Haem Cancers

Question 1

Why do haem cancer pts end up in ICU

Answer 1

Critical illness relating to disease
Illness relating to treatment
Something else unrelated to their cancer

1) Neutropenia and sepsis
2) Resp failure —> infection, oedema, haemorrhage, infitltrates
3) TLS
4) GvHD
5) Chemo complications
6) CNS dysfunction —> hyperviscosity, venous thrombosis, intracerebral bleed, cancer, electrolytes
7) GI - neutropenic enterocolitis - typhilitis
8) AKI - nephrotoxics, sepsis

Question 2

Define neutropenia| Neutropenic sepsis

Answer 2

Neutro - Neutrophil count < 0.5 x 10.9/LSepsis - Neutropenia plus temp >38C OR signs of infection

Question 3

Precautions in neutropenic patients to reduce sepsis risk

Answer 3

Reverse barrier nursing
Positive pressure side room
Avoid invasive things - bladder cathter, CVP
Avoid rectal exam/temp probes good oral hygiene

Question 4

Principles of managing neutropenic sepsis

Answer 4

ABCDE etc
History and exam - pets, animal exposure, hobbies, foreign travel, TB exposure Indwelling lines
Look for absesses in skin, oropharynx, perirectal areas

Sepsis Tx	Immediate Abx as per protocols	
FBC, U&E, LFT, CRP, Lactate	Blood cultures, culture lines, and sites	Atypical tests	
FLuid and vasopressor

ImagesCXR +/- AXR

Question 5

Empirical treatment for Neutropenic Sepsis

Answer 5

ANti-pseudomonal b-lactam e.g tazocin
Additional - gent/quinolones if gram negative or resistant Alternatives to pen allergy - cipro and clindamycin

Question 6

What is Tumour Lysis Syndrome

Answer 6

Metabolic abnormalities with large volume tumour cells lyse and release contentsUsually with chemo, but can be spontaneous.Associated with acute leukeamias and high grade lymphomas (Burkitt)

Question 7

Features of TLS

Answer 7

Life threatening Hyperkalemia
Metabolic Acidosis
Renal Failure
Hypocalcaemia
Hyperphosphataemia
Increasaed serum and urinary urate

Question 8

Treatment of TLS

Answer 8

ABCDE etcGoals: Aggressive fluid resus ?forced alkaline diuresis - questionable, risk of fluid overload Treat hyperkalaemia (including RRT) Rasburicase (urate oxidase enzyme reduces uric acid concentrations)

Question 9

What is graft vs host disease

Answer 9

Immune mediated
Follwing Allogeneic hematopoietic cell transplantation
Results in complex interaction between donor and recipient adaptive immunity

Question 10

Complications of stem cell transplant

Answer 10

Early <100 days or late >100 days

Early:	Infectioni	Haemorrhage	Acute GvHD	Interstitial pneumonitis	Aplastic anaemia due to graft failure

Late:	Chronic GvHD	Chronic pulmonary disease	Infections	Autoimmune disorders

Question 11

How does acute GvHD present

Answer 11

Less than 100 days post HCT
Enteritis
Hepatitis
Dermatitis

Question 12

Diagnosis of GvHD

Answer 12

Histology - skin rectal or liver biopsy
Clinical by staging system - Seattle Glucksberg system

Question 13

Describe the Seattle Glucksberg systemfor Grading and staging of acute GVHD

Answer 13

Stage 1 - Skin rash < 25% of body, Bili 26-60 and GI fluid loss 500-100
2 - 25-50%. /61-137./1 to 1.5 litres
3 - >50% and erythroderma/ >138. />1500
4. Bullous desquamation. / >257. / >2500 ileus

Question 14

Treatment of GvHD

Answer 14

High dose steroids
Immunsuppressants - ciclosporin
Parental nutrition for gut rest (consider octrotide)

Question 15

Features of Chronic GvHD

Answer 15

> 100 days post HCT
Diverse range of autoimmune disorders
Scleroderma
PBC
Bronchiolitis obliterans

Question 16

What is typhilitis

Answer 16

Neutropenis enterocolitis
GI complication of chemoN/V/abdom pain and distention, chills and fever
Poor prognosis
High index of suspition and CT imaging
Elective right hemi to prevent recurrent