ICU Issues in Haem Malignancy

Question 1

Key Emergencies in Haem onc patients

Answer 1

1. Acute oncological emergencies
   
   2. Neutropenia & neutropenic sepsis
   3. Respiratory failure
   4. Neutropenic enterocolitis
   5. Acute kidney injury (AKI)
   6. Tumour lysis syndrome
   7. Neurological dysfunction
   8. Cardiac dysfunction
      - Myocarditis, pericardial effusion, endocarditis, arrhythmias
   9. GI & liver dysfunction

Question 2

1. Acute Oncological Emergencies
   (Chemo in ICU may be required)

Answer 2

Common Causes:
* CNS involvement
* Mediastinal masses
* DIC
* Macrophage activation syndrome (MAS)
* Hyperleukocytic AML

Question 3

CNS Involvement:

Answer 3

• Altered consciousness
• Focal neurological deficits
• Seizures
  
  • Spinal cord compression

Note: These may be indications for urgent chemotherapy or radiotherapy

Question 4

Mediastinal Masses

Answer 4

• May compress:
  
  • Trachea
  • Major bronchi
  • Major vessels
  • Often due to Non-Hodgkin Lymphoma (NHL)
  • Urgent chemo/radiotherapy may be needed to relieve compression

Question 5

Disseminated Intravascular Coagulation (DIC)

Answer 5

• Can be a presenting feature of Acute Promyelocytic Leukemia (APML)
  
  • Treatment:
    
    • Specific chemo (e.g., ATRA)
    • Supportive care

Question 6

Hyperviscosity Syndrome

Q. Conditions where it occurs

Q. Clinical features

Q. Management

Answer 6

Occurs in:

*	Multiple myeloma
*	Waldenström’s macroglobulinaemia
*	Leukemic states

Clinical Features:
* Headache
* Visual impairment
* Seizures
* Coma
* Retinal haemorrhage
* Bleeding

Emergency Management:
* Reduce blood viscosity via plasmapheresis
* Urgent chemotherapy to reduce monoclonal immunoglobulin production

First few symptoms similar to PRES

Question 7

Hyperleukocytic AML:
Q. Common in Which condition
Q. What are the clinical concerns
Q. Management approach

Answer 7

• Hyperleukocytic AML:
  
  • Defined as total leukocyte count >100 × 10⁹/L.
  • Typically seen in patients with AML in blast crisis.

=> Pathophysiology:

*	WBC plugs in vasculature → ↓ tissue perfusion.
*	Leads to neurological dysfunction, respiratory failure, and coagulopathy

=> Clinical concern:

*	Leukostasis is a medical emergency with high mortality.
*	Requires prompt treatment with chemotherapy and leukapheresis.

=>Management approach:

*	Preliminary cytoreduction with hydroxycarbamide is recommended.

*	This is done before intensive chemotherapy to prevent tumor lysis syndrome.

Question 8

HLH

Answer 8

Pathological activation of T cells and Macrophages-leading to excessive release of cytokines resulting in MOF
*Diagnosis: >/= 5 of foll
-Fever>38.5
-Bicytopenia
-Splenomegaly
-Feritin>500mcg/l
-Hypertriglyceridemia
- Reduced NK cell activity (flowcytometry)
- -Reduced soluble CD25
- Haemophagocytosis demonstrated in bome marrow Bx

*Management:
-Tt underlying cause
-Antibiotics/Antivirals as indicated
- Dexamethasone
- Etoposide/Emapalumab
- HCT when more stable