12- Acute presentations in cancer (secondary to treatment) Flashcards
(41 cards)
acute presentations secondary to cancer therapy e.g. chemotherapy/radiotherapy
- Neutropenic sepsis
- Tumour lysis syndrome
- Immune related colitis
- Radiation mucositis
- Thrombocytopenia
Neutropenic sepsis
background
Definition
- Patient undergoing systemic anticancer treatment (SACT)
- Temp >38 or over 37.5 degrees over 1 hour
- Neutrophil count < 0.5 x 10 9 per litre or <1.0 and falling
- Patient can have infection and no fever
Remember
Suspect in all chemo patients who become unwell as some chemo patients cannot mount a fever (corticosteroids)
what is neutrophil nadir
Neutrophil levels reach a low point about 7 to 14 days after treatment. This is called the nadir. At this point, you are most likely to develop an infection. Your neutrophil count then starts to rise again.
when does neutrophil nadir typically occur
day 10
- Haematological malig Rx; deeper nadir, greater duration of neutropenia
newer biological/targeted therapies and neutropenic sepsis
less propensity to cause neutropenia
causes of neutropenic sepsis
Gram-negatives: can all produce extended-spectrum beta-lactams
* E.coli
* Klebsiella
* Enterobacter spp. - can get carbapenem-resistant strains (CRE)
* Pseudomonas aeruginosa
* Acinetobacter
* Gram-positives:
Coagulase-negative staphylococci (e.g. staph epidermidis)
* Staphylococcus aureus (including MRSA)
* Enterococcus (including VRE)
* Viridans group strep
* Strep pneumoniae
* Group A streptococci
Fungal:
* Candida
* Aspergillus
Risk of infection increased with
- Prolonged neutropenia (>7 days)
- Severity of neutropenia
- Significant comorbidities (COPD, DM, renal/hepatic impairment)
- Aggressive cancer
- Central lines
- Mucosal disruption
- Hospital inpatient
presentation of neutropenic sepsis
- Fever >38 or over 37.5 degrees over 1 hour
- Tachycardia >90
- HYPOTENSION < 90 systolic= URGENT
- RR > 20
- Symptoms related to a specific system e.g. cough, SOB, line, mucositis
- Drowsy
- Confused
investigations for neutropenic sepsis
Investigations
Blood tests
- FBC (with differential)
- U&Es
- LFTs
- Lactate/ABG
- CRP
Cultures/swabs
Urine
Sputum
Wound swabs
CXR
initial management of suspected neutropenic sepsis
DO NOT WAIT TO DO TESTS OR GET TEST RESULTS
GIVE STAT DOSE: IV TAZOCIN +- PIPERACILLIN (TAZOBACTAM)
full management of neutropenic sepsis
- Prompt assessment by HCPs who are familiar with NS
- Don’t wait for the FBC
- Empiric IV broad spectrum antibiotics within the
- hour (NICE guidelines)
o Tazocin
o Meropenem +/- Vancomycin if no improvement after 48h - Fluid resuscitation
- Oxygen
- Consider catheterisation
- Involve senior members of the team – SpR/Consultant
- Consider need for escalation of care
- Usually need 5/7 broad spectrum ABx, may switch to oral ABx after 48 hours if risk low
- GCSF (Granulocyte colony stimulating factor) can reduce severity and duration of neutropenia (sub cut injection)
o Side effects: bone pain, headache, fatigue and nausea - NOT used routinely, may be considered in patients who are profoundly septic/neutropenic
When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.
Neutropenic sepsis and GCSF
Granulocyte colony stimulating factor can reduce severity and duration of neutropenia (sub cut injection)
o Side effects: bone pain, headache, fatigue and nausea
- NOT used routinely, may be considered in patients who are profoundly septic/neutropenic
Prophylaxis for neutropenic sepsis
- A neutrophil count of < 0.5 x 109 as a consequence of their treatment they should be offered a fluoroquinolone
- All patients should be issued with an alert card with 24hr contact numbers
what can be used to risk assess neutropenic sepsis
MASCC risk index
Antifungal management for neutropenic sepsis
give IV voriconazole
Tumour lysis syndrome background
- Generally triggered by the initiation of cytotoxic therapy – mortality 15%
- Metabolic emergency that presents as severe electrolyte abnormality
- Massive tumour cell lysis -> release of large amounts of potassium, phosphate and uric acid into the systemic circulation
- Requires appropriate prophylaxis and early recognition and treatment
blood test findings for tumour lysis syndrome
3 High
- Hyperuricemia
- Hyperkalaemia
- Hyperphosphatemia
1Low
- Hypocalcaemia
AKI from uric acid and/or calcium phosphate crystals in renal tubules
tumour lysis syndrome susceptible tumour types
Susceptible tumour types
Risk greatest for haematological malignancies
- High grade lymphoma
- Leukaemia
- Myeloma
Bulky chemo-responsive tumour
- Less common in solid tumour
Patient specific risk factors for TLS
- High volume/bulky disease
- Pre-treatment LDH high
- High circulating WCC
- Pre-existing renal dysfunction/nephropathy
- Pre-treatment hyperuricaemia
- Hypovolemia
- Pre-treatment diuretic use
- Urinary tract obstruction from tumour
presentation of TLS
- Normally day 3-7 post chemotherapy
- N and V
- Diarrhoea
- Anorexia
- Lethargy
- Haematuria-> oliguria -> anuric
- Fluid overload
- Cardiac arrhythmia/arrest (peaked T waves, QTc derangement)
- Muscle cramps/ tetany/ seizures
what kills patients with tumour lysis syndrome
cardiac arrythmia due to electrolyte problems e.g. high pottassium, low calcium
investigations for TLS
Important investigations include: U&E (potassium and phosphate are typically raised), calcium (low), uric acid (raised), and ECG (metabolic abnormalities e.g. hyperkalaemia may precipitate life-threatening arrhythmias)
management of tumour lysis syndrome
1) Hydration
- Pre-hydration and vigorous hydration throughout treatment
- maintain urine output
2) Monitoring of electrolytes and fluid balance
3) Lowering of uric acid levels
- Allopurinol (xanthine oxidase inhibitor –> less hyperuricaemia)
- Rasburicase -> synthesic uricase -> degraded uri acid to allantoin (water soluble)
what is given prophylactically to prevent TLS
allopurinol
