Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Hematology > Oncological Malignancies > Flashcards

Oncological Malignancies Flashcards

1
Q

What are the CVS oncological emergencies?

A

SVCO

Pericardial tamponade

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the CNS oncological emergencies?

A

Inc. ICP

Spinal cord compression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the GIT oncological emergencies?

A

IO, perforated viscus
Ascites
Oesophageal obstruction/perforation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the haematologic oncological emergencies?

A

DIVC
Thrombocytopaenia
Leukostasis*, hyperviscosity syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the metabolic oncological emergencies?

A 
Tumour lysis syndrome  
Hypercalcaemia 
Hyperuricaemia 
Hypoglycaemia 
Lactic acidosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the infectious oncological emergencies?

A

Neutropaenic fever
Disseminated viral infections
Fungal/parasitic dz

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the orthopaedic oncological emergencies?

A

Pathological #

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the urologic oncological emergencies?

A

Post-renal AKI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the respiratory oncological emergencies?

A

Airway obstruction
Pneumothorax
Pleural effusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

[SVCO] What are the causes of SVCO?

A

Lung CA: Most Common Cause

  • Small Cell Lung Carcinoma (SCLC)
  • Squamous Cell Carcinoma (SCC)
  • Adenocarcinoma does NOT cause SVCO because it tends to be peripheral whereas SCC tends to be more central

Lymphoma: The second most common cause

  • Any lymphoma can cause SVCO
  • But most common lymphomas are DLBCL (the most common form of lymphoma) and Burkitt’s

Other mediastinal masses:

  • Thymoma and Teratoma (Germ Cell Tumor)
  • Recall the 5Ts (Thymus, Ectopic Thyroid, Terrible Lymphoma, Thoracic Aorta, Teratoma)

Breast cancer

Iatrogenic causes

  • Lines: CVP/chemo port – SVC Thrombosis
  • Benign neoplasm
  • Post radiation fibrosis
  • Infection / Inflammation
  • Sarcoidosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

[HyperCa] What are the most common cancers that cause hyperCa?

A

Osteolytic: MM, Breast, RCC

Ectopic PTHrp (80%): SCC of Head & Neck & Lung

HUMORAL: Ectopic 1α-hydroxylase – lymphoma (such as HL) or non-malignant granulomatous disorder such as sarcoidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

[MSCC] What are the most common cancers that cause metastatic spinal cord compression?

A

Thyroid, Breast, Lung, RCC, Ovaries, Prostate, MM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

[TLS] What are the most common cancers that cause tumour lysis syndrome?

A

Rapid Turnover: ALL/AML, Burkitt’s/DLBCL, MM

Tumor Burden (bulky disease): Breast, Ovarian

Chemo-sensitivity of CA (aka post-chemo TLS): SCLC (small cell lung carcinoma), Lymphomas, Acute Leukemias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Where does lung CA mets to?

A

Brain, Bone, Liver (& Adrenals), Lung (contralateral)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Where does prostate CA mets to?

A

Bone, Brain (less common + pre-terminal), Liver (& adrenals), Lung

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

[Malignant pericardial effusion]] What are the most common cancers that cause pericardial temponade?

A
  • Solid tumours (lung, breast) most common

- Hematologic malignancies less common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

[Brain mets] What are the most common cancers that cause brain metastasis?

A

Secondary Metastasis

  • Most Common: breast, lungs, melanoma
  • Lung and Breast mets to brain v early in clinical Hx – especially important!

Less Common: RCC, Prostate

  • Whereas Prostate mets to brain at pre-terminal phase only + Quite Rarely
  • Haemorrhagic mets: renal cell, melanoma and choriocarcinoma

Primary brain CA – glioblastoma (v rare)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

[HVS] What are the most common cancers that cause hyperviscosity syndrome?

A

Dysproteinaemia in monoclonal gammopathies such as Waldenstrom macroglobulinemia, MM
- Immunoglobulin binds to each other 🡪 forming clumps 🡪 hyperviscosity + thrombi

Leukostasis in CA with ↑↑WCC 🡪 ALL / AML
- If WCC > 100x109/L 🡪 causes abnormal intravascular leukocyte aggregation and clumping 🡪 hyperviscosity + thrombi 🡪 causing microcirculation occlusion  local hypoxemia and haemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

[SVCO] How does SVCO present?

A

Usually gradual, if sudden consider thrombus (e.g. lines) OR rapidly growing tumor.

