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Crit Care, Oncology & Hematology > Oncologic Emergencies: Key Points > Flashcards

Oncologic Emergencies: Key Points Flashcards

1
Q

What are the three major oncologic emergencies?

A

Hypercalcemia of malignancy
Tumor Lysis Syndrome
Febrile Neutropenia

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2
Q

What kinds of cancers can cause hypercalcemia of malignancy? (6)

A

Non-small cell lung cancer
Squamous cell cancer [head and neck]
Breast cancer
Urothelial carcinomas
Multiple myeloma
Ovarian cancer

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3
Q

What calcium level defines hypercalcemia?

A

Corrected Ca ≥ 10.5 mg/dL

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4
Q

What corrected calcium level is MILD hypercalcemia?

A

10.5 - 11.9

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5
Q

What corrected calcium level is MODERATE hypercalcemia?

A

12-13.9

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6
Q

What corrected calcium level is SEVERE?

A

≥ 14

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7
Q

What is the corrected calcium equation?

A

0.8 x (4 - Albumin) + serum calcium

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8
Q

What are RENAL symptoms of hypercalcemia of malignancy?

A

Polydipsia/polyuria
Dehydration
Decreased GFR

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9
Q

What are GI symptoms of hypercalcemia of malignancy?

A

Constipation
Anorexia
N/V

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10
Q

What are NEURO symptoms of hypercalcemia of malignancy?

A

Lethargy
Confusion/stupor
Irritable
Muscle weakness
Seizure
Coma

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11
Q

What are CARDIAC symptoms of hypercalcemia of malignancy?

A

Shortened QT interval
Widened T wave
Heart block
Asystole
Arrhythmias

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12
Q

What are FOUR mechanisms of hypercalcemia of malignancy?

A

HUMORAL - increased PTH-related peptide causes increased renal reabsorption of Ca
Bone invasion - increased local osteolytic activity
RARE:
Vitamin D intoxication
Ectopic PTH production

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13
Q

What are the 3 steps to approaching hypercalcemia of malignancy treatment?

A
  1. Fluids (increase excretion)
  2. Stop bone resorption
  3. Reduce intestinal absorption of Ca
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14
Q

What fluid is used for hydration in hypercalcemia of malignancy? What additional drug may help flush out excess Ca?

A

NS - 1-2 L bolus, then 200-500 mL/hr infusion
Furosemide 20-40 mg lowers calcium in volume overload or HF pts

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15
Q

What agents can be used for inhibiting bone resorption in hypercalcemia of malignancy?

A

Bisphosphonates: Pamidronate, Zoledronic acid
RANKL inhibitor: denosumab
Calcitonin

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16
Q

What are some AEs of bisphosphinates? What is a major clinical pearl for dose adjustment?

A

AEs:
Pamidronate = fractures, musculoskeletal pain, flu-like illness, osteonecrosis of jaw
Zoledronic acid = electrolyte abnormalities, nausea, anemia

AVOID IN RENAL IMPAIRMENT!
(Pamidronate - CrCl<30 mL or SCr > 3, Zoledronic acid - SCr > 4 mg/dL)

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17
Q

If bisphosphinates cannot be used in hypercalcemia of malignancy, what is the next best option and in WHAT PATIENTS might it be preferred?

A

Denosumab
Preferred in RENAL IMPAIRMENT (bisphosphinates not recommended in these pts)

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18
Q

Calcitonin: what kind of therapy is it (adjunctive/standalone)? What is one major AE? Why do we have to limit use to <48 hrs?

A

Adjunct therapy to IV fluids and bisphosphonates
AE = facial flushing
Limit to <48 hr due to tachyphylaxis

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19
Q

What drug class is used to reduce intestinal Ca absorption in hypercalcemia of malignancy?

A

Glucocorticoids
Prednisone 60 mg/day x 10 days

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20
Q

In TLS, what INCREASES?

A

Potassium
Uric acid
Phosphate

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21
Q

In TLS, what DECREASES?

A

Calcium

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22
Q

Patient risk classification for TLS depends on what TWO factors?

A

Cancer type
WBC count (higher count = higher risk)

23
Q

How does tumor lysis syndrome occur?

A

Chemo effectively destroys cells, allowing its contents to flood the body

24
Q

According to the Cairo-Bishop Definition of TLS, what are the CUTOFF levels for each of the four electrolytes?

A

K ≥ 6 mEq/L
Uric acid ≥ 8 mEq/L
Phos ≥ 4.5 mg/dL
Ca ≤ 7.0 mg/dL
[OR 25% increase from baseline]

25
Q

What are the most common clinical presentations of TLS? (4)

A

AKI
Seizures
Arrhythmias
Altered mental status

26
Q

For TLS, what are the steps for LOW RISK treatment?

A

Monitor only

27
Q

For TLS, what are the steps for INTERMEDIATE RISK treatment?

A

Hydration (NS)
Allopurinol
(If cont. hyperuricemia, then +rasburicase)

28
Q

For TLS, what are the steps for HIGH RISK treatment?

A

Hydration (NS)
Rasburicase
(Consider allopurinol if extra treatments needed)

29
Q

What is the MoA of allopurinol? What is the standard dosing?

