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Emergencies In Oncology
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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 Emergencies In Oncology Presentation Transcript

  • Emergencies in Oncology
  • 1. Neutropenic fever 2. SVCO 3. Malignant pericardial tamponade 4. Hypercalcemia 5. Tumour lysis syndrome 6. Cord compression 7. Brain metastases 8. Pain
  • Neutropenic fever
  • • 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
  • 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
  • Most common causes • Majority are bacterial in origin • 30% have bacteremia • 80% are endogenous • Gram (-) used to predominate • Gram (+) are on the rise
  • Bacterial infection • Gram (-) • E coli • Klebsiella • Pseudomonas • Enterobacter • Gram (+) • Staphylococcus species • Streptococcus species • Enterococcus • Corynebacterium
  • 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
  • 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
  • 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
  • Treatment • evaluation for subtle signs & symptoms of infection • Full blood count • Liver and renal panels • CXR • Blood and urine cultures
  • Treatment • Perform blood culture from ALL PORTS and the peripheral vein • Start antibiotic therapy IMMEDIATELY!
  • 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
  • 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
  • ? 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
  • CVC-related infection • Classification • Exit wound infection • Tunnel infection • CVC-associated bacteremia • Septic thrombophlebitis
  • CVC-related infection • Most commonly • Coagulase-negative staph • S aureus • Less commonly • Gram (+) bacilli (Corynebacterium and bacillus specie) • Candida • Mycobacteria
  • Catheter removal • Tunnel infection • Septic thrombophlebitis • Septic emboli • Culture (+) after 72 hrs of therapy
  • Catheter removal • Selected pathogens • Corynebacterium • Bacillus • S aureus • VRE • Candida • Mycobacterium
  • 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
  • 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
  • Treatment • Oral Augmentin + Ciprofloxacin x 5 days • Follow up with Doctor in ≤3 days • Trace preliminary culture results O/A
  • Colony-stimulating factor • to shorten duration of neutropenia • Can reduce neutropenia-related morbidities • Use of antibiotics • Cost of management
  • Superior vena cava syndrome
  • 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
  • Causes • Lung (65%) • Lymphoma (8%) • Other cancers (10%) • Nonmalignant (12%) • Undiagnosed (5%)
  • 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%)
  • complications • Cerebral edema • Laryngeal edema
  • Imaging studies • CXR • CT scan is often diagnostic • Upper extremity venography seldom needed
  • 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
  • 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
  • Treatment • Treat underlying cancer • Radiation therapy • Chemotherapy • Re-establish patency • Thrombolytic therapy • Endovascular stenting • Bypass surgery
  • Pericardial Tamponade
  • 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
  • Clinical Presentations • Symptoms similar to CCF • Signs • Kussmaul’s sign • Pulsus paradoxus • Distant heart sounds
  • imaging studies • CXR • Water-bottle silhouette • Echocardiography • Echo separation • RA or RV collapse • CT chest
  • Treatment • IV fluids • Supplemental O2 • Morphine for SOB • Inotropic support • Pericardiocentesis
  • Treatment • Pericardial window • Pericardial sclerosis • Radiotherapy • Treat underlying cancer
  • Hypercalcemia
  • • 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
  • Causes • The 2 most common causes are cancer and hyperparathyroidism
  • Causes • The most common malignancies are • Multiple myeloma • Breast • NSCLC • RCC • Hypercalcemia is the most common life-threatening metabolic oncologic disorder
  • Clinical presentation • General • Dehydration, fatigue, lethargy, pruritis • Neuromuscular • Confusion, psychosis, obtundation, seizure • Proximal myopathy, hyporeflexia • GIT • Nausea, emesis • Dyspepsia • Pancreatitis • Constipation, ileus
  • Clinical manifestations • Renal • Polyuria, ARF • Cardiac • Bradycardia, prolonged PR, shortened QT, widen T, arrhythmia
  • 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
  • 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