  • If sudden 🡪 medical emergency!
  • Obstruction due to cancer is usually has insidious gradual onset

Dyspnoea the most common, earliest presentation

Head fullness

Facial swelling, Facial Plethora, Limb Swelling in very severe obstruction
- Worst in the morning, often exacerbated by bending forwards or lying down
Cough (worse on lying flat/forward)

Venous distension (of neck, chest wall) due to formation of collaterals is a sign of chronicity

Uncommon: chest pain, dysphagia, headache/confusion (if cerebral oedema – v severe)

Late / severe symptoms

  • Visual disturbance
  • Confusion
  • Stridor, cyanosis

+ve Pemberton’s sign: bilateral arm elevation causes facial plethora

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

[SVCO] What are the investigations in a patient with SVCO?

A

Fundoscopy for papilledema (2’ to cerebral edema)

1st line = CXR

  • Suspect if CXR shows mediastinal mass/widening OR abnormal shadow
  • Abnormal in >80% of cases

Definitive Dx w/ CT thorax w/ contrast

  • Assess level of obstruction
  • Identify cause of SVCO

Followed by Histology (Fine Needle Aspirate/ CT-guided biopsy/ Bronchoscopy)

SVC Stenting is the treatment of choice for patients with severe symptoms
- Rapid palliation within 24-48h, and can be placed before tissue Dx is available

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

[SVCO] What is the management of SVCO?

A

Sit up at 30 degrees

Supplemental O2

Establish IV access (avoid UL) – will only worsen the syndrome

Observe for signs of cerebral edema / airway compromise

+/- bridging therapy of stenting will awaiting Histo Dx + Definitive Therapy

+/- IV dexamethasone if established cancer diagnosis

Definitive therapy

1) RadioTx as 1st line for radiosensitive tumors
- Non-small cell lung cancer (75-90% respond)
- Occasionally used in the absence of a histo Dx, however this does not provide immediate symptomatic benefit and will affect histology
2) Chemotherapy as 1st line for chemosensitive tumors
- Small cell lung cancer
- Lymphomas
- Germ cell tumors

Note: if aetiology is a SVC thrombosis 🡪 remove catheter and give anticoagulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

[MSCC] What is the presentation of a patient with metastatic spinal cord compression?

A

Back pain that may/may not be:

  • Constant and Dull
  • Worse with movement and weight bearing
  • Worsens at night [ unexplained but somehow all pain a/w CA worsens at night! (this includes headaches etc)]
  • 90% of pt with MSSC will present w back pain as 1st symptom
If compressing centrally, 
causes spinal cord compression, cauda equina, conus medullaris
- Sensory level
- LL Weakness, Numbness
- Incontinence (urinary and fecal)
- Saddle Anaesthesia

If compressing laterally, can cause radicular shooting pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

[MSCC} What are the investigations required to diagnose metastatic spinal cord compression? What are the indications of each modality?

A

Urgent MRI Whole Spine (preferred modality of Dx, helps evaluate the cord)

  • In cancer pt with unexplained back pain
  • Focal weakness / abnormal neuro exam
  • Unexplained bowel/bladder dysfunction

CT Myelography

  • Equivalent to MRI in sensitivity and specificity
  • Still useful in situations where MRI is contraindicated
  • Permits CSF analysis

CT Spine

  • Less sensitive than MRI for detecting metastases
  • Does not demonstrate the spinal cord or epidural space clearly
24
Q

[MSCC] What is the management of metastatic spinal cord compression?

A

Immediate Management
- Urgent MRI Whole spine
- IV dexamethasone STAT 16mg/day (4mg QDS or 8mg BD) with PPI cover. Always give steroids FIRST before Tx unless there is huge C/I to steroids. Will help reduce edema around the cord compression
- Insert IDC for ARU
- Adequate analgesia
- Urgent Orthopaedic or Neurosurgery consult
Radiation Oncology consult

Definitive Management

  • Radiotherapy is the mainstay of management
  • Surgical Circumferential Decompression + Spinal Stabilisation w/ Post-Op RadioTx

Conservative Mx

  • IDC Insertion (long-term, ibtermittent), Patient Education
  • PT / OT / Rehab Physician
25
Q

[MSCC] What are the strong indications for surgery?

A
  • Residual distal sensory / motor function (regardless of ability to walk) + good prognosis
  • Spinal instability: when collapse is imminent / has occurred; because such mechanical pain will NOT be relieved by RT
  • Bony compression (eg: fragments)
  • Single site of cord compression
  • Neurologic deterioration during or after RT
  • Radioresistant tumours
  • Intractable pain unresponsive to nonsurgical measures
26
Q

[MSCC] What are the contraindications for surgery?