A

Dose = 300 mg daily
Does NOT lower existing uric acid levels, only prevents more uric acid from forming

30
Q

What is a key monitoring parameter of rasburicase? What is the standard dosing?

A

Must obtain a “rasburicase uric acid” level, put it on ice to prevent progressive uric acid breakdown [more accurate to body levels]

Flat dosing = more common
1.5 or 3 mg IV x1, repeat if uric acid ≥7.5

31
Q

What is the treatment of hyperkalemia in TLS? (Remember from crit care!)

A

Calcium chloride/gluconate
Insulin
Bicarb
Loop diuretic
HD

32
Q

What is the treatment of hyperphosphatemia in TLS?

A

IV fluids +/- diuretics (if overloaded)
Phosphate binders
- calcium acetate/carbonate
- aluminum hydroxide
- Lanthanum
- Sevelamer

33
Q

What is the treatment of hypocalcemia in TLS?

A

DO NOT TREAT UNLESS SYMPTOMATIC!

Ie. Arrhythmias, seizures or tetany
Treatment = calcium gluconate (like hyperkalemia)

34
Q

What are risk factors for febrile neutropenia?

A

Age ≥ 65
Pre-existing neutropenia
Gender
Low BMI
Hx of chemo/radiation therapy
Poor performance status (not mobile)
Comorbidities
[Bone involvement by tumor
Recent surgery or open wounds]

35
Q

Define febrile neutropenia by its FEBRILE and NEUTROPENIC levels

A

Febrile = temp > 38.8 C x1 OR temp > 38 C x 1 hr
Neutropenia = ANC < 500 OR ANC < 1000 expected to drop to <500 in next 48hr

36
Q

What kinds of cancers/neutropenia duration indicates LOW infection risk in febrile neutropenia pts?

A

Solid tumors
Neutropenia < 7 days

37
Q

What kinds of cancers/neutropenia duration indicates INTERMEDIATE infection risk in febrile neutropenia pts?

A

Autologous hemo cell transplant
Lymphoma
Multiple myeloma
Chronic lymphocytic leukemia
Purine analog therapy
Neutropenia 7-10 days

38
Q

What kinds of cancers/neutropenia duration indicates HIGH infection risk in febrile neutropenia pts?

A

Also genie hemo cell transplant
ACUTE leukemia
Alemtuzumab use
Graft-vs-host disease
Neutropenia >10 days

39
Q

What kinds of treatments should be used/considered for LOW infection risk PROPHYLAXIS in febrile neutropenia pts?

A

Viral ONLY if hx of HSV

40
Q

What kinds of treatments should be used/considered for INTERMEDIATE infection risk PROPHYLAXIS in febrile neutropenia pts?

A

Antiviral
Consider: antibiotics, antifungal, anti-PJP

41
Q

What kinds of treatments should be used/considered for HIGH infection risk PROPHYLAXIS in febrile neutropenia pts?

A

Antibiotics, antiviral
Consider: antifungal, anti-PJP

42
Q

What 4 antibiotics can be used in infection prophylaxis for febrile neutropenia?

A

Levofloxacin
Cirpofloxacin
Cefpodoxime
Penicillin VK

43
Q

What 5 antifungals can be used in infection prophylaxis for febrile neutropenia?

A

Fluconazole
Posaconazole
Voriconazole
Isavuconazole
Micafungin IV

44
Q

What antiviral can be used in infection prophylaxis for febrile neutropenia?

A

Acyclovir

45
Q

What anti-PJP agent can be used in infection prophylaxis for febrile neutropenia?

A

Bactrim daily on MWF OR BID on Sat + Sun

46
Q

In febrile neutropenia, what is the MASCC score cutoff for LOW RISK or HIGH RISK patients?

A

≥ 21 - low risk
< 21 - high risk
Recall: higher MASCC score = better!

47
Q

If a LOW risk febrile neutropenia pt is currently on levofloxacin/ciprofloxacin prophy, what is the treatment of choice?

A

Cefepim

48
Q

If a LOW risk febrile neutropenia pt is currently NOT on levofloxacin/ciprofloxacin prophy, what are the treatments of choice?

A

Levofloxacin
Moxifloxacin
Augmentin + ciprofloxacin

49
Q

If a febrile neutropenia pt is HIGH risk, what are the treatments of choice?

A

Zosyn
Cefepime
Meropenem (last line, too broad but if beta lactam allergy then use)

50
Q

Should MRSA coverage be regularly added to febrile neutropenia treatment?

A

No, unless high risk for MRSA

51
Q

What kinds of febrile neutropenia pts should get fungal treatment?

A

Consider in high-risk patients who have hematologic malignancies/ are hemodynamically unstable or septic
Add at 4-7 day mark

52
Q

If febrile neutropenia is of an UNKNOWN source, when should treatment be D/Ced?

A

If neutrophils ≥500: D/C
If neutrophils <500: Deescalate to prophylaxis and continue until neutropenia resolved

53
Q

If febrile neutropenia is from a documented infection, generally how long is treatment duration?

A

5-14 days

Crit Care, Oncology & Hematology (18 decks)

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