ICU issues in Haem Malignancy cont…

Question 1

FEBRILE NEUTROPENIA

Q. Definition

Q. Causes of fever in neutropenia

Q.Invx

Q.Management

Q.Choice of Antimicrobials

Q.Role of GCSF

Answer 1

Definitions:

*	 Neutropenia: ANC < 1.5 × 10⁹/L
*	Severe Neutropenia: ANC < 0.5 × 10⁹/L

• Fever in neutropenia can be non-infectious (e.g. malignancy, chemotherapy, DVT) or infectious.
  
  • Distinguishing infection from non-infectious causes is very difficult.
  • Prompt identification of infectious source is critical:

1.# Investigate body fluids – urine, blood, sputum, pleural/ascitic/tissue fluid
* Blood cultures x2 sets
* Important labs: WCC, CRP, Procalcitonin
*Relevant Imaging-USG for suspected cholecystitis/CT scan

*	Neutropenic sepsis has high mortality – initiate empiric antibiotics early.

2.# First-line treatment:
* Anti-pseudomonal beta-lactam with a good Gram positive and Gram negative cover (e.g. cefepime, tazobactam-piperacillin)
* Add aminoglycoside/fluoroquinolone if AB resistance is suspected or for septic shock
*Add vanc if suspicion of MRSA or resistant Enterococcus/risk factors/ previous colonisation
* Cover suspected pneumonias or CLABSI with suitable agents
* Empirical antifungals if high suspicion or persistent fever with no source found

⸻

3.#G-CSF (e.g. filgrastim):
* Used to promote neutrophil recovery
* Particularly for profound neutropenia (ANC < 0.5 × 10⁹/L)
* SE:
-Flu like symptoms
-Rash
-Bone pain

4.Environmental measures:
*	Hand hygiene
*	Barrier precautions
*	Protective isolation in high-risk patients

Question 2

Neutropenic enterocolitis

Q.Pathophysiology

Q. Diagnosis

Q.Complications

Q.Management

Answer 2

Classic triad:

    -	Fever
    -	Abdominal pain
     -Diarrhoea
*	Common post-chemotherapy

*Pathophysiology:
1.Chemotherapy-induced colonic mucosal wall damage

 2.	Thrombocytopenia → GI bleeding

  3.	Translocation of gut flora & pathogenic bacteria

*	Bacteraemia
*	GI bleeding
*	Colonic perforation

*	CT: 
  -Bowel wall thickening, pneumatosis- (colonic pneumatosis suggests necrosis)
 -Free Gas- sugg perforation

*	Bowel rest
*	Parenteral nutrition (PN)
*	Broad-spectrum antibiotics (cover Gram-negative, anaerobes)
*	Surgery if: bowel perforation, life-threatening GI bleed, immunological compromise, or sepsis

Question 3

Respiratory Failure in Haematological Malignancies

Q. Causes of RF in Haem malignancy

Q. Causes specific to HCT

Q. Outline Mx

Answer 3

Causes of Acute Respiratory Failure (ARF):

=>Non-Infectious:
1. * ARDS
2* Drug-induced pneumonitis
3* Radiation pneumonitis
4* Pulmonary oedema
5* Pulmonary fibrosis
6* Tumour-related obstruction
7 Pulmonary Embolism
8 Complications of HCT:
- GVHD
- DAH (diffuse alveolar haemorrhage)
- Idiopathic pneumonia syndrome
- Engraftment syndrome

=> Infectious:
* Bacterial: Staph, Strep, Pseudomonas, Klebsiella, Enterococcus, Nocardia, Mycoplasma, Legionella
* Viral: CMV, HSV, VZV, RSV, adenovirus, influenza, parainfluenza
* Fungal: Aspergillus, Candida, PCP
* Others: Mycobacterium tuberculosis

*	Early use of NHF (nasal high flow) and NIV (non-invasive ventilation)
*	Lung-protective ventilation if intubated
*	Full ventilation = poor prognostic indicator
*	BAL (bronchoalveolar lavage) – useful in select patients but may precipitate ARF
*	Trend:
*	Prognosis has improved, but intubation still carries high mortality

Question 4

AKI
Q. Causes of AKI in haem malignancy

Answer 4

Causes include:

1. Sepsis
   2* Monoclonal light chain deposition (e.g., multiple myeloma)
   3* Tumor lysis syndrome
   4* Chemotherapy-induced toxicity (e.g., methotrexate, foscarnet)
   5* Antibiotic toxicity (e.g., aminoglycosides, amphotericin)
   6* Hepatorenal syndrome (HRS, secondary to VOD)

#Need for RRT is an independent predictor of mortality

Question 5

Q. Causes of Neurological dysfunction in Haem Malignancy

Answer 5

1. cerebral infarcts,
2. CVST*
3. hyperviscosity syndrome*
4. chemotherapy-induced encephalopathy (e.g., high-dose cytarabine, Ifosfamide toxicity)
5. Septic encephalopathy
6. Metabolic causes
7. Meningoencephalitis

Question 6

Q.Causes of Gastrointestinal & Liver Dysfunction in Hematologic Malignancies

Answer 6

1* GvHD
2* Infections: EBV, CMV, hepatitis
3* Tumor infiltration
4* VOD
5* Drugs (e.g., methotrexate, platinum agents)

Question 7

• Tumor lysis syndrome:
  Q. Pathophysiology and general outline

Answer 7

• Rapid tumor cell death releases large amounts of intracellular contents (↑ K+, PO4, urate)
  
  • Leads to: AKI, metabolic disturbances
  • Common in high-grade lymphomas (e.g., Burkitt’s), acute leukemias
  • Management: Aggressive IV hydration, correct electrolyte/acid-base imbalance, allopurinol, rasburicase,+/- dialysis

Question 8

Q* Poor prognostic indicators

Answer 8

• Advanced age
  
  • Allogeneic transplant
  • Mechanical ventilation
  • Vasopressor use
  • GvHD
  • Elevated serum lactate at admission

Question 9

What are some strategies to improve outcomes in pts with haem malignancy

Answer 9

Early multidisciplinary care: hematologists, intensivists, ID

# Strict infection control & hygiene measures
# Early ICU involvement