A
  • Poor surgical candidates
  • Paraplegia > 48 hours
  • Multiple sites of compression
  • Expected survival of < 3 months
  • Patient’s choice
27
Q

[MSCC] What is the prognosis of MSCC?

A

Median survival time for patients with cord compression is approximately 3-6 months

Factors associated with longer survival times:

  • Ability to walk before and after treatment
  • Radiosensitive tumor histologies
  • No visceral or brain metastases
  • Single site of cord compression
28
Q

[Brain mets] What is the presentation of a patient with brain mets?

A

Headache, N&V, Seizures, behavioural change, blurred vision, convulsion if v severe (however should also rule out encephalitis)

Headache that worsens with COUGHING or STRAINING 🡪 points to increased ICP

Headache that WORSENS AT NIGHT 🡪 points to CA! (all CA related pain worsens @ night)

Cushing’s reflex/triad for raised ICP

  • Seen in terminal stages of raised ICP and indicate imminent brain herniation
  • Irregular respiration from impaired brainstem function
  • Bradycardia
  • Systolic hypertension (widening pulse pressure)
29
Q

[Brain mets] What are the investigations required?

A

? CN Examination + Full Neurological Examination

CT / MRI brain (w contrast)

  • Usually in A/E we will do PLAIN CT BRAIN first (since v fast and not TOO expensive) to rule our large infarct / haemorrhage (very little other information) / big masses / big fractures 🡪 very plain hence we can only pick up large defects
  • MRI better visualises the posterior aspect of brain (cerebellum, midbrain, pons and medulla)
  • MRI better visualise the DETAILS compared to plain CT 🡪 can see the midbrain, pons, medulla, the various gyrus of the brain
30
Q

[Brain mets] What is the management?

A

IV dexamethasone 16mg STAT + 8mg bd
- Give IV dexamethasone empirically once increased ICP is suspected
to ↓ further breakdown of BBB by the mets causing vasogenic cerebral edema

Mannitol, acetazolamide with close monitoring of electrolytes to reduce oedema

Avoid excess IV fluid will swell the brain more

Surgery

  • Such an aggressive method should be considered based on symptoms 🡪 for MASS EFFECT due to massive lesion
  • OR SOLITARY/OLIGOMETASTATIC (1-4) brain metastasis (not too many hence removal via surgery).

Whole brain RT (☹ risks cognitive dysfunction eg dementia, esp bad if pt has good life expectancy/ long prognosis)

  • Preferred for Multiple Metastasis
  • We use Radiotherapy NOT Chemotherapy! – hard for chemo to cross the BBB
  • We still do this, as cognitive dysfunction is more of a theoretical complication
31
Q

[HVS] What is the presentation of someone with HVS?

A

Headache, blurred vision, TIA, Stroke and Dyspnea

CNS – headache, dizziness, seizures, impaired consciousness, stroke

Eye – blurry vision, diplopia, retinal vein occlusion, papilledema

Mucosa – epistaxis, gingival bleed, GI bleed

Others – SOB, CHF, priapism

32
Q

[HVS] What is the management of a patient with HVS?

A

Dysproteinemia

  • Plasmapheresis to decrease plasma viscosity, especially useful in WM
  • Hydroxycarbamide (Hydroxyurea) to lower viscosity
  • Glucocorticoids & chemo agents (cyclophosphamide, chlorambucil) to prevent recurrence of symptoms

Hyperleukostasis

  • Unless leucapheresis can be obtained immediately, venesect 500ml of blood and replace with packed red cells if Hb <7g/Dl or 0.9% saline
  • Arrange leucapheresis if not done
  • Initiate tumor lysis prophylactic protocol in preparation for chemo (to avoid TLS)
33
Q

[Anaphylactic Reaction to Chemotherapeutics / Biologics] What is the presentation?

A

Angioedema and Urticaria are the most common manifestations

Others include: Abdo pain, chest tightness, Upper airway obstruction, Bronchospasm, HypoTN

34
Q

[Anaphylactic Reaction to Chemotherapeutics / Biologics] What is the management?

A

1) STOP the offending drug
2) Fluid resuscitation
3) Steroids / antihistamines / O2 / Bronchodilator

4) Adrenaline 1:1000 IM (Adrenaline is still the best drug for anaphylaxis)
- IM Adrenaline is indicated - ONLY if pt has haemodynamic instability
- Adrenaline will not be necessary if pt is hemodynamically stable 🡪 just fluid resuscitate, give other drugs (3) and monitor!

