
  19. 19. Catheter removal • Selected pathogens • Corynebacterium • Bacillus • S aureus • VRE • Candida • Mycobacterium
  20. 20. Typhlitis • Neutropenic enterocolitis • ? when neutropenia + “appendicitis” • Distended cecum, edematous cecal wall, pneumatosis intestinalis on CT • Typically pseudomonas + clostridium • Primary treatment: antibiotics! • Surgery if with bowel complications
  21. 21. Treatment • No localizable focus • No s/s of systemic infection other than fever • ANC > 500/ mm3 • Cancer responding to treatment • No significant co-morbidity • No recent hospitalization • Age <60 • Stable patient
  22. 22. Treatment • Oral Augmentin + Ciprofloxacin x 5 days • Follow up with Doctor in ≤3 days • Trace preliminary culture results O/A
  23. 23. Colony-stimulating factor • to shorten duration of neutropenia • Can reduce neutropenia-related morbidities • Use of antibiotics • Cost of management
  24. 24. Superior vena cava syndrome
  25. 25. Superior vena cava • Drains venous blood from head, neck, upper limbs and thorax • Surrounded by relatively rigid structures • Thin walled, low pressure and easily compressible • Completely encircled by chains of lymph nodes that drain the whole right and lower left thorax
  26. 26. Causes • Lung (65%) • Lymphoma (8%) • Other cancers (10%) • Nonmalignant (12%) • Undiagnosed (5%)
  27. 27. Clinical Presentations • Most common symptoms • Dyspnoea (63%) • Facial swelling (50%) • Head fullness (24%) • Most common signs • Venous distension of neck (66%) • Venous distension of chest wall (54%) • Facial edema (46%)
  28. 28. complications • Cerebral edema • Laryngeal edema
  29. 29. Imaging studies • CXR • CT scan is often diagnostic • Upper extremity venography seldom needed
  30. 30. CXR findings Findings Patients (%) Sup mediastinal widening 64 Pleural effusion 26 (R) hilar mass 12 Bilateral infiltrates 7 Cardiomegaly 6 Calcified paratracheal LNs 5 Ant mediastinal mass 3 Normal 16
  31. 31. Treatment • Raise the upper body • Transfer iv access to lower limbs • Supplemental oxygen • Mist morphine 5-10 mg q4-6 hrly • Furosemide 20-40 mg om • Hydrocortisone 100 mg q6-8 hrly
  32. 32. Treatment • Treat underlying cancer • Radiation therapy • Chemotherapy • Re-establish patency • Thrombolytic therapy • Endovascular stenting • Bypass surgery
  33. 33. Pericardial Tamponade
  34. 34. Causes • Often (but not always) a preterminal event • Occurs in about 10-15% of advanced cancer pts • Lung and breast cancer make up 75% of all the cases
  35. 35. Clinical Presentations • Symptoms similar to CCF • Signs • Kussmaul’s sign • Pulsus paradoxus • Distant heart sounds
  36. 36. imaging studies • CXR • Water-bottle silhouette • Echocardiography • Echo separation • RA or RV collapse • CT chest
  37. 37. Treatment • IV fluids • Supplemental O2 • Morphine for SOB • Inotropic support • Pericardiocentesis
  38. 38. Treatment • Pericardial window • Pericardial sclerosis • Radiotherapy • Treat underlying cancer
  39. 39. Hypercalcemia
  40. 40. • Elevated levels of ionized calcium in the blood • Corrected calcium = measured calcium + 0.02 x (40 – measured albumin) mmol/L • Normal 2.2 – 2.6 mmol/L • Symptomatic > 3.0 mmol/L
  41. 41. Causes • The 2 most common causes are cancer and hyperparathyroidism
  42. 42. Causes • The most common malignancies are • Multiple myeloma • Breast • NSCLC • RCC • Hypercalcemia is the most common life-threatening metabolic oncologic disorder
  43. 43. Clinical presentation • General • Dehydration, fatigue, lethargy, pruritis • Neuromuscular • Confusion, psychosis, obtundation, seizure • Proximal myopathy, hyporeflexia • GIT • Nausea, emesis • Dyspepsia • Pancreatitis • Constipation, ileus