  • Treatment • Hydrocortisone 250-500 mg q8 hrly • Inhibits osteoclasts • Helpful in MM, lymphoma, some breast cancers • No value in most solid tumours
  • Treatment • Hemodialysis can be considered in those with severe symptomatic hypercalcemia who are unable to tolerate forced diuresis
  • Watch for: • Fluid status • Hemodynamic status • Metabolic status • Hypomagnesemia • Hypokalemia
  • 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
  • Acute Tumor Lysis Syndrome
  • ATLS • Rapid lysis of malignant • Release of intracellular products • Exceeds renal excretory capacity • Resulting in life-threatening metabolic derangements
  • Usual presentation • Usually during 1st cycle chemotherapy • Anticipated event • Treatment is primarily PROPHYLACTIC
  • • 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
  • 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
  • High risk: • Hematological cancers • Aggressive lymphomas • Acute leukemias • Chemosensitive solid cancers • Small cell lung cancer • Germ cell tumour
  • • Bulky disease • Abdominal disease • LDH >1500 U/L • Pre-existing volume depletion • Pre-existing renal dysfunction • Post-treatment ARF • Concentrated urine • Acidic urine
  • 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
  • Spinal Cord Compression
  • 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
  • Causes of Spinal Cord Compression • Breast 29% • Lung 17% • Prostate 14% • Lymphoma 5% • Myeloma 4% • Renal 4%
  • 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)
  • • Weakness • Second most common symptom • Most evident with proximal LL • Can progress rapidly • Autonomic symptoms • Occurs late • Poor prognosis
  • • Classically, spastic paralysis with sensory level • But if in cord shock, can present with absent motor, sensory, reflex and autonomic function
  • Conus medullaris • Saddle anaesthesia (S3-5) • Early sphincter involvement (S4-5) • Impotent (S2-4) • Spares the lower limbs (spares S1)
  • Cauda equina • Radicular pain • Asymmetrical sensory loss • Asymmetrical flaccid paralysis • Relative autonomic sparing
  • Level involved • Thorax 70% • Lumbosacral 20% • Cervical 10%
  • Extent • Single level (46%) • Multiple non-contiguous levels (28%) • Multiple contiguous levels in about (26%)
  • 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
  • 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%
  • Management • Pain control • Preserve spinal stability • Relieve cord edema • Relieve autonomic dysfunction • Confirm diagnosis • Surgical decompression/stabilization • Treat the bone mets
  • management • Mist morphine • Bedrest • Dexamethasone 8 mg q6 hrly • Bladder catherization • MRI spine • Refer spine team • Radiation therapy
  • Surgical indication: • Need histology • Retropulsed bone fragment • Spinal instability • Previous RT or progression on RT • Single level • Rapid progression
  • Brain Metastases
  • Cerebral metastases • Occurs in 20-40% of cancer patients • Majority are from lung and breast • Majority are supratentorial (80%) • Majority are multiple (70%)
  • causes • Metabolic such as hypoglycemia • Cerebrovascular • Infective • Nutritional • Paraneoplastic
  • Features that needs close monitoring • Massive lesion • Haemorrhage • Extensive edema • Mass effect • Hydrocephalus • Posterior cranial fossa
  • management • Dexamethasone 8 mg Q8 hourly • Restrict fluids • Anticonvulsant only if symptomatic • Refer neurosurgeon if worrisome features present
  • Pain Management
  • Pain in a cancer • Concepts of pain • Physical pain • Clinical pain • Total suffering
  • Physical pain • It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage
  • Pathophysio classification • Nociceptive • Soft tissue pain • Bone pain • Visceral pain • Neuropathic • Psychogenic
  • • Inadequate analgesia e.g. undertreated, poor compliance • Breakthrough pain • Disease progression • Acute complication e.g. tumour rupture, pathological fracture
  • • Opioid: most pains • Steroid: inflammatory pains, raised ICP • NSAID: bone pains • Antispasmodic: colicky pains • Anticonvulsants: “shooting’’ pains • Antidepressants: “burning” pains • Anxiolytics: muscle pains
  • 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
  • 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)
  • 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
  • • Source: Google Medscape Harrison’s Oxford Old notes in Medical School http://crisbertcualteros.page.tl