5) CALL FOR HELP

35
Q

[HyperCa of Malignancy] What is the presentation?

A

Features of hypercalcaemia esp. if acute “Moans Groans Stones Bones”

  • Lethargy, confusion, polyuria, polydipsia, anorexia, nausea, constipation
  • General: confusion, polydipsia, LOA/LOW, pruritus, “patient not himself”
  • Renal: polyuria, nephrocalcinosis
  • GI: N&V, constipation/ileus (constipation is v late stage), epigastric pain, pancreatitis
  • CNS: lethargy, AMS, seizures
  • MSK: weakness, myalgia/arthralgias
  • ECG: short QT interval, long PR interval, wide T waves, bradycardia, arrhythmia

Hypovolemia
- Due to hypercalcemia-induced urinary salt wasting and, in some cases, vomiting

36
Q

[HyperCa of Malignancy] What are the investigations required?

A
  • Corrected serum Ca
  • Renal Panel (AKI, choice of Tx)
  • STAT ECG
  • Others: serum PTH, PTHrp levels, 1,25-DHCC, 25-HCC
37
Q

[HyperCa of Malignancy] What is the management?

A

1) IV Normal Saline 2-3L (HYDRATE FIRST)
- IV normal saline 0.5L/hour and continue at lower rate till euvolemic!
- And 100-150mh/hr IV after volume repletion

2) Discontinue medications that can increase Ca levels (eg: Thiazides)

3) Monitor serum Ca + RP, I/O
- Renal Panel is V important as Bisphosphonates can cause renal damage!

4) Reduce Serum Ca via:
- IV bisphosphonates (commonly used: pamidronate and zoledronic acid)
- Alternative – SC Denosumab – rank-L inhibitor 🡪 used more commonly in renally impaired
- Alternative: SC Calcitonin – rarely given

5) Once rehydrated, small dose of IV Furosemide/ Lasix can be used as calciuric agent + give K supplementation
6) IV Corticosteroid helpful if steroid responsive disease eg: NHL, MM
7) Dialysis in patients with renal failure or CHF
8) Mithramycin

38
Q

[HyperCa of malignancy] What are the side effects of bisphosphonates?

A
  • Risk of osteonecrosis of the jaw (~2-3%, worse in pt with poor dentition or renal impairment)
  • WATCH eGFR!!
  • Will take a long time to drop the calcium 🡪 at least 36-48 hours for Ca to reduce significantly
39
Q

[Malignant pericardial effusion] What is the presentation?

A

Dyspnoea, non-productive cough, chest pain, hoarseness

Pulses Paradoxus

  • Abnormally large decrease in systolic blood pressure during inspiration
  • The normal fall in pressure is < 10 mmHg
  • Pulses paradoxus = drop > 20mmHg

Beck’s Triad for Cardiac tamponade

  • Low arterial pulse pressure (due to impaired LV function)
  • Distended jugular veins (due to backlog of blood due to LV dysfunction)
  • Distant, muffled heart sounds (due to pericardial effusion – may even hear pericardial friction rub)

ECG findings only seen in MASSIVE pericardial effusion

  • Low Voltage 🡪 due to limited activity of the heart
  • Tachycardia
  • Electrical alternans
40
Q

[Malignant pericardial effusion] What is the management?

A

Echocardiography-guided pericardiocentesis for symptomatic patients

Pericardial window also an option 🡪 for insertion of catheter for long term drainage

Chemotherapy/radiotherapy may provide palliation in selected cases

41
Q

[TLS] What is the criteria for diagnosis of laboratory TLS?

A

Biochemical component

  • ≥2 of ]: Hyperuricaemia, Hyperkalaemia, Hyperphosphatemia, Hypocalcaemia
  • OR >25% change from baseline (if baseline is already out of normal range)

Time component
- AND within 3 days prior to OR 7 days after initiation of therapy

42
Q

[TLS] What is the criteria for diagnosis of clinical TLS?

A
  • Renal impairment based on KDIGO criteria of AKI
  • Cardiac Arrhythmias
  • Symptomatic Hypocalcaemia: arrhythmia, seizure, NMJ irritability (tetsnus, Trousseau’s, Chvostek’s), sudden death
  • Seizures
  • Sudden death
43
Q

[TLS] How to prevent TLS?