  44. 44. Clinical manifestations • Renal • Polyuria, ARF • Cardiac • Bradycardia, prolonged PR, shortened QT, widen T, arrhythmia
  45. 45. Treatment • Forced diuresis • Saline 4-6 L over 24 hr • Urine output 150-200 ml/h • Volume re-expansion • Calciuresis • Loop diuretic • Calciuresis • may worsen dehydration • Those at risk of hypervolemia
  46. 46. Treatment • Pamidronate 60-90 mg IV over 2-4 hr • Inhibits osteoclasts • Commence when diuresis is achieved • Calcitonin 2-8 U/kg SC or IM q6-12 hrly • Inhibits osteoclasts • Fast, safe but short • Severe symptomatic hypercalcemia before the onset of bisphosphonate
  47. 47. Treatment • Hydrocortisone 250-500 mg q8 hrly • Inhibits osteoclasts • Helpful in MM, lymphoma, some breast cancers • No value in most solid tumours
  48. 48. Treatment • Hemodialysis can be considered in those with severe symptomatic hypercalcemia who are unable to tolerate forced diuresis
  49. 49. Watch for: • Fluid status • Hemodynamic status • Metabolic status • Hypomagnesemia • Hypokalemia
  50. 50. Supportive Treatment • Avoid drugs that may worsen hypercalcemia or those that are nephrotoxic • Decrease intestinal absorption by restricting dietary calcium intake or with the use of oral phosphate (1-3 g/day) • Ensure early mobilization
  51. 51. Acute Tumor Lysis Syndrome
  52. 52. ATLS • Rapid lysis of malignant • Release of intracellular products • Exceeds renal excretory capacity • Resulting in life-threatening metabolic derangements
  53. 53. Usual presentation • Usually during 1st cycle chemotherapy • Anticipated event • Treatment is primarily PROPHYLACTIC
  54. 54. • Hyperkalemia (3.5-4.5 mmol/L) • Hyperphosphatemia (0.8-1.45 mmol/L) • Hypocalcemia (2.12-2.65 mmol/L) • Hyperuricemia (M < 420; F < 360 umol/L) • Acute renal failure
  55. 55. Prophylaxis • Identify who is at risk • Hydration 3 L/m2/day • Don’t add potassium • Keep urine flow 150-200 ml/ hr • Alkalinization • 50-100 mEq Na(HCO3)2 • Keep urine pH 6.5 to 7 • Allopurinol 300 mg/day • Institute these measures 24-48 hr before chemotherapy for treatment of cancer at risk of ATLS
  56. 56. High risk: • Hematological cancers • Aggressive lymphomas • Acute leukemias • Chemosensitive solid cancers • Small cell lung cancer • Germ cell tumour
  57. 57. • Bulky disease • Abdominal disease • LDH >1500 U/L • Pre-existing volume depletion • Pre-existing renal dysfunction • Post-treatment ARF • Concentrated urine • Acidic urine
  58. 58. Treatment • Same measures as those for prophylaxis • Correct electrolyte derangements but don’t try to correct the hypocalcemia • Urate oxidase (Rasburicase) • Coverts UA to highly soluble allantoins • Rapid onset of action • Very expensive • Hemodialysis
  59. 59. Spinal Cord Compression
  60. 60. Spinal cord compression • Overall frequency about 5% • 2nd most common cancer neurological complication • Definition broaden to include • Conus medullaris • Cauda equina • All can be caused by secondaries to the spine
  61. 61. Causes of Spinal Cord Compression • Breast 29% • Lung 17% • Prostate 14% • Lymphoma 5% • Myeloma 4% • Renal 4%
  62. 62. Clinical Manifestations: • Pain • Most common initial symptom (90%) • Almost always antedate (days - months) • Local pain almost always present •  by coughing, neck flexion or straight leg raising •  when lying down (c.f. disc disease) • Radicular pain (nerve root)
  63. 63. • Weakness • Second most common symptom • Most evident with proximal LL • Can progress rapidly • Autonomic symptoms • Occurs late • Poor prognosis
  64. 64. • Classically, spastic paralysis with sensory level • But if in cord shock, can present with absent motor, sensory, reflex and autonomic function
