Emergencies in Pediatric Oncology

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Definition:

WBC > 100

Leukapheresis

treatment for extreme cases

lots of risks: electrolyte imbalance, hemorrhage, respiratory failure, renal failure, allergic reaction

need to be in ICU setting, pheresis trained nurse, central line, blood bank

INTERVENTIONS

-close monitoring

-fluids at 1.5-2x maintenance

-avoid PRBCs if possible

-give platelets, FFP, cryo PRN

-treat/monitor tumor lysis

-start chemo as soon as possible

-leukapheresis

More common in AML & infants

Affects overall prognosis, if symptomatic - higher risk of M&M

POSSIBLE COMPLICATIONS

-neuro: stroke, headache, blindness, decreased LOC

-respiratory: hypoxia, dyspnea

-hemorrhage

-renal failure

-tumor lysis syndrome

Result of the rapid destruction of malignant cells in bulky, rapidly proliferating tumors or in highly chemo-sensitive disease

Causes electrolyte imbalances

1. Elevated Uric Acid >8

2. Elevated Phosphorus >2.1

3. Elevated Potassium >6

4. Decreased Calcium

Cell damage = release of nucleic acid (which eventually is converted into uric acid)

Rapid release of phosphates as malignant cells have as much as 4x the amount of phosphate compared to normal cells

Can cause precipitation in the renal tubules, which can lead to renal failure

RISK FACTORS

-Diagnosis: Burkitt's leukemia & lymphoma, ALL, other lymphomas

-Increased LDH

-bulky disease

-initial WBC >25K

-uric acid >8

-serum creatnine 1.5x upper normal limit

COMPLICATIONS

Renal Insufficiency Cardiac Arrhythmias

Seizures

Clinical Manifestations

-Usually occur 12-72 hours after first chemo

nausea, vomiting

decreased urine output

edema, fluid overload

dysrhythmias

congestive heart failure

lethargy

muscle cramping

tetany

Supportive Care for Prevention & Treatment of TLS

IV Hydration

Baseline lab work; if abnormalities noted or high risk factors, repeat Q4-6 hours

Weight monitoring, fluid balance

Severe cases may require dialysis

****Best to use GFR or creatinine clearance as an indicator of acute renal failure****

ALLOPURINOL

-xanthine oxidase inhibitor

-reduces uric acid production

-give 10 mg/kg/day divided every 8-24 hours

-used in low-moderate risk patients as prevention

RASBURICASE

-enzyme found in other

mammals but not humans

-catabolizes existing uric acid to allantoin (much more soluble)

-0.05-0.2 mg/kg for single dose

-very expensive

HypErleukocytosis

Tumor lysis syndrome