A

Optimise renal function: aggressive hydration
- IV Normal Saline 200-300mL/h (aka 3-4L/24hrs) prior to chemo and during Tx (for 2-3 days) – achieve high urine output >2mL/kg/h

Correct electrolyte abnormalities

1) Baseline HyperPi
- Low Phosphate diet: avoid excessive protein & dairy products
- Phosphate binders: Ca Acetate / Carbonate, Lanthanum
2) Baseline HyperK
- Low K diet: avoid banana, green leafy veg, fruits except melon, apple, pear
- KIV Resonium +/- IV Insulin & Dextrose +/- Ca Gluconate (if >6 or ECG Δ)
3) Baseline HypoCa
- Don’t give Ca Supplementation if there is concurrent HyperPi (eg: CKD)
- First give phosphate binders 🡪 then medical parathyroidectomy w/ Calcitriol 🡪 then Ca supplementation

Allopurinol 600mg/day pre-treatment at least 48h prior to chemo if low risk

Rasburicase pre-treatment if high risk

  • C/I if G6PD deficiency
  • Very expensive ☹
44
Q

[TLS] What is the mechanism of Allopurinol in preventing TLS?

A
  • Xanthine Oxidase Inhibitor
  • Prevents synthesis of Uric acid
  • Hence does NOT reduce [uric acid]
  • Hence need to be initiated EARLY to ↓ [uric acid] by time of Chemo
45
Q

[TLS] What is the mechanism of Rasburicase in preventing TLS?

A
  • Recombinant Urate Oxidase
  • Converts uric acid to allantoin (↑ soluble)
  • Breaks down urate deposits
  • Hence reduced [uric acid]
46
Q

[TLS] What is the management of TLS?

A

Hyperhydration, strict IO monitoring

  • Support renal function if AKI: aggressive Hydration +/- RRT
  • Prognosis for a complete renal recovery is excellent if dialysis is initiated early
  • CCRT is preferred over intermittent HD as more Pi can be removed with longer durations of dialysis

Manage complications of arrhythmia – continuous cardiac monitoring

Manage complications of seizures

Correct electrolyte abnormalities

1) Hyperkalaemia: if >6 or ECG changes 🡪 Ca Gluconate + IV Insulin + Dextrose + Resonium
2) Hypocalcaemia: Phosphate binders before Ca
- Treat w/ Ca at the lowest doses required to relieve symptoms
- Asymptomatic HypoCa may not need Tx

Manage elevated Uric Acid

  • Rasburicase C/I in G6PD def individuals
  • Urine alkalinisation is NOT recommended (alkaline urine increases uric acid excretion but also increases risk of calcium phosphate precipitation and xanthine crystallization)
47
Q

[Neutropenic fever] What is the definition of neutropenic fever?

A

Single Temperature >38.3ºC OR ≥1h of 38ºC

AND ANC <500 cells/mm3

  • or ANC expected to decrease to <500 within next 48 hours)
  • or profound neutropenia w/ ANC < 100
48
Q

[Neutropenic fever] What is the MASCC score?

A

High risk patients: MASCC score <21/26 = criteria for ADMISSION: Mx inpatient with IV antibiotics

Low risk patients: MASCC score ≥21

Burden of illness

  • no or mild symptoms (5)
  • moderate symptoms (3)
  • severe symptoms (0)

No hypotension (5)

No COPD (4)

Solid tumour or haematological malignancy with no previous fungal infection (4)

No dehydration requiring parenteral fluids (3)

Outpatient at presentation (3)

Age < 60 years (2)

49
Q

[Neutropenic fever] What is the history required?

A

Fever + Localising symptoms of infection. In most cases will be MILDLY LOCALISING or ABSENCE of localising signs

Date/regimen of most recent chemo

Antibiotic prophylaxis

Infectious exposure, previous pathogens (i.e. contact, travel hx; esp if outpatient)

Comorbidities (DM, COPD etc)

Recent procedures/surgery

50
Q

[Neutropenic fever] How do you examine the patient to localise the infection?

A

IV sites (for line infection)

Skin – cellulitis

Neck stiffness, Neck Nodes

Lungs – crepitations, decreased breath sounds

Abdomen – tenderness, guarding, rebound

Urological system – CV angle tenderness, suprapubic tenderness

Perineum (avoid DRE) – Sacral sores, perineal abscess/ discharge/ ulcers

Oral cavity – thrush, ulcers, mucositis, dental caries

51
Q

[Neutropenic fever] What are the investigations required?