  65. 65. Conus medullaris • Saddle anaesthesia (S3-5) • Early sphincter involvement (S4-5) • Impotent (S2-4) • Spares the lower limbs (spares S1)
  66. 66. Cauda equina • Radicular pain • Asymmetrical sensory loss • Asymmetrical flaccid paralysis • Relative autonomic sparing
  67. 67. Level involved • Thorax 70% • Lumbosacral 20% • Cervical 10%
  68. 68. Extent • Single level (46%) • Multiple non-contiguous levels (28%) • Multiple contiguous levels in about (26%)
  69. 69. Imaging • Plain XRAY (+): 70-80% when either back pain or signs present • MRI is the modality of choice • CT myelography if MRI unavailable • Bone scan indicates the presence of spinal metastases but does not diagnose cord compression
  70. 70. Predictor of recovery • The most single most powerful predictor of treatment outcome is the pretreatment neurologic status Pre-treatment Recovery after RT Ambulatory 98% Paraparetic 60% Paraplegic 11%
  71. 71. Management • Pain control • Preserve spinal stability • Relieve cord edema • Relieve autonomic dysfunction • Confirm diagnosis • Surgical decompression/stabilization • Treat the bone mets
  72. 72. management • Mist morphine • Bedrest • Dexamethasone 8 mg q6 hrly • Bladder catherization • MRI spine • Refer spine team • Radiation therapy
  73. 73. Surgical indication: • Need histology • Retropulsed bone fragment • Spinal instability • Previous RT or progression on RT • Single level • Rapid progression
  74. 74. Brain Metastases
  75. 75. Cerebral metastases • Occurs in 20-40% of cancer patients • Majority are from lung and breast • Majority are supratentorial (80%) • Majority are multiple (70%)
  76. 76. causes • Metabolic such as hypoglycemia • Cerebrovascular • Infective • Nutritional • Paraneoplastic
  77. 77. Features that needs close monitoring • Massive lesion • Haemorrhage • Extensive edema • Mass effect • Hydrocephalus • Posterior cranial fossa
  78. 78. management • Dexamethasone 8 mg Q8 hourly • Restrict fluids • Anticonvulsant only if symptomatic • Refer neurosurgeon if worrisome features present
  79. 79. Pain Management
  80. 80. Pain in a cancer • Concepts of pain • Physical pain • Clinical pain • Total suffering
  81. 81. Physical pain • It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage
  82. 82. Pathophysio classification • Nociceptive • Soft tissue pain • Bone pain • Visceral pain • Neuropathic • Psychogenic
  83. 83. • Inadequate analgesia e.g. undertreated, poor compliance • Breakthrough pain • Disease progression • Acute complication e.g. tumour rupture, pathological fracture
  84. 84. • Opioid: most pains • Steroid: inflammatory pains, raised ICP • NSAID: bone pains • Antispasmodic: colicky pains • Anticonvulsants: “shooting’’ pains • Antidepressants: “burning” pains • Anxiolytics: muscle pains
  85. 85. Analgesics • Opioid naïve start 5 mg PO • Scheduled doses q4-6h strictly • Breakthrough doses 5 mg q2h prn • Increase dose by 25-50% • Caution in elderly, liver failure and renal failure
  86. 86. doses • IV Morphine 10 mg (x 1) • TD Fentanyl 0.1 mg (x 100) • IV Pethidine 75 mg (x 0.13) • PO Methadone 20 mg (x 0.5) • PO Oxycodone 20 mg (x 0.5) • PO Morphine 30 mg (x 0.33) • PO Tramadol 120 mg (x 0.08) • PO Codeine 240 mg (x 0.04)
  87. 87. Titration of morphine dose • For controlling severe pain • i.v. morphine 1 mg • Every 1 min until pain relief or drowsy • Cumulative dose given = dose per 4h • Calculate dose needed for 24h and run as a continuous infusion
  88. 88. • Source: Google Medscape Harrison’s Oxford Old notes in Medical School http://crisbertcualteros.page.tl

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