A

FBC, CRP, ESR, Procalcitonin, UECR

Full septic workup

  • Blood culture
  • UFEME, Urine culture
  • Chest Xray
  • +/- Sputum culture if chest symptoms
  • +/- Stool culture, CD toxin (Stool toxin test) if any diarrhoea
  • /- Abdominal Xray if suspect neutropenic enterocolitis
52
Q

[Neutropenic fever] What is the management of low risk patient?

A

Consider treating outpatient with oral antibiotics

PO ciprofloxacin and Augmentin (to cover G+ve)

  • We cant give Ceftriaxone as there is no PO, only IM and IV Ceftriaxone
  • Cipro also has Pseudomonal Coverage

If penicillin allergy: PO levofloxacin 750mg (but weaker Pseudomonas coverage) / ciprofloxacin + clindamycin

Patient should have good family support, able to reach hospital in 1hr if relapse

53
Q

[Neutropenic fever] What is the management of high risk patient?

A

1) Antibiotics choice
- Monotherapy w/ any of the following: IV Pip-tazo 4.5g q8h (most commonly used) OR Cefepime / Ceftazidime (i.e. anti-pseudomonal beta-lactam agent) OR Imipenam, Meropenem
- Add IV vancomycin 15mg/kg q12h in some cases
- Add Amikacin if: suspecting G-ve sepsis in pt who is haemodynamically unstable in some cases

2) Management of CVP BSI (central venous port-related bloodstream infection)
- Coag-neg Staph 🡪 keep CVP +/- antibiotic lock therapy
- S. aureus, Pseudomonas, fungi, mycobacteria 🡪 remove CVP and treat for >2/52

3) Re-assessment of the patient 🡪 considerations for
4) Anti-fungal therapy

54
Q

[Neutropenic fever] What are the indications to add IV vancomycin?

A
  • Clinically suspected catheter-related infection 🡪 ↑Risk of GP Sepsis
  • Skin or soft-tissue infection 🡪 usually G+
  • Pneumonia (identified radiologically) 🡪 usually G+
  • Haemodynamic instability or other evidence of severe sepsis patient 🡪 we cannot afford to miss out G+ve sepsis
  • Colonisation with MRSA infection
55
Q

What are the indications to add anti fungal therapy?

A

Persistent / Recurrent fever after 4-7 days

For anticipated prolonged neutropaenia > 7/7

Yeast (neutropenia for >1/52):

  • IV fluconazole
  • most common: Candida Sp.

Mould (neutropenia for >2/52):

  • IV amphotericin B, caspofungin, itraconazole, or voriconazole
  • most common: Aspergillus
56
Q

[Neutropenic fever] When do you stop the administration of abx?

A

If patient is on empirical Abx (does not apply to Vanco), stop:

  • Based on cell count: Until ANC >500 (aka no longer severely neutropenic)
  • OR Based on clinical picture: when Tx course is completed + S&S recovered
  • If there is recovery but still neutropenia w/ ANC < 500 🡪 take PO fluoroquinolone prophylaxis

Vancomycin: if started empirically for G+ve, stop after 2/7 if no evidence of G+ve

Pt has documented infections (i.e. culture +ve) & is on culture-directed Abx

  • Tx for 10-14/7, during which to use narrow-spectrum Abx once fever resolves
  • However: if abscess 🡪 drain + min 6/52 Abx Tx
  • However: if CVP BSI by S. Aureus, Pseudomonas, Fungus, Mycobacteria 🡪 min 2/52 Abx Tx
57
Q

[Neutropenic fever] What is the prophylaxis required?

A

High Risk = Prophylactic Fluoroquinolone!
- PO levofloxacin

Allogenic SCT OR treatment for Acute leukaemia = Prophylaxis against Candida Infection!
- PO fluconazole

All patients

  • Yearly Influenza vaccination
  • Reduce next dose of chemo (~25%)

It pt has >20% risk of neutropaenic fever (prev. episodes, or very high risk)

  • G-CSF (eg: Filgrastim / PEGfilgrastim)
  • Pegfilgrastim = higher dose
  • Helps patient be more prepared with higher FBC to face the next chemo cycle
  • Side Effect: Bone pain (give paracetamol)

Environmental Precautions

  • Strict hand hygiene, barrier protection (barrier / hospital isolation)
  • Neutropenic diet: No raw / semi-cooked food, No pre-prepared/ pre-opened fruits
  • Allogenic SCT: private room with >12 air exchanges/hour + HEPA filtration
  • Daily shower w good perineal hygiene
  • No flowers/plants (no matter dried or fresh)

Hematology (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions